Lymphatic drainage of the bladder is to the common iliac nodes via the internal iliac nodes.

Pre-eclampsia is defined as hypertension of at least 140/90 mmHg recorded on at least two separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24 hour collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the sixth postpartum week. Significant proteinuria = urinary protein: creatinine ratio >30 mg/mmol or 24-hour urine collection result shows greater than 300 mg protein.

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.

Warfarin inhibits Vitamin K dependent clotting factors. These include factors 2,7,9 and 10.

Leiomyomas uterine (fibroids)
Clinical features:
Menses that are heavy and last a long time, symptoms of pressure, pelvic discomfort, constipation, frequency of urination, complications during pregnancy, fertility problems, loss of pregnancy, premature birth, uterus enlargement and irregularity

Workup:
Ultrasound

Treatment:
Asymptomatic: monitoring
Surgical intervention, hormonal contraception

This patient has uterine leiomyomata, or fibroids, which are benign smooth muscle (myometrial) tumours that are very prevalent in adult women (up to 25%). These tumours can expand the endometrium’s surface area, the uterus’ overall size and thickness, and compress adjacent structures; nevertheless, some individuals have no symptoms and are identified by chance during a physical examination or imaging (as in this patient’s CT scan after a car accident).
Heavy, prolonged menses are among the indications for uterine leiomyomata treatment (particularly if associated with anaemia).
Pelvic discomfort that persists (e.g., dyspareunia).
Symptoms in abundance (e.g., pelvic pressure, hydronephrosis, constipation).
Recurrent miscarriages.
Medical or surgical treatment options are available for patients with these clinical characteristics (e.g., myomectomy).

This woman had mild menses and no pelvic discomfort or mass symptoms while having many big intramural and pedunculated leiomyomata (e.g., no ureter compression). There is no need for extra treatment in persons with asymptomatic fibroids. Only observation and reassurance are required.
In the treatment of symptomatic fibroids, a combination of oral contraceptive pills and progestin-containing intrauterine devices can be utilised, although they are not required in the management of asymptomatic fibroids. Furthermore, this patient has a minimal risk of unwanted pregnancy (e.g., monogamous, same-sex relationship), and the hazards of these contraceptives (e.g., venous thromboembolism, uterine perforation) outweigh the benefits.

GnRH agonist therapy (e.g., leuprolide) is a treatment for symptomatic uterine fibroids that works by inhibiting pulsatile FSH and LH production in the hypothalamus, lowering oestrogen levels. Low oestrogen levels cause a temporary reduction in leiomyoma size, which helps with heavy menses and bulky symptoms. Because long-term usage of GnRH agonists is linked to an increased risk of osteoporotic fractures, they are only administered preoperatively.

Tranexamic acid is a nonhormonal medicinal medication that reduces heavy menstrual bleeding by preventing fibrin breakdown (i.e., an antifibrinolytic drug). This patient’s menses are light.
Uterine leiomyomata (fibroids) are benign myometrial tumours that can produce a range of symptoms but are often identified by chance. Heavy menstrual blood, pelvic pain, and bulk symptoms are all indications for treatment. Patients with asymptomatic fibroids merely need to be monitored and reassured.

There is 70% chance that a women who has had a C-section can deliver via spontaneous vaginal delivery.

This is a case of a pregnant patient having vaginal bleeding. Given the patient’s presentation, the most likely cause of this patient’s antepartum haemorrhage is placenta praevia. The haemorrhage is unlikely to be due to a vasa praevia because a loss of 300mL would usually cause fetal distress or death, neither of which has occurred. Cervical malignancy is also unlikely as it typically would not have bleeding of this magnitude. A possible diagnosis would be a small placental abruption as it would fit with the lack of uterine tenderness and normal uterine size.

