Contraindications of PROVERA (medroxyprogesterone acetate) include: undiagnosed abnormal genital bleeding, known, suspected, or history of breast cancer, known or suspected oestrogen- or progesterone-dependent neoplasia, active DVT, pulmonary embolism, or a history of these conditions, active arterial thromboembolic disease (for example, stroke and MI), or a history of these conditions, known anaphylactic reaction or angioedema, known liver impairment or disease, known or suspected pregnancy.

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.

High FSH and low E2 levels would be expected in menopause. FSH levels would be raised as her body attempts to stimulate ovarian activity and E2 would be low due to reduced ovarian function. The other options would be possible if she was younger, and if occurring with amenorrhea, would warrant further hormonal tests.

It is often challenging to interpret hormone test results close to the time of menopause, especially if the woman is still experiencing irregular menstruation, as remaining ovarian follicles might still produce oestrogen, causing both bleeding and FSH suppression. Elevation of FSH then can be seen again once the oestrogen level drops. Hence, the results would be influenced by the timing of blood sample collection. Once amenorrhea occurs more consistently, it would be easier to interpret the results.

The vaginal epithelium is made of squamous cells. Hence the most common carcinoma that occurs in the Vagina is squamous cell carcinoma. Diagnosis is made with vaginal biopsy. Usually the pain only presents if the disease extends beyond the vagina involving the perineal nerves.

The period from attaining a complete cervical dilation of 10 cm to fetal delivery is considered as the second stage of labor. In the given case patient have achieved an excellent fetal descent to +3 due to her average-sized infant of 3.4 kg, suitable pelvis (no fetal molding or caput, suggesting no resistance against the bony maternal pelvis), and a favorable fetal position of left occiput anterior. 
But with no further fetal descent the patient fulfills the following criterias suggestive of second-stage arrest like:
≥3 hours of pushing in a primigravida without an epidural or ≥4 hours pushing with an epidural, as in this patient
OR
≥2 hours of pushing in a multigravida without an epidural or ≥3 hours pushing with an epidural.

As continued pushing without any effect will lead to complications like postpartum hemorrhage, limiting the chances of spontaneous vaginal delivery, it is better to manage this case by operative vaginal delivery procedures like vacuum-assisted delivery, to expedite delivery. maternal exhaustion, fetal distress, and maternal conditions like hypertrophic cardiomyopathy, in which the Valsalva maneuver is not recommended are the other indications for performing an operative vaginal delivery.

Fundal pressure is the technique were external pressure is applied to the most cephalad portion of the uterus, were the applied force is directed toward the maternal pelvis. The maneuver was not found to be useful in improving the rate of spontaneous vaginal deliveries.

Epidurals will not arrest or affect spontaneous vaginal delivery rates, instead they just lengthen the second stage of labor. Also an appropriate analgesia is a prerequisite to use in operative vaginal delivery.

Manual rotation of an infant to a breech presentation for breech vaginal delivery is called as internal podalic version. It is contraindicated in singleton deliveries due to the high risk associated with breech vaginal delivery in regards to neonatal mortality and morbidity.

The ideal fetal head position in vaginal delivery is occiput anterior (OA) as the flexed head in this provides a smaller diameter and facilitates the cardinal movements of labor. The occiput posterior (OP) position, in contrast to OA, presents with a larger-diameter head due to the deflexed position. So the chance for spontaneous vaginal delivery will be decreased if fetal head is rotated to OP position.

A lack of fetal descent after ≥4 hours of pushing in a primigravida with an epidural (≥3 hours without) or ≥3 hours in a multigravida with an epidural (≥2 hours without) is defined as second stage arrest of labor.  The condition is effectively managed with operative vaginal delivery procedures like vacuum-assisted delivery. Other common indications for operative vaginal delivery are maternal exhaustion, fetal distress, and maternal conditions where the Valsalva maneuver is not recommended.

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.

Bacterial vaginosis (BV) affects women of reproductive age and can either be symptomatic or asymptomatic. Bacterial vaginosis is a condition caused by an overgrowth of normal vaginal flora. Most commonly, this presents clinically with increased vaginal discharge that has a fish-like odour. The discharge itself is typically thin and either grey or white.

Although bacterial vaginosis is not considered a sexually transmitted infection, women have an increased risk of acquiring other sexually transmitted infections (STI), and pregnant women have an increased risk of early delivery.

Though effective treatment options do exist, metronidazole or clindamycin, these methods have proven not to be effective long term.

BV recurrence rates are high, approximately 80% three months after effective treatment.

Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.

Remember patients with PCOS have elevated LH. COCPs suppress synthesis and secretion of FSH and the mid-cycle surge of LH, thus inhibiting the development of ovarian follicles and ovulation COCPs reduce hyperandrogenism as reduced LH secretion results in decreased ovarian synthesis of androgens. Furthermore they stimulate the liver to produce Sex Hormone Binding Globulin which leads to decreased circulating free androgens. Other mechanisms include reduction in adrenal androgen secretion and inhibition of peripheral conversion of testosterone to dihydrotestosterone and binding of dihydrotestosterone to androgen receptors

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

Ovarian insufficiency is a failure of the ovary to function adequately in a woman younger than 40 years, in its role either as an endocrine organ or as a reproductive organ. In women aged 40 years or older, the expected physiologic decline of ovarian function that takes place with aging is termed perimenopause or the menopausal transition.
Medical treatment of patients with primary ovarian insufficiency should address the following aspects:

Ovarian hormone replacement
Restoration of fertility
Psychological well-being of the patient

It is not appropriate to give this patient contraceptive pills since she desires pregnancy.

There is no evidence that Danazol or Metformin would improve ovarian follicle function.

When cervical biopsy or colposcopy doesn’t explain the severity of the pap smear results cone biopsy is done. In 10% of biopsies, results will be different from that of the pap smear as in this patient with pap smear showing HSIL and colposcopy showing chronic cervicitis.

In such cases conization is indicated. Repeating the pap smear could risk prompt management of a serious problem. No destructive procedure, ablation or cryotherapy, should be done before diagnosis is certain.

CMV effects 1 in 200 pregnancies of which 30% will transmit the virus to the foetus and of which 30% foetus will be effected.

The normal fetal heart rate is between 110-150 bpm.

Risk factors of fibroids include early menarche, nulliparity, early exposure to oral contraceptives (one study showed 13-16 years old), diet rich in red meats and alcohol, vitamin D deficiency, hypertension, obesity, and/or history of sexual or physical abuse.

Smoking is associated with actual reduced risk due to an unknown mechanism.

Signs of shoulder dystocia:
– Difficulty with delivery of the face and chin
– The head remaining tightly applied to the vulva or even retracting (turtle-neck sign)
– Failure of restitution of the fetal head
– Failure of the shoulders to descend
Upon identifying shoulder dystocia additional help should be called and McRoberts manoeuvre (flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen) should be performed first. Fundal pressure is associated with uterine rupture and should not be used.

This question is about the differential diagnoses that should be considered if a patient presents with postpartum fever. The work-up for such patients would usually involve vaginal swabs, midstream urine culture and sensitivity and an ultrasound scan of the wound to look for any presence of a haematoma. LSCS is a major surgery and one common cause of puerperal fever would be surgical site infection. It is not surprising that women who deliver via LSCS are at higher risk of developing post-partum fever compared to those who deliver vaginally. Other common causes include endometritis and UTI. Ultrasound examination of the pelvic deep venous system and the legs would also be done to look for any thrombosis. Deep vein thrombosis can occur due to immobility, however it is unlikely to present with fever.

Tetracycline is a broad-spectrum antibiotic that crosses placental barrier. Tetracycline was the first line of therapy in treating infections caused by Mycoplasma pneumoniae, chlamydia, rickettsia, and some spirochaetes. It has a wide range of adverse effects and is known for a unique property of being incorporated into skeletal and dental tissues at sites of active mineralization and staining of these tissues.

Polycystic ovary syndrome (PCOS) is a condition in which the ovaries produce an abnormal amount of androgens, male sex hormones that are usually present in women in small amounts. The name polycystic ovary syndrome describes the numerous small cysts (fluid-filled sacs) that form in the ovaries. However, some women with this disorder do not have cysts, while some women without the disorder do develop cysts.

