A 16-week visit is advised for all pregnant women to offer an alpha-fetoprotein (AFP) screening for neural tube defects and Down syndrome- An AFP level 2-5 times the median value for normal controls at the same gestational age is considered elevate- Approximately 5%-10% of patients who undergo AFP screening will have an elevated level, and most of these women will have normal foetuses. Fetal ultrasonography should be performed to detect multiple gestation, fetal demise, or fetal anomalies (neural tube defects, ventral abdominal wall defects, and urinary tract anomalies) as well as to confirm gestational age, as all of these factors are associated with elevated AFP levels. Amniocentesis is offered if the ultrasonography does not indicate the reason for the elevated AFP. Chorionic villus sampling is offered in the evaluation of suspected chromosomal anomalies as an adjunct to amniocentesis. Serum hCG would be indicated in the workup of suspected Down syndrome, where the AFP would be low, not elevate- The hCG level would be expected to be over 2-5 multiples of the mean (MoM) with Down syndrome.

Atenolol and propranolol are associated with intrauterine growth retardation when used for prolonged periods during pregnancy. They are class D agents during pregnancy. Other beta-blockers may not share this risk.

Methyldopa, hydralazine, and calcium channel blockers have not been associated with intrauterine growth retardation. They are generally acceptable agents to use for established, significant hypertension during pregnancy.

Endometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. It is characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus and includes three different manifestations: ovarian endometriomas, peritoneal implants, deep pelvic endometriosis. The primary locations are in the pelvis; extra pelvic endometriosis may rarely occur.

Diagnosis requires a combination of clinical history, invasive and non-invasive techniques. The definitive diagnosis is based on laparoscopy with histological confirmation. Diagnostic imaging is necessary for treatment planning. MRI is as a second-line technique after ultrasound. The MRI appearance of endometriotic lesions is variable and depends on the quantity and age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. The purpose of surgery is to achieve complete resection of all endometriotic lesions in the same operation.

Owing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.

Though ESR maybe elevated due to the presence of inflammation, it is not specific for endometriosis and has no role in preoperative staging. The same holds true for any possible CBC finding.

Transvaginal ultrasound is preferred for diagnosis but doesn’t aid in preoperative staging of endometriosis.

CA125 values are elevated in severe infiltrative endometriosis but unchanged in mild disease. Relaying on CA125 cause a high rate of false negatives.

A fibroid is a benign tumour of the smooth muscles of the uterus also known as a leiomyoma. It has a typical whorled appearance and this may be altered following degeneration which occurs in four main types:
1. Red degeneration, also known as carneous degeneration, of degeneration that can involve a uterine leiomyoma. While it is an uncommon type of degeneration, it is thought to be the most common form of degeneration of a leiomyoma during pregnancy. Red degeneration follows an acute disruption of the blood supply to the fibroid during growth typically in a mid-second trimester presenting as sudden onset of pain with tenderness localizing to the area of the uterus along with pyrexia and leucocytosis. On ultrasound it can have peripheral (rim).

2. Hyaline degeneration is the most common form of degeneration that can occur in a uterine leiomyoma. It is thought to occur in up to 60% of uterine leiomyomasoccurs when the fibroid outgrows its blood supply. this may progresses to central necrosis leaving a cystic space in the centre knowns as cystic degeneration.

3. Cystic degeneration is an uncommon type of degeneration that a uterine leiomyoma (fibroid) can undergo. This type of degeneration is thought to represent ,4% of all types of uterine leiomyoma degeneration. When the leiomyoma increases in size, the vascular supply to it becomes inadequate and leads to different types of degeneration: hyaline, cystic, myxoid, or red degeneration. Dystrophic calcification may also occur. Hyalinization is the commonest type of degeneration. Cystic degeneration is an extreme sequel of edema. Ultrasound may show a hypoechoic or heterogeneous uterine mass with cystic areas.

4. Myxoid degeneration of leiomyoma is one of the rarer types of degeneration that can occur in a uterine leiomyoma. While this type of degeneration is generally considered rare, the highest prevalence for this type of degeneration has been reported as up to 50% of all degenerations of leiomyomas. Fibroids (i.e. uterine leiomyomas) that have undergone myxoid degeneration are filled with a gelatinous material and can be difficult to differentiate from cystic degeneration; however, they typically appear as more complex cystic masses. They appear hypocellular with a myxoid matrix.

Occipitomental diameter is the greatest diameter of the fetal scalp and runs from chin to the prominent portion on the occiput. It measure about 12.5cm in diameter.

Major vessel injury is the most important potential complication when undertaking laparoscopy. It’s incidence is 0.2/1000. Bowel Injury is more common at 0.4/1000

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

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

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

The most consistent finding in obstructed labour is a 4cm head that is palpable on the abdomen. The bony part is usually palpated at the level of the ischial spine on pelvic examination.
When prolonged labour is suspected, a pelvic vaginal examination helps to differentiate obstructed labour from inefficient/incoordinate labour.

Findings in a pelvic examination:
Obstructed labour
moulding of fetal head ++
caput formation on the fetal head ++
cervical oedema – anterior lip oedema
fetal tachycardia ++
station of the head (relation to lowest part of ischial spines) – just at or above the IS
amount of head palpable above the pelvic brim when the lowest point of the head is at the IS – > 2 finger breadths (FB)

Inefficient or incoordinate labour
moulding of fetal head usually none
caput formation on fetal head +
absent cervical oedema
fetal tachycardia +
station of the head (relation to lowest part of ischial spines) – can be above or below IS
amount of head palpable above the pelvic brim when the lowest point of the head is at the IS – < 1 finger breadth (FB).

This patient presents because of significant mood changes since she gave birth to her child: she is sad most of times and she is having guilt feelings about her adequacy for motherhood- She is also complaining of insomnia, tiredness, and even some suicidal ideation. These symptoms are highly suggestive postpartum depression. This should be differentiated from postpartum blues, which usually present within the first 2 weeks and last for few days. This patient’s symptoms started 5 weeks postpartum. Postpartum depression usually presents within the first 6 weeks to the first year postpartum.

Postpartum depression is the most common complication of childbearing and affects the mother, the child, and relationship with the partner. It is diagnosed the same way as major depressive disorder in other patients. Since untreated postpartum depression can have long-term effects on the mother and the child, appropriate therapy should be undertaken as soon as possible- Antidepressant medications such as sertraline can be used to treat postpartum depression. In a patient who has suicidal ideation, electroconvulsive therapy has a more rapid and effective action than medication and should be considered in these patients.

→ Cognitive behavioural therapy is effective in women with mild to moderate postpartum depression; it would not be a good choice in this patient with suicidal ideation and at risk of harming the baby.
→ Estrogen therapy used alone or in combination with antidepressant, has been shown to significantly reduce the symptoms of postpartum depression; however, it would not be the most appropriate choice in a patient with suicidal ideation.
→ Peer support has shown equivocal results in various studies even though most postpartum patients report that lacking an intimate friend or confidant or facing social isolation are factors leading to depression.
→ Non-directive counselling also known as ”listening visits“ has been found to be effective in postpartum patients, though the studies that were conducted are deemed to be of small sample and larger studies still need to be done to validate these findings. It would not be an appropriate choice for this patient with suicidal ideation.

Pelvic inflammatory disease (PID) refers to acute and subclinical infection of the upper genital tract in women, involving any or all of the uterus, fallopian tubes, and ovaries; this is often accompanied by involvement of the neighbouring pelvic organs. It results in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or tubo-ovarian abscess.

Lower abdominal pain is the cardinal presenting symptom in women with PID. The abdominal pain is usually bilateral and rarely of more than two weeks’ duration. The character of the pain is variable, and in some cases, may be quite subtle. The recent onset of pain that worsens during coitus or with jarring movement may be the only presenting symptom of PID. The onset of pain during or shortly after menses is particularly suggestive.

Other non-specific complaints include urinary frequency and abnormal vaginal discharge.

Ovarian cyst, uterine leiomyoma, appendicitis or ectopic pregnancy do not present with fever and vaginal discharge although tenderness is noted in appendicitis and ectopic pregnancy. Therefore, these options do not explain the patient’s symptoms.

Ultrasound has emerged as the more accurate method of assessing fetal gestational age, especially in the first trimester. Both transvaginal and transabdominal probe assessments are used to obtain a more accurate measurement of gestational age. Transvaginal is more helpful in first trimester pregnancies.

A transvaginal ultrasound exam should not be performed in a pregnant patient with vaginal bleeding and known placenta previa, a pregnant patient with premature rupture of membranes, and a patient who refuses exam despite informed discussion.

