The broad ligament is one of the secondary supporting structures of the uterus which attaches the lateral portion of the uterus to the pelvic sidewall. The broad ligament primarily serves a protective layer for important structures including the fallopian tubes, the ovaries, the ovarian arteries, and the uterine arteries, the round and ovarian ligaments, and the infundibulopelvic ligaments.

The patient is suffering from Bartholin cyst abscess.
Insertion of an inflatable balloon is a non-surgical procedure that can be performed as an outpatient using a local anaesthetic (LA) injection to numb the area. It involves making a passage from the cyst or abscess through which the pus can drain over 4 weeks. After the LA injection, a small skin cut is made into the cyst or abscess, which allows drainage. A fluid/ pus swab sample may be taken to check for an infection at this stage. A cotton bud is used to break the pockets of abscess/ cyst fluid. A flexible tube (called a Word catheter) with a small, specially designed balloon at its tip is then inserted into the cyst or abscess to create a passage. The balloon is inflated with 3–4mls of sterile fluid to keep the catheter in place. Rarely, a stitch may be used to partly close the cut and hold the balloon in position. It is then left in place for up to 4 weeks; new skin to forms around the passage and the wound heals.

Marsupialization can be done for drainage but is inferior or word catheter because of the technical challenges and complications. Hot compressions and analgesics alone do not suffice in the presence of an abscess. Antibiotics are given after drainage but are not effective alone when there is a large collection of pus.

Maternal exposure to dietary factors during pregnancy can influence embryonic development and may modulate the phenotype of offspring through epigenetic programming. Folate is critical for nucleotide synthesis, and preconceptional intake of dietary folic acid (FA) is credited with reduced incidences of neural tube defects in infants.

These are the most common ovarian tumours in young women. The most common form is the mature dermoid cyst (cystic teratoma). It can consist of a combination of all the type of tissues (mesenchymal, stromal and epithelial). Any mature tissue type can be present such as muscle, cartilage, bone, teeth and often hair. Treatment is cystectomy.

Perineal tears are common at the time of child birth. First degree perineal laceration means that the wound is so small that it doesn’t require any stitches and usually heals on its own. 2nd degree means that skin and smooth muscles are both torn. 3rd degree tear means that the tear is beyond the perineal muscles and the muscles surrounding the anal canal, while in 4th degree, the perineal tear goes through the anal sphincter up to the rectum.

Trichomoniasis is a common sexually transmitted infection caused by a parasite. In women, trichomoniasis can cause a foul-smelling vaginal discharge which might be white, grey, yellow or green, genital itching and painful urination.

All of the options provided could cause amenorrhoea and therefore need to be evaluated.

The luteinising hormone (LH) level reported here is exceedingly elevated. A patient with polycystic ovarian syndrome (PCOS) is unlikely to have such a raised level, but it could be because of a LH-producing adenoma. Such tumours are, however, extremely rare.

Early pregnancy (correct answer) is the most likely cause of this woman’s elevated LH level. This would be due to the presence of beta human chorionic gonadotropin (hCG) hormone that is produced during pregnancy.

LH and beta-HCG both have similar beta-subunits and cross-reactions are commonly noted in LH assays.

The serum prolactin (PRL) level is at the upper end of the normal range and this correlates to the levels observed in the early stages of pregnancy.

The follicle-stimulating hormone (FSH) levels remain low during early pregnancy.

If her amenorrhea had been caused by stress from her recent marriage, the LH level would have been normal or low.

If the cause was premature ovarian failure, the FSH level would have been significantly higher.

Analysis of presentation shows the patient has developed hyperemesis gravidarum.
She is in early shock, presented as sinus tachycardia and hypotension, with ketonuria and requires immediate fluid resuscitation and anti-emetics. The first line fluid of choice is administration of normal saline 0.9%, and should avoid giving dextrose containing fluids as they can precipitate encephalopathy and worsens hyponatremia.

The most appropriate management of a pregnant patient in this situation is administration of metoclopramide as the first line and Ondansetron as second line antiemetic, which are Australian category A and B1 drugs respectively. The following also should be considered and monitored for:
1. More refractory vomiting.
2. Failure to improve.
3. Recurrent hospital admissions.

Steroids like prednisolone are third line medications which are used in resistant cases of hyperemesis gravidarum after proper consultation.

The principal screening test for detecting maternal HBV infection is the serologic identification of HBsAg. Screening should be performed in each pregnancy, regardless of previous HBV vaccination or previous negative HBsAg test results.

A test for HBsAg should be ordered at the first prenatal visit. Women with unknown HBsAg status or with new or continuing risk factors for HBV infection (e.g., injection drug use or a sexually transmitted infection) should be screened at the time of admission to a hospital or other delivery setting.

