Any new onset of hypertension associated with proteinuria after 20 weeks of gestation in a previously­ normotensive woman is referred to as Preeclampsia.
Most commonly found risk factors for pre-eclampsia are:
– Preeclampsia in a previous pregnancy
– Family history of preeclampsia
– a prior pregnancy with poor outcome like placental abruption, IUGR, fetal death in utero, etc
– An interdelivery interval greater than 10 years
– Nulliparity, increases risk by 8 times
– Pre-existing chronic medical conditions or chronic hypertension
– pre-existing or gestational Diabetes
– chronic Renal disease
– Thrombophilias g. protein C and S deficiency, antithrombin Ill deficiency, or Factor V Leiden mutation
– Antiphospholipid syndrome
– Systemic lupus erythematous
– Maternal age greater than or equal to 40 years
– Body Mass Index (BMI) greater than 30 kg/m2
– Multiple pregnancy
– Raised blood pressure at booking
– Gestational trophoblastic disease
– Fetal triploidy

Maternal age between 18 and 40 years is found to be associated with a decreased risk for developing preeclampsia, and not an increased risk.
NOTE– Previously, age 16 years or younger was thought to be a risk factor for developing preeclampsia; however, recent studies conducted had failed to establish any meaningful relationship between the two.

Congenital cytomegalovirus infections are the most common cause of sensorineural hearing loss in babies. Cytomegalovirus infection during the perinatal period can be transferred to the foetus especially if the primary infection is during pregnancy. In babies born with congenital CMV about 10-15% are symptomatic, while 10-15% of those who are asymptomatic will develop symptoms in life. Some of the features of CMV infection include sensorineural hearing loss, visual impairment, cerebral palsy, microcephaly and seizures. Other causes of infective congenital sensorineural hearing loss include: Rubella, HIV, Herpes Simplex Virus, Measles, Varicella Zoster virus, Mumps and West Nile Virus.

TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. The signs and symptoms of trichomoniasis are present in this patient. Trichomonas vaginalis is the reason.
Increased vaginal discharge that is frothy, yellowish, and has an unpleasant odour are among the symptoms. It’s frequently linked to dyspareunia and dysuria. Normally, the genital area is red and painful.

In both men and women, trichomoniasis can cause preterm labour and raise the risk of infertility. Both the patient and the partner must be treated at the same time.

The active infection can be treated with a single oral dose of metronidazole 2 g taken with food.
To avoid disulfiram-like symptoms, alcohol should be avoided during the first 24-48 hours after treatment.

Fetal crown-rump length (CRL) is recommended over last menstrual period for estimating GA when measured in early pregnancy i.e. before 9 to 13+6 weeks.

This lady is most likely suffering from primary syphilis. Since the chancre is asymptomatic, it is often only found on deep examination of the vulvo-vaginal mucosa. The chief organism causing syphilis is Treponema Pallidum which is a spirochete and one of the most widely distributed sexually transmitted infections.

Maximum levels of progesterone are detected at day 21 of 28 days in the menstrual cycle, assuming that ovulation has occurred at day 14. A value of >30nmol/l indicates an ovulatory cycle.

Atosiban is a modified form of oxytocin that is administered by intravenous infusion for 2–48 hours.

Turner syndrome, a condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing. Turner syndrome can cause a variety of medical and developmental problems, including short height, failure of the ovaries to develop and heart defects. Streak ovaries are a form of ovarian dysgenesis and are associated with Turner syndrome. Occasionally they may be functional and secondary sexual characteristics may develop.

Factor V Leiden is the most common congenital thrombophilia. Named after the Dutch city Leiden where it was first discovered. Protein C and S deficiencies are type 1 (Not type 2) thrombophilias Antiphospholipid syndrome is an acquired (NOT congenital) thrombophilia

Combined oral contraceptives are a safe and highly effective method of birth control, but they can also raise problems of clinical tolerability and/or safety in migraine patients. It is now commonly accepted that, in migraine with aura, the use of combined oral contraceptives is always contraindicated, and that their intake must also be suspended by patients suffering from migraine without aura if aura symptoms appear.

