This patient has developed symptoms of ovulation discomfort, which is also known as Mittelschmerz syndrome. Lower abdominal and pelvic pain that arises around the middle of a woman’s menstrual cycle characterises this condition.
The discomfort usually appears suddenly and disappears within hours, though it can continue up to three days.

The symptoms of ovulation pain can include:
– Lower abdomen pain.
– The pain typically occurs about two weeks before the menstrual period is due.
– The pain is felt on the right or left side, depending on which ovary is releasing an egg.
– The pain may switch from one side to the other from one cycle to the next, or remain on one side for a few cycles.
The duration of pain ranges anywhere from minutes to 48 hours.

WHO guidelines
Semen volume: Greater than or equal to 1.5 ml
pH: Greater than or equal to 7.2
Sperm concentration: Greater than or equal to 15 million spermatozoa per ml
Total sperm number: 39 million spermatozoa per ejaculate or more
Total motility (% of progressive motility and nonprogressive motility): 40% or more motile or 32% or more with progressive motility
Vitality: 58% or more live spermatozoa
Sperm morphology (percentage of normal forms): 4% or more

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

The normal fetal heart rate ranges from 120-160 beats per minute in the uterine period.

Neural tube defects (NTDs) are common complex congenital malformations resulting from failure of the neural tube closure during embryogenesis. It is established that folic acid supplementation decreases the prevalence of NTDs, which has led to national public health policies regarding folic acid.

Neural tube defects (NTD) were 43% more common in Indigenous than in non-Indigenous infants in Western Australia in the 1980s, and there has been a fall in NTD overall in Western Australia since promotion of folate and voluntary fortification of food has occurred.

Women should take 5 mg/d of folic acid for the 2 months before conception and during the first trimester.

Women planning pregnancy might be exposed to medications with known antifolate activities affecting different parts of the folic acid metabolic cascade. A relatively large number of epidemiologic studies have shown an increased risk of NTDs among babies exposed in early gestation to antiepileptic drugs (carbamazepine, valproate, barbiturates), sulphonamides, or methotrexate. Hence, whenever women use these medications, or have used them near conception, they should take 5 mg/d of folic acid until the end of the first trimester of pregnancy.

The normal range for a term baby is pH: 7.18 – 7.38, and preterm pH: 7.14 – 7.4. A pH below 7.1 therefore indicates acidosis.

Pre-eclampsia is defined as hypertension of at least 140/90 mmHg recorded on at least two separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24 hour collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the sixth postpartum week. Significant proteinuria = urinary protein: creatinine ratio >30 mg/mmol or 24-hour urine collection result shows greater than 300 mg protein.

Toxoplasma gondii, an intracellular protozoan, is the main causative agent for Toxoplasmosis. Though the primary host for the organism is the domestic cat, humans can become infected by eating undercooked meat of animals harbouring cysts, consuming water or food contaminated with cat faeces, or through maternal-fetal transmission. Toxoplasmosis can cause complications in pregnancy such as miscarriages and congenital infection which can lead to hydrocephalus, microcephaly, mental disability and vision loss.

Oestrogen can be produced by variety of organs including the corpus leuteum, placenta, adrenal glands and testes. However it is not produced by the anterior pituitary. The anterior pituitary produces LH and FSH which in turn causes oestrogen secretion.

Different changes can occur during the menstrual cycle including an increased body temperature at the time of ovulation, thinning of the cervical mucus and few other changes, but it is the LH surge which is the most important factor necessary for ovulation.
Mittelschmerz is characterised by recurrent midcycle pain which occurs around the time of ovulation.

Wound healing is initiated when inflammation begins. Macrophages predominate after neutrophils and peak 3-4 days after inflammation begins. They destroy and phagocytose the organism and debris using enzymes. The next step is the resolution of inflammation and healing of the wound.

About 1 in 4 pregnant women carry GBS bacteria in their body. Doctors should test pregnant woman for GBS bacteria when they are 36 through 37 weeks pregnant.

Giving pregnant women antibiotics through the vein (IV) during labour can prevent most early-onset GBS disease in newborns. A pregnant woman who tests positive for GBS bacteria and gets antibiotics during labour has only a 1 in 4,000 chance of delivering a baby who will develop GBS disease. If she does not receive antibiotics during labour, her chance of delivering a baby who will develop GBS disease is 1 in 200.

Pregnant women cannot take antibiotics to prevent early-onset GBS disease in newborns before labour. The bacteria can grow back quickly. The antibiotics only help during labour.

Oestrogen-containing contraceptives are not recommended for this woman since she has a history of DVT. This is most likely why she was started on POP instead of standard combination tablets prior. Progesterone is also contraindicated with a history of ectopic pregnancy and should never be used again. Barrier approaches, for example, could be applied in this woman’s case.
The following are absolute contraindications to taking just progesterone pills:
– Pregnancy
– Breast cancer
– Vaginal bleeding that hasn’t been diagnosed
– Ectopic pregnancy history or a high risk of ectopic pregnancy

Progesterone-only pills have the following relative contraindications:
– Active viral hepatitis
– Severe chronic liver disease
– Malabsorption syndrome
– Severe arterial disease
– Successfully treated breast cancer more than 5 years ago
– Concomitant use of hepatic enzyme inducing medications.

Threatened abortion:
– Vaginal bleeding with closed cervical os during the first 20 weeks of pregnancy
– Occurs in 25% of 1st-trimester pregnancies
– 50% survival
More than half of threatened abortions will abort. The risk of spontaneous abortion, in a patient with a threatened abortion, is less if fetal cardiac activity is present.

Placental abruption is defined as the premature separation of placenta from uterus and the condition usually presents with bleeding, uterine contractions and fetal distress. It is one of the most significant cause of third-trimester bleeding and is often associated with fetal and maternal mortality and morbidity. In all pregnant women with vaginal bleeding in the second half of the pregnancy, this condition should be considered as a differential diagnoses.
Though vaginal bleeding is the most common presenting symptom reported by almost 80% of women with placental abruption, vaginal bleeding is concealed in 20% of women with placental abruption, therefore, absence of vaginal bleeding does not exclude placental abruption.

Symptoms and complications of placental abruption varies according to patient, frequency of appearance of some common features is as follows:
‌- Vaginal bleeding is the common presentation in 80% of patients.
‌- Abdominal or lower back pain with uterine tenderness is found in 70%
‌- Fetal distress is seen in 60% of women.
‌- Abnormal uterine contractions like hypertonic, high frequency contractions are seen in 35% cases.
‌- Idiopathic premature labor in 25% of patients.
‌- Fetal death in about 15% of cases.

Examination findings include vaginal bleeding, uterine contractions with or without tenderness, shock, absence of fetal heart sounds and increased fundal height due to an expanding hematoma. Shock is seen in class 3 placental abruption which represents almost 24% of all cases of placental abruption.

There are no interactions between the combined oral contraceptive pill, progesterone-only pill, medroxyprogesterone injections or levonorgestrel implants and the AEDs valproic acid (sodium valproate), vigabatrin, lamotrigine, gabapentin, tiagabine, levetiracetam, zonisamide, ethosuximide and the benzodiazepines. So she can use COCP along with Sodium valproate.

Vaginal atrophy (thinning of vaginal tissue): Oestrogen helps to keep this tissue healthy. After menopause, low oestrogen levels can cause your vaginal walls to become thin, dry, and inflamed. That often leads to bleeding after sex.