Interventions to prevent perinatal transmission of HBV infection include screening all pregnant women for HBV, vaccinating infants born to HBV-negative mothers within 24 hours of birth, and completing the HBV vaccination series in infants by age 18 months.

Ovarian granulosa cells (GC) are the major source of oestradiol synthesis. Induced by the preovulatory luteinizing hormone (LH) surge, cells of the theca and, in particular, of the granulosa cell layer profoundly change their morphological, physiological, and molecular characteristics and form the progesterone-producing corpus luteum that is responsible for maintaining pregnancy. 

Call for help.
• Ensure personnel are available to ‘scribe’.
Document the time the head delivered, which shoulder is anterior (this is the arm most vulnerable to injury) and the times at which each manoeuvre is employed.
• Drop the level of the delivery bed as low as it will go, and flatten the back of the bed so the woman is completely flat. Remove the foot of the bed to allow access.
• Assess for and perform an episiotomy, if needed.
• Using one assistant on each of the mother’s legs, flex and abduct the legs at the hip (thighs to abdomen, known as McRoberts manoeuvre). This flattens the lumbosacral spine and will facilitate delivery is around 90 per cent of cases.
• If this fails, suprapubic pressure should be
applied by another assistant. This should be
applied over the posterior aspect of the anterior fetal shoulder and will act to push the shoulders together. It can be used in a constant and then rocking motion.
• If both these fail, then internal manoeuvres are necessary. The order of these will depend on the skill and experience of the person conducting the delivery and the individual case. These manoeuvres have been named after famous obstetricians, but it is the process rather than the name that is important:
• An attempt can be made to rotate the baby, so that the shoulders enter the diagonal to allow delivery. The first procedure is usually to insert a hand behind the anterior shoulder, and push it towards the chest (Rubin II). This will adduct the shoulders then push them into the diagonal. This can be combined with pressure on the
anterior aspect of the posterior shoulder
to aid rotation (Woods’ screw). If this fails,
an attempt can be made to rotate the baby
in the opposite direction (reverse Woods’
screw). Delivery of the posterior arm can be
attempted passing a hand into the vagina, in
front of the posterior shoulder and deliver
the posterior arm by swinging it in front of
the fetal chest.
If these all fail, the patient can be moved on to all fours as this increases the anterior–posterior diameter of the inlet. In this position, the posterior arm can be delivered.
After this, manoeuvres of last resort include a symphysiotomy, in which the maternal symphysis is divided, Zavanelli’s, in which the head is reduced back into the vagina and a Caesarean section performed and intentional fracture of the fetal
clavicle.

6 and 11 are considered low risk and are commonly associated with genital warts and low-grade squamous intraepithelial lesions of the cervix (can correspond cytologically to CIN 1)

Chorioamnionitis occurs due to prolong rupture of the fetal membranes. It is most commonly caused by B streptococcus.

With increasing maternal age, the risk of miscarriage increases. For women between the ages of 40-44, the miscarriage rates sit at about 50% and increases to over 75% for women 45 years and over. The miscarriage rate for women between the ages of 35-39 is 25%.

Uterine atony is the most common cause for postpartum haemorrhage and the conditions like multiple pregnancy, polyhydramnions, macrosomia, prolonged labour and multiparity are the most common risk factor for uterine atony.

Whereas less common causes for postpartum haemorrhage are laceration of genital tract, uterine rupture, uterine inversion and coagulopathy.

Patient mentioned in the case has developed severe nausea and vomiting at the initial weeks of pregnancy. If the following clinical features are present, it confirms the diagnosis of hyperemesis gravidarum:
– Weight loss of more than 5% of pre-pregnancy weight
– Moderate to severe dehydration.
– Ketosis
– Electrolyte abnormalities.

Management of hyperemesis gravidarum include:
– Temporary suspension of oral intake, followed by gradual resumption.
– Intravenous fluid resuscitation, beginning with 2 L of Ringer’s lactate infused over 3 hours to maintain a urine output of more than 100 mL/h.
– Use of Antiemetics like metoclopramide, if needed.
– Oral administration of Vitamin B6.
– Replacement of electrolytes if required in the case.

Encouraging oral intake and sending this patient home without any intravenous hydration, is not considered the correct treatment option in this case.

HPV Gardasil® is a quadrivalent vaccine against HPV Types 6, 11, 16, and 18. HPV types16 and 18 are responsible for 70% of cases of HPV related cancers. They are considered the most important high risk genotypes of HPV.