The symptoms of PCOS may include:
– Missed periods, irregular periods, or very light periods
– Ovaries that are large or have many cysts
– Excess body hair, including the chest, stomach, and back (hirsutism)
– Weight gain, especially around the belly (abdomen)
– Acne or oily skin
– Male-pattern baldness or thinning hair
– Infertility
– Small pieces of excess skin on the neck or armpits (skin tags)
– Dark or thick skin patches on the back of the neck, in the armpits, and under the breasts

The so-called Laurence-Moon-Biedl syndrome is a fairly rare condition characterized by six cardinal signs, namely obesity, atypical retinitis pigmentosa, mental deficiency, genital dystrophy, polydactylism and familial occurrence.

Froehlich syndrome is characterized by increased or excessive eating that leads to obesity, small testes, and a delay in the onset of puberty. It is also common for children with Froehlich syndrome to experience the delay in physical growth and the development of secondary sexual characteristics.

Cushing’s syndrome is a disorder that occurs when your body makes too much of the hormone cortisol over a long period of time. Cortisol is sometimes called the “stress hormone” because it helps your body respond to stress. Cortisol also helps. maintain blood pressure. regulate blood glucose, also called blood sugar.

Pseudohypoparathyroidism is characterized by short stature, a round face, short neck, and shortened bones in the hands and feet. Intelligence usually ranges from low normal to mentally retarded. Headaches, weakness, tiring easily, lethargy, cataracts and blurred vision or hypersensitivity to light may also be present.
This patient’s condition can only be explained by PCOS.

The most common gram negative diplococci include Neisseria, haemophilus and Moraxella.

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy, associated with weight loss of more than 5% of pre-pregnancy weight, dehydration and electrolyte imbalance. HG is usually most severe during the first 12 weeks of pregnancy and is thought to be caused by high circulating levels of HCG.

There is not yet any evidence that pregnancy itself increases the sensitivity of the area postrema, or that the hormones, oestradiol, or progesterone increase vomiting. Generally, higher concentrations of dopamine stimulates receptors in the chemoreceptor trigger zone leading to nausea and vomiting. Although this has not been demonstrated as the cause of hyperemesis gravidarum.

CMV is the most common congenital infection causing sensorineural deafness.
10-15% of infected infants will be symptomatic at birth. A further 10-15% who are asymptomatic at birth will develop symptoms later in life. Transmission can also be via breastmilk and the incubation period for CMV is 3-12 weeks. Diagnosis of fetal CMV infection is via amniocentesis however this should not be performed for at least 6 weeks after maternal infection and not until the 21st week of gestation

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia. There is no consensus on specific diagnostic criteria, but it generally refers to the severe end of the spectrum regarding nausea and vomiting in pregnancy.

Hormone changes wherein hCG levels peak during the first trimester corresponds to the typical onset of hyperemesis symptoms. It is well-known that 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.

Hyperemesis gravidarum refers to extreme cases of nausea and vomiting during pregnancy. The criteria for diagnosis include vomiting that causes significant dehydration (as evidenced by ketonuria or electrolyte abnormalities, and the dry with coated tongue) and weight loss (the most commonly cited marker for this is the loss of at least five percent of the patient’s pre-pregnancy weight) in the setting of pregnancy without any other underlying pathological cause for vomiting.

The juxtaglomerular apparatus is the main site for the production of renin. It plays an important role in the regulation of the blood pressure. These structures are mainly located in the cortex of the kidneys.

Human Papillomavirus has been is implicated in the development of genital warts as well as, head and neck, anogenital and cervical cancers, with the most important high-risk strains being 16 and 18. Over 50% of women worldwide are thought to possess antibodies against various strains of HPV after natural infection. Many infections are asymptomatic and are cleared within 2 years. Several vaccines have been formulated against HPV, one of which is Gardasil, a quadrivalent vaccine against HPV types 6,11, 16,18.

Spinnability (or Spinnbarkeit), which measures the capacity of fluids to be drawn into threads, represents an indirect measurement of the adhesive and elastic properties of mucus.

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

Tamoxifen increases risk of endometrial hyperplasia Aromatase inhibitors such as Letrozole and Anastrozole are not associated and have not been shown to increase the risk of endometrial pathology Whereas unopposed oestrogens increase endometrial cancer risk combined oral contraceptive decrease risk

IUS or Intra Uterine System/Device releases progestin. The progestin thickens the cervix, preventing the sperm from penetrating the cervix, and it also causes the uterine lining to become thinner, preventing any implantation. IUS may also prevent excessive bleeding and can help women with fibroids.

Common risk factors for Rectovaginal fistula are Pelvic radiation, Obstetric trauma, Pelvic surgery, Colon cancer, Diverticulitis and Crohn disease. Uncontrollable passage of gas &/or feces from the vagina is considered the common clinical feature of Rectovaginal fistula.
Diagnosis is done with the help of physical examination, fistulography, Magnetic resonance imaging and Endosonography.

This patient, mentioned in the case, presents with malodorous vaginal discharge (ie, stool), gas passing through the vagina, and a posterior vaginal lesion most likely has a rectovaginal fistula, which is an aberrant connection between bowel and vagina.  Although development of rectovaginal fistula is commonly associated with obstetric trauma or pelvic surgery, patients without these risk factors are recommended to be evaluated for other additional causes like gastrointestinal conditions.
This patient’s intermittent, crampy abdominal pain and perianal sinus in the setting of a rectovaginal fistula is most likely due to an underlying Crohn disease.  Crohn disease, is a transmural inflammation of the gastrointestinal tract, which predisposes patients to bowel abscess, fissure, and fistula formation.  Although the rectum is typically spared in Crohn disease, a non-healing, transmural ulcer present in the anal canal can progress to form a rectovaginal fistula.
In addition to standard Crohn disease management like anti-TNF inhibitors, glucocorticoids, etc patients with a rectovaginal fistula may require surgical correction.

Bartholin gland cysts or abscesses can present with malodorous vaginal discharge; however, patients typically have a posterior vulvar mass located at the 4 or 8 o’clock position. In addition, Bartholin gland cysts will not present with crampy abdominal pain or passage of flatus or stool through the vagina.

Hidradenitis which is the chronic occlusion and inflammation of hair follicles, can cause groin abscesses with sinus tracts and associated purulent drainage.  However, it is not associated with abdominal pain or malodorous vaginal discharge. In addition, this condition is typically multifocal and located in more than one intertriginous areas like axillary, inguinal or gluteal regions.

Cervical cancer or a retained foreign body in the vagina can cause malodorous vaginal discharge and abdominal pain.  However, patients will typically have visible findings like cervical lesion, foreign body etc on speculum examination, and these neither are associated with the passage of flatus through the vagina.

Complications of Crohn disease include perianal disease like abscess, fissure and fistula like rectovaginal fistula, due to transmural inflammation of the gastrointestinal tract.  Patients with a rectovaginal fistula typically presents with malodorous, tan vaginal discharge, passage of flatus through the vagina and a posterior vaginal lesion.

In early pregnancy Progesterone is produced by the corpus luteum.. This organ is fundamental for pregnancy maintenance until the placenta (syncytiotrophoblast) takes over its function at the 7-9th week of gestation, just after the expression of major histocompatibility complex antigens is suppressed in extra-embryonic fetal tissue.

Factor V Leiden is the most common congenital thrombophilia. Named after the Dutch city Leiden where it was first discovered. Protein C and S deficiencies are type 1 (Not type 2) thrombophilias Antiphospholipid syndrome is an acquired (NOT congenital) thrombophilia

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.

The internal anal sphincter is innervated by pelvic splanchnic nerves

This patient presenting with oligohydramnios in her third trimester and had reported an episode of sudden gush of fluid secondary to ruptured membrane which she had mistaken to be “urinary incontinence”.  Hence, the most likely cause of oligohydramnios in this patient will be premature preterm rupture of membrane (PPROM).

