At 12 weeks gestation the fundus is expected to be palpable above the pubis symphysis and it is expected to be felt at the level of umbilicus by 20 weeks. Though the uterine fundus stands in between from 12 and 20 weeks, the height of the fundus in centimeters is equivalent to the weeks of pregnancy after 20 weeks.

For 14-week pregnant uterus a fundal height of 18cm is definitely large and dating errors is considered as the most common cause for such a discrepancy. Hence, it is better to perform an ultrasound scan for more accurately estimating the gestational age. Also if the case is not a simple dating error, ultrasonography can provide definitive additional information about other possible conditions such as polyhydramnios, multiple gestation, etc that might have led to a large-for-date uterus.

A large-for-gestational-age uterus are most commonly found in conditions like:
– Dating errors which is the most common cause
– Twin pregnancy
– Gestational diabetes
– Polyhydramnios
– Gestational trophoblastic disease, also known as molar pregnancy

Obligate anaerobes are a group of bacteria that cannot survive in an oxygen-rich environment. In the body, they are usually found on mucosal membranes such as that of the lower gastrointestinal system, or the vagina. Infection with these organisms is usually suprative and causes abscesses. Examples of gram-negative anaerobes include Bacteroides, Fusobacterium and Prevotella, while gram-positive anaerobes include Actinomyces and Clostridia. Staphylococcus and Streptococcus are both gram-positive facultative anaerobes.

The BPP is performed in an effort to identify babies that may be at risk of poor pregnancy outcome, so that additional assessments of wellbeing may be performed, or labour may be induced or a caesarean section performed to expedite birth.

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

Amniotic fluid volume begins to increase rapidly in the second and third trimester as the fetal kidneys continue to develop. By 35 weeks gestation the amniotic fluid volume reaches a maximum average of about 800 ml after which it decreases slightly to term.

Diastolic murmurs occur in conditions such as mitral stenosis, tricuspid stenosis and even in carditis. They are always pathological during pregnancy. Systolic murmurs and left axis deviation may be normal during pregnancy due to an increase in the blood volume and load on the heart.

This woman has mixed incontinence, which includes signs and symptoms of both stresses and urges incontinence. The urge, on the other hand, irritates her. Bladder training would be the most appropriate management approach to investigate first for women with urge incontinence as the most troublesome symptom. The objectives are:
– Using a bladder diary to establish a baseline
– Creating a voiding schedule
– Over a long period, gradually increase the voiding interval in increments of 2- 5 minutes, to void every 3 hours.
– Other important strategies to consider are lifestyle changes like reducing fluid intake, losing weight, and avoiding diuretics-producing foods and beverages (e.g., alcoholic beverages, caffeine, etc).

When urge incontinence does not respond to physical or behavioural therapy, anticholinergics along with ongoing bladder training are an alternative. A 4- to 6-week trial is employed. At six months, risk and benefit are weighed to see if treatment should be continued for those who react. Patients should be informed about anticholinergic side effects such as dry mouth and constipation, as well as how to control them.

Anterior colporrhaphy is a treatment for cystocele that involves repairing the front vaginal wall. It can help people with urine incontinence. If you don’t have a cystocele, bladder neck suspension is the best option.
Retropubic bladder suspension is a more intrusive surgery for treating stress urinary incontinence in patients who haven’t responded to less invasive treatments like pelvic floor exercise.

The most essential initial conservative therapy to explore for patients with real stress incontinence and mixed (both stress and urge) urine incontinence when stress incontinence is the more prominent symptom is pelvic floor muscle exercise (e.g. Kegel exercise). For urge incontinence, more difficult training can be applied.

The treatment of asphyxia starts with the correct perinatal management of high-risk pregnancies. The management of the hypoxic-ischemic new-borns in the delivery room is the second fundamental step of the treatment. Low Apgar scores and need for cardiopulmonary resuscitation at birth are common but nonspecific findings. Most new-borns respond rapidly to resuscitation and make a full recovery. The outcomes for new-borns who do not respond to resuscitation by 10 minutes of age are very poor, with a very low probability of surviving without severe disability. Resuscitation in room air is advised for term new-borns, since the use of 100% oxygen is associated with worse outcomes compared to the use of room air.

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.

Penicillin is the treatment of choice for treating syphilis. For treatment of syphilis during pregnancy, no proven alternatives to penicillin exist. Treatment guidelines recommend desensitization in penicillin-allergic pregnant women, followed by treatment with penicillin. Syphilis in pregnancy is associated with mental retardation, stillbirth and sudden infant death syndrome; therefore it should be treated promptly.