For the immediate management of this patient, induction of labour is contraindicated before the placental site has been confirmed. Also, induction should not be performed when the gestation is only at 33 weeks, especially after an episode of a small antepartum haemorrhage. An ultrasound examination of the uterus is appropriate as it would define whether a placenta praevia is present and its grade. It would also show whether there is any evidence of an intrauterine clot associated with placental abruption from a normally situated placenta.

If a placenta praevia is diagnosed by ultrasound, a pelvic examination under anaesthesia may be a part of the subsequent care, if it is felt that vaginal delivery might be possible. Usually it would be possible if the placenta praevia is grade 1 or grade 2 anterior in type. However, pelvic exam at this stage is certainly not the next step in care, and is rarely used in current clinical care.

A Papanicolaou (Pap) smear will be necessary at some time in the near future, but would not be helpful in the care of this patient currently.

Immediate Caesarean section is not needed as the bleeding has stopped, the foetus is not in distress, and the gestation is only 33 weeks.

Fetal lie refers to the relationship between the long axis of the foetus relative to the long axis of the mother. If the foetus and maternal column are parallel (on the same long axis), the lie is termed vertical or longitudinal lie.

Fetal presentation means, the part of the foetus which is overlying the maternal pelvic inlet.

Position is the positioning of the body of a prenatal foetus in the uterus. It will change as the foetus develops. This is a description of the relation of the presenting part of the foetus to the maternal pelvis. In the case of a longitudinal lie with a vertex presentation, the occiput of the fetal calvarium is the landmark used to describe the position. When the occiput is facing the maternal pubic symphysis, the position is termed direct occiput anterior.

Fetal attitude is defined as the relation of the various parts of the foetus to each other. In the normal attitude, the foetus is in universal flexion. The anatomic explanation for this posture is that it enables the foetus to occupy the least amount of space in the intrauterine cavity. The fetal attitude is extremely difficult, if not impossible, to assess without the help of an ultrasound examination.

Obstetric complications during or following a cesarean section delivery include:
-Increased risk of maternal mortality.
-Increased need for cesarean sections in the subsequent pregnancies.
-Increased risk for damage to adjacent visceral organs especially bowels and bladder.
-Increased risk of infections.

Increased risk for formation of adhesions is a complication after cesarean section and this is the correct response for the given question.

The use of long-acting reversible contraceptives (LARCs) is globally accepted as a strategy that is successful in decreasing rates of unintended pregnancy, especially in very young women.
Long-acting reversible contraceptives (LARCs) are defined as any contraceptive that requires administration less than once per cycle (i.e. per month). This includes copper and progestogen-only intrauterine devices (IUDs), and progestogen subdermal implants and injections. However, subdermal implants and IUDs, which have a life of at least three years, have superior efficacy over injections, which require administration every three months. Implants and IUDs are highly cost-effective when compared with other contraceptive methods.

LARCs are widely recommended by professional bodies and the World Health Organization (WHO) as first-line contraception for young women as they are safe, effective and reversible. Young women should be offered the choice of a LARC as part of a fully informed decision for their first form of contraception.

LARCs surpass barrier methods and contraceptive pills in effectiveness and safety therefore all other options are incorrect.

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 5th week, the neural crest cells migrate along each side of the spinal cord where they form ganglions located dorsolateral to the aorta. Some of these cells migrate ventrally and form neurons in the preaortic ganglia as the celiac and mesenteric ganglia.

The Mantoux test is based on type IV hypersensitivity reaction.

Disseminated intravascular coagulation (DIC) in pregnancy is the most common cause of an abnormal haemorrhage tendency during pregnancy and the puerperium. Although pregnancy itself can cause DIC, its presence is invariably evidence of an underlying obstetric disorder such as abruptio placentae, eclampsia, retention of a dead foetus, amniotic fluid embolism, placental retention or bacterial sepsis.