Sonographic assessment within the first 13 weeks and 6 days will provide the most accurate estimate of gestational age. Both transvaginal and transabdominal approaches may be used. However, the transvaginal approach may provide a more clear and accurate view of early embryonic structures. Although the gestational sac and yolk sac are the first measurable markers visible on ultrasound, these poorly correlate with gestational age.

Both the female hormones, namely progesterone and oestrogen as well as the male hormones or androgens are lipid soluble. The common precursor of these is cholesterol.

1st Arch = Trigeminal V2 & V3 (CN V) 2nd Arch = Facial (CN VII) 3rd Arch = Glossopharyngeal (CN IX) 4th and 6th Arches = Vagus (CN X)

This woman has experienced a septic abortion. Therefore the first step is commencement of intensive antibiotic treatment as soon as cervical swabs have been taken.

The next step is evacuation of the uterus. Curettage can be performed after a few hours, to extract any remaining infected products of conception from the uterine cavity.

The choice of antibiotics depends on the most likely microorganism involved. Therefore, prior to commencing any other procedure, it is vital to take cervical swabs for microscopic examination to guide further antibiotic therapy (correct answer).

If curettage is performed immediately there is a risk that the infection would spread.

However, if Clostridium welchii infection is suspected from the cervical smear (particularly if encapsulation of the microorganisms is present), then curettage should be performed immediately along with commencing antibiotic treatment.

Curettage can be delayed for up to 12-24 hours if other microorganisms are suspected; unless a significant increase in bleeding occurs.

Ergometrine is not essential as an immediate treatment measure as the patient is not bleeding heavily and reports that her bleeding has decreased. However, ergometrine is commonly given when curettage is performed.

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.

Cephalosporins are beta lactum drugs, like penicillin. They act by inhibiting the cross linkage of the peptidoglycan wall in bacteria.

Gestational trophoblastic disease (GTD) is a group of tumours defined by abnormal trophoblastic proliferation. Trophoblast cells produce human chorionic gonadotropin (hCG).

GTD is divided into hydatidiform moles (contain villi) and other trophoblastic neoplasms (lack villi). The non-molar or malignant forms of GTD are called gestational trophoblastic neoplasia (GTN).
Hydatidiform mole (HM) is associated with abnormal gametogenesis and/or fertilization. Risk factors include extremes of age, ethnicity, and a prior history of an HM which suggests a genetic basis for its aetiology.

GTD is best managed by an interprofessional team that includes nurses and pharmacists. Patients with molar pregnancies must be monitored for associated complications including hyperthyroidism, pre-eclampsia, and ovarian theca lutein cysts. Molar pregnancy induced hyperthyroidism should resolve with the evacuation of the uterus, but patients may require beta-adrenergic blocking agents before anaesthesia to reverse effects of thyroid storm. Pre-eclampsia also resolves quickly after the evacuation of the uterus. Theca lutein cysts will regress spontaneously with falling beta-HCG levels. However, patients must be counselled on signs and symptoms of ovarian torsion and ruptured ovarian cysts.

A single uterine evacuation has no significant effect on future fertility, and pregnancy outcomes in subsequent pregnancies are comparable to that of the general population, despite a slight increased risk of developing molar pregnancy again.

Combined oral contraceptives are a safe and highly effective method of birth control, but they can also raise problems of clinical tolerability and/or safety in migraine patients. It is now commonly accepted that, in migraine with aura, the use of combined oral contraceptives is always contraindicated, and that their intake must also be suspended by patients suffering from migraine without aura if aura symptoms appear.

Discontinuation of contraception could risk in pregnancy. Barrier methods can be used but aren’t as effective as pills.

Placenta previa typically presents with painless bright red vaginal bleeding usually in the second to third trimester. Although it’s a condition that sometimes resolves by itself, bleeding may result in serious complications for the mother and the baby and so it should be managed as soon as possible.

In the given case pre-pregnancy counselling and management of chronic hypertension is very much essential.
Some commonly prescribed antihypertensive drugs like ACE inhibitors, angiotensin receptor antagonists, diuretics and most beta blockers are contraindicated or is best to be avoided before conception and during pregnancy.
Methyldopa is considered as the first line drug for the management of mild to moderate hypertension in pregnancy and is the most commonly prescribed antihypertensive for this indication.
Hydralazine can be used during any hypertensive emergencies in pregnancy.
Intake of Angiotensin receptor blockers and ACE inhibitors during the first trimester can lead to complications as they are both teratogenic; use of these drugs during second and third trimesters can result in foetal renal dysfunction, oligohydramnios and skull hypoplasia.
Diuretics can cause foetal electrolyte disturbances and significant reduction in maternal blood volume.
All beta blockers, except labetalol, can result in foetal bradycardia, and growth restriction in case its long-term use.
Calcium channel antagonists, except nifedipine, are avoided during pregnancy due to its high risk for maternal hypotension and foetal hypoxia.

Most common risk factors for spontaneous abortion are considered to be:
– Age above 35 years.
– Smoking.
– High intake of caffeine.
– Uterine abnormalities like leiomyoma, adhesions.
– Viral infections.
– Thrombophilia.
– Chromosomal abnormalities.
Conditions like subclinical thyroid disorder, subclinical diabetes mellitus and retroverted uterus are not found to cause spontaneous abortions.
The term retroverted uterus is used to denote a uterus that is tilted backwards instead of forwards.

First trimester abortions are performed using mifepristone 600 mg followed by insertion of 1 mg gemeprost vaginal pessary. The patients stays in the hospital for about 4-6 hours. At the time of abortion azithromycin 1 g and metronidazole 800 mg should be given to cover the gram positive and negative bacteria.

Lichen sclerosus is characterized by hypopigmented atrophic plaque in the perineal region along with features of pruritis and dyspareunia.
It is more common in post menopausal women and on histology there is epidermal atrophy, inflammatory infiltrate in the dermis and basal layer degeneration.

Vitiligo is characterised by hypopigmentation but without any other symptoms.
Extramammary Paget’s disease is characterized by erythematous plaque located mostly in the perianal region but its histology is different.
Lichen simplex chronicus is a chronic scaly pruritic condition characterized by itchy papules and plaques plus lichenification and it mostly results from chronic irritation and itching of the area.

After the release of the oocyte, the theca and the granulosa cells form the corpus luteum which undergoes extensive vascularization for continued steroidogenesis. Progesterone is secreted by the luteal cells and is synthesized from cholesterol. The luteal phase lasts for 14 days and if implantation does not occurs the corpus luteum starts to degenerate. As B-HCG produced by the implanted embryo maintains it and without it luteolysis occurs.

In eukaryotes, the genome comprises several double-stranded, linear DNA molecules bound with proteins to form complexes called chromosomes. Each species of eukaryote has a characteristic number of chromosomes in the nuclei of its cells. Human body cells (somatic cells) have 46 chromosomes.

The patient is presenting with classic symptoms of round ligament pain.
Round ligaments are structures which extends from the lateral portion of the uterus below to the oviduct and will travel downward in a fold of peritoneum to the inguinal canal to get inserted in the upper portion of the labium majus. As the gravid uterus grows out of pelvis during pregnancy, these ligaments will stretch, mostly during sudden movements, resulting in a sharp pain. Due to dextrorotation of uterus, which occurs commonly in pregnancy, the round ligament pain is experienced more frequently over the right side. Usually this pain improves by avoiding sudden movements, by rising and sitting down gradually, by the application of local heat and by using analgesics.

As the patient is not experiencing any symptoms like fever or anorexia a diagnosis of appendicitis is not likely. Also in pregnant women appendicitis often presents as pain located much higher than the groin area as the growing gravid uterus pushes the appendix out of pelvis.

As the pain is localized to only one side of groin and is alleviated with a heating pad the diagnosis of preterm labor is unlikely. In addition, the pain would persist even at rest and not with just movement in case of labor.

As the patient has not reported of any urinary symptoms diagnosis of urinary tract infection is unlikely.

Kidney stones usually presents with pain in the back and not lower in the groin. In addition, with a kidney stone the pain would occur not only with movement, but would persist at rest as well. So a diagnosis of kidney stone is unlikely in this case.

Cilia are small hair line projections in the fallopian tube. Their main function is to transport the egg through he fallopian tube towards the uterus. It is present in many other tubular organs and its function varies accordingly to the organ.

About 1 in 4 pregnant women carry GBS bacteria in their body. Doctors should test pregnant woman for GBS bacteria when they are 36 through 37 weeks pregnant.

Giving pregnant women antibiotics through the vein (IV) during labour can prevent most early-onset GBS disease in newborns. A pregnant woman who tests positive for GBS bacteria and gets antibiotics during labour has only a 1 in 4,000 chance of delivering a baby who will develop GBS disease. If she does not receive antibiotics during labour, her chance of delivering a baby who will develop GBS disease is 1 in 200.