An amniotic fluid volume which is less than expected for gestational age is called as Oligohydramnios and is typically diagnosed by ultrasound examination. This condition can be qualitatively described as reduced amniotic fluid volume and quantitatively as amniotic fluid index ≤5 cm or a single deepest pocket <2 cm. Oligohydramnios either can be idiopathic or may have a maternal, fetal or placental cause. Fetal prognosis in this case depends on several factors like the underlying cause, the severity of loss ie. reduced versus no amniotic fluid state and the gestational age at which oligohydramnios occurred. As an adequate volume of amniotic fluid is critical for the normal fetal movements, for fetal lung development and for cushioning the fetus and umbilical cord from uterine compression, so pregnancies complicated with oligohydramnios are at higher risk for fetal deformation, pulmonary hypoplasia and umbilical cord compression.
Oligohydramnios is also associated with an increased risk for fetal or neonatal death, which can either be related to the underlying cause of reduction in amniotic fluid volume or due to the sequelae caused due to reduced amniotic fluid volume. The amniotic fluid volume reflects the balance between fluid production and movement of fluid out of the amniotic sac and the most common mechanisms behind oligohydramnios are fetal oliguria/anuria or fluid loss due to rupture of membranes; also reduction in the amount of lung fluid or increased swallowing do not play major roles in this. Idiopathic cases as in idiopathic oligohydramnios, may be due to alterations in the expression of water pores like aquaporin 1 and aquaporin 3, present in fetal membranes and placenta.

Causes of oligohydramnios
a) Maternal causes includes:
– Medical or obstetric conditions associated with uteroplacental insufficiency like preeclampsia, chronic hypertension, collagen vascular disease, nephropathy, thrombophilia.
– Intake of medications like angiotensin converting enzyme inhibitors, prostaglandin synthetase inhibitors, trastuzumab.
b) Placental causes are:
– Abruption of placenta
– Twin polyhydramnios-oligohydramnios sequence which is the Twin to twin transfusion
– Placental thrombosis or infarction
c) Fetal cases leading to oligohydramnios are:
– Chromosomal abnormalities
– Congenital abnormalities which are associated with impaired urine production
– Growth restriction
– Demise
– Post-term pregnancy
– Ruptured fetal membranes
– Infections
– Idiopathic causes

During First trimester: Etiology of oligohydramnios during the first trimester is often unclear. As the gestational sac fluid is primarily derived from the fetal surface of the placenta via transamniotic flow from the maternal compartment and secretions from the surface of the body of the embryo reduced amniotic fluid prior to 10 weeks of gestation is rare.

During Second trimester: Fetal urine begins to enter the amniotic sac and fetus begins to swallow amniotic fluid by the beginning of second trimester, therefore, during this period any disorders related to the renal/urinary system of the fetus begins to play a prominent role in the etiology of oligohydramnios. Some of such anomalies include intrinsic renal disorders like cystic renal disease and obstructive lesions of the lower urinary tract like posterior urethral valves or urethral atresia. Other common causes of oligohydramnios in the second trimester are maternal and placental factors and traumatic or nontraumatic rupture of the fetal membranes.

During Third trimester: Oligohydramnios which is first diagnosed in the third trimester is often associated with PPROM or with conditions such as preeclampsia or other maternal vascular diseases leading to uteroplacental insufficiency. Oligohydramnios frequently accompanies fetal growth restriction as a result of uteroplacental insufficiency.

As B-HCG and TSH have similar structures, increased B-HCG can lead to hyperthyroidism, however there is only a 3% chance of this happening.

Circulation in the foetus: 1. Deoxygenated fetal blood is conducted to the placenta via the two umbilical arteries. The umbilical arteries arise from the internal iliac arteries.
2. Gas exchange occurs in placenta.
3. Oxygenated blood from the placenta passes through the single umbilical vein and enters the inferior vena cava (IVC).
4. About 50% of the blood in the IVC passes through the liver and the rest bypasses the liver via the ductus venosus. The IVC also drains blood returning from the lower trunk and extremities.
5. On reaching the heart, blood is effectively divided into two streams by the edge of the interatrial septum (crista dividens) (1) a larger stream is shunted to the left atrium through the foramen ovale (lying between IVC and left atrium) (2) the other stream passes into right atrium where it is joined by blood from SVC which is blood returning from the myocardium and upper parts of body. This stream therefore has a lower partial pressure of oxygen.
6. Because of the large pulmonary vascular resistance and the presence of the ductus arteriosus most of the right ventricular output passes into the aorta at a point distal to the origin of the arteries to the head and upper extremities. The diameter of the ductus arteriosus is similar to the descending aorta. The patency of the ductus arteriosus is maintained by the low oxygen tension and the vasodilating effects of prostaglandin E2;
7. Blood flowing through the foramen ovale and into left atrium passes into the left ventricle where it is ejected into the ascending aorta. This relatively oxygen rich blood passes predominantly to the head and upper extremities.

The Apgar test scores appearance, pulse, grimace, activity, and respiration and is generally done at 1 and 5 minutes after birth but may be repeated if the child continues to score low (Table). This child’s score is as follows: Appearance, 1; Pulse, 1; Grimace, 2; Activity, 2; Respiration, 2 (APGAR score = 8). A score of 3 or less is generally regarded as critically low, 4 to 6 is fairly low, and 7 to 10 is generally normal. Contrary to common belief, the Apgar score is not used to decide if a neonate requires resuscitation. Decisions about resuscitation are based on emergency assessment of airway, breathing, and circulation.5,6

In the management of postpartum haemorrhage, it is essential that the bleeding is first mechanically prevented, followed by the administration of oxytocic drugs, which cause the uterine smooth muscle to contract and clamping off bleeding sites in the endometrium. The drug of choice in the treatment protocol of PPH is 5 units of syntocin, a synthetic oxytocin uterotonic, by slow intravenous infusion. This is particularly suitable in the case of uterine atony. Other uterotonics, misoprostol, carboprost, ergometrine, can be used, but are not as effective in an emergency setting.

Elevated fasting plasma glucose means gestational diabetes mellitus and is not considered to be in the spectrum of a normal pregnancy. In normal pregnancy however, maternal tissues become progressively insensitive to insulin. This is believed to be caused partly by hormones from the placenta and partly by other obesity and pregnancy related factors that are not fully understood. Gestational diabetes mellitus (GDM) occurs in about 5% of pregnancies but figures vary considerably depending upon the criteria used and demographic characteristics of the population.

Testing for GD should use the 2 hour 75g oral glucose tolerance test (OGTT) to test for GD in women. Testing women who have had GD in a previous pregnancy: early self monitoring of blood glucose OR a 75 g 2 hour OGTT as soon as possible after booking (whether in the first or second trimester) and a further 75 g 2hour OGTT at 24-28 weeks if the results of the first OGTT are normal. Testing women with risk factors for GD: 75g 2 hour OGTT at 24-28 weeks

Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and foetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values. 

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.

All non-sensitised RhD negative women should receive Anti-D IgG within 72 hours following abortion

Oesophageal atresia/TE fistula may be suspected prenatally with ultrasound findings of polyhydramnios, absence of fluid in the stomach, small sized abdomen, or the presence of a dilated proximal oesophageal pouch. An underlying disease is only found in 17 % of cases in mild polyhydramnios. In contrast, an underlying disease is detected in 91 % of cases in moderate to severe polyhydramnios. The literature lists the following potential aetiologies: fetal malformations and genetic anomalies (8–45 %), maternal diabetes mellitus (5–26 %), multiple pregnancies (8–10 %), fetal anaemia (1–11 %), other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios.

Achieving spontaneous pregnancy is rare in cases where a couple have been infertile with abnormal semen analysis (count <5million/mL and reduced motility), hence there is generally an indication for treatment. FSH injection usually would not be expected to improve the semen specimen. Rate of pregnancy would be much lower if at the time of intrauterine insemination, the total motile count is less 5 million. In this case, his count is 1 million. Pregnancy is likely to be achieved with donor sperm but as it would not contain the husband’s genetic material, it would be only considered later on once all other methods involving his own sperm have failed. Out of all the options, IVF would most likely result in a pregnancy, in which it allows the husband’s sperm to spontaneously fertilise the oocyte. Rate of pregnancy would roughly be 2% per treatment cycle. This rate would increase to roughly 20% if ISCI is also used.

Meconium is the earliest stool of a newborn. Occasionally, newborns pass meconium during labour or delivery, resulting in a meconium-stained amniotic fluid (MSAF).