Vaginal atrophy is the most common cause of post menopausal vaginal bleeding.

With a normal pap smear a year ago, this patient is unlikely to develop cervical cancer.

Cervical ectropions are not common in post-menopausal women.

Endometrial cancer and cervical polyps are possible causes of postcoital bleeding, however, they are not as common as vaginal atrophy.

The first sign of puberty in females is the development of breasts.

Fetal urine contributes significantly to amniotic fluid production in the second trimester of pregnancy. As early as 8-11 weeks, urine production begins and can be observed in the fetal bladder on ultrasound scans. The urine creates a hypotonic fluid which contains increasing concentrations of urea and creatinine. By term, a foetus produces about 800 ml of urine a day, of which 250ml is eliminated through fetal swallowing.

Incontinence in women is typically related to dysfunction of the bladder or pelvic floor muscles, with such dysfunction often arising during pregnancy or childbirth, or at the time of menopause.

A pregnant woman may experience an increase in the size of the kidneys and ureter due to the increased blood volume and vasculature.
Later in pregnancy, the woman might develop physiological hydronephrosis and hydroureteronephrosis, which are normal.
There is an increase in glomerular filtration rate associated with an increase in creatinine clearance, protein, albumin excretion, and urinary glucose excretion.
There is also an increase in sodium retention from the renal tube so oedema and water retention is a common sign in pregnant women

Lamotrigine, a drug used to treat epilepsy, is less effective when taken with combined oral contraceptives. The oestrogen component of the pill decreases the circulating levels of Lamotrigine, increasing the risk of seizures. The combination is therefore classified as a UKMEC 3, as the risk of the drug combination may outweigh the benefit. As an alternative, the progesterone-only pill, depo progesterone, Mirena or the copper IUD may be considered as there is no restriction on concomitant use. Lamotrigine is not metabolised through cytochrome P450 like other antiepileptic drugs such as carbamazepine and phenytoin, neither is it an enzyme inhibitor.

According to the WHO, active management of the third stage of labour has been shown to decrease the risk of postpartum haemorrhage in vaginal births worldwide. Per the guidelines from the International Federation of Gynaecologists and Obstetricians (FIGO), the active management of the third stage is summarised as follows:
1. The administration of a uterotonic (oxytocin, ergometrine or misoprostol), within one minute of fetal delivery,
2.Controlled cord traction with manual support to the uterus until placental delivery
3. Fundal massage immediately after placental delivery.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Weighted cones or topical steroids can be used as adjuvants but are not sufficient when used alone.

Tension free vaginal tape and Burch’s colposuspension are considered for patients who fail to respond to conservative management strategies.

(13-20 weeks). If a mother has chickenpox in late pregnancy (5 days prior to delivery) then there is risk of neonatal varicella infection which may be severe.

The pelvic outlet is bounded anteriorly by the inferior border of the pubic arch, posteriorly by the sacrotuberous ligament and the tip of the coccyx and laterally by the ischial tuberosities.

AFI involves measuring the depth of amniotic fluid pockets in all 4 quadrants.
Oligohydramnios AFI< 5cm or deepest amniotic fluid pocket < 2cm
Polyhydramnios AFI > 25cm or deepest amniotic fluid pocket > 8cm

Lymphatic vessels from the vagina drain from the parts of the vagina as follows:
• Superior part: to the internal and external iliac lymph nodes.
• Middle part: to the internal iliac lymph nodes.
• Inferior part: to the sacral and common iliac nodes.

Venous thromboembolism (VTE) during pregnancy and the postpartum window occurs at a 6-10-fold higher rate compared with age-matched peers and is a major cause of morbidity and mortality. Hypercoagulability persists for 6-8 weeks after delivery with the highest risk of PE being during the postpartum period. The lack of randomized trials in pregnant women leads to variability in practice, which are largely based on expert consensus or extrapolation from non-pregnant cohorts. The standard treatment of VTE in pregnancy is anticoagulation with low molecular weight heparin (LMWH), which like unfractionated heparin does not cross the placenta and is not teratogenic.

The half-life of Oxytocin is approximately 5 minutes
The half-life of Misoprostol is approximately 20-40 minutes
The half-life of Ergometrine is approximately 30-120 minutes

This woman suffers from a classic migraine with focused neurological symptoms. The use of any OCP preparation containing oestrogen in such patients is strictly prohibited. Androgenic consequences of progesterone include hirsutism, acne, and weight gain. Progesterone of any sort (norgestrel, drospirenone, cyproterone, etc.) should be avoided by a lady of her size; consequently, a barrier approach such as male condoms is the best option.

It is recommended that formulations containing 20-30 mcg ethinylestradiol be evaluated first when choosing a combined oral contraceptive pill (COCP). The progesterone component can be norgestrel, drospirenone, cyproterone, and so on; however, norgestrel-containing formulations are less expensive and more accessible to patients.

For specific cases, the type of progesterone should be considered:
– Patients who have unpleasant fluid retention and weight gain as a side effect of COCPs may be administered drospirenone (Yaz®. Yasmin®)-containing preparations.
– Drospirenone inhibits the production of mineralocorticoids and does not cause fluid retention. It may even be linked to a small amount of weight reduction.
– A preparation containing cyproterone acetate is preferable if the patient has suspected polycystic ovarian syndrome (PCOS).

Dehydroepiandrosterone (DHEA) is a steroid hormone synthesised from cholesterol (via Pregnenolone) by the adrenal glands. The foetus manufactures DHEA, which stimulates the placenta to form oestrogen, thus keeping a pregnancy going. Production of DHEA stops at birth, then begins again around age seven and peaks when a person is in their mid-20s

Upon penetration, if all is normally occurring, the process of egg-activation occurs, and the oocyte is said to have become activated. This is thought to be induced by a specific protein phospholipase c zeta. It undergoes its secondary meiotic division, and the two haploid nuclei (paternal and maternal) fuse to form a zygote.

Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus. It causes the formation of multiple ossification centres in the long bones. Resulting in stippled epiphyses and hence deform long bones.

This is Linea Nigra. It occurs in 3/4 of pregnancies and is due to increased melanocyte-stimulating hormone production by the placenta. This also causes melasma and darkening of the nipples.

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

Macrophages are the antigen presenting cells, they phagocytose the pathogen and after breaking them down present their protein structure to the B and T cells for a specific immune reaction to take place.

Hormones that are secreted into the circulation at one site but have effects on distal target organs are endocrine as is the case with the hormones above. Autocrine and Intracrine messengers act within the same cell. Exocrine glands secrete their products into ducts. Apocrine is a histological term used to describe some types of exocrine gland.

Clomiphene citrate is widely used in the induction of ovulation, especially in the treatment of anovulatory infertility and in conditions such as PCOS. The drug functions as a selective oestrogen receptor modulator, which acts in the hypothalamus to indicate low serum oestrogen levels. Reduced levels of negative feedback stimulate the secretion of GnRH from the hypothalamus, which in turn stimulate the production of gonadotropins (FSH and LH) from the anterior pituitary. These work to increase ovarian follicular activity.