Pregnant women cannot take antibiotics to prevent early-onset GBS disease in newborns before labour. The bacteria can grow back quickly. The antibiotics only help during labour.

Vulvar Intraepithelial Neoplasia (VIN) is a non-invasive squamous type lesion that carries a 15% chance of developing into squamous cell carcinoma of the vulva. Human Papillomavirus (HPV) infection, or chronic inflammatory conditions such as lichen sclerosis and lichen planus, can cause changes in the basal cells of the vulvar epithelium. Other risk factors of VIN include multiple sexual partners, cigarette smoking, and immunocompromised states. Diagnosis is by clinical examination and a biopsy confirms neoplasia.

Vaginal spotting, malodorous vaginal discharge and no signs of trauma like lacerations are the clinical features of vaginal foreign bodies in prepubertal girls. The most common object found as foreign body is toilet paper and its management includes warm irrigation and vaginoscopy under sedation/anesthesia.

Common cause of vulvovaginitis in prepubertal girls are vaginal foreign bodies. Although other objects like small toys, hair bands, etc can be occasionally found, the most common vaginal foreign body is toilet paper. Symptoms like malodorous vaginal discharge, intermittent vaginal bleeding or spotting and urinary symptoms like dysuria are caused due to the chronic irritation caused by the foreign body (the whitish foreign body in this case) on the vaginal tissue.

An external pelvic examination is performed with the girl in a knee-chest or frog-leg position in cases of suspected vaginal foreign body. An attempt at removal, after application of a topical anesthetic in the vaginal introitus, using vaginal irrigation with warm fluid or a swab can be done in case of an easily visualized small foreign body like toilet paper. In cases were the age of the girl or the type of foreign body prohibit adequate clinical evaluation the patient should be sedated or given a general anesthesia for examination using a vaginoscope and the foreign body should be removed.

In cases where child abuse or neglect is suspected Child Protective Services should be contacted. Vaginal or rectal foreign bodies can be the initial presentation of sexual abuse; however in otherwise asymptomatic girls with no behavioral changes, urinary symptoms and vulvar or anal trauma, presence of toilet paper is not of an immediately concerning for abuse.

To evaluate pelvic or ovarian masses CT scan of the abdomen and pelvis can be used; but it is not indicated in evaluation of a vaginal foreign body.

Patients in there prepubertal age have a narrow vaginal introitus and sensitive hymenal tissue due to low estrogen levels, so speculum examinations should not be performed in such patients as it can result in significant discomfort and trauma.

Topical estrogen can be used in the treatment of urethral prolapse, which is a cause of vaginal bleeding in prepubertal girls. This diagnosis is unlikely in this case as those with urethral prolapse will present with a beefy red protrusion at the urethra and not a material in the vagina.

Prepubertal girls with retained toilet paper as a vaginal foreign body will present with symptoms like malodorous vaginal discharge and vaginal spotting secondary to irritation. Initial management is topical anaesthetic application and removal of foreign body either by vaginal irrigation with warm fluid or removal with a swab.

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.

Despite the fact that this question includes many true-false options, the knowledge examined is particularly essential in the treatment of women who have genital herpes.
It answers many of the questions that such women have regarding the disease, how it spreads, how it may be controlled, and how it affects an unborn or recently born child.
All of these issues must be addressed in a counselling question.
Currently, the most prevalent type of genital herpes is type 1, while in the past, type 2 was more common, as confirmed by serology testing.
Type 2 illness is nearly always contracted through sexual contact, but it can go undetected for years.
Acyclovir can be taken during pregnancy, and there are particular reasons for its usage.
Neonatal herpes is most usually diagnosed when the newborn has no cutaneous lesions, and past genital herpes in the mother is protective against neonatal infection, although not always.
Where the genital infection is the initial sign of the disease rather than a relapse of earlier disease, neonatal herpes is far more frequent.
Many patients and doctors are unaware that, while the original infection might be deadly, it is usually asymptomatic.
This explains how the illness spreads between sexual partners when neither has had any previous symptoms of the disease.

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.

The treatment of Chlamydia includes avoidance of intercourse, use of condoms and antibiotic treatment. Erythromycin 500mg orally QID for 7 days or Amoxicillin 500mg TDS for 7 days or Ofloxacin 200mg orally BD for 7 days.

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.

During pelvimetry, the shape of the pubic arch is usually examined. It helps in determining the outcome of the type of fetal delivery.

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.

A variety of changes in the cardiovascular system occur during normal pregnancy, including increases in cardiac output, arterial compliance, extracellular fluid volume and decreases in blood pressure (BP) and total peripheral resistance.

SLE is a type III hypersensitivity reaction

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.

Visual disturbances although very common during pregnancy are not a normal sign. Physicians should have a firm understanding of the various ocular conditions that might appear pregnancy or get modified by pregnancy. In addition, it is very important to be vigilant about the rare and serious conditions that may occur in pregnant women with visual complaints. Prompt evaluation may be required and the immediate transfer of care of the patient may help saving the lives of both the mother and the baby.

Fat necrosis is a benign (non-cancerous) breast condition that can develop when an area of fatty breast tissue is injured. It can also develop after breast surgery or radiation treatment.

There are different stages of fat necrosis. As the fat cells die, they release their contents, forming a sac-like collection of greasy fluid called an oil cyst. Over time, calcifications (small deposits of calcium) can form around the walls of the cyst, which can often be seen on mammograms. As the body continues to repair the damaged breast tissue, it’s usually replaced by denser scar tissue. Oil cysts and areas of fat necrosis can form a lump that can be felt, but it usually doesn’t hurt. The skin around the lump might look thicker, red, or bruised. Sometimes these changes can be hard to tell apart from cancers on a breast exam or even a mammogram. If this is the case, a breast biopsy (removing all or part of the lump to look at the tissue under the microscope) might be needed to find out if the lump contains cancer cells. These breast changes do not affect your risk for breast cancer.

Mastectomy, axillary node dissection and radiation therapy are all management options for malignancy which this patient doesn’t have.

Realignment of collagen is part of the remodelling phase. Remodelling is usually underway by week 3. Maximum tensile wound strength is typically achieved by week 12.

Congenital uterine abnormalities are associated with an increased risk of spontaneous abortions, preterm delivery of the foetus, fetal growth retardation and malpresentation.

The maximum dose of lidocaine with adrenaline is 7mg/kg.

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.

Women with a bicornuate uterus are at increased risk of recurrent abortions, premature birth, fetal malpositioning, placenta previa and retained products of placenta leading to post partum haemorrhage.

Dinoprostone is associated with a transient pyrexia. This typically normalises within 4 hours of stopping treatment

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.

The levels of evidence range from I-IV:
1a: Systematic reviews (with homogeneity) or metanalysis of randomized controlled trials: highest level of evidence.
1b: Individual randomized controlled trial (with narrow confidence interval)
1c: All or none randomized controlled trials
2a: Systematic reviews (with homogeneity) of cohort studies
2b: Individual cohort study or low quality randomized controlled trials (e.g. <80% follow-up)
2c: Outcomes Research; ecological studies
3a: Systematic review (with homogeneity) of case-control studies
3b: Individual case-control study
4: Case series (and poor quality cohort and case-control studies)
5: Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles.

NICE guidelines (CG74) advise the following regarding postoperative wound management Use sterile saline for wound cleansing up to 48 hours after surgery. Advise patients that they may shower safely 48 hours after surgery. Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus. Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention to reduce the risk of surgical site infection

The best method to provide symptomatic relief to this woman is to use pressure stockings and a vulval pad (correct answer). This will provide relief without causing any adverse effects.

In order to prevent ulceration, care is required to avoid trauma.

Since the patient is pregnant, surgical ligation or injecting of sclerosing solutions cannot be considered and are contraindicated.

Development of varices is often exacerbated in subsequent pregnancies; and therefore surgery should be eschewed until child-bearing is complete,

Bed rest in hospital would reduce the symptoms of the varicose veins; however this should be avoided as it can increase the risk of developing deep vein thrombosis.

Anticoagulant therapy has not been shown to be beneficial for treatment of varicosities that only affect the superficial venous system and should therefore not be used.

The Rubella virus, also known as German measles, is found in the Togavirus family and is a single-stranded RNA virus. The virus, which is acquired through contact with respiratory secretions, primarily replicates in the nasopharynx and lymph nodes, and produces a mild and self-limiting illness. Congenital infection, however, is associated with several anomalies including sensorineural deafness, cataracts and cardiac abnormalities.