No particular cardio-tocograph pattern can be considered to have a poor prognostic value in the presence of thick MSAF and the decision to deliver and the mode of delivery should be based on the overall assessment and the stage and progress of labour. While management should be individualized, a higher Caesarean section rate in thick MSAF can be justified to ensure a better outcome for the neonate even in the presence of a normal CTG trace.

Nipple stimulation during breastfeeding triggers the production of oxytocin from the hypothalamus and its subsequent release from the posterior pituitary gland. The hormone causes the myoepithelial cells of the breast to contract causing milk to flow through the ducts.

Ergometrine and Prostaglandin E2 are used during labour to control uterine bleeding after delivery, or ripen the cervix, while Atosiban is an oxytocin antagonist.

Antidiuretic hormone is also released from the posterior pituitary, and acts on the kidneys to decrease fluid excretion.

The following hormones are excreted from the anterior pituitary gland: TSH, GN, ACTH, LH, FSH, MSH, PRL.
Human chorionic gonadotropin (hCG, or human chorionic gonadotrophin) is a placental hormone secreted by syncitiotrophoblasts during the second week of gestation.

Patients suffering from androgen insensitivity syndrome have 46XY chromosomes. Due to insensitivity to androgens, they have female characteristics e.g. scant pubic or body hairs, enlarged mammary glands, and a small penis.

Majority of the lymph from the ovaries drain into the para-aortic lymph nodes.

The maxillary arteries and the external carotid arteries develop from the first pharyngeal arch. The stapedial arteries arise from the second, the common carotid artery and the internal carotid arteries from the third and the arch of the aorta and the right subclavian artery from the forth arch.

Anti phospholipid syndrome is an autoimmune disorder in which abnormal antibodies are formed which increases the risk of blood clots to develop in vessels and leads to recurrent miscarriages to occurs. The changes of recurrent miscarriage in a previously known case of APL is 15%.

The signs and symptoms of premenstrual dysmorphic disorder are well-known in this patient. Fluoxetine is the greatest therapeutic option among the available options.
For severe symptoms, clomipramine and danazol can be used interchangeably.
Bromocriptine, like oral contraceptives and evening primrose, has no scientific evidence to support its use in this syndrome.
NSAIDs are helpful for painful symptoms, but they only address a limited number of them.

The changes seen in breast tissue with the menstrual cycle are accentuated during pregnancy. Deposition of fat around glandular tissue occurs, and the number of glandular ducts is increased by oestrogen, while progesterone and human placental lactogen (hPL) increase the number of gland alveoli. Prolactin is essential for the stimulation of milk secretion and during pregnancy prepares the alveoli for milk production. Although prolactin concentration increases throughout pregnancy, it does not then result in lactation since it is antagonized at an alveolar receptor level by oestrogen.

Osteogenesis imperfect is an autosomal dominant condition. All the rest of the options are autosomal recessive conditions.

Pruritus of pregnancy is a common disorder, which occurs in 1 in 300 pregnancies, and presents as excoriated papules on extensor limbs, abdomen
and shoulders. It is more common in women with a history of atopy. Prurigo usually starts at around 25–30 weeks of pregnancy and resolves after delivery,
with no effect on the mother or baby. Treatment is symptomatic with topical steroids and emollients. It occurs due to derangement in the LFTs. ALP can rise to up to 3 times the normal non-pregnant value in the 3rd trimester.
All of the other tests above typically decrease during pregnancy.

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.

In women of childbearing age, the most likely cause of abnormal vaginal bleeding is pregnancy; thus, the most appropriate initial test would be an hCG level. Once pregnancy has been excluded, patient history would guide further testing. Iatrogenic causes, usually resulting from certain medicines or supplements, are the next most common cause in this age group, followed by systemic disorders. Haemoglobin and haematocrit would be appropriate only if the patient seemed acutely anaemic due to the abnormal bleeding.

Nausea and vomiting experienced in 80% of pregnancies Hyperemesis gravidarum (HG) is an extreme form of nausea and vomiting which affects around 1.5% of women. Caused by high levels HCG. Definitions vary but most consider it to be defined by severe nausea and vomiting associated with weight loss greater than 5% of pre-pregnancy weight with metabolic disturbance (typically dehydration and/or ketosis).

The T10 spinal segment provides the sympathetic nerve fibres that innervate the testes

The blastocyst hatchs from the Zona Pellucida

Fibroids (uterine leiomyomas) are benign uterine tumours. Asymptomatic uterine leiomyomas merely require follow-up without any specific intervention because histological confirmation of the clinical diagnosis is not required in most cases.

Symptoms and consequences necessitate treatment. The definitive therapy is hysterectomy. Other options include various types of myomectomy, endometrial ablation, uterine artery embolization, and myolysis.
The following situations call for a hysterectomy:

Women suffering from an acute haemorrhage who have failed to react to various treatments
Women who are finished having children who are at risk for other disorders (cervical intraepithelial neoplasia, endometriosis, adenomyosis, endometrial hyperplasia, or greater risk of uterine or ovarian cancer) that a hysterectomy might eliminate or reduce.

Women who have had previous attempts at minimally invasive therapy for leiomyomas failed.
Women who have finished having children and have severe symptoms, many leiomyomas, and a desire for a permanent cure.

If a hysterectomy is planned, total abdominal hysterectomy is the procedure of choice.
A course of gonadotropin-releasing hormone (GnRH) agonists followed by myomectomy is the therapy of choice for women who want to keep their capacity to bear children.

Total abdominal hysterectomy is the best option for this woman who does not want to have further children, has had her tubes tied, and is experiencing painful symptoms and anaemia.
Hysterectomy is superior to endometrial ablation.

Amenorrhea is achieved after endometrial ablation, however, leiomyomas remain untreated.

Women who have previously failed minimally invasive treatment for leiomyomas

Women who have finished having children and have severe symptoms, many leiomyomas, and a strong desire for a cure.

If a hysterectomy is planned, total abdominal hysterectomy is the preferred technique.

A course of gonadotropin-releasing hormone (GnRH) agonists followed by myomectomy is the therapy of choice for women who want to maintain their capacity to bear children.

Total abdominal hysterectomy is the best option for this woman who does not want to have any more children and has had her tubal ligation removed. She also has troublesome symptoms and anaemia.
Hysterectomy is better than endometrial ablation.

Amenorrhea can be accomplished with endometrial ablation, however, leiomyomas are not.

Myomectomy is not recommended unless you want to increase your fertility. There is a chance of recurrence, which would demand additional procedures. It will also be difficult to remove all of the leiomyomas if the uterus is enlarged with several leiomyomas. Remaining leiomyomas might grow and cause symptoms again over time.

Hormonal therapies such as combination contraceptive tablets, progesterone-only approaches, danazol, and others have been used with anecdotal results on symptoms like menorrhagia. Some have dubious efficacy, while others with confirmed efficacy have unfavourable side effects, restricting their use.
In leiomyomas-related menorrhagia, NSAIDs have not been widely researched. Although NSAIDs do not appear to diminish blood loss in women with leiomyomas, they do lower painful menses and may be effective for this.

Serum progesterone has been proposed as a useful test to distinguish a viable pregnancy from a miscarriage or ectopic pregnancy. Low progesterone values are associated with miscarriages and ectopic pregnancies, both considered non-viable pregnancies, and high progesterone concentrations with viable pregnancies. A single progesterone measurement for women in early pregnancy presenting with bleeding or pain and inconclusive ultrasound assessments can rule out a viable pregnancy. The probability of a non-viable pregnancy was raised from 62.9% to 96.8%.

The pudenal nerves has three branches, namely the inferior rectal, perineal and the dorsal nerve of the clitoris. The perineal nerve has two branches: The superficial perineal nerve gives rise to posterior scrotal or labial (cutaneous) branches, and the deep perineal nerve supplies the muscles of the deep and superficial perineal pouches, the skin of the vestibule, and the mucosa of the inferior most part of the vagina. The inferior rectal nerve communicates with the posterior scrotal or labial and perineal nerves. The dorsal nerve of the penis or clitoris is the primary sensory nerve serving the male or female organ, especially the sensitive glans at the distal end.

