Dehydroepiandrosterone is an androgen precursor produced primarily by the adrenal glands in women. The steroid hormone is produced from cholesterol at birth by the fetal adrenal glands, after which its output reduces. DHEA production picks up again from the age of 5-7 years and peaks between the ages of 20-30.

The life time risk of breast cancer in BRCA 1 gene is 70% and of ovarian cancer is 40%.

Gardnerella vaginalis is one of the bacteria implicated in the development of bacterial vaginosis , many women (>50%) with this vaginal infection have no signs or symptoms, when these are present they are most often :
Vaginal discharge, grey, white or green, with a strong unpleasant odour
Strong vaginal odour and fishy smell after sex
Vaginal itching
Burning during urination
Vaginal bleeding after sex
Gardnerella vaginalis can also be responsible for serious infections (sepsis, wound infections) in locations other than those associated with the genital tract or obstetrics, these cases are very rare but have been reported, including in men.

Mycoplasma Hominis is one of the organisms involved in the pathogenesis of BV but it appears normal on wet mount.

Candida presents with white cottage cheese like discharge.

Chlamydia is not seen on wet mount and produces clear vaginal discharge.

Trichomonas shows clue cells on wet mount.

Shoulder dystocia occurs when the fetal shoulder impacts on the maternal symphysis or sacrum during vaginal delivery. About 10% of babies with shoulder dystocia will suffer a brachial plexus injury, the most common one being Erb-Duchenne palsy. In Erb’s palsy, the upper nerve roots C5 and C6 are damaged due to excessive widening of the angle between the head and the shoulder. This causing temporary paralysis in the affected arm whereby the infant will present with its hand hanging limp by his side, internal rotation of the forearm, plus wrist and finger flexion. This sign is called the ‘waiter’s tip hand’. The palsy usually resolves spontaneously in a large proportion of cases.

The ureters receive innervation by a number of nerve plexuses. The nerves supplying the ureters originate from spinal segments T11 to L2. When you think about ureteric colic giving classic ‘loin to groin’ pain it is because the pain is referred to these dermatomes.

The median umbilical ligament is the remnant of the Urachus.

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justified to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specificity for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges. The women should be tested as soon as possible after booking if there is a history of GD.

Promethazine or Cyclizine are 1st choice options for management of nausea and vomiting in pregnancy according to NICE. Prochlorperazine is also appropriate 1st line.

It is classified under type II hypersensitivity reaction. Antibodies are formed against the rhesus antigen i.e. D antigen. Hence when the Antibody reacts with the antigen on the RBC it results in activation of the complement cascade leading to lysis.

Ovulation in the menstrual cycle usually occurs over 4 days. There is an increase in basal body temperature at the time of ovulation due to the effect of progesterone.

A high Day 21 progesterone level indicates ovulation and the release of an egg.

Dysmenorrhea is described as painful menstruation. The symptoms start at the time of ovulation and persist till menstruation.

In patients who have an HbA1C value above 10%, it is better to postpone pregnancy until diabetes is under control. Also in those patients with type 2 diabetes mellitus, who are suffering from severe gastroparesis, those with advanced retinopathy, with severe diabetic renal disease and severe ischemic heart disease with uncontrolled hypertension pregnancy is contraindicated.

All the other options mentioned are incorrect.

Vulvar Intraepithelial Neoplasia (VIN) is a non-invasive squamous type lesion that carries a 15% chance of developing into squamous cell carcinoma of the vulva. Human Papillomavirus (HPV) infection, or chronic inflammatory conditions such as lichen sclerosis and lichen planus, can cause changes in the basal cells of the vulvar epithelium. Other risk factors of VIN include multiple sexual partners, cigarette smoking, and immunocompromised states. Diagnosis is by clinical examination and a biopsy confirms neoplasia.

Diastolic murmurs occur in conditions such as mitral stenosis, tricuspid stenosis and even in carditis. They are always pathological during pregnancy. Systolic murmurs and left axis deviation may be normal during pregnancy due to an increase in the blood volume and load on the heart.