G0 is a resting phase. Interphase (G1,S,G2) is where the cell grows and DNA replication occurs forming chromatids. Mitosis is where cell division occurs and this happens in a the following phases: Prophase Chromatin condenses to chromosomes (paired as chromatids). Mitotic spindle forms Metaphase Chromatids align at the equatorial plane AKA the metaphase plate Anaphase Chromatids pulled apart into 2 constituent daughter chromosomes Telophase New nuclear envelopes form around each daughter chromosome Cytokinesis Cells divide Diagram illustrating Mitosis Image sourced from Wikipedia

The half-life of lidocaine is approximately 1.5 hours. It is a local anaesthetic and the maximum dose that can be given is 3mg/kg.

Shoulder dystocia occurs when the anterior or posterior fetal shoulder impacts on the maternal symphysis or sacrum and may require additional manevours to release the shoulders after gentle downward traction has failed. The most common injury that can occur, is to the brachial plexus due to lateral flexion of the head during traction. This may cause a neurological disability, Erb’s Palsy ( injury to C5 and C6 of the brachial plexus) in which there is a less than 10% chance that this injury would be permanent.

Primary infertility is defined as the inability to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient under the age of 35. (After 35 years of age, infertility testing can begin after 6 months.) Because the patient’s partner’s sperm analysis is normal, female factor infertility is the most likely explanation. This patient’s adolescent hospitalizations are likely due to pelvic inflammatory disease (PID), a common cause of infertility caused by tubal scarring and blockage.

A hysterosalpingogram, which includes infusing radiocontrast into the cervix under fluoroscopy, is the first-line imaging technique for determining fallopian tube patency. A hysterosalpingogram is a non-invasive procedure that can detect uterine cavity irregularities (e.g., bicornuate uterus).

Peritoneal adhesions and endometriosis can be seen and treated directly using laparoscopy.

PID-related scarring inside the fallopian tubes can be assessed by laparoscopy with chromotubation; however, it is invasive, expensive, and not utilized first-line.

Ovulation is detected using a mid-cycle LH level. The LH surge can be detected in urine and serum 36 hours before ovulation. Regular menstrual periods are characterized by mittelschmerz (mid-cycle pelvic pain), which indicates ovulation. As a result, an LH level would be useless.

Ovarian reserve begins to deteriorate around the age of 35, and serum FSH levels rise in women who are losing their ability to ovulate. Because this patient is much younger and has regular periods, a drop in ovum quantity is unlikely to be the reason for infertility.

Increased serum androgen levels can prevent ovulation by inhibiting the release of GnRH and FSH through feedback inhibition. The patient has regular cycles and no hyperandrogenic symptoms, despite her sister having polycystic ovarian syndrome (e.g., hirsutism, irregular menses).

In a nulliparous patient under the age of 35, primary infertility is defined as the inability to conceive after a year of unprotected sexual intercourse. A hysterosalpingogram is used to determine the cause of infertility, such as tubal blockage caused by a previous pelvic infection.

Oral progestogen therapy for 21 days (day 5-26) is considered effective but is only a short-term therapy for menorrhagia. Myomectomy should only be considered if the woman would like to conceive later on. Due to the recurrent nature of fibroids, it is likely that the woman would need more surgeries in the future, which is not ideal. Furthermore, if there is a large number of fibroids or the size of the fibroids are large, myomectomy would not be an option for reasons such as the feasibility. If myomectomy for multiple fibroids prove to be unsuccessful, the ultimate outcome would still have to be a hysterectomy.

In cases where there is significant enlargement of the uterus, endometrial ablation would be difficult and the long-term cure rate of symptoms would be considerably low. The best next step would be a total abdominal hysterectomy since it would solve her menorrhagia and within a few years’ time, she would be expected to attain menopause anyway. Ponstan or mefenamic acid has been found to be superior to tranexamic acid for menorrhagia. However, it can still prove to be ineffective in some cases and also not a long term solution.

Despite the fact that pregnancy at her age is uncommon, the best advise you can give her is to take a pregnancy test.

If the test results show she is not pregnant, she can next decide whether to restart the oral contraceptive pill (0CP) or simply weep until the post-pill amenorrhoea goes away.

Although an increased follicle-stimulating hormone (FSH) level may indicate ovarian failure, it does not guarantee that no more periods will occur and does not rule out the possibility of a future pregnancy.

Obviously, she should be recommended to use a contraceptive method like condoms until the cause of her amenorrhoea is determined.
Other hormonal tests, such as luteinizing hormone and prolactin testing, may be required.

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

Adnexa refer to the anatomical area adjacent to the uterus, and contains the fallopian tube, ovary, and associated vessels, ligaments, and connective tissue. The reported incidence of adnexal masses in pregnancy ranges from 1 in 81 to 1 in 8000 pregnancies. Most of these adnexal masses are diagnosed incidentally at the time of dating or first trimester screening ultrasound (USS). Functional cyst is the most common adnexal mass in pregnancy, similar to the nonpregnant state. A corpus luteum persisting into the second trimester accounts for 13-17% of all cystic adnexal masses. Pain due to rupture, haemorrhage into the cyst, infection, venous congestion, or torsion may be of sudden onset or of a more chronic nature.

The testicular artery arises from the aorta and supplies the testis and the epididymis. The testis is supplied by 3 arteries.: Testicular artery, cremasteric artery that arises from the inferior hypogastric artery and the artery to the vas deferens from the internal iliac artery.

GI Tract initially forms via gastrulation from the endoderm of the trilaminar embryo around week 3. It extends from the buccopharyngeal membrane to the cloacal membrane. Later in development there are contributions from all three germ cell layers.

The normal FHR is 110-160

In the period immediately after the delivery of the placenta, known as the puerperium, the female reproductive system begins to undergo some physiological changes to return to a non-pregnant state. One of these changes is uterine involution. The myometrium contracts, constricting blood vessels which impedes blood flow. It is thought that the uterine tissues then undergo apoptosis and autophagy. It takes about 4-6 weeks for the uterus to decrease is size from about 1 kg to 60 grams.

Consuming alcohol and risk of cervical cancer are not associated. Not even drinking often and in large amounts are risk factors for developing cervical cancer.

So drinking alcohol and risk of cervical cancer aren’t associated. Based on their analyses of the scientific research evidence, that is the conclusion of, among many others, the:
American Cancer Society.
Centres for Disease Control and Prevention (CDC).
National Cancer Institute.
UK’s National Health Service.
Canadian Cancer Society.
Cancer Council Australia.
World Health Organization (WHO).

All other options can increase the risk of acquiring cervical cancer.

Sertoli-Leydig cell tumours constitute less than 0.5 percent of ovarian neoplasms. They may behave in a benign or malignant fashion, which correlates with the degree of differentiation in an individual case. Approximately 75 percent occur in women under the age of 40 years (mean age at diagnosis is 25), but they occur in all age groups. The neoplasms are characterized by the presence of testicular structures that produce androgens. This can result in virilization, although not all of these neoplasms are functionally active.

Pure Sertoli cell tumours are usually estrogenic and may also secrete renin, leading to refractory hypertension and hypokalaemia. In addition, these tumours may be associated with Peutz-Jeghers syndrome.

Pure Leydig cell tumours are androgen secreting; only a few cases have been reported. Virtually all of these rare tumours are unilateral and confined to the ovary at diagnosis.

Granulosa cell tumours typically present as large masses; the mean diameter is 12 cm. Women may present with an asymptomatic mass noted on abdominal or pelvic examination. Granulosa cell tumours often produce oestrogen and/or progesterone; consequently, symptoms related to hyperestrogenism are common at diagnosis.

Krukenberg tumour, also known as carcinoma mucocellulare, refers to the signet ring subtype of metastatic tumour to the ovary. The stomach followed by colon are the two most common primary tumours to result in ovarian metastases, pursued by the breast, lung, and contralateral ovary.

A rare tumour that is made up of more than one type of cell found in the gonads (testicles and ovaries), including germ cells, stromal cells, and granulosa cells. Gonadoblastomas are usually benign (not cancer), but they may sometimes become malignant (cancer) if not treated.

Hyaline degeneration is the most common form of fibroid degeneration. Fibroids:
Risk Factors
– Black Ethnicity
– Obesity
– Early Puberty
– Increasing age (from puberty until menopause)
Protective Factors
– Pregnancy
– Multiparity

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.

During mid secretory phase, the endometrium cells undergo distension, become more tortuous and are lined by columnar cells.
In the early proliferative phase, the glandular epithelium is cubo-columnar, while in the late proliferative phase, the glands increase in size, becoming tortuous and there is pseudostratification of the epithelium.