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

Ureters are muscular tubes that run from the kidneys to the urinary bladder. It is lined by transitional epithelium.

The maternal mortality rate starts low and raises steeply after the age of 30 years. The lowest mortality rate recorded among women is between 19-30 years of age group.

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.

TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. The signs and symptoms of trichomoniasis are present in this patient. Trichomonas vaginalis is the reason.
Increased vaginal discharge that is frothy, yellowish, and has an unpleasant odour are among the symptoms. It’s frequently linked to dyspareunia and dysuria. Normally, the genital area is red and painful.

In both men and women, trichomoniasis can cause preterm labour and raise the risk of infertility. Both the patient and the partner must be treated at the same time.

The active infection can be treated with a single oral dose of metronidazole 2 g taken with food.
To avoid disulfiram-like symptoms, alcohol should be avoided during the first 24-48 hours after treatment.

This describes the sensory area supplied by the ilioinguinal nerve. This is a potential complication with pelvic surgery.

Haemoglobin decreases from 13.3 g/dL to 10.5 g/dL from the start of pregnancy i.e. First trimester till the 3rd trimester.

LH, FSH and Oestrogen have their peaks just before ovulation on day 14 whereas progesterone peaks around day 21.

Staph aureus is the most common causative organism of skin and soft tissue infections.

If the patient has a negative Chlamydia screen then a stat dose of metronidazole monotherapy is appropriate. You do not know this patients Chlamydia status and therefore dual therapy with metronidazole + doxycycline or azithromycin is appropriate.

Congenital Herpes Simplex Virus infection may cause high levels of morbidity and mortality in neonates. Risk of infection with HSV 1 and 2 is highest within 6 weeks of delivery and is transferred to the neonate via maternal secretions at birth. Affected babies can present as skin manifestations, CNS infection, or disseminated infection, which carries an 85% risk of mortality if left untreated. Treatment with high dose antivirals such as acyclovir can help decrease the case mortality rate to 30% in cases of disseminated infection.

In girls, delayed puberty and primary amenorrhea may be subdivided according to associated changes in stature. If the affected girl is short, the likely causes are gonadal dysgenesis (Turner syndrome) or hypopituitarism (with both gonadotropin and growth hormone deficiency). Gonadal dysgenesis results from the absence of a sex chromosome or other abnormality of a sex chromosome. In affected girls the gonads are streaks of fibrous tissue and contain no follicles, and these girls may have a variety of congenital anomalies, including a webbed neck, a shieldlike chest, or a small jaw.

Kallmann syndrome presents with amenorrhea, infantile sexual development, low gonadotropins, normal female karyotype, and anosmia (the inability to perceive odours).

In Müllerian agenesis, the Müllerian ducts either fail to develop or regress early in fetal life. These patients have normal ovarian development and normal secondary sexual characteristics. They present with a blind vaginal pouch and no upper vagina, cervix, or uterus, and primary amenorrhea.

The McCune-Albright syndrome rather presents with precocious puberty.

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.

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.

Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus.

Counselling her about the risks associated with obesity during pregnancy will be the best possible advice to give this patient. A combined follow up by an obstetrician and a diabetes specialist at a high-risk pregnancy clinic is required to formulate the best ways in management of gestation with obesity.
An oral glucose tolerance test should be done at 26 weeks of her pregnancy, along with advising her on controlling her weight by diet and lifestyle modifications. During the early weeks of their pregnancy all obese patients must be routinely tested for pre-existing diabetes.

It is highly inappropriate to advice her not to get pregnant.

Without making a proper diagnosis of diabetes, it is wrong to ask her to start oral hypoglycemic agent and/or insulin.

Checking urinary proteins is not indicated at this stage, but can be considered as a part of antenatal check up.

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.

Pregnant women with high-grade squamous intraepithelial lesions (HSIL) on cervical cytology should be evaluated with colposcopy. Principles of management of pregnant women include the following:
– An immediate diagnostic excisional procedure should NOT be performed.
– When colposcopy is performed during pregnancy:
– Endocervical sampling with a curette and endometrial sampling should NOT be performed, as there is a risk of disturbing the pregnancy; however, the endocervical canal may be sampled gently with a cytobrush.
– Cervical biopsy should be performed only if a lesion is present that appears to be high grade or suspicious for cancer.
– If the examination is unsatisfactory, repeating the colposcopy after 6 to 12 weeks should allow visualization of the entire squamocolumnar junction.

There is no indication for inducing abortion or performing a hysterectomy.

As the most likely diagnosis, this woman meets diagnostic criteria for premenstrual syndrome (PMS).
Affective and physical symptoms that begin one week before menstruation and end four days after menstrual flow begins are diagnostic criteria for premenstrual syndrome. The symptoms must be present for at least three menstrual cycles and must not occur during the preovulatory period.
It’s critical to note that these symptoms are not caused by any medical or psychological condition, medications, drugs, or alcohol.

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent tears, and a lack of interest in daily activities. To put it another way, emotional impairment is the most prominent trait.

This woman does not meet the diagnostic criteria for PMDD because she only has psychological symptoms of irritation and anxiety, as well as physical symptoms of headache and breast soreness (five symptoms).

PMDD diagnostic criteria include:
Symptoms and their timing
A) At least 5 symptoms must be present in the final week before menses, improve within a few days after menses, and become mild or non-existent in the week after menses in the majority of menstrual cycles.
Symptoms
B) At least one of the symptoms listed below must be present:
1) Affective lability that is noticeable (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
2) Excessive irritation, wrath, or interpersonal conflicts
3) Depressed mood, hopelessness, and self-depreciating thoughts
4) Severe anxiety, tension, and/or a sense of being tense or on edge
C) In addition to the symptoms listed in criterion B, one (or more) of the following symptoms must also be present to reach a total of five symptoms.
1) Loss of enthusiasm for customary activities
2) Subjective concentration problems
3) Lethargy, fatigability, or a noticeable lack of energy
4) Significant changes in appetite, such as binge eating or specific food desires
5) Insomnia or hypersomnia
6) A feeling of being overwhelmed or powerless
7) Physical signs and symptoms include breast discomfort or swelling, joint or muscle pain, bloating, or weight gain.
Severity
D)The symptoms are linked to clinically substantial distress or interfere with employment, school, regular social activities, or interpersonal relationships.
E) Think about other mental illnesses. The disturbance isn’t only a sign of another disorder, like major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
Confirmation of the condition
F)Prospective daily ratings throughout at least two symptomatic cycles should be used to confirm Criterion A. (although a provisional diagnosis may be made prior to this confirmation)
Other medical explanations are ruled out.
G) The symptoms aren’t caused by the physiological consequences of a substance (e.g., drug misuse, medication, or other treatment) or a medical condition (e.g., hyperthyroidism).
The severity of the symptoms cannot be explained by normal menstrual physiology.
Generalized anxiety disorder and depression are improbable diagnoses because these symptoms are temporally tied to menstrual cycles.

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.

Medical abortion is preferred from 4 to 9 weeks of gestation and in Australia, suction curettage is the most frequently used method of abortion as it is considered useful from 6 to 14 weeks of gestation.

Mifepristone is a synthetic anti-progesterone, which is found to be effective for abortion when combined with misoprostol. There are evidences which suggest the effectiveness of misoprostol and mifepristone in both first and second trimesters. It is most commonly administered as a single dose of mifepristone followed by misoprostol, a prostaglandin, given orally or vaginally two days later. Prostaglandin can be repeated at an interval of 4 hours if required.
As the vaginal use shows only few gastrointestinal side effects Misoprostol is more effective and better tolerated vaginally than orally. Misoprostol is not approved for its use in termination of pregnancy, but is available in the market due to its indications in other conditions.
Methotrexate can be used orally or as an intramuscular injection followed by misoprostol up to seven days later, but this also is not a preferred method for termination of pregnancy in Australia.

Prolactin levels rise steadily during pregnancy during which time it promotes mammary growth (along with the other hormones mentioned below). Oestrogen and progesterone inhibit lactogenesis and it is only with the loss of these placental steroid hormones at term that Prolactin exhibits its lactogenic effect.

The half life of oxytocin is 5 mins, which is why is should be started as an infusion at a low rate.