The rectus sheath is formed by the aponeurosis of the internal and external oblique muscles and the transversus abdominus muscle. The internal oblique divides into two lamellae and encloses the rectus muscle. Anteriorly it fuses with the aponeurosis of the external oblique and posteriorly with that of the transverus abdominus. Below the arcuate line the aponeurosis of all the flat muscles lies anteriorly and posteriorly it is only enclosed by the transveralis fascia.

A fibroid is a benign tumour of the smooth muscles of the uterus also known as a leiomyoma. It has a typical whorled appearance and this may be altered following degeneration which occurs in four main types:
1. Red degeneration, also known as carneous degeneration, of degeneration that can involve a uterine leiomyoma. While it is an uncommon type of degeneration, it is thought to be the most common form of degeneration of a leiomyoma during pregnancy. Red degeneration follows an acute disruption of the blood supply to the fibroid during growth typically in a mid-second trimester presenting as sudden onset of pain with tenderness localizing to the area of the uterus along with pyrexia and leucocytosis. On ultrasound it can have peripheral (rim).

2. Hyaline degeneration is the most common form of degeneration that can occur in a uterine leiomyoma. It is thought to occur in up to 60% of uterine leiomyomasoccurs when the fibroid outgrows its blood supply. this may progresses to central necrosis leaving a cystic space in the centre knowns as cystic degeneration.

3. Cystic degeneration is an uncommon type of degeneration that a uterine leiomyoma (fibroid) can undergo. This type of degeneration is thought to represent ,4% of all types of uterine leiomyoma degeneration. When the leiomyoma increases in size, the vascular supply to it becomes inadequate and leads to different types of degeneration: hyaline, cystic, myxoid, or red degeneration. Dystrophic calcification may also occur. Hyalinization is the commonest type of degeneration. Cystic degeneration is an extreme sequel of edema. Ultrasound may show a hypoechoic or heterogeneous uterine mass with cystic areas.

4. Myxoid degeneration of leiomyoma is one of the rarer types of degeneration that can occur in a uterine leiomyoma. While this type of degeneration is generally considered rare, the highest prevalence for this type of degeneration has been reported as up to 50% of all degenerations of leiomyomas. Fibroids (i.e. uterine leiomyomas) that have undergone myxoid degeneration are filled with a gelatinous material and can be difficult to differentiate from cystic degeneration; however, they typically appear as more complex cystic masses. They appear hypocellular with a myxoid matrix.

Beta Thalassaemia is autosomal recessive.

Contracted pelvis occurs when one or more of its diameters is reduced so that it interferes with the normal mechanism of labour. A transverse diameter below 11 cm will result in difficult delivery of the foetus and C-section will be the better option in that case

The diagnosis of listeria depends on clinical suspicion and isolation of the organism from blood, vaginal swabs or the placenta. Meconium staining of the amniotic fluid in a preterm foetus may increase clinical suspicion for listeriosis. For women with listeriosis during pregnancy, intravenous antibiotic treatment (ampicillin 2 g given every 6 hours) is indicated.

During the early fetal life, oogonia proliferate by mitosis. They enlarge to form primary oocyte before birth. No primary oocyte is form after birth. The primary oocyte is dormant is the ovarian follicles until puberty. As the follicle matures, the primary oocyte completes its first meiotic division and gives rise to secondary oocyte. During ovulation the secondary oocytes starts the second meiotic division but is only completed if a sperm penetrates it. This 1st and 2nd meiotic division is known as ootidogenesis.

Clomiphene shouldn’t be continued for more than 6 months. The second line options are Gonadotrophins or ovarian drilling.

Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications.

When symptoms are present, they may include abdominal pain, mass or swelling, and abnormal uterine bleeding. Bladder symptoms, gastrointestinal disturbances, and back pain are less frequent. When abdominal pain is present, it usually is constant and ranges from slight to moderate in intensity.

Mucinous cystadenomas are relatively common (12% to 15% of all ovarian tumours). They can become massive. These tumours usually develop in the third to fifth decades of life and typically cause vague symptoms, such as increasing abdominal girth, abdominal or pelvic pain, emesis, fatigue, indigestion, constipation, and urinary incontinence.

Corpus luteal cysts present with irregular menses, abdominal fullness due to fluid build up and pelvic pressure.

Endometriosis mainly presents with cyclic pain at site of involvement and dysmenorrhea.

Both the female hormones, namely progesterone and oestrogen as well as the male hormones or androgens are lipid soluble. The common precursor of these is cholesterol.

Shoulder dystocia occurs when the anterior or posterior fetal shoulder impacts on the maternal symphysis or sacrum and may require additional manevours to release the shoulders after gentle downward traction has failed. The most common injury that can occur, is to the brachial plexus due to lateral flexion of the head during traction. This may cause a neurological disability, Erb’s Palsy ( injury to C5 and C6 of the brachial plexus) in which there is a less than 10% chance that this injury would be permanent.

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 life time risk of breast cancer in BRCA 2 gene is 45% and of ovarian cancer is 15%.

Bicarbonate is the main buffer in blood.

Ectopic pregnancy is a known complication of pregnancy that can carry a high rate of morbidity and mortality when not recognized and treated promptly. It is essential that providers maintain a high index of suspicion for an ectopic in their pregnant patients as they may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting. Ectopic pregnancy, in essence, is the implantation of an embryo outside of the uterine cavity most commonly in the fallopian tube.

Providers should identify any known risk factors for ectopic pregnancy in their patient’s history, such as if a patient has had a prior confirmed ectopic pregnancy, known fallopian tube damage (history of pelvic inflammatory disease, tubal surgery, known obstruction), or achieved pregnancy through infertility treatment.

Performance of laparoscopic surgery is safe and effective treatment modalities in hemodynamically stable women with a non-ruptured ectopic pregnancy.

Patients with relatively low hCG levels would benefit from the single-dose methotrexate protocol. Patients with higher hCG levels may necessitate two-dose regimens. There is literature suggestive that methotrexate treatment does not have adverse effects on ovarian reserve or fertility. hCG levels should be trended until a non-pregnancy level exists post-methotrexate administration.

Surgical management is necessary when the patients demonstrate any of the following: an indication of intraperitoneal bleeding, symptoms suggestive of ongoing ruptured ectopic mass, or hemodynamically instability. Women who present early in pregnancy and have testing suggestive of an ectopic pregnancy would jeopardize the viability of an intrauterine pregnancy if given Methotrexate. The patient may have a cervical ectopic pregnancy and would thus run the risk of haemorrhage and potential hemodynamic instability if a dilation and curettage are performed.

Hegar’s sign: softening of womb (uterus) due to its increased blood supply, perceptible on gentle finger pressure on the neck (cervix). This is one of the confirmatory signs of pregnancy and is usually obvious by the 16th week.

According to the RCOG greentop guidelines, a women who have underdone chemotherapy for GTD are advised not to conceive for 1 years after completion of the chemotherapy.

Luteal phase defect is an ovulatory disorder of considerable clinical importance that is implicated in infertility and recurrent spontaneous abortion. 

A local exam might not help in locating the cause of the bleeding because it might be underneath the superficial structures. A thorough examination should be done under GA to accurately locate the source of bleeding.

Flumazenil is used for benzodiazepine overdose.
Naloxone is used for opioid overdose.
Parvolex (N-acetyl cysteine) is used for paracetamol overdose.
Protamine can be used for Heparin reversal.
Beriplex can be used for Warfarin reversal.