Pelvic organ prolapse is a common condition amongst ageing women where a weakness in the pelvic support structures of the pelvic floor allows pelvic viscera to descend.
The Pelvic Organ Prolapse Quantification system (POP-Q) is useful for describing and staging the severity of the pelvic organ prolapse.
Grade 1: the most distal portion of the prolapse is more than 1 cm above the level of the hymen
Grade 2: the most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane
Grade 3: the most distal portion of the prolapse protrudes more than 1 cm below the hymen but protrudes no farther than 2 cm less than the total vaginal length (for example, not all of the vagina has prolapsed)
Grade 4: vaginal eversion complete

During the first 8 weeks of pregnancy, concentrations of hCG in the blood and urine usually double every 24 hours. Levels of the hormone typically peak at around 10 weeks, decline until 16 weeks, then remain constant.

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.

The uterine and vaginal arteries branch from the internal iliac artery. The ovarian artery branches direct from the aorta.

The rectus sheath is formed by the decussation and interweaving of the aponeuroses of the fl at abdominal muscles. The external oblique aponeurosis contributes to the anterior wall of the sheath throughout its length. The superior two thirds of the internal oblique aponeurosis splits into two layers (laminae) at the lateral border of the rectus abdominis; one lamina passing anterior to the muscle and the other passing posterior to it. The anterior lamina joins the aponeurosis of the external oblique to form the anterior layer of the rectus sheath. The posterior lamina joins the aponeurosis of the transversus abdominis to form the posterior layer of the rectus sheath.

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

Stress UI (SUI) is more common among puerperal women, followed by mixed UI (MUI) and urge UI (UUI). Generally, episodes of urine leakage are infrequent and the amount of urine leakage is small.

Maternal age greater than 35 years, UI during pregnancy, elevated body mass index (BMI), multiparity, and normal birth are considered risk factors for postpartum UI. A 10-year cohort study developed with the goal of assessing the effect of the first normal birth on urinary symptoms showed that it was associated with an increase in SUI, in addition to UUI, regardless of maternal age or number of births.

Other factors such as: colour or race, episiotomy, perineal tears, newborn’s head circumference, newborn’s weight, gestational age at birth, smoking, and constipation require further studies in order to prove their association with postpartum UI.

This woman at her 37 weeks of gestation, has developed multiple herpetic lesions over her genitals. In every case were the mother develops herpes simplex infection after 28 weeks of pregnancy, chances for intrapartum and vertical transmission of the infection to the neonate is considered to be very high.

Risk factors of intrapartum herpes simplex infection of the child includes premature labour, premature rupture of membrane, primary herpes simplex infection and multiple lesion in the genital area.

The most appropriate methods for managing this case includes:
– checking for herpes simplex infection using PCR testing of a cervical swab.
– starting prophylactic antiviral therapy for the mother from 38 weeks of gestation until delivery.
– preferring a cesarean section delivery if there are active lesions present in the cervix and/or vulva.

Cesarean delivery is advised in this case along with maternal antiviral therapy before delivery to minimise the risk of vertical transmission.

P wave = Atrial depolarisation
QRS complex = Ventricular depolarisation
T wave = Ventricular repolarisation
U wave = repolarisation of the interventricular septum

Cardiotocography, also known as the non-stress test is used to monitor fetal heartbeat and uterine contractions of the uterus. An abnormal CTG may indicate fetal distress and prompt an early intervention. Variability refers to the variation in the fetal heartbeat form one beat to another. Normal variability is between 5-25 beats per minute while an abnormal variability is less than 5 bpm for more than 50 minutes, or more than 25 bpm for more than 25 minutes.

The normal functional bladder capacity is around 400-600ml. First urge to void is typically felt when the bladder is approximately 150ml full.

Perineal tears are common at the time of child birth. First degree perineal laceration means that the wound is so small that it doesn’t require any stitches and usually heals on its own. 2nd degree means that skin and smooth muscles are both torn. 3rd degree tear means that the tear is beyond the perineal muscles and the muscles surrounding the anal canal, while in 4th degree, the perineal tear goes through the anal sphincter up to the rectum.

Uterine atony and failure of contraction and retraction of myometrial muscle fibres can lead to rapid and severe haemorrhage and hypovolemic shock. Poor myometrial contraction can result from fatigue due to prolonged labour or rapid forceful labour, especially if stimulated.

Factors shown to decrease risk of ovarian cancer are:
– Oral contraceptive use
– Higher Parity
– Breast feeding
– Hysterectomy
– Tubal Ligation
– Statins
– SLE

This patient is presenting with a low-lying placenta at 18 weeks of gestation. This is a common finding on ultrasound at 18-20 weeks. If there is not bleeding, there is an 80-90% chance that by late pregnancy, the placenta will have moved and is no longer occupying the lower uterine segment. For this reason, the repeat ultrasound examination is usually performed at 32-34 weeks of gestation. Further discussions about management can then be made after obtaining those results.

Leaving the repeat ultrasound until term would be inappropriate as intervention would be needed prior. If the placenta praevia is still present, it is typically advisable to deliver prior to term.

Cardiotocographic (CT) fetal heart rate monitoring is not required in the absence of bleeding or other symptoms.

Delivery by Caesarean section would not be necessary if the placenta was no longer praevia by the time the repeat ultrasound is done.

Repeat ultrasound examination at 22 weeks of gestation would also unnecessary and inappropriate as it is too close in time for the change to occur.

With the help of molding, the fetal head changes its shape as the skull bones overlap. This helps in smooth delivery of the foetus through the birth canal.

When it comes to questions on venous drainage the ovarian vein is likely to be a common question given its varied drainage depending on laterality. The right ovarian vein travels through the suspensory ligament of the ovary and generally joins the inferior vena cava whereas the left ovarian vein drains into the left renal vein.

A rectovaginal swab taken for Group B streptococci culture should be done in women presenting with threatened preterm labour

If labour is establishes, intrapartum antibiotic prophylaxis for Group B streptococci should be commenced and continued until delivery. In cases were labour is not establish, prophylaxis for Group B streptococci should be ceased and should be re-established only if the culture is found to be positive, that too at the time of onset of labour.

Strategies acceptable for reducing early onset Group B streptococci sepsis includes universal culture-based screening using combined low vaginal plus or minus anorectal swab at 35-37 weeks gestation or a clinical risk factor based approach.

No additional prophylaxis is recommended irrespective of Group B streptococci carriage, for elective cesarean section before the commencement of labour. However, if a woman who commences labour or has spontaneous rupture of the membranes before her planned Caesarean section is screened positive for Group B streptococci, she should receive intrapartum antibiotic prophylaxis while awaiting delivery.

Although there is little direct evidence to guide this practice, consideration of the above mentioned evidences it is recommendation that, every women with unknown Group B streptococci status at the time of delivery should be managed according to the presence of intrapartum risk factors.
All women at increased risk of early onset Group B streptococci sepsis must be offered an intrapartum antibiotic prophylaxis with IV penicillin-G or ampicillin.

Tranexamic acid is an antifibrinolytic drug which is one of the treatment options in menorrhagia i.e. heavy menstrual bleeding. It acts by binding to the receptor sites on plasminogen thus preventing plasmin from attaching to those receptors thus inhibiting plasminogen activation.

If pharmaceutical treatment is appropriate NICE advise treatments should be considered in the following order:

1. levonorgestrel-releasing intrauterine system (LNG-IUS) provided at least 12 months use is anticipated
2. tranexamic acid or NSAIDs* or combined oral contraceptives (COCs) or cyclical oral progestogens
3. Consider progesterone only contraception e.g. injected long-acting progestogens

*When heavy menstrual bleeding (HMB) coexists with dysmenorrhoea NSAIDs should be preferred to tranexamic acid. Also note NSAIDs and tranexamic are appropriate to use if treatment needed pending investigations.

Invasive procedures as fetal scalp blood sampling or internal electrode and episiotomy increase vertical transmission of HCV, especially in patients with positive HCV RNA virus load at delivery that is why it should be avoided.

Treatment with Clomiphene should not exceed 6 months.

Mammary duct ectasia occurs when the lactiferous duct becomes blocked or clogged. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age.

Since the car crash happened two weeks prior, breast trauma is suggested and thus fat necrosis is the most probable diagnosis. Phyllodes tumours are typically a firm, palpable mass. These tumours are very fast-growing, and can increase in size in just a few weeks. Occurrence is most common between the ages of 40 and 50, prior to menopause.

Immediately after birth the liver is deprived of the large flow of blood supplied during foetal development via the umbilical vein and portal sinus. Simultaneously the blood pressure in the portal sinus, previously as high as in the umbilical vein, falls.

