Normal labour is characterized by spontaneous onset, rhythmical uterine contractions along with vertex presentation. Cervical dilatation starts from the 1st stage of labour and intensity of the uterine contractions increases with passing time. Bleeding occurs after the child is expelled and the average loss is about 250-500 ml in a normal vaginal delivery.

While HSV-1 often affects the perioral region and can be known to cause genital lesions, HSV-2 is more commonly the consideration when patients present with genital lesions.
HSV-2 is transmitted through direct contact of sections in a seropositive individual who is actively shedding the virus. The virus preferentially affects the skin and mucous membranes with the virus invading epithelial cells on initial exposure and ultimately replicating intracellularly at that site.

HSV-2, in particular, may present as a primary infection with painful genital ulcers, sores, crusts, tender lymphadenopathy, and dysuria. The classical features are of macular or papular skin and mucous membrane lesions progressing to vesicles and pustules that often last for up to 3 weeks. Genital lesions can be especially painful, leading to swelling of the vulva in women, burning pain, and dysuria.

Given that symptoms can mimic acute urinary tract infection, consider urinalysis and culture.

Thyroxine requirement during pregnancy will increases by 25 to 30 percent, which is seen as early as fifth week of pregnancy.

Children born to those women whose hypothyroidism was inadequately treated during pregnancy, are at higher risk for developing neuropsychiatric impairments.

When a woman who is on thyroxine is planning to conceive, they are advised to increase their thyroxine dose by 30 percent at the time of confirmation of pregnancy.

During pregnancy TSH also should be monitored at every 8 to 10 weeks, with necessary dose adjustments.

Dose requirements of thyroxine will return to pre-pregnancy level soon after delivery and it will not change according to whether the mother is breastfeeding or not.

Patient mentioned in the given case has developed clinical features of cervical insufficiency and the possible treatment options include:
1- Cerclage, which is the technique used for the reinforcement of cervical ring with nonabsorbable suture material and is indicated based on ultrasonographic findings. It is the treatment of choice when cervical shortening is detected by ultrasonography before 22 to 24 weeks of gestation.

2- Vaginal progesterone is used to reduce the risk of preterm delivery in women who have a prior history of idiopathic preterm delivery or cervical shortening, which is confirmed in the current pregnancy also by ultrasonography.This method is applicable only to those women who do not meet the criteria for Cerclage.

All the other options of management are incorrect in the given case.

The NICE guidelines on Hypertension in pregnancy define blood pressure in pregnancy as follows:
Mild hypertension: DBP=90-99 mmHg, SBP=140-149 mmHg. Moderate hypertension: DBP=100-109 mmHg, SBP=150-159 mmHg.
Severe hypertension: DBP=110 mmHg or greater, SBP=160 mmHg or greater.

If a mother has been abusing drugs during antenatal period, there are some contraindications to discharge her baby home. These conditions includes:
– excessive weight loss, which is greater than ten percent of birth weigh
– suspected baby neglect or abuse
– suspected domestic violence
– a court order preventing baby from being discharged home or if there is requirement for further assessment of withdrawal symptoms.

A 2-3 percentages weight loss during the early neonatal period is considered to be a normal finding and is therefore not considered as a contraindication to discharge the baby home.

Twin gestations are at increased risk for postpartum haemorrhage (PPH). A number of maternal and peripartum factors are associated with PPH requiring blood transfusion in twin gestations. Reducing the rate of caesarean delivery in twin pregnancies may decrease maternal hemorrhagic morbidity.

As they respond differently to different drugs, a thorough distinguishing must be done between the two major groups of epilepsies while approaching a woman, who wishes to become pregnant while on antiepileptic drugs.

Partial epilepsies will respond to most of the antiepileptic drugs, but in case of idiopathic generalized epilepsies, especially in juvenile myoclonic epilepsy, seizure can be controlled only with a reasonably low dose of sodium valproate. Although lamotrigine may be helpful but substitution of sodium valproate with lamotrigine is not the right choice. This is because lamotrigine is not as effective as sodium valproate and will sometimes worsens myoclonic seizures in juvenile myoclonic epilepsy.

Topiramate and levetiracetam are found to be effective in idiopathic generalized epilepsy, while carbamazepine, phenytoin and gabapentin may worsen some seizure types, especially in myoclonic and absence seizures. For some women with idiopathic generalized epilepsies, there will be no effective alternative to sodium valproate as cessation of sodium valproate will lead to recurrence of the generalized seizures, especially juvenile myoclonic epilepsy. Hence, it is not advisable to discontinue the drug in auch patients.

