There are four types pelvic shapes:
1) Android pelvis: it has a larger inlet and smaller outlet along with small posterior sagittal diameter, prominent ischial spines and has a two finger arch.
2) Gynecoid pelvis: it has a transverse or nearly a circular ellipse and it is the most favourable for delivery.
3) Anthropoid pelvis: the brim is an anteroposterior ellipse.
4) Platypelloid pelvis: in this type the pelvic brim is kidney shape

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.

Maternal blood volume expands during pregnancy to allow adequate perfusion of vital organs, including the placenta and foetus, and to anticipate blood loss associated with delivery. The rapid expansion of blood volume begins at 6–8 weeks gestation and plateaus at 32–34 weeks gestation. While there is some increase in intracellular water, the most marked expansion occurs in extracellular fluid volume, especially circulating plasma volume. This expanded extracellular fluid volume accounts for between 8 and 10 kg of the average maternal weight gain during pregnancy. Overall, total body water increases from 6.5 to 8.5 L by the end of pregnancy.

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.

Adenomyosis or dysfunctional uterine haemorrhage are the most likely causes of heavy periods.
Because she refuses to have a hysterectomy or endometrial ablation, hormonal therapy must be administered in addition to the iron therapy she is already receiving.
Any of the choices could be employed, but using therapy only during the luteal phase of the cycle in someone who is virtually surely ovulating (based on her typical monthly cycles) is unlikely to work.

Danazol is prone to cause serious adverse effects (virilization), especially when used for a long period of time.
GnRH agonists would cause amenorrhoea but are more likely to cause substantial menopausal symptoms, and the °fa contraceptive pill (OCP) is generally best avoided in someone using hypertension medication.

Treatment with norethisterone throughout the cycle is likely to be the most successful of the treatments available.
If a levonorgestrel-releasing intrauterine device (Mirena®) had been offered as an alternative, it would have been acceptable.

Prolactin is the hormone that is responsible for the production of milk (Lactogenesis). Oxytocin is responsible for the let down reflex during suckling.

Diagnosis can be made using the Amsel’s criteria:
1. Presence of clue cells on microscopic examination (these cells are epithelial cells covered with the bacteria).
2. Creamy greyish discharge.
3. Vaginal pH of more than 4.5.
5. Positive whiff test – release of fishy odour on addition of alkali solution. Other criteria include the nugent score and the Hay/Ison criteria. The Nugent score estimates the relative proportions of bacterial morphotypes to give a score between 0 and 10 (<4 = normal, 4-6 = intermediate, >6 = BV)
The Hay/Ison criteria
Grade 1 (Normal): Lactobacillus morphotypes predominate
Grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present
Grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli.

The femoral triangle is bounded superiorly by the inguinal ligament which forms the base of the triangle, medially by the lateral border of the adductor longus and laterally by the sartorius muscle.

An elevation in serum PRL is associated with a variety of reproductive disorders, including amenorrhea, oligomenorrhea, anovulation and/or luteal phase defects with subsequent infertility.

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.

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.

Women who have used oral contraceptives for 5 years or more are more likely to get cervical cancer than women who have never used them. The longer a woman uses oral contraceptives, the higher her chances of developing cervical cancer become. According to one study, using marijuana for less than 5 years increases the risk by 10%, using it for 5–9 years increases the risk by 60%, and using it for 10 years or more increases the risk by double. After women cease using oral contraceptives, their risk of cervical cancer appears to decrease over time. Endometrial, ovarian, and colorectal cancer risks, on the other hand, are lowered.
Compared to women who had never used oral contraceptives, women who were taking or had just discontinued using oral combination hormone contraceptives had a slight (approximately 20%) increase in the relative risk of breast cancer. Depending on the type of oral combination hormone contraception used, the risk increased anywhere from 0% to 60%. The longer oral contraceptives were used, the higher the risk of breast cancer.

Turner syndrome patients have malfunctioning or streak ovaries due to which they can never conceive. It affects females, who will have a short stature, widely spaced nipples, webbed neck and karyotyping shows 45XO.

Depot medroxyprogesterone acetate and the combination contraceptive vaginal ring are the most effective hormonal contraceptives for obese women because they do not appear to be affected by body weight. Women using the combination contraceptive patch who weight 90 kg may experience decreased contraceptive efficacy. Obese women using oral contraceptives may also have an increased risk of pregnancy.