Expected date of delivery (EDD) is a calculated from the first day of the woman’s last menstrual period. If her periods are regular i.e., 28-day menstrual cycle, Naegele’s rule may be used. Naegele’s rule involves a simple calculation: add seven days to the first day of your LMP and then subtract three months. e.g. 30 June + 7 days = 7 July, minus 3 months = 7 April.

Normal menstrual blood loss is about 40-45 ml. More than 80 ml per period is defined as heavy menstrual bleeding.

The external carotid develops from the 1st arch. The common and internal carotid develop from the 3rd arch.

Oxytocin acts via the G protein receptors and the calcium-calmodulin complex. It activates phospholipase C which produces IP3 to further trigger the calcium-calmodulin complex increasing intracellular Ca ion release.

Antiepileptic, phenytoin more so than topiramate are inducers of cytochrome P450. They should not be given with COCPs. The metabolism of oestrogen and progestogen is increased by anti-epileptic drugs that induce cytochrome P450 leading to a loss of contraceptive effect.

The Sella turcica is composed of three parts:
1. The tuberculum sellae (horn of saddle): a variable slight to prominent median elevation forming the posterior
boundary of the prechiasmatic sulcus and the anterior boundary of the hypophysial fossa.
2. The hypophysial fossa (pituitary fossa): a median depression (seat of saddle) in the body of the sphenoid that accommodates the pituitary gland (L. hypophysis).
3. The dorsum sellae (back of saddle): a square plate of bone projecting superiorly from the body of the sphenoid.
It forms the posterior boundary of the Sella turcica, and its prominent superolateral angles make up the posterior clinoid processes.

Anomalies of the cervico-uterus are widely diagnosed by HSG. The diagnostic value of HSG in the detection of anomalies varies, depending on the type of malformation.

of cases there is no permanent neurological disability. Shoulder dystocia is the most common cause of Erb’s palsy (Erb-Duchenne palsy) where there is injury to C5 and C6 of the brachial plexus (C5 to T1)

When there are about 12-32 blastomeres, the developing human is referred to as morula. It enters the uterine cavity around the 4th day after fertilization.

The next best line of management is immediate delivery via Caesarean section ( C section).

This is because of the change in cardiotocography (CTG). The pattern became much more severe with a virtual lack of short-term variability and prolonged decelerations. These changes indicate the necessity for an immediate C section as the cervix is not fully dilated.

As immediate delivery is indicated, another pH assessment is unnecessary as it would delay delivery and increase the likelihood of fetal hypoxia.

Delivery by ventose, in a primigravida where the cervix is only 8cm dilated is not indicated as it would allow the labour to proceed or augmenting with Syntocinon.

Breech presentation refers to the foetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first.

The current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned caesarean section for delivery sometime after 39 weeks.

When the palpated uterine size is in discrepancy with the expected size based on the duration of amenorrhoea, it can have several causes including reduced fluid volume or fetal growth (both of which are more common when there is fetal malformation), or miscalculated age of gestation as a result of wrong dates or actual ovulation occurring at a later date than expected. Reduced fluid volume and fetal growth are the most likely aetiologies during the third trimester of pregnancy, unlike in this patient at 20 weeks age of gestation.

Premature rupture of membranes is less likely the cause when there is negative vaginal fluid loss like this patient.

The most likely cause in this case is that ovulation did not occur as expected, especially when the patient ceased her OCPs during this period. In some instances, ovulation can occur 2 weeks later in about 50% of women, 6 weeks later in 90%, and may still not occur 12 months later in 1% of women.

The other listed statements are unlikely to explain the discrepancies in dates and the observed uterine size in this patient.

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.

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.

Domperidone and metoclopramide are D2 dopamine receptor antagonists. They are primarily used to promote gastric motility. They are also known as galactagogues and they promote the production of milk. Cabergoline and bromocriptine are prolactin inhibitors and they reduce milk production.

The pelvis is supported by a variety of ligaments. At term, these ligaments allow for variation in its structure such that the overall size of the pelvic cavity is increased in order to accommodate the upcoming foetus into the cavity.

Cord entanglement, a condition unique to MoMo pregnancies, occurs in 42 to 80% of the cases and it has been traditionally related to high perinatal mortality. Umbilical cord entanglement is present in all monoamniotic twins when it is systematically evaluated by ultrasound and colour Doppler. Perinatal mortality in monoamniotic twins is mainly a consequence of conjoined twins, twin reversed arterial perfusion (TRAP), discordant anomaly and spontaneous miscarriage before 20 weeks’ gestation. Expectantly managed monoamniotic twins after 20 weeks have a very good prognosis despite the finding of cord entanglement. The practice of elective very preterm delivery or other interventions to prevent cord accidents in monoamniotic twins should be re-evaluated.

The uterus is divisible into two portions. The portion above the isthmus is termed the body, and that below, the cervix. The uterine cervix is the narrow inferior segment of the uterus, which projects into the vaginal cavity. It is a fibromuscular organ lined by a mucous membrane and measures approximately 3cm in length and 2.5cm in diameter. The cervix is continuous at its superior margins with the body of the uterus and at its inferior margins with the vagina.

The production of milk is regulated by the hormone Prolactin. Oxytocin on the other hand is responsible for the let down reflex that occurs during breast feeding.

Women aged 25-49 years living in England are routinely recalled for screening every three years. Women receive their first invitation for cervical screening at 25 years of age. They are not invited earlier as changes in the young cervix can be normal and result in unnecessary treatment. Provided the smears remain negative and there are no symptoms to suggest cervical cancer, the routine recall is three years for women aged 25-49 years. Women aged 50-64 years old are routinely recalled for a smear every five years. After the age of 65 years, women are only screened if they have not had a smear since the age of 50 years (including those who have never had a smear) or those who have had recent abnormal smears. This is because due to the natural history and progression of cervical cancer, it is highly unlikely that women over 65 years old will go on to develop the 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.

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.

Treatment for infertility caused by ovulation issues has had the best results by far. PCOS, also known as Stein-Leventhal syndrome, is marked by hyperandrogenism, tiny cysts in the ovaries, acne, and hirsutism, as well as ovulation issues that result in anovulatory cycles due to hormonal imbalance.

70% of females with anovulatory periods begin ovulation under medical supervision, and 50% of those conceive within 6 to 9 months.

Infertility can be caused by low or no sperm counts, poor sperm motility, or dysmorphic sperms. Treatment options include fertility medicines that promote sperm production, artificial insemination with donor sperm, and intracytoplasmic injection of sperm, but success rates are poor (less than 25 percent ). Following pelvic inflammatory disease, previous surgery, or tuberculosis, the Fallopian tubes become obstructed or damaged, preventing sperm from reaching the ovum. Tubal blockages and adhesions are treated by laparoscopic surgery. The success rate of conception varies greatly depending on the degree of the blockage, ranging from 10% to 70%.

Turner syndrome is linked to infertility and ovarian dysgenesis. Treatment for gonadal dysgenesis and reversal of infertility is not an option. Because of the high likelihood of miscarriages, even after egg donation, the success rate is relatively low.

Mifepristone is a prostaglandin antagonist. It acts as a competitive inhibitor of the receptor.

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

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

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

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

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

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

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

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

Pulmonary embolism (PE) is a treatable disease caused by thrombus formation in the lung-vasculature, commonly from the lower extremity’s deep veins compromising the blood flow to the lungs.
Computed tomography of pulmonary arteries (CTPA) and ventilation-perfusion (V/Q) scan are the two most common and widely practiced testing modalities to diagnose pulmonary embolism.

Pulmonary ventilation (V) and Perfusion (Q) scan, also known as lung V/Q scan, is a nuclear test that uses the perfusion scan to delineate the blood flow distribution and ventilation scan to measure airflow distribution in the lungs. The primary utilization of the V/Q scan is to help diagnose lung clots called pulmonary embolism. V/Q scan provides help in clinical decision-making by evaluating scans showing ventilation and perfusion in all areas of the lungs using radioactive tracers.

Ventilation-perfusion V/Q scanning is mostly indicated for a patient population in whom CTPA is contraindicated (pregnancy, renal insufficiency CKD stage 4 or more, or severe contrast allergy) or relatively inconclusive.

In pregnancy, progesterone is produced by the corpus luteum followed by the placenta- Exogenous progesterone will not lead to withdrawal bleeding. In ovarian failure as well as pituitary failure, no oestrogen stimulation of the endometrium exists, and progesterone cannot cause withdrawal bleeding. With Mullerian agenesis, there is no endometrium. Polycystic ovarian syndrome has an abundance of circulating oestrogen, so the endometrium will proliferate.

→ In pregnancy progesterone withdrawal will not occur since the corpus luteum is producing progesterone- The placenta will take over, starting at 7 weeks, and will be the sole producer of progesterone by 12 weeks.
→ In ovarian failure no oestrogen will be produced; no proliferation of the endometrium will occur.
→ Pituitary failure is an incorrect answer because without gonadotropin stimulation, there will not be enough oestrogen to stimulate the endometrial lining.
→ Mullerian agenesis is an incorrect answer – there is no uterus, thus no bleeding.

Although acyclovir should be given, this patient is in the 3rd trimester so the course should continue until delivery. Dose will be 400mg TDS unless disseminated disease. If this is a primary HSV infection (This should be confirmed by lesion swabs to confirm HSV infection and bloods to check no antibody response i.e. evidence previous infection) then C-section is indicated.

Radiotherapy causes ionisation, primarily of water. This leads to hydroxyl and other free radicals being generated. Free radicals are highly reactive and cause DNA damage to cells via their reactions with them. Free radicals are relatively short lived and eventually form stable compounds. The DNA damage leads to cellular death.

First stage: The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions. A definition of active labour in a British journal was having contractions more frequent than every 5 minutes, in addition to either a cervical dilation of 3 cm or more or a cervical effacement of 80% or more.

Second stage: fetal expulsion begins when the cervix is fully dilated, and ends when the baby is born.

Third stage: placenta delivery – The period from just after the foetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage.

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 commonest foetal presentation in twin pregnancy is cephalic-cephalic.

Bacterial vaginosis (BV) is a clinical condition characterized by a shift in vaginal flora away from Lactobacillus species toward more diverse bacterial species, including facultative anaerobes. The altered microbiome causes a rise in vaginal pH and symptoms that range from none to very bothersome. Future health implications of BV include, but are not limited to, increased susceptibility to other sexually transmitted infections and preterm birth. Fifty to 75 percent of women with BV are asymptomatic. Symptomatic women typically present with vaginal discharge and/or vaginal odour. The discharge is off-white, thin, and homogeneous; the odour is an unpleasant fishy smell that may be more noticeable after sexual intercourse and during menses.

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.

PMNs phagocytise debris and kill bacteria via free radicals (AKA respiratory burst). They also break down damaged tissue. PMNs typically undergo apoptosis after 48 hours. They are then engulfed and degraded by macrophages. Macrophages therefore become the predominant cell type in the wound on days 3-4.

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.

Foetal movements often become apparent at about 18-20 weeks gestation. This phenomenon is also called quickening. The Foetal movements continue to increase in frequency and force until 32 weeks where they plateau. Foetal movements can be used to monitor the wellbeing of the foetus, alerting the mother and healthcare providers to a problem.

The management of low-grade squamous intraepithelial lesions (LSIL) on cervical cytology in women ages 25 years or older depends upon whether the patient underwent high-risk human papillomavirus (HPV) testing.

Women in this age group comprise two different populations in terms of cervical cancer screening strategies. Professional organizations recommend that women ages 25 to 29 years be screened with cytology alone, while women 30 years or older should be screened with cytology and HPV co-testing. Thus, the American Society for Colposcopy and Cervical Pathology (ASCCP) prefers that women ages 25 to 29 years are not managed based upon HPV results, even if an HPV test was performed at the time of screening. For women with ages 30 years or older and HPV positive, colposcopy must be performed.

Risk of fibroids is more common among African ethnicity and is also related to obesity and early puberty. The role of combined oral contraceptive pills is still debatable and its results are conflicting, whereas the risk of fibroids decreases with the increase in number of pregnancies. i.e. multiparous women have a lower risk of fibroids.

It is important to be aware of which ant-epileptics induce cytochrome P450. Of the above Topiramate and Phenytoin are moderate and strong inducers respectively.

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.

As the mother is found to be rhesus negative while her baby being rhesus positive, the given case is clinically diagnosed as spontaneous abortion due to Rh incompatibility. The mother should be administered anti-D for prophylaxis for avoiding future complications.

Rhesus (Rh) negative women who deliver a Rh-positive baby or who comes in contact with Rh positive red blood cells are at high risk for developing anti-Rh antibodies. The Rh positive fetuses
eonates of such mothers are at high risk of developing hemolytic disease of the fetus and newborn, which can be lethal or associated with serious morbidity.
In such situations both spontaneous and threatened abortion after 12 weeks of gestation, are indications to use anti-D in such situations.

All the other options are incorrect.

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

Trichomoniasis is considered a sexually transmitted infection found both in men and women, and is caused by the flagellate protozoan Trichomonas vaginalis. The organism is mainly found in the vagina and the urethra. Though many infected women can be asymptomatic, they can also present with yellow frothy vaginal discharge, itching and vaginitis, dysuria or an offensive odour. About 20-30% of women with the infection however are asymptomatic. For the diagnosis of t. vaginalis in women, a swab is taken from the posterior fornix during speculum examination and the flagellates are detected under light-field microscopy. The recommended treatment for t. vaginalis during pregnancy and breastfeeding is 400-500mg of metronidazole twice daily for 5 -7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated and screened for other STIs.

The case above gives a classic presentation of preterm premature rupture of membranes(PPROM). In term or near term women rupture of membrane harbingers labor, so if ROM does not end up in established labor in 4 hours, is called as premature ROM (PROM). In other words, PROM is defined as ROM before the onset of labor and if it occurs before 37 weeks, the preferred term is PPROM. In both these scenarios treatment approach will be different.
A sudden gush of watery fluid per vagina, continuous or intermittent leakage of fluid, a sensation of wetness within the vagina or perineum are the classic presentation of rupture of the membranes(ROM), regardless of the gestational age. Pathognomonic symptoms symptoms of ROM are presence of liquor flowing from the cervical os or pooling in the posterior vaginal fornix.
PPROM is associated with many risk factors and some of them are as follows:
– Preterm labor
– Cord prolapse
– Placental abruption
– Chorioamnionitis
– Fetal pulmonary hypoplasia and other features of prematurity
– Limb positioning defects
– Perinatal mortality
Once the diagnosis is confirmed the following measures should be considered in the management plan:
a) Maternal corticosteroids
Adverse perinatal outcomes like respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis can be effectively reduced using corticosteroids. The duration of using neonatal respiratory support, in case of respiratory distress, can be significantly reduced by the administration of corticosteroids. If preterm labor is a concern in cases were gestational age is between 23•0d and 34•6d weeks or if preterm birth is planned or expected within the next 7 days corticosteroids are indicated.
Recommended regimens to the woman are IM betamethasone in two doses of 11.4 mg, given 24 hours apart and if betamethasone is unavailable, IM dexamethasone given 24 hours apart in two doses of 12 mg.
A single repeat dose of corticosteroid given seven days or more after the first dose is suggestive in cases were the gestational age is less than 32• 6d, if the woman is still considered to be at risk of preterm labor, up to 3 repeated doses can be considered.
Another option is Tocolysis using nifedipine and is indicated if the woman is in labor. This helps in cessation of labor for at least 48 hours, providing a window for corticosteroid to establish its effects. Tocolysis is not indicated in cases with absence of uterine contractions suggestive of labor.
It is appropriate to transfer this woman to a tertiary hospital after administering the first doses of corticosteroid and antibiotics. This ensures optimal neonatal care in case of premature delivery.
As the patient needs investigations and fetal monitoring along with close observation for development of any signs of infection and preterm labor, it is not appropriate to discharge this patient on oral antibiotics
Admitting to a primary care center without neonatal ICU (NICU) does no good to the outcome of this patient.

Wound healing typically undergoes different stages that include haemostasis, inflammation, proliferation and remodelling. The phases are often shortened when healing occurs by primary intention such as in a surgical wound. Remodelling, which is the major strengthening phase, takes about 3 weeks, while it takes a total of 12 weeks to reach maximum tensile strength.

Luteo-placental shifts occurs around 6-8 week when the placenta takes over from the corpus luteum as the main producer of oestrogen and progesterone.

Condition where there is insufficient fetal descent after pushing for ≥3 hours in nulliparous and ≥2 hours if multiparous women is defined as Second stage arrest of labor. Common risk factors for this presentation are maternal obesity, excessive weight gain during pregnancy and diabetes mellitus. Cephalopelvic disproportion, malposition, inadequate contractions and maternal exhaustion are the common etiologies of Second stage arrest of labor. Management includes Operative vaginal delivery or cesarean delivery as indicated in the case.

The second stage of labor begins with the dilatation of cervix to 10 cm and will end with fetal delivery. Parity and use of neuraxial anesthesia are the two factors which will affect the duration of second stage of labor and fetal station, which measures the descent of the fetal head through the pelvis determines its progression.

When there is no fetal descent after pushing for ≥3 hours or ≥2 hours in in nulliparous and multiparous patients respectively the condition is called an arrested second stage of labor. As her first delivery was a cesarean session due to breech presentation, this patient in the case is considered as nulliparous.

Most common cause of a protracted or arrested second stage is fetal malposition, which is the relation between the fetal presenting part to the maternal pelvis. Occiput anterior is the optimal fetal position as it facilitates the cardinal movements of labor, any deviations from this position like in occiput transverse position, can lead to cephalopelvic disproportion resulting in second stage arrest.
Inadequate contractions, that is less than 200 MVU averaged over 10 minutes, can lead to labor arrest but contractions are adequate in case of the patient mentioned.
Second stage arrest can be due to maternal obesity and excessive weight gain during pregnancy but this patient had a normal pre-pregnancy BMI of 20 kg/m2 and an appropriate weight gain of 15.9 kg 35 lb. So this also cannot be the reason.

Maternal expulsive efforts will change the fetal skull shape. This process called as molding helps to facilitate delivery by changing the fetal head into the shape of the pelvis. Whereas prolonged pressure on head can result in scalp edema which is called as caput, presence of both molding and caput suggest cephalopelvic disproportion, but is not suggestive of poor maternal effort.

Patients with a prior history of uterine myomectomy or cesarean delivery are at higher risk for uterine rupture.  In cases of uterine rupture, the patient will present with fetal heart rate abnormalities, sudden loss of fetal station (eg, going from +1 to −3 station) along with fetal retreat upward and into the abdominal cavity through the uterine scar due to decreased intrauterine pressure. In the given case patient’s fetal heart rate tracing is category 1 and fetal station has remained 0 which are non suggestive of uterine rupture.

When there is insufficient fetal descent after pushing ≥3 hours in nulliparous patients or ≥2 hours in multiparous patients is considered as second stage arrest of labor. The most common cause of second stage arrest is cephalopelvic disproportion, were the fetus presents in a nonocciput anterior position called as fetal malposition.

The Fallopian tubes, also known as, uterine tubes, and salpinges, are two very fine tubes lined with ciliated columnar epithelia, leading from the ovaries of female mammals into the uterus, via the uterotubal junction.

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.

The most likely cause of her postcoital bleeding is cervical ectropion as suggested by her postcoital bleeding, normal pap smears and use of oral contraceptive pills.

Cervical ectropion is a benign condition that occurs as a result of overexposure to oestrogen. Here, glandular cells (the columnar epithelium) lining the endocervix, begin to grow on the ectocervix, leading to exposure of the columnar cells to the vaginal environment.

These columnar cells are prone to trauma and bleeding during coitus.

This patient has acidosis as the pH is low <7.35 The pO2 is irrelevant. The pCO2 is raised i.e. the respiratory system is causing acidosis. The patient is acidotic so this is a respiratory acidosis The Base Excess is normal. You would typically expect the base excess to rise but metabolic compensation is slower than respiratory compensation so this picture may be seen acutely.

As the time of onset of fever is the 4th day of postpartum and absence of uterine tenderness on exam makes infection of vaginal laceration the most likely cause of this presentation.

Exquisite uterine tenderness will be experienced in case of endometritis and symptoms are expected to start much earlier like by 2-3 days of postpartum.

UTI is often expected on days one or two of postpartum, also there are no urinary symptoms suggestive of UTI

Breast engorgement usually develops by 7th -2st day of postpartum and in the given case it’s too soon for it to occur.

As it is expected during the first 2 hours postpartum, Atelectasis is unlikely to be the cause of symptoms in the given case.

Twin pregnancies are at risk for iron deficiency due to significant maternal, fetal, and placental demands. Recommendations regarding the optimal iron dose in twin pregnancies are based on clinical expert opinions, advocating doubling the dose of iron from 30 mg of elemental iron to 60 mg routinely during the second and third trimester, regardless of maternal iron stores.

If pregnant with twins, patient should take the same prenatal vitamins she would take for any pregnancy, but a recommendation of extra folic acid and iron will be made. The additional folic acid and extra iron will help ward off iron-deficiency anaemia, which is more common when patient is pregnant with multiples.

Lymphatic drainage of the breast.
The lateral two thirds of the breast drains into the axillary lymph nodes. This constitute about 75% of the lymphatic drainage of the breast. The medial third of the breast drains into the parasternal lymph nodes and these communicate with the ipsilateral lymph nodes from the opposite breast. The superior part of the breast drains into the infraclavicular lymph nodes and inferior part drains into the diaphragmatic lymph nodes.

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.

Protein C, protein S, plasminogen and anti thrombin III are all anti thrombotic agents. Thromboplastin is a pro-thrombotic.

Extreme headache, vision defects, such as blurring of the eyes, rib pain, sudden swelling of the face, hands or feet are all consistent with pre-eclampsia. Women with the mentioned symptoms should have their blood pressure checked immediately. They should also be checked for proteinuria.

Diarrhoea is not related to pre-eclampsia. Pruritus would be more related to pregnancy cholestasis. Meanwhile, bruising and abnormal LFTs are common in complicated pre-eclampsia but not in an uncomplicated one.

The fetal head is engaged when the head of the foetus or the presenting part enters the pelvic inlet or pelvic brim. It usually occurs at 38 weeks of gestation.
The Spalding sign refers to the overlapping of the fetal skull bones caused by collapse of the fetal brain. It appears usually a week or more after fetal death in utero.
In brow presentation the scalp is deflexed as the foetus is looking upward. Normally the head is inflexed such that the chin is touching the chest.

Breakthrough bleeding, or spotting, refers to when vaginal bleeding occurs between menstrual cycles. It may look like light bleeding or brown discharge.

Spotting is the most common side effect of birth control pills. It happens because the body is adjusting to changing levels of hormones, and the uterus is adjusting to having a thinner lining.

Taking the pill as prescribed, usually every day and at the same time each day, can help prevent bleeding between periods.

All other options are incorrect as this is a common side effect and will resolve on its own.

Oxygenation of fetal blood occurs in the placenta before it returns in the umbilical vein which joins the left branch of the portal vein. It bypasses the capillaries of the liver by going through the ductus venosus, which is obliterated after birth and becomes the ligamentum venosum. The oxygenated blood enters the inferior vena cava and is transported to the right atrium and
then through the patent foramen ovale to the left atrium and on to the left ventricle. From the left ventricle, the blood flows into the aorta and through the fetal vascular network. Blood returning from the head of the foetus passes through the superior vena cava to the right atrium and straight on to the right ventricle and pulmonary artery. However, it does not enter the pulmonary
circulation, being short-circuited by the ductus arteriosus to the aorta. Aortic blood is carried via the umbilical arteries back to the placenta for reoxygenation. At birth, the three short circuits, the ductus venosus, foramen ovale and ductus arteriosus, close.

Varicella is a live vaccine. The recent RCOG green top guidelines suggest vaccine can be considered postpartum or pre pregnancy but NOT whilst pregnant. In the non-immune pregnant woman they should be advised to avoid contact with people with chickenpox or shingles and to contact a healthcare professional promptly if exposed. If they have a significant exposure VZIG should be offered as soon as possible.