Consideration of the risk of scar rupture is probably the most important consideration when determining whether delivery should be by elective Caesarean section or by trial of vaginal delivery.
Most published studies do not differentiate between scar dehiscence and rupture, however, analysis of observational and comparative studies indicates that the excess risk of uterine rupture following trial of labour compared with women undergoing repeat elective Caesarean section is considerably lower than 1 per cent (25/10000); indeed, some studies do not demonstrate any increased risk.

Listeria Monocytogenes is a cause of congenital infection. The most common source of the bacteria is food, especially unpasteurised milk. Congenital listeriosis can lead to spontaneous abortions, premature birth and chorioamnionitis. At birth, neonates may present with septicaemia, respiratory distress and inflammatory granulomatosis. The case mortality rate for listeriosis is thought to be between 20-30%.

Sigmoid colon is part of the hindgut and the hindgut is innervated by the T12-L1 segment of the spinal nerves.

Primary hyperparathyroidism is the most common cause of hypercalcaemia with incidence rates in the UK approximately 30 per 100,000 The majority of patients are postmenopausal women.

Toxoplasma gondii, an intracellular protozoan, is the main causative agent for Toxoplasmosis. The primary host for the organism is the domestic cat. Humans can become infected by eating undercooked meat of animals harbouring cysts, consuming water or food contaminated with cat faeces, or through maternal-fetal transmission. Toxoplasmosis can cause complications in pregnancy such as miscarriages and congenital infection can lead to hydrocephalus, microcephaly, mental disability and vision loss.

The risk of transplacental transmission from mother to foetus is greater in later pregnancy i.e. 26-40 weeks. Although the risk of transmission is lower in early pregnancy, if infection does occur earlier, particularly before 10 weeks, then complications are typically more severe.

Abnormal uterine bleeding is a relatively common disorder which may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions. However, the patient who is younger than 30 years of age will rarely be found to have a structural uterine defect. Once pregnancy, hematologic disease, and renal impairment are excluded, administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs.

Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problem or for older women. Oestrogen would only increase the problem, which is usually due to anovulation with prolonged oestrogen secretion, producing a hypertrophic endometrium.

The number of stillbirths and deaths in the first week of life per 1000 births.
According to WHO the perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth.

When it comes to questions on venous drainage the ovarian vein is likely to be a common question given its varied drainage depending on laterality. The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.

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

Adenomyosis is a disorder characterised by the presence of endometrial glands deep within the myometrium. It presents with increasing severe secondary dysmenorrhoea and increased in the flow of menstrual blood.

Diastolic murmurs should be considered pathological until proven otherwise. The following are common and typically benign findings in pregnancy: A third heart sound after mid-pregnancy. Systolic flow murmurs are common. Left axis deviation on ECG is common, Sagging ST segments and inversion or flattening of the T wave in lead III may also occur

Firstline medical management of PCOS is with clomiphene.

Ovulation Disorders

WHO Group I : Hypothalamic pituitary failure (Stress, anorexia, exercise induced)
Management:
Increase BMI if <19 kg/m2
Reduce exercise if high levels
Pulsatile GnRH or Gonadotrophins with LH activity to induce ovulation

WHO Group II : Hypothalamic-pituitary-ovarian dysfunction (PCOS)
Management:
Weight reduction if BMI >30
Clomiphene/Clomiphene (1st line)
Metformin (1st line)
Clomiphene & Metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)

WHO Group III : Ovarian failure
Management:
Consider IVF with donor eggs

Occipitomental diameter is the greatest diameter of the fetal scalp and runs from chin to the prominent portion on the occiput. It measure about 12.5cm in diameter.

Puerperal sepsis is defined as sepsis occurring after birth until 6 weeks postnatal. The most common cause of puerperal sepsis is Group A streptococcus. Until 1937, puerperal sepsis was the major cause of maternal mortality. The discovery of sulphonamides in 1935 and the simultaneous reduction in the virulence of the haemolytic streptococcus resulted in a dramatic fall in maternal mortality.

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).

Significant proteinuria = urinary protein:creatinine ratio >30 mg/mmol or 24-hour urine collection result shows greater than 300 mg protein

The pudendal nerve provides sensory and motor innervation to regions of the anus, the perineum, the labia and the clitoris in women. The nerve is formed from the ventral rami of the S2-S4 sacral spinal nerves. The nerve is paired, each innervating the left and the right side of the body. The nerve gives the following branches in females: the inferior anal nerve, the perineal nerve and the dorsal nerve of the clitoris.

Labour induction is indicated as no fetal movements have been felt for 24 hours, with a normal cardiotocograph (CTG) and the pregnancy is at near/full term with a favourable cervix.

Amniotic fluid volume assessment would have been indicated 24 hours earlier as, if it was low, induction would have been indicated then, despite a normal CTG.

Ultrasound examination of the foetus is not indicated as it is necessary to expedite delivery.

Carrying out another CTG, with or without oxytocin challenge, is not indicated, although MG monitoring during induced labour would be mandatory.

Delivery immediately by Caesarean section is not indicated unless the lack of fetal movements is due to fetal hypoxia. This can result in fetal distress during labour, necessitating an emergency Caesarean section if the cervix is not fully dilated.

The biochemical and mechanical effects of progesterone and the enlarging uterus are responsible for some changes in lung function during pregnancy.

Progesterone increases the sensitivity of the respiratory centre to arterial carbon dioxide while also causing hyperaemia in the airway leading to nasal obstruction. As a result, minute ventilation and tidal volume increase by 50% to allow greater arterial oxygen saturation.

The enlarging uterus displaces the diaphragm upwards, and also limits the movement of the thoracic cage, thereby decreasing the functional residual capacity (FRC) and the expiratory reserve volume (ERV) by 20%.

Functional Expiratory Volume in 1 second (FEV1) and Forced Vital Capacity (FVC) remain unchanged in pregnancy.

Opiates and spinal anaesthetics reduce the variability of a CTG. Including some antihypertensives like labetalol and alpha methyl dopa.

Organisms frequently associated with obstetric sepsis include: beta haemolytic streptococci, Gram-negative rods such as Escherichia coli, Streptococcus pneumoniae and influenza A and B.

E. coli is the most common sepsis pathogen in pregnancy.

History of amenorrhoea, abdominal and vaginal examination are more favour of ectopic pregnancy. Endometriosis usually has a chronic cause and dysmenorrhoea. Salpingitis usually presents with fever. Ovarian torsion and ovarian tumours have different clinical presentations.

This lady should be admitted to hospital for early surgical exploration. Taking into account her age, mild abdominal discomfort and a palpable lower abdominal mass, it is imperative that ovarian malignancy be ruled out as soon as possible. Patients with ovarian malignancy often present in advanced stages of cancer as the symptoms tend to be occult and non-specific. Other things to include in her workup would be her CA125 level. Any form of hormonal therapy is contraindicated until ovarian malignancy has been ruled out. A pap smear is not relevant here since we are suspecting an ovarian malignancy rather than cervical. Evaluation of her mass takes priority over an assessment for osteoporosis.

It is important to be aware of the difference between management of simple hypertension and pre-eclampsia in pregnancy. A BP of 140/90 to 149/99 mmHg is classed as mild hypertension. Without proteinuria this can be monitored once weekly and the patient can be discharged. If proteinuria is present with any degree of hypertension the patient requires admission and BP should be monitored at least 4 times daily according to NICE guidance.