Pelvic organ prolapse is a common condition amongst ageing women where a weakness in the pelvic support structures of the pelvic floor allows pelvic viscera to descend.
The Pelvic Organ Prolapse Quantification system (POP-Q) is useful for describing and staging the severity of the pelvic organ prolapse.
Grade 1: the most distal portion of the prolapse is more than 1 cm above the level of the hymen
Grade 2: the most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane
Grade 3: the most distal portion of the prolapse protrudes more than 1 cm below the hymen but protrudes no farther than 2 cm less than the total vaginal length (for example, not all of the vagina has prolapsed)
Grade 4: vaginal eversion complete

Breakthrough bleeding, breast tenderness, nausea, bloating, amenorrhea, hypertension, venous thromboembolic disease, increased risk of cervical cancer with decreased risk of ovarian & endometrial cancer, liver disorders like hepatic adenoma and increase in triglycerides due to estrogen component are the common side effects & risks of using combination oral contraceptives.

Patient in the given case mentioned symptoms of primary dysmenorrhea, which is recurrent lower abdominal pain associated with menstruation. Combination estrogen-progestin oral contraceptive pills (OCPs) are considered as the first-line treatment for dysmenorrhea in sexually active patients as OCPs help to reduce pain by thinning the endometrial lining, reducing prostaglandin release and by decreasing uterine contractions.
Nausea, bloating and breast tenderness, are considered as the early side effects of OCPs and will usually improve with continued use. The most common side effect is breakthrough bleeding which is usually associated with lower estrogen doses and other adverse effects caused by the pills include hypertension, increased risk of cervical cancer and venous thromboembolism. Although common perception considers weight gain as a side effect, several studies have shown that no significant weight gain is associated with OCPs, particularly with low-dose formulations.  Considering this, the patient should be reassured that her weight gain is not associated with regular use of OCPs.

In patients who are not sexually active, nonsteroidal anti-inflammatory drugs are considered as the first-line treatment for primary dysmenorrhea. As stopping contraception will increase this Patient’s risk of unintended pregnancy this is not advisable to her.

Switching the patient to a copper intrauterine device (IUD) will decrease systemic side effects, but as its inflammatory reaction in the uterus may increase pain symptoms, copper IUD is not recommended for patients with dysmenorrhea.

As Medroxyprogesterone will increase body fat and decrease lean muscle mass resulting in weight gain is not a good option for this patient. Also medroxyprogesterone due to its risk of significant loss of bone mineral density, is not recommended for adolescents or young women. So it can be used in this age group only if other options are unacceptable.

Presence of estrogen component is the main reason behind the side effects of combination OCPs. Progesterone-only pills have relatively fewer side effects but as they do not inhibit ovulation, they are less effective for treating dysmenorrhea and for contraception.

Combination oral contraceptive pills are the first-line therapy for primary dysmenorrhea in sexually active patients.  Its side effects include breakthrough bleeding, hypertension, and increased risk of venous thromboembolism. Researches proves that weight gain is usually not an adverse effect of OCPs.

This patient presents because of significant mood changes since she gave birth to her child: she is sad most of times and she is having guilt feelings about her adequacy for motherhood- She is also complaining of insomnia, tiredness, and even some suicidal ideation. These symptoms are highly suggestive postpartum depression. This should be differentiated from postpartum blues, which usually present within the first 2 weeks and last for few days. This patient’s symptoms started 5 weeks postpartum. Postpartum depression usually presents within the first 6 weeks to the first year postpartum.

Postpartum depression is the most common complication of childbearing and affects the mother, the child, and relationship with the partner. It is diagnosed the same way as major depressive disorder in other patients. Since untreated postpartum depression can have long-term effects on the mother and the child, appropriate therapy should be undertaken as soon as possible- Antidepressant medications such as sertraline can be used to treat postpartum depression. In a patient who has suicidal ideation, electroconvulsive therapy has a more rapid and effective action than medication and should be considered in these patients.

→ Cognitive behavioural therapy is effective in women with mild to moderate postpartum depression; it would not be a good choice in this patient with suicidal ideation and at risk of harming the baby.
→ Estrogen therapy used alone or in combination with antidepressant, has been shown to significantly reduce the symptoms of postpartum depression; however, it would not be the most appropriate choice in a patient with suicidal ideation.
→ Peer support has shown equivocal results in various studies even though most postpartum patients report that lacking an intimate friend or confidant or facing social isolation are factors leading to depression.
→ Non-directive counselling also known as ”listening visits“ has been found to be effective in postpartum patients, though the studies that were conducted are deemed to be of small sample and larger studies still need to be done to validate these findings. It would not be an appropriate choice for this patient with suicidal ideation.

The ovarian arteries, arising from the abdominal aorta and the ascending uterine arteries which are branches of the internal iliac artery all supply the ovaries. They terminate by bifurcating into the ovarian and tubal branches and anastomose with the contralateral branches providing a collateral circulation.