– Data are insufficient to recommend ceftriaxone for treatment of maternal infection and prevention of congenital syphilis.
– Erythromycin and azithromycin should not be used, because neither reliably cures maternal infection or treats an infected foetus.
– Tetracycline and doxycycline are contraindicated in pregnancy and ceftriaxone is much less effective than penicillin.

The most common causative agent found in female urinary tract infections is Escherichia Coli. E. Coli is a bacteria found in the environment and the human gastrointestinal system. Other common causes of UTI include Klebsiella sp, Proteus sp and various Enterococci.

Urinary incontinence can be divided into two main aetiologies, stress incontinence, or overactive bladder. Conservative management include lifestyle interventions, controlling fluid intake, or bladder exercises. If conservative management is no longer efficient, then medications may be indicated. Oxybutynin is an anticholinergic drug used in the treatment of urinary incontinence. As with other anticholinergic drugs, side effects include dry mouth, dry eyes, blurry vision and constipation. About 1 in 10 patients taking Oxybutynin will experience some of these side effects.

This patient has developed deep vein thrombosis during pregnancy and required anti-coagulation as part of treatment for up to 3-6 months. Enoxaparin, which is a low molecular weight heparin, is preferred over heparin due to the once or twice a day therapeutic dosing. Also monitoring of aPTT is not required in this case.

There is an association between Enoxaparin and an increased risk for epidural hematoma in women receiving epidural anaesthesia during labour. Considering that the patient mentioned is expected to go for delivery in 4 weeks and the possibility of her needing an epidural anaesthesia or general anaesthesia in case of undergoing a cesarean section, enoxaparin should be switched to unfractionated heparin, four weeks prior to the anticipated delivery. This is because of the fact that heparin can be antidoted with protamine sulphate.

Woman in the given case is taking a full bottle of Whisky every day. As per standards, a small glass of Whisky (1.5 Oz) is equivalent of a standard drink and a bottle definitely exceeds 12 standard drinks. This makes her fetus at significant risk for fetal alcohol syndrome (FAS) which is associated with many congenital malformations. Low-set ears, midfacial hypoplasia, elongated philtrum, upturned nose and microcephaly along with skeletal and cardiac malformations are the congenital malformations commonly associated with fetal alcohol syndrome.

Health risks of benzodiazepines during pregnancy has not been clearly established, but there are inconsistent reports of teratogenic effects associated with fetal exposure to benzodiazepines. Neonatal abstinence syndrome of delayed onset can be associated with regular use of benzodiazepine in pregnancy.

Use of Amphetamine in controlled doses during pregnancy is unlikely to pose a substantial teratogenic risk, but a range of obstetric complications such as reduced birth weight and many these outcomes which are not specific to amphetamines but influenced by use of other drug and lifestyle factors in addition to amphetamine are found commonly among women who use it during pregnancy. Exposure to amphetamines in utero may influence prenatal brain development, but the nature of this influence and its potential clinical significance are not well established.

3,4- methylenedioxymetham phetamine(MOMA), which is an amphetamine derivative and commonly known as ecstasy, have existing evidences suggesting that its use during first trimester poses a potential teratogenic risk. So it is strongly recommended to avoided the use of ecstasy during 2-8 weeks post conception or between weeks four to ten after last menstrual period as these are the considered periods of organogenesis.

Role of cocaine in congenital malformations is controversial as cases reported of malformations caused by cocaine are extremely rare. However, it may lead to fetal intracranial haemorrhage leading to a devastating outcome.

Opiate addictions carry a significant risk for several perinatal complications, but it has no proven association with congenital malformation.

Second-trimester ultrasound markers have low sensitivity and specificity for detecting Down syndrome, especially in a low-risk population.

The highest detection rate is acquired with ultrasound markers combined with gross anomalies. Although the detection rate with this combination of markers is high in a high-risk population (50 to 75 percent), false-positive rates are also high (22 percent for a 100 percent Down syndrome detection rate).

The lower vagina drains to the inguinal nodes where as the upper vagina drains to the internal and external iliacs

Vulvovaginal candidiasis is the most common genital infection and it is caused by candida albicans in 80-92% of the cases. Other non albicans species include C.tropicalis, C.glabrata, C.krusei and C.parapsilosis. 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.

Condylomas are warty neoplasms of the vulvar area. The most common type are condyloma acuminatum which occur due to HPV 6 or 11. Condyloma latum are also known as secondary syphilis are less common. Both of these are sexually transmitted.