90% of genital candida infections are the result of Candida albicans. 20% of women of childbearing age are asymptotic colonisers of Candida species as part of their normal vaginal flora. This increases to 40% in pregnancy

Early decelerations: a result of increased vagal tone due to compression of the fetal head during contractions. Monitoring usually shows a symmetrical, gradual decrease and return to baseline of FHR, which is associated with a uterine contraction.

TORCH infections are responsible for perinatal complications. CMV is the most common amongst them. Primary infection often produces no symptoms or mild non-specific flu-like symptoms in the mother. The diagnosis is often made after abnormalities are seen in the foetus on ultrasound scan. The main features seen in an affected foetus are FGR, microcephaly, ventriculomegaly, ascites or hydrops. Some foetuses which are infected may not show any features on ultrasound, but may later be found to have neurological damage such as blindness, deafness or developmental delay. The neonate can also be anaemic and thrombocytopenic, with hepatosplenomegaly, jaundice and a purpureal rash.

Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most HPV types cause no symptoms and go away on their own, but some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts.

HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years. CDC recommends 11 to 12 year olds get two doses of HPV vaccine to protect against cancers caused by HPV.

The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed.

Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should wait until after her pregnancy to finish any remaining HPV vaccine doses.

Up to 20% of women have been found to have Group B streptococcus (GBS). GBS is considered a normal flora of the gastrointestinal tract. GBS infection is generally asymptomatic although some women might end up having a UTI. Infants born to mothers who are colonised with GBS during labour are at a higher risk of developing early-onset GBS infection. If a pregnant woman develops a UTI due to GBS, it is suggestive of significant GBS colonisation. IV penicillin would be the drug of choice and is to be administered to the mother during labour which would provide sufficient protection for the foetus and would be effective enough. If penicillin is unavailable, ampicillin is a reasonable alternative. If a patient has penicillin allergy, vancomycin can be used. If not for penicillin, roughly 50% of babies delivered vaginally to women who are GBS positive would be colonised with the organism and out of this percentage, 1-2% can go on to develop a severe infection such as septicaemia and meningitis which could often be fatal.

IM penicillin can be administered to the newborn immediately post-delivery would be an effective prophylaxis in most cases but one should not wait until signs of infection are present to give the injection. Many newborns would still have an immature immune system which could cause some to die. Hence, it is more suitable to treat all women who tested positive during labour and the newborn as well if any signs of infection do appear. The majority of babies don’t need antibiotic treatment if their mother has been treated.

1st Arch = Trigeminal V2 & V3 (CN V) 2nd Arch = Facial (CN VII) 3rd Arch = Glossopharyngeal (CN IX) 4th and 6th Arches = Vagus (CN X)

Cilia are small hair line projections in the fallopian tube. Their main function is to transport the egg through he fallopian tube towards the uterus. It is present in many other tubular organs and its function varies accordingly to the organ.

The pudendal nerve is formed by sacral nerve roots S2, S3 and S4 almost immediately as they exit the spinal foramina. The pudendal nerve exits the pelvis via the greater sciatic foramen, travels behind the sacrospinous ligament before re-entering the pelvis via the lesser sciatic foramen. It is an important nerve to be aware of as it supplies sensation to the genitalia and can also be damaged/compressed at a number of places along its course. Image sourced from Wikipedia

HPV types 6 and 11 are associated with low risk, low grade squamous intraepithelial lesion. While types 16,18,31 and 33 are associated with high risk, high grade neoplasia.

It blocks the voltage gated sodium channels and reduce the influx of sodium ions preventing depolarization of the membrane and blocking the conduction of the action potential. The affinity of the receptor site in the sodium channels depends on whether it is resting, open or inactive.

There are between 250 and 400 lobules in each testis. The lobule is a structural unit of the testis with each lobule contained in one of the intervals between fibrous septa which extend between the mediastinum testis and the tunica albuginea. Each lobule contains 1 to 3 seminiferous tubules.

Dysplasia has 4 microscopic characteristics:
Anisocytosis (unequal cell size)
Poikilocytosis (abnormal cell shape)
Hyperchromatism (pigmentation)
Mitotic figures (increased cells currently dividing)

Hyperplasia and hypertrophy is characterised by increase in cell number and increase in cell size respectively, whereas atrophy means decrease in cell size.
Metaplasia is characterised by change of one form of cell to another type e.g. changes of columnar epithelium to squamous epithelium.

Breast carcinoma is one of the most common malignancies in women. It presents as an irregular, firm consistency nodule/lump, which is attached to the skin most of the time. The overlying skin also exhibits a peau d’ orange appearance, along with dimpling. A sebaceous cyst is a small cystic swelling with no colour change and can occur anywhere over the skin. A lipoma is a benign tumour of fats which is soft in consistency.

There is evidence that folic acid, iodine and vitamin D are important for reproductive outcomes. Folic acid and iodine supplementation is recommended for women planning to conceive and in pregnancy.

The recommended dose of folic acid for women without special considerations planning to conceive is 400-500 mcg. The recommended dose of folic acid for women with special considerations is 2-5 mg per day.

Women planning a pregnancy, including those with thyroid disease, should take iodine supplements in the dose of 150 mcg per day prior to and during pregnancy.

The placenta is important for regulating feto-maternal blood circulation, ensuring that the two circulatory systems do not come into direct contact. The placenta receives 70-80% of the uterine blood flow into the decidual spiral arteries where nutrient, waste and gaseous exchange with fetal blood takes place via the villous core fetal vessels. Deoxygenated blood arrives at the placenta via two uterine arteries while oxygenated, nutrient-rich blood is circulated back to the foetus via a single umbilical vein. The pressure in the umbilical vein is about 20 mmHg.

Patient mentioned above is a known case of type 2 diabetes which makes her at high risk of having neural tube defects. She should be advised to start taking a high dose of (5mg) folic acid supplement daily for at least 1-month prior to conception and it should be continued upto 12 weeks of her pregnancy.

Folate, which is a water-soluble B vitamin, is usually obtained from diet or through supplementation. For those patients with a history of type 2 diabetes mellitus, who are planning for pregnancy, high doses are recommended to prevent any possible neural tube defects.

Vitamin A is not safe and should be avoided in pregnancy due to chances for toxicity.

Vitamin C and iron are not considered as essential vitamins to be taken during pregnancy.

The Rotterdam criteria for the diagnosis of PCOS is based on a score of two out of the three criteria:
1) Oligo or anovulation
2) Hyperandrogenism – clinical (hirsutism or less commonly male pattern alopecia) or biochemical (raised FAI or free testosterone)
3) on ultrasound – contain 12 or more follicles measuring 2 to 9 mm in diameter and/or have an increased volume of 10 cm3 or greater.