The most common congenital thrombophilia is Factor V Leiden mutation. Other congenital causes are JAK-2 mutations and the Prothrombin G20210A mutation. Protein C and S deficiencies are type 1 and antiphospholipid syndrome is not congenital it is an acquired thrombophilia.

CAH leads to virilization of the female foetus. It occurs to an enzyme deficiency (21-hydroxylase). This results in a reduced levels of corticosteroids from being circulated resulting in hyperplasia of the adrenal glands and increased progesterone production. The CYP21A gene has been implicated in causes this deficiency.

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral 75g glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges.

Dinoprostone is associated with a transient pyrexia. This typically normalises within 4 hours of stopping treatment

Functional closure of the ductus arteriosus is neonates is completed within the first few days after birth. It normally occurs by the 12th postnatal week. It has been suggested that persistent patency of DA results from a failure of the TGF-B induction after birth. Due to increased arterial pO2, constriction of the DA occurs. In addition to this on inflation the bradykinin system is activated with cause the smooth muscles in the DA to constrict. A decrease in the E2 prostaglandin is also an important factor as raised levels have been indicated in keeping the patency of the DA.

Tocolytics are used to suppress contractions. The Canadian preterm labour trial which remains a very influential tocolytic trial to date concluded that tocolytics such as a beta agonist have no significant benefit on perinatal mortality or morbidity or prolong pregnancy to term however it did reduce the number of women delivering within 2 days by 40%. This 48 hour window is the only reason for the use of tocolytics.
Choice of tocolytic (NICE)
1st line: Nifedipine
2nd line: Oxytocin receptor antagonists e.g. atosiban

Lower abdominal pain during menstrual periods and lower back or leg pain are associated with endometriosis in the uterosacral ligaments. Endometriosis can cause diarrhoea and IBS type symptoms. Note Endometriosis on the uterosacral ligament can cause tender nodules to form. These can be palpated during pelvic exam. Tender nodules are specific to endometriosis of the uterosacral ligament so if the question mentions feeling a tender nodule during PV exam think endometriosis of the Uterosacral ligaments!

Ergometrine has a half life of 30-120 minutes.

This woman has mixed incontinence, which includes signs and symptoms of both stresses and urges incontinence. The urge, on the other hand, irritates her. Bladder training would be the most appropriate management approach to investigate first for women with urge incontinence as the most troublesome symptom. The objectives are:
– Using a bladder diary to establish a baseline
– Creating a voiding schedule
– Over a long period, gradually increase the voiding interval in increments of 2- 5 minutes, to void every 3 hours.
– Other important strategies to consider are lifestyle changes like reducing fluid intake, losing weight, and avoiding diuretics-producing foods and beverages (e.g., alcoholic beverages, caffeine, etc).

When urge incontinence does not respond to physical or behavioural therapy, anticholinergics along with ongoing bladder training are an alternative. A 4- to 6-week trial is employed. At six months, risk and benefit are weighed to see if treatment should be continued for those who react. Patients should be informed about anticholinergic side effects such as dry mouth and constipation, as well as how to control them.

Anterior colporrhaphy is a treatment for cystocele that involves repairing the front vaginal wall. It can help people with urine incontinence. If you don’t have a cystocele, bladder neck suspension is the best option.
Retropubic bladder suspension is a more intrusive surgery for treating stress urinary incontinence in patients who haven’t responded to less invasive treatments like pelvic floor exercise.

The most essential initial conservative therapy to explore for patients with real stress incontinence and mixed (both stress and urge) urine incontinence when stress incontinence is the more prominent symptom is pelvic floor muscle exercise (e.g. Kegel exercise). For urge incontinence, more difficult training can be applied.