Stages of Syphilis:
– Primary 3-90 days
Chancre and lymphadenopathy
– Secondary 4-10 weeks
Widespread rash typically affecting hands and soles of feet.
Wart lesions (condyloma latum) of mucus membranes
– Latent Early <1 yr. after secondary stage
– Late >2 yr. after secondary stage
Asymptomatic
– Tertiary 3+ years after primary infection
Gummas or
Neurosyphilis or
Cardiovascular syphilis

A cephalic presentation is the one where head of the foetus enters the pelvic cavity at the time of delivery. The commonest form of cephalic presentation is the vertex presentation in which the occiput of the foetus enters the birth canal.

Antepartum haemorrhage is any bleeding that occurs from the female genital tract during the antenatal period after the 24+0 week of pregnancy and prior to the birth of the baby. The most common causes are placenta previa and placental abruption.

The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve (S2-4) while the internal anal sphincter is innervated by autonomic nerves.

The pudendal nerve has its origins form S2, S3 and S4 spinal segments. It provides sensation to the clitoris and labia along with the ilioinguinal nerve.

Syphilis is a sexually transmitted disease which is caused by spirochete called treponema pallidum. It can be divided into three stages. i.e. primary, secondary and tertiary syphilis.
– Primary syphilis is characterized by chancre formation at the site of sexual contact.
– Secondary syphilis ranges from maculopapular lesions to scaly lesions, inguinal lymphadenopathy, condylomata lata and split papules at the corner of mouth.
– Tertiary syphilis is the late stage of syphilis which is characterized by gummas formation and general paresis along with signs and symptoms of visceral involvement.

Proteinuria of more than 1+ on dipstick should be investigated to quantify the amount of proteinuria. A protein: creatinine ratio can be used to determine the severity of proteinuria, where levels of more than 30 mg/mmol indicate significant proteinuria.

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.

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.

Genetically, patients suffering from androgen insensitivity syndrome are 46XY. They are males but insensitive to male hormones i.e. androgens.

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

Oesophageal atresia of the foetus interrupts the normal circulation of the amniotic fluid. This causes polyhydramnios and subsequent distension of the uterus impacting proper expansion of the lungs. This would explain the difficulty breathing.

The WHO defines maternal death as female death from any cause related to pregnancy or its management, including childbirth or within 42 days of termination of pregnancy. This is irrespective of the duration or site of the pregnancy.

There is an increase risk of developing carcinoma of the uterus, if the endometrium shows hyperplasia with atypia. The standard surgery is total hysterectomy with bilateral salpingectomy which can be performed abdominally or laparoscopically If the disease is grade 1-2 and less than 1B i.e. less than 50% invasion of the uterine body.

As there has been no bleeding or expulsion of the products of conception this is a missed miscarriage

Folic Acid should be increased in diet of a pregnant women. Deficiency will lead to neural tube defects i.e. spina bifida.

Bacterial vaginosis is the most common cause of acute vaginitis, accounting for up to 50% of cases in some populations. It is usually caused by a shift in normal vaginal flora- Mixed vaginal flora is considerably more common as a cause of vaginal discharge than – albicans and T. vaginalis.

The clinical picture demonstrated is most likely that of a ruptured ectopic pregnancy. The period of amenorrhea may point to pregnancy, while the past medical history of 2 recent terminations of pregnancy may indicate a failure of her current contraceptive method. Smoking cigarettes have been shown to not only decrease the efficacy of OCPs, but also serve as a known risk factor for ectopic pregnancy. The lady is unlikely to have endometritis as her last termination was over 6 months ago. The lack of fever helps to make appendicitis, PID and pyelonephritis less likely, though they are still possible.

Congenital rubella infection that occurs after 16 weeks gestation does not typically cause fetal abnormalities. This however plays no part in vaccination advice. Rubella vaccine is live and should not be given during pregnancy. The mother should be offered vaccination after giving birth. It is safe for the vaccine (typically given as combined MMR) to be administered if the mother is breastfeeding.

The condition should be an X-linked recessive condition, as it affects only male offspring. Duchene muscular dystrophy is an X-linked recessive condition. Cystic fibrosis is an autosomal recessive disorder. Spina bifida is a multifactorial condition. Down syndrome is caused by trisomy of chromosome 21. Spinal muscular atrophies are inherited in an autosomal-recessive pattern.