Discontinuation of contraception could risk in pregnancy. Barrier methods can be used but aren’t as effective as pills.

Expected date of delivery/estimated due date (EDD) is a calculated date (i.e., an estimation), determined by counting forward 280 days (40 weeks) from the first day of the woman’s last menstrual period.

The most suitable treatment would be to use intracytoplasmic sperm injection (ICSI) in IVF. If hyperprolactinemia was the isolated underlying cause for the infertility, then treatment with a dopamine agonist would be suitable. However, since it is not the sole contributing factor, it is unlikely to be effective in this case. The same reasoning can be applied to the use of danazol to treat any remaining endometriosis.

Unfortunately, there is no treatment (including gonadotrophin injections) that would improve the severely abnormal semen specimen. The most appropriate option would be to use intracytoplasmic sperm injection (ICSI) with IVF. Through this method, any remaining tubal issues would be bypassed. Furthermore, it would be useful in mild endometriosis cases and would also treat the amenorrhea resulting from hyperprolactinemia. There is no justification to perform another laparoscopy to either check or treat endometriosis or any remaining tubal obstruction.

To provide suitable advice to this couple, the candidate must be aware of the following facts:
Because the luteal phase is 14 days long, regardless of the follicular phase length, ovulation happens 14 days before the period.
As a result, ovulation in this lady might have occurred as early as day 12 or as late as day 15 of her cycle.
In the presence of adequate and normal cervical mucus, sperm survival has been demonstrated to be far longer than previously thought, with intercourse occurring up to 6 days before the known period of ovulation, resulting in pregnancy.
Intercourse should be stopped six days before the earliest ovulation in this woman (i.e. on day six).
– It is generally accepted that the ovulated egg can be fertilised for approximately 24-36 hours.
Intercourse should not be restarted for at least two days after the most recent ovulation.
This would be day 17 for this woman.
Between days 6 and 17 of the cycle, abstinence is required.

Screening for gestational diabetes should be offered and performed between 24-28 weeks. It should be noted PCOS alone does not make screening essential. It is advised for PCOS patients who are overweight or if not overweight but has other risk factors (age >40, personal history of gestational diabetes or family history of type II diabetes). Screening is via a 2-hour post 75 g oral glucose tolerance test.

When there are about 12-32 blastomeres, the developing human is referred to as morula. It enters the uterine cavity around the 4th day after fertilization.

Calcium phosphate salts are the most abundant form of calcium in the body, making up 99%. The majority of these salts are stored in the skeleton in different forms, mostly, hydroxyapatite, a lattice-like crystal composed of calcium, phosphates and hydroxide. The remaining calcium can be found in the extracellular fluid, tissues and skeletal muscle.

A type II deceleration is due to placental insufficiency which can result in fetal distress and asphyxia. The fetal heart rate is lowest at the start of the contraction and returns to normal after the contraction is complete.

Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.

Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.

In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.

In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.

An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.

In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.

Normally, there will be a slight raise in prolactin level throughout pregnancy even despite estrogen stimulating and progesterone inhibiting prolactin secretion.

Serum alkaline phosphatase levels will be increased in pregnancy due to placental ALP.

During the first trimester of pregnancy there is a physiological mechanism by hCG causing cross-stimulation of the TSH receptors and as a result of this the concentration of thyroid stimulating hormone (TSH) normally decreases. During second trimester TSH concentration will again return back to its pre-pregnancy levels and then rises slightly by the third trimester. However, most of the changes still occur within the normal non-pregnant range, and the serum free T3 and T4 concentrations remain unchanged throughout pregnancy. But the total concentrations, which include both free and protein-bound fractions, elevates significantly due to an increase in the circulating binding globulins.

Iron binding capacity reflects transferrin, a protein used for iron transportation, which is a globulin found in the beta band on electrophoresis. To counteract the reduction of plasma iron during pregnancy both transferrin and iron binding capacity are elevated during this period.

When compared to the non-pregnant level, cortisol levels are been elevated up to three times than normal.

