HPV 16 and 18 are responsible for 70% of cases of HPV related cancers. They are considered the most important high risk genotypes of HPV. As well as cervical cancer they are associated with cancers of the oropharynx and anogenital region.

There are over 100 genotypes of HPV including several other high risk HPV types. Gardasil® is a quadrivalent vaccine against HPV Types 6, 11, 16, and 18

HPV genotypes 6 and 11 are low risk and cause anogenital warts.

Typically 70% of HPV infections are cleared within 1 year and 90% are cleared within 2 years

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.

The treatment of stage 1A cervical cancer is excision of the margins using the Loop electrical excision procedure (LLETZ). Hysterectomy is not necessary. This treatment enables fertility to be preserved.

2010 FIGO classification of cervical carcinoma
0 – Carcinoma in situ
1 – Confined to the cervix (diagnosed microscopy)
1A1 – Less than 3mm depth & 7mm lateral spread
1A2 – 3mm to 5mm depth & less than 7mm lateral spread
1B1 – Clinically visible lesion or greater than A2 & less than 4 cm in greatest dimension
1B2 – Clinically visible lesion, greater than 4 cm in greatest dimension
2 – Invades beyond uterus but not to pelvic wall or lower 1/3 vagina
2A1 – Involvement of the upper two-thirds of the vagina, without parametrical invasion & Less than 4cm
2A2 – Greater than 4 cm in greatest dimension
2B – Parametrial involvement
3 – Extends to Pelvic side wall or lower 1/3 vagina or hydronephrosis
3A – No pelvic side wall involvement
3B – Pelvic side wall involved or hydronephrosis
4 – Extends beyond true pelvis 4A Invades mucosa bladder and rectum
4B – Distant Metastasis

A complication of bilateral salpingo-oophorectomy and hysterectomy is the formation of adhesions in the GIT that can cause intestinal obstruction. Abdominal X-ray is sufficient to visualize any obstruction in the GIT.

Fibroids are a common gynaecological condition found in many women above the age of 35. They are however uncommon before puberty. They are most common in black women vs white women, and its prevalence increases from puberty to menopause. Risk factors for fibroids include increasing age, obesity and infertility. Protective factors, on the other hand, include pregnancy, as the risk of fibroids decreases with increasing numbers of pregnancies.

Fertilization usually occurs in the fallopian tubes after ovulation. The zygote moves through the fallopian tube and implants in the endometrium about 7-9 days after fertilisation, or 6-12 days after ovulation.

This patient should be given promethazine and codeine as she presents with severe migraine.

Usage of metoclopramide is safe during pregnancy and for increasing effectiveness it can be added to paracetamol. However, because of its risk for causing extrapyramidal effects it should be used only as a second-line therapy and Promethazine should be considered as the first line choice of remedy. So the answer is Codeine and promethazine.

Opioid pain relievers such as codeine are not been reported of having any associated with increased birth defects or miscarriage, but its long-term use can lead to dependency in mother and withdrawal signs in the baby.

Paracetamol alone or combined with codeine is not found to be useful in controlling vomiting.

It is advised to completely avoid dihydroergotamine and the triptans throughout pregnancy.

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

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

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

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

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

Ovulation usually occurs on day 14 in a typical 28-day cycle. Luteinizing hormone levels spike as a result of increased oestrogen levels secreted from maturing follicles. This LH spike occurs about 24-36 hours before the release of the oocyte from the mature follicle.