If a patient presents with PROM at 27 weeks of gestation, her management plan would have to include:

1) Cervical swabs to rule out infection
2) Commencement of prophylactic antibiotics such as erythromycin until results from the swabs are available
-If only normal vaginal flora are seen, prophylactic antibiotics can be stopped.
3) Administration of glucocorticoid- usually for 48 hours to promote maturity of the fetal lung and lower the chance of intracranial bleeding if the foetus has to be delivered prematurely
4) Transfer to a healthcare centre that has neonatal intensive care facilities to ensure if intensive care is needed post-delivery, the healthcare staff are prepared
5) Blood profile (particularly white cell count) and inflammatory markers (CRP) to look for any signs of chorioamnionitis
6) CTG assessment every 2-3 days. Abnormalities found on the CTG tracing are often the first evidence of problems such as a subclinical chorioamnionitis
7) Tocolysis with tocolytics such as IV salbutamol or nifedipine if contractions start before the course of glucocorticoid therapy is finished. Post-glucocorticoid therapy, tocolysis would not be often employed since there is a risk of masking contractions that occur due to an infection. In those cases, it is better to deliver the baby rather than to prolong the pregnancy. If there is no infection, the management plan should aim to prolong the pregnancy and delay delivery of a very premature baby.

Monozygotic (MZ) twins originate when a single egg is fertilized to form one zygote, which then divides into two embryos. Although they share the same genotype they are not phenotypically identical.

Alcohol exposure during pregnancy results in impaired growth, stillbirth, and fetal alcohol spectrum disorder. Fetal alcohol deficits are lifelong issues with no current treatment or established diagnostic or therapeutic tools to prevent and/or ameliorate some of these adverse outcomes.

Alcohol readily crosses the placenta with fetal blood alcohol levels approaching maternal levels within 2 hours of maternal intake. As there is known safe level of alcohol consumption during pregnancy, and alcohol is a known teratogen that can impact fetal growth and development during all stages of pregnancy, the current recommendation from the American College of Obstetricians and Gynaecologists, Centre for Disease Control (CDC), Surgeon General, and medical societies from other countries including the Society of Obstetricians and Gynaecologists of Canada all recommend complete abstinence during pregnancy.

World Health Organization (WHO) Group I ovulation disorder is due to hypothalamic pituitary failure. This is sometimes termed hypothalamic amenorrhoea or hypogonadotropic hypogonadism. Women can improve frequency of ovulation, conception and an uncomplicated pregnancy by increasing their body weight (if BMI of <19) and/or moderating their exercise levels (if they undertake high levels of exercise). GnRH and LH may be administered in these patients. PCOS falls under type II ovulation disorders. WHO Group III ovulation disorder is due to ovarian failure.

Fetal position and presentation is best evaluated by Leopold’s manoeuvre. It will determine which part of the foetus is in the uterine fundus.
Cullen’s sign is found in ruptured ectopic pregnancy characterised by bruising and oedema of the periumbilical region.
Mauriceau-Smelli-Veit manoeuvre is done during a breech delivery.

The incidence of 45,XO turner syndrome is around 1 in 8000 live births. Approximately 1% of monosomy X female embryos survive. Phenotypically they are females and 90% do not develop secondary sexual characteristics and hormone replacement is required.

Skin signs during pregnancy may include: dark spots on the breasts, nipples and inner thighs, melasma (chloasma), linea nigra, stretch marks, acne, spider telangiectasis and varicose veins.

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. The intermittent vaginal bleeding and the requirement for manual removal of the placenta suggest endometritis as the most possible diagnosis.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor. These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

COCs do not increase the risk of developing breast and endometrial cancer, Type 2 DM or breast fibroadenoma.

This is Polymorphic Eruption of Pregnancy (PEP) also known as Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP). Papules and plaques form on the abdomen (commonly within striae). It is most common in women during their first pregnancy and typically occurs in the 3rd trimester.

Gestational trophoblastic disorder is abnormal conception that is characterised by swollen and oedematous villi with proliferation of the trophoblasts. In a complete mole there is absence of fetal tissue, there is diffuse proliferation of trophoblastic tissue around hydropic villi and on USG it appears as a bunch of grapes or snow storm appearance.

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.

During the first 12 weeks of pregnancy, cardiac output increases by about 30-50%. To maintain this increase, systemic vascular resistance decreases by 20-30%, while stroke volume and the heart rate increase by 25-30% and 15 beats per minute respectively.

Causes of Hyperprolactinemia: Prolactinomas, Medication (phenothiazines, metoclopramide, risperidone, selective serotonin reuptake inhibitors, oestrogens, verapamil), Stress, Pregnancy, Hypothyroidism, Kidney disease, Chest trauma

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.

Thee good news in regard to incontinence after childbirth is that there are many treatment options. Some common treatment options are listed below.

Food and drinks such as coffee, citrus, spicy foods and soda can all irritate the bladder. Cutting back on or eliminating these foods may help improve incontinence symptoms. Keeping weight within a healthy BMI range, and/or focusing on losing pregnancy weight, can also help with bladder control.

Kegels strengthen the pelvic floor, giving more control over urinary urges. Pelvic floor physical therapy can also help build muscle memory and strength. The abdominal muscles, hip muscles and pelvic floor muscles work together when a woman performs strengthening exercises like Kegels. Physical therapists identify areas of weakness in those muscle groups to help a woman build a strong core and pelvic floor.

The bladder is a muscle that should be regularly strengthened. Scheduling urination times and then gradually increasing the amount of time in between urination can increase bladder strength.

Percutaneous tibial nerve stimulation is a nonsurgical treatment for overactive bladder and a form of neuromodulation therapy. During PTNS treatments, a doctor places a slim needle in the ankle where the tibial nerve is located. The needle delivers electrical impulses to the tibial nerve, which sends signals to the sacral nerves in the spine that control bladder and pelvic floor function. Over time, these pulses block nerve signals that are not working properly to lessen urinary incontinence symptoms.

Evaluating lifestyle factors. Excessive coughing due to smoking or being overweight can put unnecessary strain on the pelvic floor muscles. Certain drugs such as antidepressants and antihistamines can also have an impact on urinary incontinence.
Pessary. A pessary is a device inserted into the vagina to provide support for vaginal tissues, in turn, aiding in bladder incontinence.

Surgical treatment options can help support the pelvic floor and may be recommended for women who have completed childbearing and have not had success with conservative therapy.

After the release of the oocyte, the theca and the granulosa cells form the corpus luteum which undergoes extensive vascularization for continued steroidogenesis. Progesterone is secreted by the luteal cells and is synthesized from cholesterol. The luteal phase lasts for 14 days and if implantation does not occurs the corpus luteum starts to degenerate. As B-HCG produced by the implanted embryo maintains it and without it luteolysis occurs.

Gonorrhoea is a diplococcus bacteria known to infect the female genital tract. The bacteria is sexually transmitted and can cause an ascending infection in the uterus and fallopian tubes. According to the BASHH guidelines (British Association for Sexual Health and HIV), indication for therapy include confirmation of intracellular diplococci on microscopy or a confirmed positive NAAT. Treatment of gonorrhoea in pregnancy is as follows: Ceftriaxone 1g intramuscularly as a single dose with azithromycin 2g oral as a single dose. Pregnant individuals are not to be treated with quinolones or tetracyclines.

The pubic symphysis is a cartilaginous joint. The cartilaginous joints are divided further into primary and secondary joints. The primary joint is called the synchondrosis. It articulates with the pubis of the other side.

In the foetus, the hypogastric artery ascends along the side of the bladder, and runs upward on the back of the anterior wall of the abdomen to the umbilicus, converging toward its fellow of the opposite side. Having passed through the umbilical opening, the two arteries, now termed umbilical, enter the umbilical cord, where they are coiled around the umbilical vein, and ultimately ramify in the placenta.