Gonorrhoea is a sexually transmitted diplococcus bacteria known to infect the female genital tract, which can cause an ascending infection in the uterus and fallopian tubes. About 15 percent of women with this infection may develop pelvic inflammatory disease (PID), which poses risks of long term consequences: ectopic pregnancy, infertility and chronic pelvic pain.

Delayed puberty is defined as the absence of breast development in girls beyond the age of 13, and the absence of testicular development in boys beyond the age of 14. The incidence of delayed puberty is 3%, with the condition being more common in boys.

Passive immunity to the neonate is provided by immunoglobulin G (IgG) since it can be transferred through the placenta from mother to the foetus.
IgA is transferred from mothers to offspring through breast milk.
IgM molecular structure is too big to be filtered through the placental vasculature to the foetus. IgM is the first Ig to be synthesised by the neonate

This patient meets the diagnostic criteria for premenstrual syndrome.
Affective and somatic symptoms over the five days before menses in each of the three previous menstrual cycles are diagnostic criteria for premenstrual syndrome.
Affective symptoms include:
– Depression.
– Anger outbursts.
– Irritability.
– Anxiety.
– Confusion.
– social withdrawal.
Somatic symptoms include:
– breast tenderness
– abdominal bloating
– headache and swelling of extremities.
Symptoms normally disappear within four days of menstruation and are present even when no medical therapy, drugs, or alcohol are used.

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent crying, loss of interest in daily activities, reduced focus, exhaustion, sleeplessness, and a sense of being overwhelmed or out of control.
Symptoms must have been present for the majority of the previous 12 months, interfering with daily activities.

The diagnoses of generalised anxiety disorder and depression alone are doubtful.

Endometrial ablation is primarily intended to treat premenopausal women with heavy menstrual bleeding (HMB) who do not desire future fertility. Women who choose endometrial ablation often have failed or declined medical management.

Absolute contraindications to endometrial ablation include pregnancy, known or suspected endometrial hyperplasia or cancer, desire for future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal. In general, endometrial ablation should be avoided in patients with congenital uterine anomalies, severe myometrial thinning, and uterine cavity lengths that exceed the capacity of the ablative technique (usually greater than 10-12 cm).

The corpus luteum is formed from the granulosa cells of the mature follicle. The structure functions as a transient endocrine organ which secretes mainly progesterone with additional secretion of oestradiol and inhibin, which serve to suppress FSH levels. In the event of no pregnancy, the corpus luteum stops producing progesterone and degenerates into the corpus albicans.

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.

Progesterone down regulates gastric motility meaning drugs are absorbed and metabolised more slowly, thus drugs are absorbed, metabolised and cleared more slowly. Most of the drugs are transported after binding to the albumin.
Lower albumin levels mean a greater unbound drug fraction but as this may be thought to increase drug concentrations it actually leaves more available for hepatic clearance or renal excretion so overall drug concentrations are unchanged and metabolism increased.
Increase in hepatic flow will increase the metabolism of the drug as the drug will be transported faster.
Increased renal blood flow will result in the faster clearance of the drug from the body.

Patient in the given case is nine weeks pregnant, and she has been exposed to a herpes zoster rash because she is working as a hospital nurse and has no prior history of chickenpox.
The most appropriate next step in this case would be checking for Varicella-Zoster IgG antibodies which assures immunity to varicella infections. If VZV IgG is present no further action is needed, but if VZV IgG antibodies are absent, then she will need Varicella Zoster Immunoglobulins within ten days from the exposure to shingles.

Arcuate means ‘bow shaped’ and there are different arcuate lines in anatomical terms. Regarding the pelvic brim this is composed of the arcuate line of the ilium, pectineal line and prominences of sacrum and pubic symphysis (as demonstrated in the images below). As can be seen the arcuate line is a smooth rounded border on the internal surface of the ilium inferior to the iliac fossa and Iliacus. Image sourced from Wikipedia Note: The pelvic outlet is also called the inferior aperture. The pelvic brim is the superior aperture

Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus.