Venous thromboembolism (VTE) during pregnancy and the postpartum window occurs at a 6-10-fold higher rate compared with age-matched peers and is a major cause of morbidity and mortality. Hypercoagulability persists for 6-8 weeks after delivery with the highest risk of PE being during the postpartum period. The lack of randomized trials in pregnant women leads to variability in practice, which are largely based on expert consensus or extrapolation from non-pregnant cohorts. The standard treatment of VTE in pregnancy is anticoagulation with low molecular weight heparin (LMWH), which like unfractionated heparin does not cross the placenta and is not teratogenic.

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

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

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

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

This patient who is at her 29 weeks of pregnancy, presented with sudden gush of clear fluid and Speculum examination has confirmed premature rupture of membrane (PROM).

Approximately, 50% of PROM progress to labour within 24 hours and in the remaining, 80% within seven days. The most important next step of management in this case is transferring this patient to tertiary care hospital as soon as possible. It is equally important to give corticosteroid therapy, like Betamethasone, if delivery prior to 34 weeks is likely to occur, as it will help in fetal lung maturity.

Cardiotocography (CTG) is usually not available in general practice settings and it can be done only while in the hospital. If CTG shows any abnormality or if there is any presence of infection it is better to induce labor.

Salbutamol and nifedipine are of no use in this case, as the patient is not in labour and does not require tocolytics.

The femoral triangle is bounded:
– Superiorly by the inguinal ligament that forms the base of the femoral triangle.
– Medially by the lateral border of the adductor longus.
– Laterally by the sartorius; the apex of the femoral triangle is formed where the borders of the sartorius and the adductor muscles meet.
– The floor of the femoral triangle is formed by the iliopsoas laterally and the pectineus muscle medially.
– The roof of the femoral triangle is formed by the fascia lata and cribriform
fascia, subcutaneous tissue, and skin.

Congenital infections can be the cause of various congenital abnormalities. Infection with the Rubella virus, part of the TORCH infections (toxoplasmosis, other organisms, rubella, cytomegalovirus, and herpes simplex), can lead to cardiac abnormalities, ophthalmic defects, sensorineural deafness and neurodevelopmental delays. At birth congenital rubella syndrome presents with a petechial rash characteristically dubbed a blueberry muffin rash, and hepatosplenomegaly with jaundice. Immunization of the mother against measles is an effective way of reducing the occurrence of congenital rubella syndrome.

The lumbar plexus is formed via contributions from the T12-L4 spinal cord segment. The plexus is responsible for the motor and sensory innervation of portions of the lower extremities and some parts of the lower abdomen and pelvis. Nerves arising from the plexus include the Iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, femoral nerve, obturator, and nerve to the lumbosacral trunk.

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.

Women with Beta-Thalassaemia require significant extra input during pregnancy. Folic acid 5 mg daily should be commenced 3 months prior to conception in these patients. NOTE Women with thalassaemia who have undergone splenectomy OR have a platelet count >600 should continue or be commenced on Aspirin (75 mg/day)

A normal pH value is above 7.25. A pH below 7.20 is confirmation of fetal compromise. Values between 7.20 and 7.25 are ‘borderline’.

The base deficit can also be useful in interpretation of the fetal scalp pH. A base excess of more than -10 demonstrates a significant metabolic acidosis, with increasing risk of fetal neurological injury beyond this level. Delivery should be considered.

Pulmonary hypertension (PH) is an increase of blood pressure in the pulmonary artery, pulmonary vein, or pulmonary capillaries, leading to shortness of breath, dizziness, fainting, and other symptoms, all of which are exacerbated by exertion. PH in pregnancy carries a 25–56% maternal mortality rate with a mixture of intrapartum and postpartum deaths.

Current recommendations for management of PH in pregnancy include termination of pregnancy if diagnosed early, or utilizing a controlled interventional approach with early nebulized prostanoid therapy and early elective caesarean section under regional anaesthesia. Other recommended therapies for peripartum management of PH include sildenafil and nitric oxide.

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

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

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

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

Trichomoniasis is caused by trichomonas. It is sexually transmitted. It is diagnosed on microscopy of vaginal discharge and cultured in Finn-Berg Whittington medium. It is characterised by valval itching, foul smelling discharge and appearance of strawberry cervix due to presence of punctate haemorrhages which occur in 2% of the cases.

IUCD is a risk factor for PID and PID has the clinical picture already described. However, fibroids should also be excluded since they may present in the same way.

Dehydroepiandrosterone is an androgen precursor produced primarily by the adrenal glands in women. The steroid hormone is produced from cholesterol at birth by the fetal adrenal glands, after which its output reduces. DHEA production picks up again from the age of 5-7 years and peaks between the ages of 20-30.

The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve (S2-4) while the internal anal sphincter is innervated by autonomic nerves.

The pelvic floor or diaphragm is composed of Coccygeus and Levator Ani. Levitator Ani is composed of 3 muscles: puborectalis, pubococcygeus and iliococcygeal. Although Piriformis assists in closing the posterior pelvic outlet it is not considered a component of the pelvic floor

Choriocarcinoma may arise as a complication of gestation or as spontaneous germ cell tumours. As this scenario depicts that the women has previous abortion points to the fact that these may have been molar pregnancies. As choriocarcinoma can arise from a molar pregnancy it can be differentiated from it by the presence of invasion into the uterus and metastasis to the lungs primarily.

HELLP syndrome stands for haemolysis, elevated liver enzyme levels, and low platelet levels and is a very severe condition that can happen during pregnancy. Management of this condition requires immediate delivery of the baby.

The risks of breast and cervical cancers are increased in women who use oral contraceptives, whereas the risks of endometrial, ovarian, and colorectal cancers are reduced.

Women who have used oral contraceptives for 5 or more years have a higher risk of cervical cancer than women who have never used oral contraceptives. The longer a woman uses oral contraceptives, the greater the increase in her risk of cervical cancer.

One study found a 10% increased risk for less than 5 years of use, a 60% increased risk with 5–9 years of use, and a doubling of the risk with 10 or more years of use. However, the risk of cervical cancer has been found to decline over time after women stop using oral contraceptives.

Incontinence in women is typically related to dysfunction of the bladder or pelvic floor muscles, with such dysfunction often arising during pregnancy or childbirth, or at the time of menopause.

A pregnant woman may experience an increase in the size of the kidneys and ureter due to the increased blood volume and vasculature.
Later in pregnancy, the woman might develop physiological hydronephrosis and hydroureteronephrosis, which are normal.
There is an increase in glomerular filtration rate associated with an increase in creatinine clearance, protein, albumin excretion, and urinary glucose excretion.
There is also an increase in sodium retention from the renal tube so oedema and water retention is a common sign in pregnant women

Anencephaly means the missing of a particular portion of the scalp and brain tissue. The other factors listed are associated with umbilical cord prolapse like multiparity, twin birth, polyhydramnios, premature delivery, long umbilical cord or breech presentation.

Her most likely diagnosis would be an ovarian carcinoma. Any palpable adnexal mass in a post-menopausal woman is a red flag for an ovarian malignancy and should be assumed so until proven otherwise.

Endometrial cancer typically presents with a post-menopausal bleed and although there might be uterine enlargement, an adnexal mass is generally absent.

It is very rare for follicular cysts to develop following menopause and it is uncommon for post-menopausal women to have a benign ovarian tumour, which is more common in younger women. A degenerating leiomyoma would be unlikely in this case, especially since her pelvic examination three years ago was normal (no history of leiomyoma noted).

During follicular phase, there is an increase in gonadotrophin hormones and a proliferation of the endometrium occurs. The duration of the cycle depends upon the overall length of the menstrual cycle. The progesterone levels are increased in the luteal phase and not in follicular phase.

This patient most likely has preeclampsia, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein, blood pressure monitoring, and laboratory evaluation that includes haemoglobin, haematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid- A peripheral smear and coagulation profiles also may be obtained- Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate.

→ Ultrasonography should be done to assess for fetal intrauterine growth restriction, but only after an initial laboratory and fetal evaluation.
→ It is not necessary to start this patient on antihypertensive therapy at this point. An obstetric consultation should be considered for patients with preeclampsia.
→ Delivery is the definitive treatment for preeclampsia- The timing of delivery is determined by the gestational age of the foetus and the severity of preeclampsia in the mother. Vaginal delivery is preferred over caesarean delivery, if possible, in patients with preeclampsia.

This is VIN. Smoking is a risk factor. It is also more common in immunocompromised patients.

Menorrhagia in a 45-year-old woman is most likely caused by an ovulation issue, most likely anovulatory cycles, particularly if the periods have grown irregular.

Endometrial carcinoma is a rare cause of menorrhagia that usually occurs after menopause.

Menorrhagia can be caused by fibroids, endometrial polyps, and adenomyosis, although the cycles are normally regular, and a dramatic change from normal cycles six months prior would be exceptional.
If fibroids or adenomyosis are the source of the menorrhagia, the uterus is usually enlarged.

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

Most women lose about 35-40 ml of blood on average during each menstrual cycle. The maximum amount of blood loss is 80 ml after which blood loss of more than 80 ml is defined as heavy menstrual bleeding, formerly known as menorrhagia.

Fetal urine contributes significantly to amniotic fluid production in the second trimester of pregnancy. As early as 8-11 weeks, urine production begins and can be observed in the fetal bladder on ultrasound scans. The urine creates a hypotonic fluid which contains increasing concentrations of urea and creatinine. By term, a foetus produces about 800 ml of urine a day, of which 250ml is eliminated through fetal swallowing.

The clinical evaluation indicates that the patient is ovulating but has not started menstruating. These observations suggest that the pain she is experiencing on a monthly basis could be related to ovulation or there could be an obstruction preventing the flow of menstrual blood from the uterus.

Uterine or vaginal anomalies that can obstruct menstrual flow include imperforate hymen, absent vagina, a transverse vaginal septum, or cervical obstruction.

If the cause was an obstruction to the flow, the retained menstrual products would have developed into a suprapubic mass (hematometra/ haematocolpos). However, no palpable mass was detected on abdominal examination.

Mullerian (paramesonephric) agenesis (correct answer) is the only condition that would result in no endometrial development; consequently there was no palpable mass observed and no menstrual loss that could be shed was present. A pelvic (lower abdominal) ultrasound examination can confirm the diagnosis.

Penicillin is the treatment of choice for treating syphilis. For treatment of syphilis during pregnancy, no proven alternatives to penicillin exist. Treatment guidelines recommend desensitization in penicillin-allergic pregnant women, followed by treatment with penicillin. Syphilis in pregnancy is associated with mental retardation, stillbirth and sudden infant death syndrome; therefore it should be treated promptly.

– Data are insufficient to recommend ceftriaxone for treatment of maternal infection and prevention of congenital syphilis.
– Erythromycin and azithromycin should not be used, because neither reliably cures maternal infection or treats an infected foetus.
– Tetracycline and doxycycline are contraindicated in pregnancy and ceftriaxone is much less effective than penicillin.

Gestational Diabetes occurs in 2-9% of all the pregnancies.

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justified to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specificity for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges. The women should be tested as soon as possible after booking if there is a history of GD.

Reduced fetal movements can be the first indication of possible fetal abnormalities. Movements are first perceived by the mother from about 18-20 weeks gestation, increase in size and frequency until 32 weeks gestation when they plateau at about 31 movements per hour. Investigations for reduced fetal heart rate include auscultation of the fetal heart rate using a handheld doppler device, and a cardiotocograph or ultrasound if the foetus is above 28 weeks gestation. About 70% of women who experience one episode of reduced fetal movement have uncomplicated pregnancies. They are advised to report to a maternal unit if another episode occurs.

HPV types 6 and 11 are associated with low risk, low grade squamous intraepithelial lesion. While types 16,18,31 and 33 are associated with high risk, high grade neoplasia.

Cases with spontaneous rupture of membrane before the onset of labour, prior to 37 weeks of gestation is defined as preterm premature rupture of membranes(PPROM). It complicates almost 2-4% of all singleton and 7- 20% of twin pregnancies and is commonly associated with more than 60% of all preterm births.

Management of PPROM In the absence of chorioamnionitis, depends on the gestational age. That is in cases of PPROM before 23 weeks, labor may be induced or the patient be sent home for bed rest and is asked to wait until any signs of spontaneous delivery to start. Between 23 and 34 + 0/7 weeks, the patient should be transferred to a tertiary hospital and be admitted there as it is very important to administer systemic corticosteroids, for the fetal lung to attain maturity. It is also mandatory the patient gets adequate bed rest, cervical and vaginal swabs for microscopy and culture, along with prophylactic antibiotics for prevention of chorioamnionitis.
NOTE –  regardless of the gestational age, chorioamnionitis is said to be an absolute indication for the termination of pregnancy.

In the given case, patient is currently in her 28th week of gestation, so she should be immediately transferred to a tertiary hospital and given systemic steroids to promote fetal lung maturation in case preterm delivery ensues.

Significant puerperal pyrexia is defined as a temperature of 38ºC or higher on any two of the first 10 days postpartum, exclusive of the first 24 hours. A mixed flora normally colonizes the vagina with low virulence. Puerperal infection is usually polymicrobial and involves contaminants from the bowel that colonize the perineum and lower genital tract. Following delivery, natural barriers to infection are temporarily removed and therefore organisms with a pathogenic potential can ascend from the lower genital tract into the uterine cavity. Placental separation exposes a large raw area equivalent to an open wound, and retained products of conception and blood clots within the uterus can provide an excellent culture medium for infection.

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.

ADH and vasopressin are synthesized in the supraoptic and periventricular nuclei of the hypothalamus, they are eventually transported to the posterior pituitary where they are stored to be released later.

CVS has decreased in frequency with the recent increased uptake of cell-free DNA screening. It remains the only diagnostic test available in the first trimester and allows for diagnostic analyses, including fluorescence in situ hybridization (FISH), karyotype, microarray, molecular testing, and gene sequencing. CVS is performed between 10 and 14 weeks’ gestation. CVS has been performed before 9 weeks in the past, though this has shown to increase the risk of limb deformities and, therefore, is no longer recommended.

Clomiphene citrate is widely used in the induction of ovulation, especially in the treatment of anovulatory infertility and in conditions such as PCOS. The drug functions as a selective oestrogen receptor modulator, which acts in the hypothalamus to indicate low serum oestrogen levels. Reduced levels of negative feedback stimulate the secretion of GnRH from the hypothalamus, which in turn stimulate the production of gonadotropins (FSH and LH) from the anterior pituitary. These work to increase ovarian follicular activity.

The contents of the inguinal canal is the ilioinguinal nerves, the round ligament of uterus in the females and the spermatic cord with its contents in males.

Post coital literally means “after intercourse” which is when this fertility test is conducted. The patient has intercourse at home usually between cycle days 12 and 15 (or a day around the LH surge as measured by urinary ovulation predictor kits). Afterwards, the female comes to the office and a sample of the cervical mucus is taken for microscopic examination.

The post coital fertility test (PCT) allows for evaluation of sperm in the cervical mucus and to determine the consistency of the mucus. Sperm must swim through the cervical mucus from the vagina, through the cervix, and into the uterus. Normal sperm will be active and swim in approximate straight lines through the mucus. If the mucus is too thick, sperm impedance can be observed.

The female pelvic inlet tilts at an inclination that is about 60 degrees from the anatomical horizontal plane. This tilt is maintained by muscles and fascia. The pelvic outlet slopes at an angle of 15 degrees.

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

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

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

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

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

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

Although there have been some mixed results regarding the use of hormone replacement therapy (HRT) and the prevalence of Alzheimer’s disease (AD), there is little question that HRT started during menopause lowers cognitive decline, which is a common early symptom of AD.
This is in contrast to the effect shown when HRT is started at the age of 60-65, when the risk of Alzheimer’s disease rises.
There are no statistics on the effect of HRT on the incidence of Alzheimer’s disease when it is started before menopause, but it is apparent that it does not slow the progression of the disease or make advanced dementia less severe.

BV typically presents as an increase in vaginal discharge and vaginal malodour caused by a change in vaginal bacterial flora. PV discharge due to BV is typically grey fluid that adheres to the vaginal mucosa. BV is a polymicrobial infection. Gardnerella is the most commonly associated pathogen. Other associated bacteria include Lactobacillus species, Prevotella, Mobiluncus, Bacteroides, Peptostreptococcus, Fusobacterium, Veillonella, Eubacterium species, Mycoplasma hominis, Urea plasma urealyticum and Streptococcus viridans.

Face presentation is the abnormal position of the fetal head in labour. In this position the neck is hyperextended.
Vertex position is the normal presentation of the foetus for delivery, in which the head is flexed and the position of the chin is towards the chest.

For the foetus to pass through the vagina, the obstetric conjugate should be 11cm or greater. If the diameter is less than 10 cm then its better to perform C-section as the labour might not progress. All the other options favour a normal vaginal delivery.

Ladd’s bands are the most common form of peritoneal bands in malrotation of the intestine.

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

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

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

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

During pregnancy, the chances for a woman to develop oral candidiasis double. An aphthous ulcer has a yellowish floor which is surrounded by an erythematous halo while in lichen planus, the lesions do not have the appearance of a thick white mark but are more or less lace-like. The lesions in leucoplakia have raised edges and they appear as bright white patches which are sharply defined and cannot be rubbed out. Smoking may affect the tongue, producing tongue coating. In this case the tongue is just inflamed which is a sign of infection.

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.

Placental abruption is defined as the premature separation of placenta from uterus and the condition usually presents with bleeding, uterine contractions and fetal distress. It is one of the most significant cause of third-trimester bleeding and is often associated with fetal and maternal mortality and morbidity. In all pregnant women with vaginal bleeding in the second half of the pregnancy, this condition should be considered as a differential diagnoses.
Though vaginal bleeding is the most common presenting symptom reported by almost 80% of women with placental abruption, vaginal bleeding is concealed in 20% of women with placental abruption, therefore, absence of vaginal bleeding does not exclude placental abruption.

Symptoms and complications of placental abruption varies according to patient, frequency of appearance of some common features is as follows:
‌- Vaginal bleeding is the common presentation in 80% of patients.
‌- Abdominal or lower back pain with uterine tenderness is found in 70%
‌- Fetal distress is seen in 60% of women.
‌- Abnormal uterine contractions like hypertonic, high frequency contractions are seen in 35% cases.
‌- Idiopathic premature labor in 25% of patients.
‌- Fetal death in about 15% of cases.

Examination findings include vaginal bleeding, uterine contractions with or without tenderness, shock, absence of fetal heart sounds and increased fundal height due to an expanding hematoma. Shock is seen in class 3 placental abruption which represents almost 24% of all cases of placental abruption.

The Rotterdam criteria for the diagnosis of PCOS is based on a score of two out of the three criteria:
1) Oligo or anovulation
2) Hyperandrogenism – clinical (hirsutism or less commonly male pattern alopecia) or biochemical (raised FAI or free testosterone)
3) on ultrasound – contain 12 or more follicles measuring 2 to 9 mm in diameter and/or have an increased volume of 10 cm3 or greater.

DNA replication occurs during S phase but that isn’t one of the options. Remember Interphase comprises G1,S and G2 phases!

Lower abdominal pain can be caused by any of the conditions listed in the answers.
A urinary tract infection is the most likely cause.
Unless it was an abdominal ectopic or an interstitial pregnancy, an ectopic pregnancy.
will almost definitely have shown up before the 15th week of pregnancy.
A retroverted gravid uterus may impinge at 15 weeks of pregnancy, however, this is unlikely to be linked to a temperature of 37.8°C.
It’s also possible that it’s the source of acute urine retention.
Complications of the corpus luteum cyst normally manifest themselves considerably earlier in pregnancy, and severe appendicitis is far less likely to be the source of discomfort than a urinary tract infection.

Vulvovaginal candidiasis is the most common genital infection and it is caused by candida albicans in 80-92% of the cases. Other non albicans species include C.tropicalis, C.glabrata, C.krusei and C.parapsilosis. 20% of women of childbearing age are asymptotic colonisers of Candida species as part of their normal vaginal flora. This increases to 40% in pregnancy.

An endometrioma, also known as a chocolate cyst is a benign ovarian cyst that occurs as a result of the trapping of endometriosis tissue inside the ovary. The findings on transvaginal ultrasound are often a unilocular cyst, with ground glass echogenicity due to haemorrhage. Other benign masses that can be evaluated using transvaginal ultrasound are functional cysts, serous and mucinous cystadenomas and mature teratomas.

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

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

Women, who have never had sexual encounter, do not need cervical screening. However, any sort of sexual encounter (Lesbian or heterosexual) is considered a risk and the patient must be screened. Otherwise, routine cervical screening test can be performed every five years for woman 25-74 years who ever had sex with no evidence of cervical pathology. Perform a cervical screening test at the age of 25 or 2 years after first sexual intercourse-whichever is later in sexually active women. Perform cervical screening test in patients above 75 years if they request or if they never had any symptoms.

All other options are unacceptable.

Blood in the peritoneal cavity rarely causes rigidity like that of a board (this is generally only found when chemical or purulent peritonitis is present).

When there is blood, there is usually a lot of rebound soreness and a lot of guarding.

A tubal ectopic pregnancy causes discomfort and tenderness in the lower abdomen, but it is not always localised to the side of the disease.

Shock is uncommon since the diagnosis is usually recognised before there is enough blood loss to elicit such signs.

Pelvic soreness is more prevalent than a pelvic mass that may be seen on a clinical exam.
Where a mass is visible, it could be an ectopic pregnancy, but it’s more likely to be a pregnancy surrounded by a blood clot caused by a leaking ectopic pregnancy.

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.

Genetically, patients suffering from androgen insensitivity syndrome are 46XY. They are males but insensitive to male hormones i.e. androgens.

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

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

Chorion villus sampling is an invasive procedure which aims to collect the rapidly dividing cells in the placenta. It is used for numerous reasons including detection of early pregnancy, viability of the foetus, singleton pregnancy, confirm gestation age and for prenatal diagnosis of the fetal chromosomal abnormalities including diagnosis of Down’s syndrome. However it hold a 2% chance of miscarriage during the procedure. Nuchal thickness and imaging are part of the combined test that must have been performed before.

Mitral stenosis is the most common cardiac condition affecting women during pregnancy and is poorly tolerated due to the increased intravascular volume, cardiac output and resting heart rate that predictably occur during pregnancy.

Young women may have asymptomatic mitral valve disease which becomes unmasked during the haemodynamic stress of pregnancy. Rheumatic mitral stenosis is the most common cardiac disease found in women during pregnancy. The typical increased volume and heart rate of pregnancy are not well tolerated in patients with more than mild stenosis. Maternal complications of atrial fibrillation and congestive heart failure can occur, and are increased in patients with poor functional class and severe pulmonary artery hypertension.

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

Patient mentioned in the given case has developed clinical features of cervical insufficiency and the possible treatment options include:
1- Cerclage, which is the technique used for the reinforcement of cervical ring with nonabsorbable suture material and is indicated based on ultrasonographic findings. It is the treatment of choice when cervical shortening is detected by ultrasonography before 22 to 24 weeks of gestation.