Closure of the uterus should be performed in either single or double layers with continuous or interrupted sutures. The initial suture should be placed just lateral to the incision angle, and the closure continued to a point just lateral to the angle on the opposite side. A running stitch is often employed and this may be locked to improve haemostasis. If a second layer is used, an inverting suture or horizontal suture should overlap the myometrium. Once repaired, the incision is assessed for haemostasis and ‘figure-of-eight’
sutures can be employed to control bleeding. Peritoneal closure is unnecessary. Abdominal closure is performed in the anatomical planes with high strength, low reactivity materials, such as polyglycolic acid or polyglactin. Diamorphine is advised for intra and post op analgesia and oxytocin is advised to reduce blood loss.

When testing for ovulation the best test is to check the progesterone level. The mid luteal progesterone levels should be checked 7 days prior to the next period. That will be the 28th day in a 35 day cycle.

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.

Levonorgestrel, also known as the morning-after pill, is a first-line oral emergency contraceptive pill with approval from the World Health Organization to prevent pregnancy. It is FDA-approved to be used within 72 hours of unprotected sexual intercourse or when a presumed contraceptive failure has occurred.

A prescription is not needed, and it is available over the counter at local pharmacies. The FDA has also approved levonorgestrel availability for all age groups due to its lack of life-threatening contraindications and side-effect profile.

There are several contraindications for the emergency contraceptive form, including allergy, hypersensitivity, severe liver disease, pregnancy, and drug-drug interactions with liver enzyme-inducing drugs. The medication is not for use in women confirmed to be pregnant; however, there is no proof nor reports of adverse effects on the mother or foetus following inadvertent exposure during pregnancy.

Gestational Diabetes occurs in 2-9% of all the pregnancies.

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

Fat necrosis may occur following a traumatic injury to the breast. The lump is usually firm, round, and painless.

The incubation period of rubella is 12-23 days.

The chorionic plate represents the fetal surface of the placenta, which in turn is covered by the amnion. The amnion is composed of a single layered epithelium and the amnionic mesenchyme, an avascular connective tissue. The amnionic mesenchyme is only weakly attached to the chorionic mesenchyme and can easily be removed from the delivered placenta. The chorionic mesenchyme contains the chorionic vessels that are continuous with the vessels of the umbilical cord. Within the mesoderm of secondary villi, haematopoietic progenitor cells develop and start to differentiate. At about day 20 post-conception, first placental blood cells and endothelial cells develop independent of the vascular system of the embryo proper.13 14 The development of first placental vessels transforms the respective villi into tertiary villi.

Postcoital bleeding refers to spotting or bleeding unrelated to menstruation that occurs during or after sexual intercourse. It can be a sign of serious underlying pathology and is usually alarming for patients. About one-third of patients also have abnormal uterine bleeding that is not associated with coitus and about 15 percent have dyspareunia. The most serious cause of postcoital bleeding is cervical cancer. About 11 percent of women with cervical cancer present with postcoital bleeding. The patient should undergo cervical cancer screening according to local guidelines. Postcoital bleeding is not an indication for cervical cytology if previous screening tests are up-to-date and normal.

Cervical screening and liquid based cytology are superior to transvaginal ultrasound.

Coagulation profile can be done if cytology is normal to rule out bleeding diathesis.

Tranexamic acid can be considered once malignancy is ruled out and cause of bleeding has been established.

Cardiotocography (CTG) helps to record the heartbeat of the foetus in parallel to measuring the contractions of the mother’s uterus, this is the most appropriate tool to assess this patient’s condition.

FEV1 and FVC are unchanged. FEV1/FVC ratio remains the same in pregnancy

WHO defines perinatal death as the number of still births and death in the first week of life per 1000 births.

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.

According to NICE guidelines women with type I diabetes, who are expecting a child should aim to keep their HbA1c level[1] below 48 mmol/mol (6.5%) without causing problematic hypoglycaemia. Women with diabetes whose HbA1c level is above 86 mmol/mol (10%) should be strongly advised not to get pregnant because of the associated risks. The risks are higher with chronic diabetes. There is an increased risk to the foetus or mother due to diabetes in pregnancy. Women who are waiting to become pregnant should take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect.

This patient presents with signs and symptoms similar to clinical features of placental abruption.

Any trauma during the last trimester of pregnancy could be dangerous to both mother and fetus. By force of deceleration, motor vehicle accidents can result in placental separation. Also when subjected to strong acceleration-deceleration forces such as those during a motor vehicle crash uterus is thought to slightly change its shape. Since the placenta is not elastic and amniotic fluid is not compressible, such uterine distortion caused due to acceleration-deceleration or direct trauma will result in abruptio placentae due to shear stress at the utero-placental interface.

A painful, tender uterus which is often contracting is characteristic of placental abruption and the condition will lead to maternal hypovolemic hypotension and consequent fetal distress which is presented as fetal bradycardia and repetitive late decelerations. Vaginal bleeding, abdominal pain, contractions, uterine rigidity with tenderness, and a nonreassuring fetal heart rate (FHR) tracing are the clinical features diagnostic of abruption. However, a significant abruption can occasionally be asymptomatic or associated with minimal maternal symptoms in the absence of vaginal bleeding. Therefore the amount of vaginal bleeding is not always an appropriate indicator to the severity of placental abruption, this is because, in cases bleeding could be very severe or it may be concealed in the form of a hematoma in between the uterine wall and the placenta.

Sharp or blunt abdominal trauma can lead to uterine rupture or penetrating injury, since there is no reported abdominal trauma to the patient, uterine rupture is less likely to happen in this case. Severe abdominal pain with tenderness, cessation of contractions and loss of uterine tone are the most common symptoms characteristic of Uterine rupture. It will also be associated with mild to moderate vaginal bleeding along with fetal bradycardia or loss of heart sound. In this case uterus will be less tense and tender in comparison to placental abruption

Symptoms like low blood pressure, tachycardia and fetal bradycardia can be justified by ruptured spleen and liver laceration, but not the tense, tender and contracting uterus.

The diagnosis of placenta previa cannot be considered with the given clinical picture as it presents with sudden, painless bleeding of bright red blood and there will not be any uterine tenderness.

Routine ultrasonography at around 18-22 weeks gestation has become the standard of care in many communities. Acceptance is based on many factors, including patient preference, medical-legal pressure, and the perceived benefit by physicians. However, rigorous testing has found little scientific benefit for, or harm from, routine screening ultrasonography.

This patient experiences a stress based mixed urinary incontinence presented as leakage of urine while sneezing or coughing and urgency which is an intense urge to urinate with small voiding volume as her symptoms. Urinary incontinence is common and may cause significant distress in some, as seen in this patient who wears a pad every day.  Initial evaluation of mixed incontinence includes maintaining a voiding diary, which helps to classify the predominant type of urinary incontinence and thereby to determine an optimal treatment by tracking the fluid intake, urine output and leaking episodes.

All patients with mixed incontinence generally require bladder training along with lifestyle changes like weight loss, smoking cessation, decreased alcohol and caffeine intake and practicing pelvic floor muscle exercises like Kegels. Depending on the predominant type, patients who have limited or incomplete symptom relief with bladder training may benefit from pharmacotherapy or surgery.

