If the external anal sphincter is in tact then this is a 1st or 2nd degree tear. As the perineal muscles are involved this is 2nd degree tear.

Endometrial cancer should always be the first diagnosis to rule out in a 65-year-old lady with brownish vaginal discharge. The inquiry focuses on the most likely source of the symptoms, rather than the most significant diagnosis to explore.
Blood typically causes the dark hue of vaginal discharge. The uterine cavity or the vagina can both be the source of bleeding. Only 5-10% of postmenopausal women with vaginal bleeding were found to have endometrial cancer. Around 60% of the women had atrophic vaginitis.

Urogenital atrophy is caused by oestrogen insufficiency in postmenopausal women. Urogenital atrophy can cause the following symptoms:
– Dry vaginal skin
– Vaginal inflammation or burning
– Vaginal lubrication is reduced during sexual activity.
– Vulvar or vaginal pain, as well as dyspareunia (at the introitus or within the vagina)
– Vaginal or vulvar bleeding (e.g. postcoital bleeding. fissures)
– Vaginal discharge from the cervix (leukorrhea or yellow and malodorous)
– A vaginal bulge or pelvic pressure
– Symptoms of the urinary tract (e.g. urinary frequency, dysuria, urethral discomfort, haematuria).

The blastocyst hatchs from the Zona Pellucida

HB gower 1 is the predominant embryonic haemoglobin when the foetus is 6 week old and is replaced by adult haemoglobin by the age of 5 months post natally. Only 2% of the haemoglobin is HbF.

Embryonic Haemoglobin:
Haemoglobin Gower 1 (HbE Gower-1)
Haemoglobin Gower 2 (HbE Gower-2)
Haemoglobin Portland I (HbE Portland-1)
Haemoglobin Portland II (HbE Portland-2)

Fetal Haemoglobin (haemoglobin F, HbF)

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

Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation. Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies.

Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the foetus to turn into the vertex presentation in the third trimester include:
– Mullerian anomalies
– Placentation
– Uterine leiomyoma
– Prematurity
– Aneuploidies and fetal neuromuscular disorders
– Congenital anomalies
– Polyhydramnios and oligohydramnios
– Laxity of the maternal abdominal wall.

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.

The Bishop score is a system used by medical professionals to decide how likely it is that you will go into labour soon. They use it to determine whether they should recommend induction, and how likely it is that an induction will result in a vaginal birth.

During the early fetal life, oogonia proliferate by mitosis. They enlarge to form primary oocyte before birth. No primary oocyte is form after birth. The primary oocyte is dormant is the ovarian follicles until puberty. As the follicle matures, the primary oocyte completes its first meiotic division and gives rise to secondary oocyte. During ovulation the secondary oocytes starts the second meiotic division but is only completed if a sperm penetrates it. This 1st and 2nd meiotic division is known as ootidogenesis.

(13-20 weeks). If a mother has chickenpox in late pregnancy (5 days prior to delivery) then there is risk of neonatal varicella infection which may be severe.

Functional Hypothalamic Amenorrhea (FHA) is a form of chronic anovulation, due to non-identifiable organic causes and often associated with stress, weight loss, excessive exercise, or a combination thereof. Investigations should include assessment of systemic and endocrinologic aetiologies, as FHA is a diagnosis of exclusion. A multidisciplinary treatment approach is necessary, including medical, dietary, and mental health support. Medical complications include, among others, bone density loss and infertility.

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.

This patient should be advised to use both an OCP and a condom. The combined oestrogen/progestogen contraceptive pill (COCP) has been found to be very effective. However, she should be made aware that it would not provide any protection from any sexually transmitted diseases so she might still be at risk of developing a STD, depending on her sexual partner preferences. To ensure protection from STDs, she should be advised to use both condoms as well as the combined OCP. An IUCD (intrauterine contraceptive device) would not be preferable if she has multiple sexual partners (high risk of STDs). If she has been screened for STDs, does not actively have an STD and has only one sexual partner then IUCD is a possible option. Some issues that may arise with spermicide use could be related to compliance. This also applies to using condoms alone. These two options are less reliable as compared to COCP.

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

Causes of Hyperprolactinemia: Prolactinomas, Medication (phenothiazines, metoclopramide, risperidone, selective serotonin reuptake inhibitors, oestrogens, verapamil), Stress, Pregnancy, Hypothyroidism, Kidney disease, Chest trauma

Chlamydia trachomatis (D-K subtypes) is the most common cause in this age group and fits the descriptors given.

Her T-score puts her in the osteopenic range. The presence of fragility fractures is more important in the osteoporotic patient. Olecranon fracture is not a typical fragility fracture.

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

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

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

All other options are incorrect.

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.

Trichomoniasis is considered a sexually transmitted infection found both in men and women 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. 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 for a HIV positive woman who is pregnant is 500mg of metronidazole twice daily for 7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated, and screening for other STIs should be carried out.

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

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

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

Endocrine hormones are released from their site of origin and travel through the blood to act on other distant target organs. Autocrine hormones act within the same cell and exocrine glands secrete their products into ducts.