The pelvic floor or diaphragm is composed of Coccygeus and Levator Ani. Levitator Ani is composed of 3 muscles: puborectalis, pubococcygeus and iliococcygeal. Although Piriformis assists in closing the posterior pelvic outlet it is not considered a component of the pelvic floor

In premenopausal women, watchful waiting usually involves monitoring for symptoms (pelvic pain or pressure) and repeating the pelvic ultrasound after six to eight weeks. If the ovarian cyst does not enlarge or if it resolves during the period of watchful waiting, it does not usually require surgical removal. Some premenopausal women will be advised to take a birth control pill during this time to help prevent new ovarian cysts from developing.

If a cyst decreases in size or does not change, the ultrasound is often repeated at regular intervals until your healthcare provider is certain that the cyst is not growing. If the cyst resolves, no further testing or follow-up is required.
Surgery may be recommended in the following situations:
– A cyst is causing persistent pain or pressure, or may rupture or twist.
– A cyst appears on ultrasound to be caused by endometriosis and is removed for fertility reasons.
– Large cysts (>5 to 10 cm) are more likely to require surgical removal compared to smaller cysts. However, a large size does not predict whether a cyst is cancerous.
– If the cyst appears suspicious for cancer. If you have risk factors for ovarian cancer or the cyst looks potentially cancerous on imaging studies, your healthcare provider may recommend surgery.
– If the suspicion for ovarian cancer is low but the cyst does not resolve after several ultrasounds, you may choose to have it removed after a discussion with your healthcare provider. However, surgical removal is not usually necessary in this case.

At the 36‑week appointment, all pregnant women should be seen again. At this appointment: measure blood pressure and test urine for proteinuria; measure and plot symphysis–fundal height; check position of baby; for women whose babies are in the breech presentation, offer external cephalic version (ECV)

Squamous cell carcinoma is the most common type of vaginal cancer.

According to the laboratory reports, patient has developed urinary tract infection and should be treated with one week course of oral antibiotics.
As the patient is pregnant, antibiotics like cephalexin, co-amoxiclav and nitrofurantoin must be considered as these are safe during pregnancy.

Due to this Patient’s allergic history to penicillin, cephalexin can be considered as the best option. Risk of cross allergy would have been higher if the patient had any history of anaphylactic reactions to penicillin.

In Australia, Amoxicillin is not recommended to treat UTI due to resistance.Tetracyclines also should be avoided during pregnancy due to its teratogenic property.

Hyaline degeneration is the most common form of fibroid degeneration. Fibroids:
Risk Factors
– Black Ethnicity
– Obesity
– Early Puberty
– Increasing age (from puberty until menopause)
Protective Factors
– Pregnancy
– Multiparity

When the red cells are coated with immune IgG antibody, the cells do not agglutinate but when anti-IgG antiserum is added to these sensitized cells visible agglutination occurs. This is known as a positive direct coombs test.

Urge incontinence is involuntary pee loss accompanied by a strong desire to urinate. The most common cause of urge incontinence is detrusor or bladder dyssynergia, which is characterized by an involuntary contraction of the bladder during urine distension.

Bladder training, eliminating excess coffee and fluid intake, biofeedback, and pharmacological therapy are all options for treating urge incontinence. Treatment with anticholinergic medicines (oxybutynin chloride), -sympathomimetic agonists (metaproterenol sulphate), Valium, antidepressants (imipramine hydrochloride), and dopamine agonists (Parlodel) has proven successful if conservative approaches fail.

The detrusor muscle will be relaxed by these pharmacologic drugs. Oestrogen therapy may improve urine control in postmenopausal women who are not on oestrogen replacement therapy. Kegel exercises can help women with stress urinary incontinence strengthen their pelvic musculature and improve bladder control.

Incidental thrombocytopenia of pregnancy is the most common cause of thrombocytopenia in an otherwise uncomplicated pregnancy. The platelet count finding in this case is of little concern unless it falls below 50×109/L.

Immune thrombocytopenia is a less common cause of thrombocytopenia in pregnancy. The anti-platelet antibodies cam cross the placenta and pose a problem both to the mother and the foetus. Profound thrombocytopenia in the baby is a common finding of this condition.

Thrombocytopenia can occur in patients with severe pre-eclampsia. However, it is usually seen concurrent with other signs of severe disease.

Maternal antibodies that target the baby’s platelets can rarely cause thrombocytopenia in the mother. Instead, it can lead to severe coagulation and bleeding complications in the baby as a result of profound thrombocytopenia.

Systemic lupus erythematosus is unlikely to explain the thrombocytopenia in this patient.