Bradycardia of <100 bpm for more than 5 minutes or <80 for more than 3 minutes is always considered abnormal. The given case describes fetal bradycardia detected on fetal heart auscultation and the most common causes for severe bradycardia are prolonged cord compression, cord prolapse, epidural and spinal anesthesia, maternal seizures and rapid fetal descent. Immediate management including identification of any reversible causes for the abnormality and initiation of appropriate actions like maternal repositioning, correction of maternal  hypotension, rehydration with  intravenous fluid,  cessation of oxytocin, tocolysis for excessive uterine activity, and initiation or maintenance of continuous CTG should be considered in clinical situations where abnormal fetal heart rate patterns are noticed. Consideration of further fetal evaluation and delivery if a significant abnormality persists are very important. The next step in this scenario where the baby is in 1+ station, with an abnormal fetal heart rate detected on auscultation would be to perform a confirmatory cardiotocography (CTG) and if the CTG findings confirm the condition despite initial measures obtained, prompt action should be taken. Cord compression or prolapse should come on the top of the differential diagnoses list as the the mother shows normal general conditions, but since the cervix is 8 cm dilated, 100% effaced and the fetal head is already engaged, cord prolapse would be unlikely; therefore, repeating vaginal exam is not as important as confirmatory CTG. However a vaginal exam should be done, if the scenario indicates any possibility of cord prolapse, to exclude cord compression or prolapse. NOTE– In cases of severe prolonged bradycardia, immediate delivery is recommended, if the cause cannot be identified and corrected.

Clinical decision making which contraceptive regimen is optimal for an individual woman with epilepsy is one of the most challenging tasks when taking care of women with epilepsy. The bidirectional interactive potential of antiepileptic drugs (AEDs) and hormonal contraceptives needs to be taken into account. Enzyme inducing (EI)-AEDs may reduce the contraceptive efficacy of hormonal contraceptives.

If combined oral contraceptives (COCs) are used in combination with EI-AEDs, it is recommended to choose a COC containing a high progestin dose, well above the dose needed to inhibit ovulation, and to take the COC pill continuously (“long cycle therapy”). But even with the continuous intake of a COC containing a higher progestin dose contraceptive safety cannot be guaranteed, thus additional contraceptive protection may be recommended.

Progestin-only pills (POPs) are likely to be ineffective, if used in combination with EI-AEDs.

Subdermal progestogen implants are not recommended in patients on EI-AEDs, because of published high failure rates.

Depot medroxyprogesterone-acetate (MPA) injections appear to be effective, however they may not be first choice due to serious side effects (delayed return to fertility, impaired bone health).

The use of intrauterine devices is an alternative method of contraception in the majority of women, with the advantage of no relevant drug–drug interactions. The levonorgestrel intrauterine system (IUS) appears to be effective, even in women taking EI-AEDs. Likelihood of serious side effects is low in the IUS users.

Patient in the given case is nine weeks pregnant, and she has been exposed to a herpes zoster rash because she is working as a hospital nurse and has no prior history of chickenpox.
The most appropriate next step in this case would be checking for Varicella-Zoster IgG antibodies which assures immunity to varicella infections. If VZV IgG is present no further action is needed, but if VZV IgG antibodies are absent, then she will need Varicella Zoster Immunoglobulins within ten days from the exposure to shingles.

The contents of the femoral triangles are femoral nerve, artery and the vein. Along with the femoral sheath and lymphatics.

If one believes that this cycle will last 35 days, the cyst in the left ovary was discovered at mid-cycle.
It’s too huge to be a ruptured pre-ovulatory follicle, and it doesn’t exhibit the characteristics of a corpus luteum, a benign cystic teratoma, or an endometrioma.

As a result, a follicular cyst is the most likely diagnosis.

A benign cyst is almost always seen on ultrasound as a unilocular, thin-walled cystic formation.

The presence of solid materials in a multiloculated cystic structure strongly suggests the presence of a malignant mass.
In a 25-year-old woman, this would be unusual, but not unheard of.

Beta Thalassaemia is autosomal recessive.

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.