The Rhesus status of a mother is important in pregnancy and abortion. The exposure of an Rh-negative mother to Rh antigens from a positive foetus, will influence the development of anti-Rh antibodies. This may cause problems in subsequent pregnancies leading to haemolysis in the newborn. Rh Anti RhD- globulin is therefore given to non-sensitised Rh-negative mothers to prevent the formation of anti-Rh antibodies within 72 hours following abortion. Anti RhD globulin is not useful for already sensitized, or RhD positive mothers.

Premature menopause occurs if menopause happens before the age of 40. It effects 1% of women under the age of 40 and 0.1% under 30.

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.

The endometrium is lined by columnar epithelium

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

Oxytocin binds to the G protein coupled receptors that triggers the IP3 mechanism leading to an elevated intracellular calcium ion.

This patient experiences a stress based mixed urinary incontinence presented as leakage of urine while sneezing or coughing and urgency which is an intense urge to urinate with small voiding volume as her symptoms. Urinary incontinence is common and may cause significant distress in some, as seen in this patient who wears a pad every day.  Initial evaluation of mixed incontinence includes maintaining a voiding diary, which helps to classify the predominant type of urinary incontinence and thereby to determine an optimal treatment by tracking the fluid intake, urine output and leaking episodes.

All patients with mixed incontinence generally require bladder training along with lifestyle changes like weight loss, smoking cessation, decreased alcohol and caffeine intake and practicing pelvic floor muscle exercises like Kegels. Depending on the predominant type, patients who have limited or incomplete symptom relief with bladder training may benefit from pharmacotherapy or surgery.

In patients with urgency-predominant incontinence, timed voiding practice like urinating on a fixed schedule rather than based on a sense of urgency along with oral antimuscarinics are found to be useful.

Surgery with a mid-urethral sling is performed in patients with stress-predominant incontinence which is due to a weakened pelvic floor muscles as in cystocele.

In patients with a suspected urethral diverticulum or vesicovaginal fistula, a cystoscopy is usually indicated but is not used in initial evaluation of urinary incontinence due to its cost and invasiveness.

Urodynamic testing involves measurement of bladder filling and emptying called as cystometry, urine flow, and pressure (eg, urethral leak point).  This testing is typically reserved for those patients with complicated urinary incontinence, who will not respond to treatment or to those who are considering surgical intervention.

Initial evaluation of mixed urinary incontinence is done by maintaining a voiding diary, which helps to classify predominant type of urinary incontinence into stress predominant or urgency predominant and thereby to determine the optimal treatment required like bladder training, surgical intervention, etc.

Uterine surgical history & scope of vaginal birth are as follows:
– In case of low transverse cesarean delivery with horizontal incision: trial of labor is not contraindicated.
– Classical cesarean delivery with vertical incision: trial of labor is contraindicated
– Abdominal myomectomy with uterine cavity entry: trial of labor is contraindicated
– Abdominal myomectomy without uterine cavity entry: trial of labor is not contraindicated.

In laboring patients with prior uterine surgical histories like a prior classical (vertical) cesarean delivery or a prior myomectomy that was extensive or has entered the uterine cavity like during removal of intramural or submucosal fibroids are at a higher risk for uterine rupture. Given this patient’s history of previous myomectomy, her intense and constant abdominal pain with an abnormal fetal heart rate tracing, like persistent variable decelerations, are pointing to uterine rupture. vaginal bleeding, abdominally palpable fetal parts, loss of fetal station and any change in contraction pattern are the other possible manifestations of uterine rupture. Based on the extent and exact location of the rupture and the presence or absence of regional anesthesia, presentation of a uterine rupture will change.

Vaginal delivery is safe after a low transverse (horizontal uterine incision) cesarean delivery. Patients with a history of either classical cesarean delivery or an extensive myomectomy are delivered via cesarean delivery at 36-37 weeks gestation, so urgent laparotomy and cesarean delivery are required if these patients present in labor. Further management is determined by other intraoperative findings like, whether uterine rupture has occurred, if occured then delivery is done through the rupture site, followed by a uterine repair; If the uterus is unruptured, a hysterotomy (ie, cesarean delivery) is performed. In patients with prior classical cesarean delivery or extensive myomectomy, an expectant management for a vaginal delivery is contraindicated.

Amnioinfusion is the technique of placing an intrauterine pressure catheter to decrease umbilical cord compression by doing an intrauterine infusion and this thereby helps to resolve variable decelerations. In patients with a history of uterine surgery Amnioinfusion is contraindicated.

In cases with abnormal fetal heart rate tracings, if the patient is completely (10cm) dilated, an operative vaginal delivery can be performed to expedite a vaginal delivery.

Terbutaline is a tocolytic, which is administered to relax the uterus in conditions with contractile abnormalities, such as tachysystole which presents with >5 contractions in 10 minutes or tetanic contractions were contractions last for >2 minutes, which results in fetal heart rate abnormalities. In the given case, the patient’s contractions are normal, which occurs in every 2-3 minutes and lasts for 45 seconds, causing pain and cervical dilation.

After a classical cesarean delivery or an extensive myomectomy, labor and vaginal delivery are contraindicated due to its significant risk of uterine rupture. Laparotomy and cesarean delivery are preferred in laboring a patients at high risk of uterine rupture.

The bladder is supplied by branches of the internal iliac artery, including the superior vesical artery, branches of the gluteal and obturator arteries and the inferior vesical artery in males and the vaginal and the uterine arteries in females.