On the other hand, sodium valproate have the highest reported teratogenicity potential among antiepileptic drugs and the Australian Pregnancy Register has reported the risk to be as high as 16% if used in first trimester. Sodium valproate should be avoided in women of reproductive age and if a patient on the medication is willing to become pregnant, she should be well informed about the risk of teratogenicity and the decision must be left to her. If she decides to accept the risks and continue with pregnancy, the lowest possible effective dose should be prescribed to her.

If the dose of sodium valproate has been reduced to minimum during pregnancy to reduce the possible teratogenesis, it is recommended to re-establish the prepartum effective dose before the onset of labor. This is because, it is the time with increased risk for seizures, especially in patients with idiopathic generalised epilepsy who are very sensitive to sleep deprivation. Valproate therapy is found to be safe during breastfeeding.

The case is most likely diagnosed a threatened miscarriage.
A diagnosis of threatened miscarriage is made when there is uterine bleeding in the presence of a closed cervix and is confirmed by the sonographic visualisation of an intrauterine pregnancy with detectable fetal cardiac activity. Miscarriages may not always follow even though there was multiple episodes or large amounts of bleeding, therefore the term “threatened” is used in these cases.
At 7 to 11 weeks of gestation, about 90 to 96 percent cases of pregnancies, will not usually miscarry if they have presented with an intact fetal cardiac activity along with vaginal bleeding and if bleeding occurs at the later weeks of gestational age chances of success rate is higher.

Topic review:
– Inevitable miscarriages presents with a dilated cervix, increasing uterine bleeding and painful uterine contractions. The gestational tissues can often be felt or seen through the cervical os and its passage occurs within a short time.
– In Incomplete miscarriage, the membranes will rupture passing the fetus out, but significant amounts of placental tissue will be retained. This occurs most commonly in late first trimester or early second trimester. On examination, the cervical os will be opened and the gestational tissue can be observed in the cervix, with a uterine size smaller than expected for gestational age, but not well contracted. The amount of bleeding varies but can be severe enough to cause hypovolemic shock. There will be painful cramps
ontractions and ultrasound reveals tissue in the uterus.
– A missed miscarriage refers to the in-utero death of the embryo or fetus prior to 20th week of gestation, with retention of the pregnancy for a prolonged period of time. In this case, women may notice that symptoms associated with early pregnancy like nausea, breast tenderness, etc have abated and they don’t “feel pregnant” anymore.
Vaginal bleeding may occur but the cervix usually remains closed. Ultrasound reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.
– Complete miscarriage, usually occurs before 12 weeks of gestation and the entire contents of the uterus will be expelled resulting in a complete miscarriage. In this case, physical examination reveals a small, well contracted uterus with an open or closed cervix with scanty vaginal bleeding and mild cramping. Ultrasound will reveal an empty uterus with no extra-uterine gestation.

Patient’s presentation and physical examination findings are most consistent with physiologic dyspnea, which is common during pregnancy. This breathing difficulty which is due to an increase in the tidal volume of lung will present itself as an increased awareness of breathing and can occur as early as the end of first trimester. Any minute increase in the ventilation occurs during pregnancy can make patients feel as if they are hyperventilating and contribute to the feeling of dyspnea.

Patient should be reassured and educated regarding these normal changes of pregnancy, also should be counselled to modify her exercise regimen accordingly to her changed tolerance.

Systolic ejection murmurs are due to increased blood flow across the aortic and pulmonic valves which is a normal finding in a pregnancy. So there is no need for this patient to be referred to a cardiologist or to order an ECG.
About 1 in 6400 pregnancies present with pulmonary embolism and there will be clinical evidence of DVT in many of these cases. Dyspnea, chest pain, apprehension, cough, hemoptysis, and tachycardia are the most common symptoms of PE and physical examination shows accentuated pulmonic closure sound, rales, or a friction rub. If there is a strong suspicion for PE, the patient should be followed up with a ventilation-perfusion scan, which will confirm PE if presented with large perfusion defects and ventilation mismatches.

This patient with a previous history of pre-eclampsia and obesity is at high risk for developing pre-eclampsia.

A daily intake of 1000mg of calcium is observed to be helpful in reducing the incidence of any hypertensive disorders and preterm labour.

Vitamin A should always be avoided during pregnancy as it is fetotoxic.

All other options are incorrect.

Fetal heart rate tracings (FHR) under category I include all of the following:
– baseline rate 110– 160 bpm
– baseline FHR variability moderate
– accelerations present or absent
– late or variable decelerations absent
– early decelerations present or absent

The onset of fetal bleeding is marked by a tachycardia followed by a bradycardia with intermittent accelerations or decelerations. Small amounts of vaginal bleeding associated with FHR abnormalities should raise the suspicion of fetal haemorrhage. This condition demands prompt delivery and immediate reexpansion of the neonatal blood volume.