Despite the fact that pregnancy at her age is uncommon, the best advise you can give her is to take a pregnancy test.

If the test results show she is not pregnant, she can next decide whether to restart the oral contraceptive pill (0CP) or simply weep until the post-pill amenorrhoea goes away.

Although an increased follicle-stimulating hormone (FSH) level may indicate ovarian failure, it does not guarantee that no more periods will occur and does not rule out the possibility of a future pregnancy.

Obviously, she should be recommended to use a contraceptive method like condoms until the cause of her amenorrhoea is determined.
Other hormonal tests, such as luteinizing hormone and prolactin testing, may be required.

The female bony pelvis is larger, broader and more of a funnel shape. The inlet is larger and oval in shape and the sides of the female pelvis are wider apart.

Endometrial hyperplasia with atypia is at high risk of progression to cancer and hysterectomy is indicated There is high risk of progression to cancer with endometrial hyperplasia with atypia and hysterectomy is indicated. Although weight loss would be beneficial this shouldn’t delay surgical management.

The clinical features of endometriosis include dyspareunia, dysmenorrhea, dysuria, dyschezia as well as infertility. Pain is characteristically long-term, cyclic (often occurring the same time as menses) and can get progressively worse over time. Laparoscopy remains the standard for diagnosis. There are many cases in which endometriosis is only discovered at the time of the workup for infertility.

Vaginismus is an uncontrollable painful spasm of the pelvic muscles and vaginal exit that this patient has. It’s mainly caused by psychological factors. It’s important to distinguish it from frigidity, which indicates a lack of sexual desire, and dyspareunia, which is characterized as pelvic and/or back pain or other discomfort linked with sexual activity. Endometriosis, pelvic adhesions, and ovarian neoplasms are all common causes of dyspareunia. Vaginismus pain can be psychogenic, or it might be caused by pelvic diseases like adhesions, endometriosis, or leiomyomas. Organic vulvar or pelvic reasons (such as atrophy, Bartholin gland cyst, or abscess) are extremely rare, hence vaginismus is mostly treated with psychotherapy.

Although uterine growth during the first few weeks of pregnancy is accomplished by increased numbers of smooth muscle cells (i.e. hyperplasia) and a smaller contribution from increased cell size (i.e. hypertrophy), the predominant growth of the uterus during pregnancy is by way of stretch‐induced myometrial hypertrophy. This ongoing process of stretch‐induced tissue remodelling and smooth muscle hypertrophy is accompanied by the lack of uterine contractions during most of gestation to accommodate the developing foetus (phase 0 of parturition). Phase 1 of parturition represents myometrial activation. The final stages of pregnancy are characterized by increases in spontaneous low‐amplitude contractions that gradually increase in frequency, rhythmicity and strength, normally culminating in labour and delivery of the foetus at term (phase 2 of parturition).

Cholestasis of pregnancy is associated with increased fetal morbidity and mortality and should be treated actively. The significance attached to pruritus in pregnancy is often minimal, but it is a cardinal symptom of cholestasis of pregnancy, which may have no other clinical features.

Primary infertility is defined as the inability to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient under the age of 35. (After 35 years of age, infertility testing can begin after 6 months.) Because the patient’s partner’s sperm analysis is normal, female factor infertility is the most likely explanation. This patient’s adolescent hospitalizations are likely due to pelvic inflammatory disease (PID), a common cause of infertility caused by tubal scarring and blockage.

A hysterosalpingogram, which includes infusing radiocontrast into the cervix under fluoroscopy, is the first-line imaging technique for determining fallopian tube patency. A hysterosalpingogram is a non-invasive procedure that can detect uterine cavity irregularities (e.g., bicornuate uterus).

Peritoneal adhesions and endometriosis can be seen and treated directly using laparoscopy.

PID-related scarring inside the fallopian tubes can be assessed by laparoscopy with chromotubation; however, it is invasive, expensive, and not utilized first-line.

Ovulation is detected using a mid-cycle LH level. The LH surge can be detected in urine and serum 36 hours before ovulation. Regular menstrual periods are characterized by mittelschmerz (mid-cycle pelvic pain), which indicates ovulation. As a result, an LH level would be useless.

Ovarian reserve begins to deteriorate around the age of 35, and serum FSH levels rise in women who are losing their ability to ovulate. Because this patient is much younger and has regular periods, a drop in ovum quantity is unlikely to be the reason for infertility.