There are four types pelvic shapes:
1) Android pelvis: it has a larger inlet and smaller outlet along with small posterior sagittal diameter, prominent ischial spines and has a two finger arch.
2) Gynecoid pelvis: it has a transverse or nearly a circular ellipse and it is the most favourable for delivery.
3) Anthropoid pelvis: the brim is an anteroposterior ellipse.
4) Platypelloid pelvis: in this type the pelvic brim is kidney shape

If a patient presents with PROM at 27 weeks of gestation, her management plan would have to include:

1) Cervical swabs to rule out infection
2) Commencement of prophylactic antibiotics such as erythromycin until results from the swabs are available
-If only normal vaginal flora are seen, prophylactic antibiotics can be stopped.
3) Administration of glucocorticoid- usually for 48 hours to promote maturity of the fetal lung and lower the chance of intracranial bleeding if the foetus has to be delivered prematurely
4) Transfer to a healthcare centre that has neonatal intensive care facilities to ensure if intensive care is needed post-delivery, the healthcare staff are prepared
5) Blood profile (particularly white cell count) and inflammatory markers (CRP) to look for any signs of chorioamnionitis
6) CTG assessment every 2-3 days. Abnormalities found on the CTG tracing are often the first evidence of problems such as a subclinical chorioamnionitis
7) Tocolysis with tocolytics such as IV salbutamol or nifedipine if contractions start before the course of glucocorticoid therapy is finished. Post-glucocorticoid therapy, tocolysis would not be often employed since there is a risk of masking contractions that occur due to an infection. In those cases, it is better to deliver the baby rather than to prolong the pregnancy. If there is no infection, the management plan should aim to prolong the pregnancy and delay delivery of a very premature baby.

Labour induction is indicated as no fetal movements have been felt for 24 hours, with a normal cardiotocograph (CTG) and the pregnancy is at near/full term with a favourable cervix.

Amniotic fluid volume assessment would have been indicated 24 hours earlier as, if it was low, induction would have been indicated then, despite a normal CTG.

Ultrasound examination of the foetus is not indicated as it is necessary to expedite delivery.

Carrying out another CTG, with or without oxytocin challenge, is not indicated, although MG monitoring during induced labour would be mandatory.

Delivery immediately by Caesarean section is not indicated unless the lack of fetal movements is due to fetal hypoxia. This can result in fetal distress during labour, necessitating an emergency Caesarean section if the cervix is not fully dilated.

Vulva is defined by the area which is located outside the female vagina and comprises of the labia majora, labia minora, clitoris, mons pubis and Bartholin glands. It is supplied by the vestibula branch of pudental artery.
Inferior hemorrhoidal artery supplies the lower part of the rectum.
Femoral artery is the continuation of external iliac artery and supplies most of the leg.

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.

Firstline medical management of PCOS is with clomiphene.

Ovulation Disorders

WHO Group I : Hypothalamic pituitary failure (Stress, anorexia, exercise induced)
Management:
Increase BMI if <19 kg/m2
Reduce exercise if high levels
Pulsatile GnRH or Gonadotrophins with LH activity to induce ovulation

WHO Group II : Hypothalamic-pituitary-ovarian dysfunction (PCOS)
Management:
Weight reduction if BMI >30
Clomiphene/Clomiphene (1st line)
Metformin (1st line)
Clomiphene & Metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)

WHO Group III : Ovarian failure
Management:
Consider IVF with donor eggs

Premenstrual dysphoric disorder (PMDD) is a more serious form of premenstrual syndrome (PMS). PMS causes bloating, headaches, and breast tenderness a week or two before your period.

With PMDD, you might have PMS symptoms along with extreme irritability, anxiety, or depression. These symptoms improve within a few days after your period starts, but they can be severe enough to interfere with your life.

PMDD symptoms appear a week or two before menstruation and go away within a few days after your period starts. In addition to PMS symptoms, you may have:

Anger or irritability.
Anxiety and panic attacks.
Depression and suicidal thoughts.
Difficulty concentrating.
Fatigue and low energy.
Food cravings or binge eating.
Headaches.
Insomnia.
Mood swings.

The following treatments have been shown to relieve symptoms:

Sertraline, escitalopram, paroxetine, and fluoxetine are SSRIs (selective serotonin reuptake inhibitors). SSRIs are the first-line treatment and are extremely effective.
The second line of defence is alprazolam (a short course recommended due to its addictive potential).
The use of temazepam has little advantage because it only aids with sleep and is relatively short-acting.
Lifestyle modifications-weight loss, exercise, quitting smoking, and relaxation therapies for less severe PMS.
Danazol-suppresses the ovulation and helps with mastalgias associated with PMS.

When considering immunoglobulins in neonates. There are only a few key points you are likely to be tested on. 1. IgA is resistant to stomach acid and found in large amounts in breast milk. 2. IgG is the only Ig that can cross the placenta so is key for passive neonatal immunity 3. When the neonate starts synthesising its own Ig it is IgM that is produced first.

Hepatitis B immune globulin (HBIG) should be administered as soon as possible to patients with known exposure to hepatitis – Hepatitis B vaccine is a killed-virus vaccine and can be used safely in pregnancy, with no need to wait until after organogenesis. This patient has been exposed to sexual transmission for at least 6 weeks, given that the incubation period is at least that long, so it is too late to use condoms to prevent infection. The patient is unlikely to be previously immune to hepatitis B, given that she has no history of hepatitis B infection, immunization, or carriage- Because the patient’s HBsAg is negative, she is not the source of her husband’s infection. Full treatment for this patient has an efficacy of only 75%, so follow-up testing is still needed.

There is an association between 20 to 30% increase in the risk for developing pyelonephritis during later pregnancy and untreated cases of bacteriuria in pregnancy. This is due to the physiological changes occurring to urinary tract during pregnancy, it is also found that untreated bacteriuria can be associated with even preterm birth and low birth weight. Risk of symptomatic urinary tract infection (UTI) during pregnancy can be reduced by antibiotic treatment of asymptomatic bacteriuria

The most common pathogen associated with asymptomatic bacteriuria is Escherichia coli, which accounts to more than 80% of isolates and the second most frequently cultured uropathogen is Staphylococcus saprophyticus. Other Gram-positive cocci, like group B streptococci, are less common. Gram-negative bacteria such as Klebsiella, Proteus or other Enterobacteriaceae are the other organisms involved in asymptomatic bacteriuria.

Although the context patient is asymptomatic, her urine dipstick shows positive nitrite and leukocyte, suggestive of urinary tract infection, so oral antibiotics like cephalexin or nitrofurantoin are advisable. Normally a five day course of oral antibiotic will be sufficient for the treatment of uncomplicated UTI or asymptomatic bacteraemia in pregnant women. As the patient is currently at her 38 weeks of gestation nitrofurantoin is contraindicated so it is best to prescribe her with Oral Cephalexin. This is because nitrofurantoin is associated with an increased risk of neonatal jaundice and haemolytic anaemia, so should not be used close to delivery, that is after 37 weeks of gestation or sooner if early delivery is planned.

Acute pyelonephritis should be treated with Intravenous antibiotic treatment, guided by urine culture and sensitivity reports as soon a available. A course of minimum of 10-14 days with IV + oral antibiotics is recommended as treatment for pyelonephritis, along with an increased fluid intake as intravenous fluids in clinically dehydrated patients. Even though urinary alkalisers are safe in pregnancy, prescription of urinary alkalisers alone is not recommended due to its low effectiveness compared to antibiotics, also as it can result in a loss of treatment efficacy urinary alkalisers should never be used in combination with nitrofurantoin.

At any stage of pregnancy, if Streptococcus agalactiae, a group B streptococcus [GBS], is detected in urine the intrapartum prophylaxis for GBS is usually indicated.

Chickenpox or varicella is a contagious disease caused by the varicella-zoster virus (VZV). The virus is responsible for chickenpox (usually primary infection in non-immune hosts) and herpes zoster or shingles (following reactivation of latent infection). Chickenpox results in a skin rash that forms small, itchy blisters, which scabs over. It typically starts on the chest, back, and face then spreads. It is accompanied by fever, fatigue, pharyngitis, and headaches which usually last five to seven days. Complications include pneumonia, brain inflammation, and bacterial skin infections. The disease is more severe in adults than in children.

Primary varicella infection during pregnancy can also affect the foetus, who may present later with chickenpox. In pregnant women, antibodies produced as a result of immunization or previous infection are transferred via the placenta to the foetus. Varicella infection in pregnant women could spread via the placenta and infect the foetus. If infection occurs during the first 28 weeks of pregnancy, congenital varicella syndrome may develop. Effects on the foetus can include underdeveloped toes and fingers, structural eye damage, neurological disorder, and anal and bladder malformation.