Cervical cerclage is performed as an attempt to prolong pregnancy in certain women who are at higher risk of preterm delivery.

There are three well-accepted indications for cervical cerclage placement. According to the American College of Obstetricians and Gynaecologists (ACOG), a history-indicated or prophylactic cerclage may be placed when there is a “history of one or more second-trimester pregnancy losses related to painless cervical dilation and in the absence of labour or abruptio placentae,” or if the woman had a prior cerclage placed due to cervical insufficiency in the second trimester.

An ultrasound-indicated cerclage may be considered for women who have a history of spontaneous loss or preterm birth at less than 34 weeks gestation if the cervical length in a current singleton pregnancy is noted to be less than 25 mm before 24 weeks of gestation. It is important to note that this recommendation is invalidated without the history of preterm birth.

Physical examination-indicated cerclage (also known as emergency or rescue cerclage) should be considered for patients with a singleton pregnancy at less than 24 weeks gestation with advanced cervical dilation in the absence of contractions, intraamniotic infection or placental abruption.

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.

Gas gangrene is synonymous with myonecrosis and is a highly lethal infection of deep soft tissue, caused by Clostridium species, with Clostridium perfringens being the most common. This organism has also had increased incidence as the cause of deep tissue infections associated with childbirth and infections after gynaecologic procedures including septic abortions, which can cause gas gangrene of the uterus.
Health care workers should suspect gas gangrene if anaerobic gram-positive bacilli are present in a wound with necrosis of soft tissue and muscle. The organisms produce a gas identifiable on x-ray or CT scans.
Patients with gas gangrene (myonecrosis) present with signs of infection such as fever, chills, pain, and less superficial inflammation at the site of infection than one would expect given the deep penetrating nature of these infections. The condition of the patient can rapidly progress to sepsis and death if not treated aggressively. The wound discharge is often dishwater looking with a musty order.

Secondary postpartum hemorrhage of bright red character accompanied with fever, between 24 hours to 12 weeks of postpartum is suggestive of retained products of conception (RPOC).
The basal portion of the decidua may remain after separation of placenta in many cases. This decidua will then divides into two layers, the superficial layer which will be shed spontaneously and the deep layer which will regenerates and covers the entire endometrial cavity with in 16 days of postpartum.
Normal shedding of blood and decidua is referred to as lochia rubra, which is red / reddish brown in colour and it lasts for few days following delivery. This vaginal discharge gradually becomes watery and pinkish brown in colour, lasting for 2 to 3 weeks and is called as lochia serosa. Ultimately, this discharge becomes yellowish-white called as lochia alba.

Scanty lochia in the first few days after delivery is suggestive of the placental site not undergoing involution, which occurs mostly due to RPOC. Later these retained products will undergo necrosis resulting in fibrin deposition which will eventually form a placental polyp. Detachment of this scar of polyp will result in brisk hemorrhage and the remaining necrotic products will get infected resulting in uterine infection which will present with fever, lower abdominal pain and uterine tenderness.

Endometritis can lead to fever, offensive lochia and abdominal pain with tenderness. It is the most common cause of postpartum fever, but occurs within the first 5 days of postpartum with the peak incidence between days 2 and 3. Though vaginal bleeding is a presenting feature, bright red bleeding is unlikely of endometritis.

Another cause of postpartum fever is genital lacerations which have a peak incidence of wound infection between 4th and 5th days. Although fever as a temporal symptom favours wound infection, this diagnosis is less likely in the given case as wound infection will not affect the normal course of lochia, also it does not present as heavy bright red bleeding. Moreover, there are no symptoms like erythema, tenderness or discharge in history suggestive of wound infection.

Another cause of bleeding and fever can be cervical tear but this tends to present as primary postpartum hemorrhage rather than secondary, which occurs after 24 hours of postpartum. An overlooked and infected minor cervical laceration can cause fever but ii will not result in bright red bleeding, also genital tract lacerations do not affect lochia.

It is very unlikely for uterine rupture to occur 24 hours after delivery.

Uterine atony and failure of contraction and retraction of myometrial muscle fibres can lead to rapid and severe haemorrhage and hypovolemic shock. Poor myometrial contraction can result from fatigue due to prolonged labour or rapid forceful labour, especially if stimulated.

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia.