Endometrial cancer should always be the first diagnosis to rule out in a 65-year-old lady with brownish vaginal discharge. The inquiry focuses on the most likely source of the symptoms, rather than the most significant diagnosis to explore.
Blood typically causes the dark hue of vaginal discharge. The uterine cavity or the vagina can both be the source of bleeding. Only 5-10% of postmenopausal women with vaginal bleeding were found to have endometrial cancer. Around 60% of the women had atrophic vaginitis.

Urogenital atrophy is caused by oestrogen insufficiency in postmenopausal women. Urogenital atrophy can cause the following symptoms:
– Dry vaginal skin
– Vaginal inflammation or burning
– Vaginal lubrication is reduced during sexual activity.
– Vulvar or vaginal pain, as well as dyspareunia (at the introitus or within the vagina)
– Vaginal or vulvar bleeding (e.g. postcoital bleeding. fissures)
– Vaginal discharge from the cervix (leukorrhea or yellow and malodorous)
– A vaginal bulge or pelvic pressure
– Symptoms of the urinary tract (e.g. urinary frequency, dysuria, urethral discomfort, haematuria).

Counselling her about the risks associated with obesity during pregnancy will be the best possible advice to give this patient. A combined follow up by an obstetrician and a diabetes specialist at a high-risk pregnancy clinic is required to formulate the best ways in management of gestation with obesity.
An oral glucose tolerance test should be done at 26 weeks of her pregnancy, along with advising her on controlling her weight by diet and lifestyle modifications. During the early weeks of their pregnancy all obese patients must be routinely tested for pre-existing diabetes.

It is highly inappropriate to advice her not to get pregnant.

Without making a proper diagnosis of diabetes, it is wrong to ask her to start oral hypoglycemic agent and/or insulin.

Checking urinary proteins is not indicated at this stage, but can be considered as a part of antenatal check up.

Oxytocin stimulates the myoepithelial cells in the breast causing the milk production. It also helps augment contractions in labour and cause uterine involution after childbirth.

Boundaries of the Femoral Triangle: Superior: Inguinal ligament Medial: Medial border of the adductor longus Lateral: Medial border of the sartorius Floor: Pectineus, Adductor longus and Iliopsoas muscles Roof: Fascia Lata (cribriform fascia at the saphenous opening) Trasversalis fascia forms part of the roof of the inguinal canal

Hyperemesis Gravidarum effects around 0.3-2% of Pregnancies. It causes imbalances of fluid and electrolytes, disturbs nutritional intake and metabolism, causes physical and psychological debilitation and is associated with adverse pregnancy outcome, including an increased risk of preterm birth
and low birthweight babies. The aetiology is unknown however various potential mechanisms have been proposed including an association with high levels of serum human chorionic gonadotrophin (hCG), oestrogen and thyroxine.

The diagnosis of functional ovarian cyst is made when the cyst measures more than 3 cm and rarely grows more than 10 cm. It appears as a simple anechoic unilocular cyst on USS. It is usually asymptomatic. If it is symptomatic then laparoscopic cystectomy should be performed.

Pyelonephritis is the most common serious medical problem that complicates pregnancy. Infection is more common after midpregnancy, and is usually caused by bacteria ascending from the lower tract. Escheria coli is the offending bacteria in approximately 75% of cases. About 15% of women with acute pyelonephritis are bacteraemia- A common finding is thermoregulatory instability, with very high spiking fevers sometimes followed by hypothermia- Almost 95% of women will be afebrile by 72 hours. However, it is common to see continued fever spikes up until that time- Thus, further evaluation is not indicated unless clinical improvement at 48-71 hours is lacking. If this is the case, the patient should be evaluated for urinary tract obstruction, urinary calculi and an intrarenal or perinephric abscess. Ultrasonography, plain radiography, and modified intravenous pyelography are all acceptable methods, depending on the clinical setting.

ADH and vasopressin are synthesized in the supraoptic and periventricular nuclei of the hypothalamus, they are eventually transported to the posterior pituitary where they are stored to be released later.