Prenatal diagnosis of fetal varicella can be performed using ultrasound, though a delay of 5 weeks following primary maternal infection is advised.

Antivirals are typically indicated in adults, including pregnant women because this group is more prone to complications.

Venous thromboembolic disease (VTE) is the most common cause of direct maternal death in the UK. In the most recent triennium, there were 41 fatalities, giving a maternal mortality rate of 1.94 per 100 000 – more than twice that of the next most common cause, pre-eclampsia. As pregnancy is a hyper coagulable state. There are alterations in the fibrinolytics and thrombotic pathways. There is also an increased production of clotting factors during pregnancy.

Radiotherapy works on the principle of ionisation. In particularly that of water leading to the formation of free radicals, these radicals are highly reactive and they react with the DNA leading to damage and cell death.

Premature menopause has been diagnosed biochemically in this patient. Menopause is considered premature when it happens without warning in a woman under the age of 40.
Follicular development is common in ultrasonography investigations of women with primary ovarian failure, but ovulation is rare. So this woman isn’t ovulating.

Exogenous oestrogen treatment in physiologic amounts does not appear to improve the rate of spontaneous ovulation.
Women with primary ovarian failure from any cause may be candidates for donor oocyte in vitro fertilisation (IVF).

Oestrogens, clomiphene citrate, and danazol are examples of treatment approaches that have been shown to be ineffective in patients with premature ovarian failure.

Taking hormone replacement therapy for more than 5 years can increase the risk of developing breast cancer. HRT is not recommended as treatment for osteoporosis alone in postmenopausal women older than 60. Raloxifene reduces risk of vertebral fracture in post menopausal women.

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.

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.

During childbearing the vagina and perineum are prone to lacerations that may involve the skin or can extend into the anal sphincter complex. It is important to be able to identify obstetric and anal sphincter injuries to provide adequate care and prevent complications. In the classification of obstetric tears according to RCOG guidelines:

First degree tear: injury to the perineal skin and/or the vaginal mucosa
Second degree tears: Injury to perineum involving perineal muscles but not the anal sphincter.
Third-degree tear: Injury to perineum involving the anal sphincter complex:
Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn.
Grade 3b tear: More than 50% of EAS thickness torn.
Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn.
Fourth-degree tear: Injury to perineum involving the anal sphincter complex (EAS and IAS)
and anorectal mucosa.

Vulvovaginal candidiasis is the most common genital infections and it is caused by candida albicans in 80-92% of the cases. It colonise the vaginal flora in 20% of non pregnant and 40% pregnant women.

Functional closure of the ductus arteriosus is neonates is completed within the first few days after birth. It normally occurs by the 12th postnatal week. It has been suggested that persistent patency of DA results from a failure of the TGF-B induction after birth. Due to increased arterial pO2, constriction of the DA occurs. In addition to this on inflation the bradykinin system is activated with cause the smooth muscles in the DA to constrict. A decrease in the E2 prostaglandin is also an important factor as raised levels have been indicated in keeping the patency of the DA.

Although a dilatation and curettage (D&C) is frequently recommended as part of a woman’s menorrhagia examination.
D&C is not indicated in a woman who had a normal hysteroscopy and laparoscopy only two years ago, and who experienced comparable symptoms when not taking the OCP in the past, especially after the age of 40.
The Filshie clips should not be removed because they will not improve the symptoms.

Although an endometrial ablation or possibly a hysterectomy may be required in the future to address the symptoms, the first line of treatment should be a nonsteroidal anti-inflammatory drug (NSAID), which will reduce the loss in up to half of the women treated.

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

The history of acutely painful defecation associated with spotting of bright blood is very suggestive of an acute anal fissure. Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.. After gently spreading the buttocks, a close check of the anal verge can typically confirm the diagnosis.
Rectal inspection is excruciatingly painful and opposed by sphincter spasm; however, if the fissure can be seen, it is not necessary to make the diagnosis at first.

A perianal abscess, which presents as a sore indurated area lateral to the anus, or local trauma linked with anal intercourse or a foreign body, are two more painful anorectal disorders to rule out.

Anal fistulae do not appear in this way, but rather with perianal discharge, and the diagnosis is based on determining the external orifice of the fistula.

Although first-degree haemorrhoids bleed, they do not cause defecation to be unpleasant.

Although carcinoma of the anus or rectum can cause painful defecation, it would be exceptional in this situation.

Normal position of the foetus in relationship to the mother is always a longitudinal lie and a cephalic presentation. Transverse lie means that the baby is sideways. The foetus lies transverse till 26-28th week of gestation, after which it usually changes its position from transverse to a longitudinal lie with head down. A transverse lie can occur in conditions like grand multiparity, preterm foetus, placenta previa and pelvic contraction.

CA-125 is the tumour marker specific for ovarian carcinoma.

HPV Gardasil® is a quadrivalent vaccine against HPV Types 6, 11, 16, and 18. HPV types16 and 18 are responsible for 70% of cases of HPV related cancers. They are considered the most important high risk genotypes of HPV.

Genital HPV is a common virus that is passed from one person to another through direct skin-to-skin contact during sexual activity. Most HPV types cause no symptoms and go away on their own, but some types can cause cervical cancer in women and other less common cancers — like cancers of the anus, penis, vagina, and vulva and oropharynx. Other types of HPV can cause warts in the genital areas of men and women, called genital warts.

HPV vaccination is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series; HPV vaccine can also be given to girls beginning at age 9 years. CDC recommends 11 to 12 year olds get two doses of HPV vaccine to protect against cancers caused by HPV.

The vaccine is not recommended for pregnant women. Studies show that the HPV vaccine does not cause problems for babies born to women who were vaccinated while pregnant, but more research is still needed. A pregnant woman should not get any doses of the HPV vaccine until her pregnancy is completed.

Getting the HPV vaccine when pregnant is not a reason to consider ending a pregnancy. If a woman realizes that she got one or more shots of an HPV vaccine while pregnant, she should wait until after her pregnancy to finish any remaining HPV vaccine doses.

Management of PCOS includes OCP, cyclical oral progesterone, metformin, clomiphene (which is more effective in inducing ovulation than metformin) and life-style changes. In women who are tolerant to these therapies Gonadotrophins should be trialled. However lifestyle changes should be able to improve the condition significantly. Clomiphene shouldn’t be continued for more than 6 months.

The following treatment regimes are recommended for the treatment of Chlamydia in Pregnancy: Erythromycin 500mg four times a day for 7 days or Erythromycin 500 mg twice a day for 14 days or Amoxicillin 500 mg three times a day for 7 days or Azithromycin 1 gm stat (only if no alternative, safety in pregnancy not fully assessed) The following treatment regimes are recommended for the treatment of Chlamydia in NON-PREGNANT patients: Doxycycline 100mg bd for 7 days OR Azithromycin 1gm orally in a single dose NOTE: Doxycycline and Ofloxacin are contraindicated in pregnancy

In high-risk pregnancies, continuous monitoring of foetal heart rate is considered mandatory.

However, in low-risk pregnancies, cardiotocograph (CTG) monitoring provides no benefits over intermittent auscultation.

A significant issue with CTG monitoring is that apparent abnormalities are identified that usually have minimal clinical significance, but can prompt the use of several obstetric interventions such as instrumental deliveries and Caesarean section. In low risk patients, such interventions may not even be required.

CTG monitoring has not been shown to reduce the incidence of cerebral palsy or other neonatal developmental abnormalities, nor does it accurately predict previous foetal oxygenation status unless the CTG is significantly abnormal when it is first connected.

Similarly, CTG cannot accurately predict current foetal oxygenation unless the readings are severely abnormal.

Therefore, there is no evidence to support routine admission CTG (correct answer).

Women who have used oral contraceptives for 5 years or more are more likely to get cervical cancer than women who have never used them. The longer a woman uses oral contraceptives, the higher her chances of developing cervical cancer become. According to one study, using marijuana for less than 5 years increases the risk by 10%, using it for 5–9 years increases the risk by 60%, and using it for 10 years or more increases the risk by double. After women cease using oral contraceptives, their risk of cervical cancer appears to decrease over time. Endometrial, ovarian, and colorectal cancer risks, on the other hand, are lowered.
Compared to women who had never used oral contraceptives, women who were taking or had just discontinued using oral combination hormone contraceptives had a slight (approximately 20%) increase in the relative risk of breast cancer. Depending on the type of oral combination hormone contraception used, the risk increased anywhere from 0% to 60%. The longer oral contraceptives were used, the higher the risk of breast cancer.