The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may contribute to the development of this disease process such as:
1. Hormone changes – hCG levels peak during the first trimester, corresponding to the typical onset of hyperemesis symptoms. Estrogen is also thought to contribute to nausea and vomiting in pregnancy.
2. Changes in the Gastrointestinal System – the lower oesophageal sphincter relaxes during pregnancy due to the elevations in estrogen and progesterone. This leads to an increased incidence of gastroesophageal reflux disease (GERD) symptoms in pregnancy, and one symptom of GERD is nausea.
3. Genetics – an increased risk of hyperemesis gravidarum has been demonstrated among women with family members who also experienced hyperemesis gravidarum.

The average onset of symptoms happens approximately 5 to 6 weeks into gestation. The physical exam should include fetal heart rate (depending on gestational age) and an examination of fluid status, including an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should be obtained for comparison to previous and future weights. If indicated, abdominal examination and pelvic examination should occur to determine the presence or absence of tenderness to palpation.

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.

Paracetamol is safe to take during pregnancy and has shown no harm to unborn children during studies. It is the treatment of choice for mild to moderate pain during pregnancy.

The postpartum period begins soon after the baby’s delivery and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state.

Bloody vaginal discharge (lochia rubra) is heavy for the first 3-4 days, and slowly it becomes watery in consistency and colour changes to pinkish-brown (lochia serosa). After the next 10-12 days, it changes to yellowish-white (lochia alba). Advise women to seek medical attention if heavy vaginal bleeding persists (soaking a pad or more in less than an hour). Women with heavy, persistent postpartum bleeding should be evaluated for complications such as retained placenta, uterine atony, rarely invasive placenta, or coagulation disorders. Endometritis may also occur, presenting as fever with no source, maybe accompanied by uterine tenderness and vaginal discharge. This usually requires intravenous antibiotics. This also should be explained and advise the mother to seek immediate medical attention.

Nausea, fatigue, breast tenderness, and increased frequency of urination are the most common symptoms of pregnancy, but their presence is not considered definitive as they are nonspecific symptoms which are not consistently found in early pregnancy, also these symptoms can occur even prior to menstruation.

In pregnancy a physical examination will reveal an enlarged uterus which is more boggy and soft, but these findings are not apparent until after 6th week of gestation. In addition, other conditions like adenomyosis, fibroids, or previous pregnancies can also result in an enlarged uterus which is palpable on physical examination.

An abdominal ultrasound will not demonstrate a gestational sac until a gestational age of 5 to 6 weeks, nor will it detect an ectopic pregnancy soon after a missed menstrual period, therefore it is not indicated in this patient.

A Doppler instrument will detect fetal cardiac action usually after 10 weeks of gestation.

A sensitive serum quantitative pregnancy test can detect placental HCG levels by 8 to 9 days post-ovulation and is considered as the most appropriate next step in evaluation of this patient.

Visual disturbances although very common during pregnancy are not a normal sign. Physicians should have a firm understanding of the various ocular conditions that might appear pregnancy or get modified by pregnancy. In addition, it is very important to be vigilant about the rare and serious conditions that may occur in pregnant women with visual complaints. Prompt evaluation may be required and the immediate transfer of care of the patient may help saving the lives of both the mother and the baby.

Women with diabetes have increased risk for adverse maternal and neonatal outcomes and similar risks are present for either type 1 or type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies, and to minimize risk of congenital defects. Haemoglobin A1c goal at conception is <6.5% and during pregnancy is <6.0%.

Decreased pregnancy-associated plasma protein (PAPP-A) in the first trimester of pregnancy is an indication to carry out further diagnostic testing for Down syndrome.

Antenatal tests available for screening Down syndrome are divided into two types:
– Screening tests includes maternal serum screening and ultrasound which are safe to conduct with relatively low predictive values.
– Diagnostic tests like chorionic villous sampling and amniocentesis are confirmative but carries higher risk of miscarriage as 1 in 100 and 1 in 200 respectively.

a) Serum screening tests for Down syndrome during first-trimester includes:
1. Pregnancy-associated plasma protein (PAPP-A) will be decreased in case of Down syndrome.
2. Free ß-human chorionic gonadotropin (HCG) will be increased in cases of Down syndrome.
If these screening tests are combined with first-trimester ultrasound nuchal translucency, it is found to be more accurate than doing only one of these tests.

b) Second-trimester serum screening tests for identifying Down syndrome:
1.Alpha-fetoprotein will be decreased.
2.Unconjugated oestriol will be decreased.
3.Free ß-HCG will be increased
4.Inhibin A will be increased.
These tests combined with maternal age and ultrasound results will provide more accurate predictive values.

Magnesium Sulphate is the drug of choice in eclamptic patients. A loading dose of 4g magnesium sulphate in 100mL 0.9% saline IVI over 5min followed by maintenance IVI of 1g/h for 24h. Signs of toxicity include respiratory depression and jerky tendon reflexes. In recurrent fits additional 2g can be given. Magnesium should be stopped when the respiratory rate is <14/min, absent tendon reflexes, or urine output is <20mL/h.