Increased serum androgen levels can prevent ovulation by inhibiting the release of GnRH and FSH through feedback inhibition. The patient has regular cycles and no hyperandrogenic symptoms, despite her sister having polycystic ovarian syndrome (e.g., hirsutism, irregular menses).

In a nulliparous patient under the age of 35, primary infertility is defined as the inability to conceive after a year of unprotected sexual intercourse. A hysterosalpingogram is used to determine the cause of infertility, such as tubal blockage caused by a previous pelvic infection.

Fibrinogen is activated by thrombin which converts it into fibrin which forms a mesh to trap red blood cells and form a clot.

A fibroid is a benign smooth muscle tumour or Leiomyoma. As such it is something of a misnomer. Leiomyosarcoma and Angioleiomyoma are malignant tumours of smooth muscle under the WHO sort tissue tumour classification Rhabdomyoma is a skeletal muscle tumour Myofibroma is seen in fibromatosis

This patient has been unable to conceive for over a year, and her fallopian tubes are blocked. Her body mass index is 42.
Because she has obstructed Fallopian tubes, in-vitro fertilisation (IVF) is an alternative to getting pregnant for this patient.
A woman with a BMI over 35, on the other hand, will need twice as many IVF rounds to conceive as a woman of normal weight.
As a result, the greatest advise for successful IVF would be to decrease weight as the first step in management.
Obese (BMI less than 40) patients’ IVF success chances are reduced by 25% and 50%, respectively.

The most suitable step would be to wait for spontaneous onset of labour. This woman would be able to deliver vaginally in 3 situations. The first would be if the foetus is estimated to weigh less than 3800g (first child weight 3800g). Another would be if the foetus is in a frank or complete breech presentation and lastly if the rate of labour progress is satisfactory and breech extraction is unnecessary. RCOG (Royal College of Obstetricians & Gynaecologists) guidelines recommends that women should be informed that elective Caesarean section for the delivery of a breech baby would have a lower risk of perinatal mortality than a planned vaginal delivery. This is because with an elective Caesarean section, we would be able to avoid stillbirth following 39 weeks of gestation as well as intrapartum and vaginal breech delivery risks. The ideal mode of delivery of a breech foetus when labour starts or at least close to term is a Caesarean section as the risks towards the foetus would be significantly increased in a vaginal delivery. The obstetrician is responsible to ensure that there are no other abnormalities that could complicate this even further such as footling presentation, low estimated birth weight (less than 10th centile), hyperextended neck on ultrasound, evidence of fetal distress and high estimated birth weight (>3.8kg). Provided that there is a normal progression of events, fetal risks during both labour and delivery should be low if such factors are absent. Hence, it is right to await the onset of labour to occur spontaneously in this case. In order to exclude a knee presentation with fetal head extension or a footling breech, ultrasound examination has to be done. These are linked to a high fetal risk if the mother attempts vaginal delivery. X-ray pelvimetry is advisable but is not essential in fetal size assessment since its accuracy is roughly 20%. In this case, it is not indicated since there is evidence that her pelvis is of adequate size as she had already delivered a 3.9kg baby prior. It is best to avoid induction of labour in breech cases for numerous reasons (need for augmentation, cord prolapse).

The best method to provide symptomatic relief to this woman is to use pressure stockings and a vulval pad (correct answer). This will provide relief without causing any adverse effects.

In order to prevent ulceration, care is required to avoid trauma.

Since the patient is pregnant, surgical ligation or injecting of sclerosing solutions cannot be considered and are contraindicated.

Development of varices is often exacerbated in subsequent pregnancies; and therefore surgery should be eschewed until child-bearing is complete,

Bed rest in hospital would reduce the symptoms of the varicose veins; however this should be avoided as it can increase the risk of developing deep vein thrombosis.

Anticoagulant therapy has not been shown to be beneficial for treatment of varicosities that only affect the superficial venous system and should therefore not be used.

Biochemical features suggest that this patient has polycystic ovary syndrome (PCOS). It is associated with signs and symptoms of hyperandrogenism (oligomenorrhea, irregular menstruation, hirsutism, hair loss, and acne) and elevated testosterone. PCOS patients are often overweight or obese, have insulin resistance (treated with Metformin) and an adverse risk profile for cardiovascular disease.

The vaginal artery is the homolog to the inferior vesical artery in males. In most of the cases it arises from the internal iliac artery.

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