The proximal portion of urethra in females or membranous urethra in males is in the deep perineal pouch

From the options given, option A is correct as primary pulmonary hypertension is considered a contraindication to pregnancy.
The patient should be educated about the possible risks and increased maternal mortality in such cases. This restriction is due to the fact that symptoms of Pulmonary hypertension gets worse during pregnancy which results in high maternal mortality.
Termination of pregnancy may be advisable in these circumstances mostly to preserve the life of the mother.
Sudden death secondary to hypotension is also a commonly dreaded complication among patients with pulmonary hypertension during pregnancy.

OCPs should be started in this patient as well as condoms to prevent likely sexually transmitted infections.

Condoms alone are not effective for prevention of pregnancy.

OCPs alone do not prevent from sexually transmitted infections.

It is not appropriate to inform the parents and the patient hasn’t refused any advice.

Research suggests the risk of having preeclampsia again is approximately 20%, however experts cite a range from 5% to 80% depending on when you had it in a prior pregnancy, how severe it was, and additional risk factors you may have. If you had preeclampsia during your first pregnancy, you may get it again. HELLP is related to preeclampsia and about 4 to 12 percent of women diagnosed with preeclampsia develop HELLP. HELLP syndrome can also cause complications in pregnancy, and if you had HELLP in a previous pregnancy, regardless of the time of onset, you have a greater risk for developing it in future pregnancies.

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

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.

T-Helper cells type 2 increase during pregnancy. They secret cytokines IL-4,5,9,10 and 13.

The gestational sac is typically visible from 31 days gestation by transvaginal ultrasound and a week later (38 days) on transabdominal ultrasound.

Dermoid cysts and teratomas contain elements from multiple germ cell layers. They are often considered the same entity (even in medical texts) however a dermoid is composed only of dermal and epidermal elements. A teratoma has mesodermal and endodermal elements Mature teratomas are composed of well-differentiated derivations from at least 2/3 germ cell layers (i.e. ectoderm, mesoderm, and endoderm). They contain developmentally mature skin complete with hair follicles, sweat glands, sometimes hair, and sometimes sebum, blood, fat, bone, nails, teeth, eyes, cartilage, and thyroid tissue.

The use of anticoagulants during pregnancy is a complicated issue because warfarin is teratogenic if used in the first trimester, and is linked with fetal intracranial haemorrhage in the third trimester (mainly at doses 5 mg daily). Low molecular weight heparin may be insufficient at preventing thrombosis in women with mechanical prosthetic heart valves, where the risk of valve thrombus is 10 per cent. Anticoagulation is essential in patients with congenital heart disease who have pulmonary hypertension, or artificial valve replacements, and in those in or at risk of atrial fibrillation. The options are either to continue warfarin for the pregnancy, or replace it with heparin between 6 and 12 weeks gestation to avoid the teratogenic risk. Warfarin should be started a week after delivery.

This patient is most likely to have a ruptured ectopic pregnancy. The history of multiple TOPs suggests her contraceptive methods are not reliable and her missed period is suggestive she may currently be pregnant. There is no temperature or vaginal discharge to suggest PID though this is of course possible as is appendicitis. The last termination was 6 months ago so endometritis is unlikely.

This is a case of a woman who presented with cyclical breast pain that is on an OCP and with a family history of breast cancer. Those with a family history of breast cancer in more than one blood relative (parent, sibling, grandparent) have a significantly higher chance of developing breast cancer than women with no family history. Regular six-monthly clinical review and yearly mammographic screening, with or without ultrasound screening, should start at least five years before the age of the diagnosis in the blood relatives.

The consensus now is that any additional risk of breast cancer from the oestrogen in the oral contraceptive pill (OCP) is less than the risk of unwanted pregnancy when using alternative, and perhaps less effective, contraception. Thus, the patient would not be advised to stop the OCP.

With two blood relatives that developed breast cancer before the age of 50, this patient is in a high-risk group of developing breast cancer. Even so, 50% of such high-risk women will not develop a breast cancer in their lifetime. There are specialised familial cancer screening clinics are available for high-risk women where genetic testing can be discussed further. Women at high risk may electively have a bilateral subcutaneous mastectomy performed prophylactically which will bring the risk of breast cancer development to an irreducible minimum.

For this pregnant patient who recently travelled overseas most likely has a deep venous thrombosis (DVT). It would also be expected that the patient would have oedema in the symptomatic leg and account for the swelling described.

Though they could cause unilateral leg pain, neither symphyseal separation nor sciatica due to a prolapsed intervertebral disc usually occur as early as 18 weeks of gestation. This patient’s symptoms also do not suggest either diagnosis.

Pain due to trauma would usually be maximal at the site where the trauma took place, which would be in the knee for this patient. Traumatic pain and house cleaning also would not cause the pain described or result in ankle swelling.