The patient most likely suffered a uterine rupture. It occurs most often in multiparous women and is less often associated with external haemorrhage. Shock develops shortly after rupture due to the extent of concealed bleeding.

Uterine inversion rarely occurs when after a spontaneous and normal third stage of labour. Although it can lead to shock, it is usually associated with a history of controlled cord traction or Dublin method of placenta delivery before the uterus has contracted. This diagnosis is also strongly considered when shock is out of proportion to the amount of blood loss.

An overwhelming infection is unlikely in this case when labour occurred for a short period of time. Uterine atony and amniotic fluid embolism are more associated with excessive vaginal bleeding, which is not evident in this case.

In pregnancy, the uterus increases in size to accommodate the developing foetus. At 16 weeks gestation, the fundus of the uterus must be palpated at the midpoint between the umbilicus and the pubic symphysis but the patient’s uterus was already palpable at just 11 weeks.

If less than seven weeks pregnant, it’s unlikely to find a heartbeat by ultrasound. Using transvaginal ultrasound, a developing baby’s heartbeat should be clearly visible by the time a woman is seven weeks pregnant. Abdominal ultrasound is considerably less sensitive, so it can take longer for the heartbeat to become visible. If past seven weeks pregnant, seeing no heartbeat may be a sign of miscarriage.

Fetal viability is confirmed by the presence of an embryo that has cardiac activity. Cardiac activity is often present when the embryo itself measures 2 mm or greater during the 6th week of gestation. If cardiac activity is not evident, other sonographic features of early pregnancy can predict viability.

It is recommended that all pregnant women undergo a routine ultrasound at 10 to 13 weeks of gestation to determine an accurate gestational age. Getting an accurate gestational age is highly important and pertinent for the optimal assessment of fetal growth later in pregnancy. Ultrasound is the most reliable method for establishing a true gestational age by measurement of crown-rump length, which can be measured either transabdominally or transvaginally.

Multiple studies have identified several risk factors for uterine atony such as polyhydramnios, fetal macrosomia, twin pregnancies, use of uterine inhibitors, history of uterine atony, multiparity, or prolonged labour.

Vaginal spotting, malodorous vaginal discharge and no signs of trauma like lacerations are the clinical features of vaginal foreign bodies in prepubertal girls. The most common object found as foreign body is toilet paper and its management includes warm irrigation and vaginoscopy under sedation/anesthesia.

Common cause of vulvovaginitis in prepubertal girls are vaginal foreign bodies. Although other objects like small toys, hair bands, etc can be occasionally found, the most common vaginal foreign body is toilet paper. Symptoms like malodorous vaginal discharge, intermittent vaginal bleeding or spotting and urinary symptoms like dysuria are caused due to the chronic irritation caused by the foreign body (the whitish foreign body in this case) on the vaginal tissue.

An external pelvic examination is performed with the girl in a knee-chest or frog-leg position in cases of suspected vaginal foreign body. An attempt at removal, after application of a topical anesthetic in the vaginal introitus, using vaginal irrigation with warm fluid or a swab can be done in case of an easily visualized small foreign body like toilet paper. In cases were the age of the girl or the type of foreign body prohibit adequate clinical evaluation the patient should be sedated or given a general anesthesia for examination using a vaginoscope and the foreign body should be removed.

In cases where child abuse or neglect is suspected Child Protective Services should be contacted. Vaginal or rectal foreign bodies can be the initial presentation of sexual abuse; however in otherwise asymptomatic girls with no behavioral changes, urinary symptoms and vulvar or anal trauma, presence of toilet paper is not of an immediately concerning for abuse.

To evaluate pelvic or ovarian masses CT scan of the abdomen and pelvis can be used; but it is not indicated in evaluation of a vaginal foreign body.

Patients in there prepubertal age have a narrow vaginal introitus and sensitive hymenal tissue due to low estrogen levels, so speculum examinations should not be performed in such patients as it can result in significant discomfort and trauma.

Topical estrogen can be used in the treatment of urethral prolapse, which is a cause of vaginal bleeding in prepubertal girls. This diagnosis is unlikely in this case as those with urethral prolapse will present with a beefy red protrusion at the urethra and not a material in the vagina.

Prepubertal girls with retained toilet paper as a vaginal foreign body will present with symptoms like malodorous vaginal discharge and vaginal spotting secondary to irritation. Initial management is topical anaesthetic application and removal of foreign body either by vaginal irrigation with warm fluid or removal with a swab.