Standard heparin, an effective treatment for antepartum thromboembolic disease, is thought to be safe for the foetus since it does not cross the placenta.

Congenital cytomegalovirus infections are the most common cause of sensorineural hearing loss in babies. Cytomegalovirus infection during the perinatal period can be transferred to the foetus especially if the primary infection is during pregnancy. In babies born with congenital CMV about 10-15% are symptomatic, while 10-15% of those who are asymptomatic will develop symptoms in life. Some of the features of CMV infection include sensorineural hearing loss, visual impairment, cerebral palsy, microcephaly and seizures. Other causes of infective congenital sensorineural hearing loss include: Rubella, HIV, Herpes Simplex Virus, Measles, Varicella Zoster virus, Mumps and West Nile Virus.

This patient should have an endometrial biopsy (SOR C). Approximately 7% of postmenopausal women with benign endometrial cells on a Papanicolaou smear will have significant endometrial pathology. None of the other options listed evaluate the endometrium for pathology. An asymptomatic premenopausal woman with benign endometrial cells would not need an endometrial evaluation because underlying endometrial pathology is rare in this group.

Dizygotic means two (di) fertilized eggs (zygotes). Dizygotic twins occur when two eggs are fertilized by two separate sperm. Dizygotic twins are also known as fraternal or non-identical twins. They are the most common type of twins.

Unlike monozygotic twins (also known as identical twins), dizygotic twins do not share the same genes. Monozygotic twins share 100 percent of each other genes. Dizygotic twins share only 50 percent. This is the same genetic similarity found between siblings conceived and born at different times.

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).

Clinical picture mentioned is indicative of hyperemesis gravidarum with resultant hypovolemia and pre-shock state, were patient needs urgent fluid resuscitation and intravenous antiemetic medications. The first-line fluid for resuscitation is normal saline (0.9% NaCl) and metoclopramide an antiemetic drug which is safe for use in pregnancy (category A).

Dextrose should be avoided in this situation as the sugar in the solution will leave behind a hypotonic fluid leading to severe hyponatraemic state which increases the risk for encephalopathy due to edema.

Ondansetron is considered as the second-line of antiemetic drug under category B1 which is used in situations like more refractory vomiting, when patient is not responding to metoclopramide and in cases of recurrent hospital admissions due to hyperemesis gravidarum.

Steroids such as prednisolone are considered as the third-line medication mostly used in resistant cases of hyperemesis gravidarum and should be used only after consulting an expert in the field.

Detrusor contraction is via Parasympathetic innervation of pelvic splanchnic nerves (S2-4). This also causes relaxation of the internal urethral sphincter Note contraction and relaxation of the external urethral sphincter is under somatic control.

This woman presents with a metastatic tumour of the ovary. Being from Australia is a hint in this question as the likely site of the primary tumour can vary depending on the country the patient is in and the availability of screening mammography. In underdeveloped countries, breast cancer is usually diagnosed later in life as screening mammography is generally not available, making the most likely site of the primary tumour in the breast. In Japan, where the incidence of stomach cancer is much higher than in western countries, the most likely primary site would be the stomach with a Krukenberg tumour in both ovaries. In Australia, mammographic screening is recommended every other year for all women over the age of 50, and so the most likely primary site would be the colon.

The most appropriate work-up to find the primary tumour in this patient would be performing a colonoscopy. A computed tomography (CT) of the abdomen may miss a small tumour, and an ultrasound examination would not be able to diagnosis a colon cancer. Mammography would be the correct response in under-developed countries. A lung malignancy would be detectable by chest X-ray, but would rarely cause a metastasis in the ovary.

Fetal hypoxia may cause absent, increased or decreased variability. Other causes of decreased variability include: normal fetal sleep-wake pattern, prematurity and following maternal administration of certain drugs including opioids.

Variability Range:
Normal – 5 bpm – 25bpm
Increased – >25 bpm
Decreased – <5 bpm
Absent – <2 bpm