In patients with urgency-predominant incontinence, timed voiding practice like urinating on a fixed schedule rather than based on a sense of urgency along with oral antimuscarinics are found to be useful.

Surgery with a mid-urethral sling is performed in patients with stress-predominant incontinence which is due to a weakened pelvic floor muscles as in cystocele.

In patients with a suspected urethral diverticulum or vesicovaginal fistula, a cystoscopy is usually indicated but is not used in initial evaluation of urinary incontinence due to its cost and invasiveness.

Urodynamic testing involves measurement of bladder filling and emptying called as cystometry, urine flow, and pressure (eg, urethral leak point).  This testing is typically reserved for those patients with complicated urinary incontinence, who will not respond to treatment or to those who are considering surgical intervention.

Initial evaluation of mixed urinary incontinence is done by maintaining a voiding diary, which helps to classify predominant type of urinary incontinence into stress predominant or urgency predominant and thereby to determine the optimal treatment required like bladder training, surgical intervention, etc.

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.

Endometrial tissue found within the myometrium is Adenomyosis. If endometrial tissue is found at a distant site to the uterus it is termed endometriosis. Fibroids are smooth muscle tumours (Leiomyoma’s) sometimes called myoma’s.

Changes in the cardiovascular system in pregnancy are profound and begin early in pregnancy, such that by eight weeks’ gestation, the cardiac output has already increased by 20%. The primary event is probably peripheral vasodilatation. This is mediated by endothelium-dependent factors, including nitric oxide synthesis, upregulated by oestradiol and possibly vasodilatory prostaglandins (PGI2). Peripheral vasodilation leads to a 25–30% fall in systemic vascular resistance, and to compensate for this, cardiac output increases by around 40% during pregnancy. 

The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.

For the foetus to pass through the vagina, the obstetric conjugate should be 11cm or greater. If the diameter is less than 10 cm then its better to perform C-section as the labour might not progress. All the other options favour a normal vaginal delivery.

In pregnancy, term refers to the gestational period from 37 to 41+6 weeks. Preterm births occur between 24 and 36+6 weeks. Only 1% of women who go into PROM have risk of having serious neonatal infections.

Management of PROM:
60% of patients with PROM will go into labour within 24 hrs
Induction is appropriate if >34 weeks gestation and more than 24 hours post rupture when labour hasn’t started.
If < 34 weeks, induction of labour should not be carried out unless there are additional obstetric indications e.g. infection

Most types of HRT increase the risk of breast cancer. But the risk is higher for those using combined HRT, which uses both oestrogen and progestogen. Vaginal oestrogens are not linked to an increased risk of breast cancer, whereas tibolone is. Taking HRT for 1 year or less only slightly increases breast cancer risk. However, the longer you take HRT the greater the risks are, and the longer they last.

Evidence is insufficient to conclude that long-term oestrogen therapy or hormone therapy use improves cardiovascular outcomes.

HRT containing oestrogen alone increases risk of endometrial cancer. However, this is not the case when using combined HRT.

HB gower 1 is the predominant embryonic haemoglobin when the foetus is 6 week old and is replaced by adult haemoglobin by the age of 5 months post natally. Only 2% of the haemoglobin is HbF.

Embryonic Haemoglobin:
Haemoglobin Gower 1 (HbE Gower-1)
Haemoglobin Gower 2 (HbE Gower-2)
Haemoglobin Portland I (HbE Portland-1)
Haemoglobin Portland II (HbE Portland-2)

Fetal Haemoglobin (haemoglobin F, HbF)

Antenatal screening for rubella IgG is a routine recommended for all pregnant women at their first visit. All pregnant women who have a history of contact with rubella or any clinical features consistent with rubella –like illness should be screened for the presence of rising antibody titre and / or rubella specific IgM. Serological confirmation is mandatory for diagnosing rubella.
As in this case scenario, positive lgM for rubella indicates active rubella infection, in such cases it is recommended to repeat the test. If lgM is still positive, it confirms rubella infection. No further testing from another laboratory is required.
The risk for fetal infection and damage is higher if rubella infection occurs during the first trimester of pregnancy, which is 85% in the first two months of pregnancy and 50 -80% in the third month. Therefore, termination of pregnancy is usually recommended in this situation. NHIG has been used in trials for prophylaxis and prevention of congenital rubella syndrome after contact to a case with rubella infection, but the results have been discouraging, therefore, it is not advisable.
In the given case, rubella infection has been established already, so NHIG will not be of any benefit as primary prevention.
Rubella-containing vaccines like MMR vaccine is a live attenuated vaccine are contraindicated throughout pregnancy, it should be avoided; and women who remain susceptible to rubella should receive MMR vaccine postpartum.
Risk of fetal infection and/or fetal damage or for development of congenital rubella syndrome is related to the timing of maternal infection. Cases with Primary infection is found to be in higher risk
In cases of asymptomatic re-infection with a good history of previous positive serology, even though it is difficult to quantify, the risk of fetal infection has been reported to be < 5 percent. Congenital rubella syndrome following maternal re-infection is considered rare particularly if re-infection occurs after 12 weeks. If the clinical picture is typically of rubella or if possibility of previous immunity is inconclusive based on serology, then the risk is assumed to be the same as that of primary infection.

In the management of a miscarriage, after the completion of 7-14 days of expectant management, the woman is advised to take a pregnancy test after 3 weeks. In case of a positive result she is to return for further care.

Tenderness is usually suggestive of a benign breast mass such as a breast abscess. Ultrasound is used to distinguish solid from cystic structures and to direct needle aspiration for abscess drainage.

Presentation in the given case is classic for premature rupture of membranes (PROM) which was probably caused due to trauma during intercourse.
Premature rupture of membrane (PROM) is defined as the rupture of embryonic membranes before the onset of labor, regardless of the age of pregnancy. If occured before 37 weeks of gestation, it is termed as preterm PROM (PPROM.)

A sudden gush of watery fluid per vagina is the classic presentation of rupture of the membranes (ROM), regardless of gestational age, however nowadays many women presents with continuous or intermittent leakage of fluid or a sensation of wetness within the vagina or on the perineum. Presence of liquor flowing from the cervical os or its pooling in the posterior vaginal fornix are considered as the pathognomonic symptom of ROM. Assessment of fetal well-being, the position of the fetus, placental location, estimated fetal weight and presence of any anomalies in PROM and PPROM are done with ultrasonographic studies.

Retained semen will not result in the findings mentioned in this clinical scenario as it have a different appearance.

Infections will not be a cause for this presentation as it will be associated with characteristic features like purulent cervical discharge, malodorous vaginal discharge, etc. Pooling of clear fluid in the posterior fornix is pathognomonic for ROM.

Urine leakage is common during the pregnancy, but it is not similar to the clinical scenario mentioned above.

Absence of findings like cervical dilation and bulging membranes on speculum exam makes cervical insufficiency an unlikely diagnosis in this case.

The anal sphincters are responsible for closing the anal canal to the passage of faeces and flatus. The smooth muscle of the involuntary internal sphincter sustains contraction to prevent the leakage of faeces between bowel movements and is innervated by the pelvic splanchnic nerves, which are a branch of the spinal segment 4. The external sphincter is made up of skeletal muscle and can therefore contract and relax voluntarily. Its innervation comes from the inferior rectal branch of the pudendal nerve, and the perineal branch of S4 nerve roots.