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

The diagnosis of listeria depends on clinical suspicion and isolation of the organism from blood, vaginal swabs or the placenta. Meconium staining of the amniotic fluid in a preterm foetus may increase clinical suspicion for listeriosis. For women with listeriosis during pregnancy, intravenous antibiotic treatment (ampicillin 2 g given every 6 hours) is indicated.

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

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

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

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

Hysterosalpingography is used to assess the patency of the fallopian tubes. It is performed by injection of a radio-opaque iodine based contrast. This test is contraindicated in pelvic inflammatory disease and during pregnancy. Should be performed in Follicular phase of menstrual cycle after cessation of menstrual bleeding and prior to ovulation (days 6-12).

Gardnerella vaginalis is one of the bacteria implicated in the development of bacterial vaginosis , many women (>50%) with this vaginal infection have no signs or symptoms, when these are present they are most often :
Vaginal discharge, grey, white or green, with a strong unpleasant odour
Strong vaginal odour and fishy smell after sex
Vaginal itching
Burning during urination
Vaginal bleeding after sex
Gardnerella vaginalis can also be responsible for serious infections (sepsis, wound infections) in locations other than those associated with the genital tract or obstetrics, these cases are very rare but have been reported, including in men.

Mycoplasma Hominis is one of the organisms involved in the pathogenesis of BV but it appears normal on wet mount.

Candida presents with white cottage cheese like discharge.

Chlamydia is not seen on wet mount and produces clear vaginal discharge.

Trichomonas shows clue cells on wet mount.

Hyperemesis gravidarum refers to intractable vomiting during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia.

The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may contribute to the development of this disease process such as:
1. Hormone changes – hCG levels peak during the first trimester, corresponding to the typical onset of hyperemesis symptoms. Estrogen is also thought to contribute to nausea and vomiting in pregnancy.
2. Changes in the Gastrointestinal System – 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.
3. Genetics – an increased risk of hyperemesis gravidarum has been demonstrated among women with family members who also experienced hyperemesis gravidarum.

The average onset of symptoms happens approximately 5 to 6 weeks into gestation. The physical exam should include fetal heart rate (depending on gestational age) and an examination of fluid status, including an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should be obtained for comparison to previous and future weights. If indicated, abdominal examination and pelvic examination should occur to determine the presence or absence of tenderness to palpation.

Secondary postpartum hemorrhage of bright red character accompanied with fever, between 24 hours to 12 weeks of postpartum is suggestive of retained products of conception (RPOC).
The basal portion of the decidua may remain after separation of placenta in many cases. This decidua will then divides into two layers, the superficial layer which will be shed spontaneously and the deep layer which will regenerates and covers the entire endometrial cavity with in 16 days of postpartum.
Normal shedding of blood and decidua is referred to as lochia rubra, which is red / reddish brown in colour and it lasts for few days following delivery. This vaginal discharge gradually becomes watery and pinkish brown in colour, lasting for 2 to 3 weeks and is called as lochia serosa. Ultimately, this discharge becomes yellowish-white called as lochia alba.

Scanty lochia in the first few days after delivery is suggestive of the placental site not undergoing involution, which occurs mostly due to RPOC. Later these retained products will undergo necrosis resulting in fibrin deposition which will eventually form a placental polyp. Detachment of this scar of polyp will result in brisk hemorrhage and the remaining necrotic products will get infected resulting in uterine infection which will present with fever, lower abdominal pain and uterine tenderness.

Endometritis can lead to fever, offensive lochia and abdominal pain with tenderness. It is the most common cause of postpartum fever, but occurs within the first 5 days of postpartum with the peak incidence between days 2 and 3. Though vaginal bleeding is a presenting feature, bright red bleeding is unlikely of endometritis.

Another cause of postpartum fever is genital lacerations which have a peak incidence of wound infection between 4th and 5th days. Although fever as a temporal symptom favours wound infection, this diagnosis is less likely in the given case as wound infection will not affect the normal course of lochia, also it does not present as heavy bright red bleeding. Moreover, there are no symptoms like erythema, tenderness or discharge in history suggestive of wound infection.

Another cause of bleeding and fever can be cervical tear but this tends to present as primary postpartum hemorrhage rather than secondary, which occurs after 24 hours of postpartum. An overlooked and infected minor cervical laceration can cause fever but ii will not result in bright red bleeding, also genital tract lacerations do not affect lochia.

It is very unlikely for uterine rupture to occur 24 hours after delivery.

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.

Turner syndrome patients have malfunctioning or streak ovaries due to which they can never conceive. It affects females, who will have a short stature, widely spaced nipples, webbed neck and karyotyping shows 45XO.

The most common treatment approach is with the dopamine receptor agonists, bromocriptine, and cabergoline. Bromocriptine normalizes prolactin and decreases tumour size in 80%–90% of patients with microadenomas. Bromocriptine should be given to this patient who has developed hyperprolactinemia anovulation.

Women with hyperprolactinaemic anovulation are treated with dopamine agonists such as bromocriptine.
This patient has also developed symptoms of a low-functioning pituitary gland tumour, which bromocriptine will assist to shrink. Before starting bromocriptine, a head MRI scan should be considered to confirm the suspected diagnosis.

Clomiphene is an oestrogen receptor modulator that is selective. It works by competing with oestrogen receptors in the hypothalamus. This disrupts normal negative feedback mechanisms, causing the release of pituitary gonadotropins, particularly LH, to rise, triggering ovulation.
When the levels of gonadotropins and oestrogen are normal but the women still have ovulatory dysfunction, it is successful in inducing ovulation. In hypogonadotropic hypogonadism and hypogonadotropic hypogonadism patients, clomiphene is frequently ineffective.

The chorionic plate represents the fetal surface of the placenta, which in turn is covered by the amnion. The amnion is composed of a single layered epithelium and the amnionic mesenchyme, an avascular connective tissue. The amnionic mesenchyme is only weakly attached to the chorionic mesenchyme and can easily be removed from the delivered placenta. The chorionic mesenchyme contains the chorionic vessels that are continuous with the vessels of the umbilical cord. Within the mesoderm of secondary villi, haematopoietic progenitor cells develop and start to differentiate. At about day 20 post-conception, first placental blood cells and endothelial cells develop independent of the vascular system of the embryo proper.13 14 The development of first placental vessels transforms the respective villi into tertiary villi.

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.

The rectus sheath is formed by the aponeurosis of the internal and external oblique muscles and the transversus abdominus muscle. The internal oblique divides into two lamellae and encloses the rectus muscle. Anteriorly it fuses with the aponeurosis of the external oblique and posteriorly with that of the transverus abdominus. Below the arcuate line the aponeurosis of all the flat muscles lies anteriorly and posteriorly it is only enclosed by the transveralis fascia.

The posterior scrotal artery is a terminal branch of the perineal artery which is a branch of the internal pudendal artery.

Ovulation in the menstrual cycle usually occurs over 4 days. There is an increase in basal body temperature at the time of ovulation due to the effect of progesterone.

A high Day 21 progesterone level indicates ovulation and the release of an egg.

Dysmenorrhea is described as painful menstruation. The symptoms start at the time of ovulation and persist till menstruation.

Paget’s disease of the breast is a type of cancer that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast. Symptoms may include redness of the nipple skin and crusting may occur around the area. In more advance cases, symptoms may include itching or a burning pain in the nipple.

Pregnancy is a hypercoagulable state, which means that risk of thromboembolism is increased. The main reason is an increase in clotting factors II, factor VII, fibrinogen, factor X and factor XII, whereas factors XI and factor XIII are reduced. Naturally occurring anticoagulants i.e. protein C and protein S are both decreased thus increasing the risk of thrombus formation.

The normal range for a term baby is pH: 7.18 – 7.38, and preterm pH: 7.14 – 7.4. A pH below 7.1 therefore indicates acidosis.

The history is typical of Intrahepatic Cholestasis of Pregnancy, also known as obstetric cholestasis and prurigo gravidarum. The features are: Intense itching typically of the hands and feet Itch gets worse at night Responds poorly to antihistamines There is no rash. The mechanism is poorly understood but tests may show deranged LFTs. It usually resolves quickly after delivery. The other diagnoses listed are possible though less likely. Scabies normally has a rash

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 urinary bladder, and most of the urinary structures are lined by epithelium called the urothelium, or the transitional epithelium. This stratified lining is divided into three parts, an apical layer, an intermediate layer and a basal layer. The transitional epithelium is available to stretch to accommodate the increased volume when the bladder is distended, without structural damage.

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.

Maximum levels of progesterone are detected at day 21 of 28 days in the menstrual cycle, assuming that ovulation has occurred at day 14. A value of >30nmol/l indicates an ovulatory cycle.