2- Vaginal progesterone is used to reduce the risk of preterm delivery in women who have a prior history of idiopathic preterm delivery or cervical shortening, which is confirmed in the current pregnancy also by ultrasonography.This method is applicable only to those women who do not meet the criteria for Cerclage.

All the other options of management are incorrect in the given case.

The major constituents of breast milk are lactose, protein, fat and water. However, the composition of breast milk is not constant; early lactation differs from late lactation, one feed differs from the next, and the composition can even change
during a feed. Artificial infant formulas cannot therefore be identical to breast milk. In addition to IgA, breast milk contains small amounts of IgM and IgG and other factors such as lactoferrin, macrophages, complement and lysozymes

The Vaginal artery, like the Uterine artery is typically a branch of the Internal Iliac artery. It can sometimes arise as a branch of the Uterine artery so it is important to read the question (if the stem stated it CAN arise from the Uterine artery then that would be true)

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

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

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

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

Clavulanic acid is a beta-lactamase inhibitor that is most often combined with a penicillin to form Augmentin or Co-amoxiclav for greater antibiotic efficacy. The drug works by irreversibly binding to enzymes present in bacteria which posses the Beta-lactamase enzyme. This enzyme is responsible for inactivating Beta-Lactam antibiotics such as penicillin.

The oocyte (eggs, ova, ovum) is arrested at an early stage of the first meiosis (first meiotic) division as a primary oocyte (primordial follicle) within the ovary. Following puberty, during each menstrual cycle, pituitary gonadotrophin stimulates completion of meiosis 1 the day before ovulation.

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

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

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

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

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

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justify ed to diagnose previously unrecognized cases of pre-existing diabetes and to identify a group of women who are at risk of developing NIDDM later in life. No single screening test has been shown to be perfect in terms of high sensitivity and specific city for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral 75g glucose tolerance test commonly used. The aim of glucose control is to keep fasting levels between 3.5 and 5.5 mmol/L and postprandial levels 7.1 mmol/L, with insulin treatment usually indicated outside these ranges.

Puberty is the process of reproductive and sexual development and the maturation which changes a child into an adult.

Multiple pregnancy is considered a high risk for obstetric complications such as spontaneous abortion, hypertensive disorders, placenta previa, and fetal malformations. Specifically, the incidence of hypertensive disorders, a common source of maternal morbidity, is 15% to 35% in twin pregnancies, which is two to five times higher than in singleton pregnancies. Additionally, the aetiology of preterm birth is not completely understood, but the association between multiple pregnancy and preterm birth is well known. A secondary analysis of the WHO Global Survey dataset indicated that 35.2% of multiple births were preterm (< 37 weeks gestation); of all multiple births, 6.1% of births were before 32 weeks gestation, 5.8% were during weeks 32 and 33, and 23.2% were during weeks 34 through 37

Gonadotropin-releasing hormone (GnRH) is the hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary gland.

The right ovarian vein ascends and enters the inferior vena cava and the left ovarian vein drains into the longer left renal vein.

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.

Changes in the cardiovascular system in pregnancy are profound and begin early in pregnancy, such that by eight weeks’ gestation, the cardiac output has already increased by 20%. The primary event is probably peripheral vasodilatation. This is mediated by endothelium-dependent factors, including nitric oxide synthesis, upregulated by oestradiol and possibly vasodilatory prostaglandins (PGI2). Peripheral vasodilation leads to a 25–30% fall in systemic vascular resistance, and to compensate for this, cardiac output increases by around 40% during pregnancy. 

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.

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

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

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

The extrinsic pathway is activated by the tissue factor, which converts factor VII to VIIa which later on converts factors X and II to their activated form finally leading to the conversion of fibrinogen to fibrin fibres.

This patient has experienced polycystic ovarian syndrome-like symptoms.
At least two out of three of the following criteria must be met to diagnose polycystic ovarian syndrome:
1- Hyperandrogenism suggesting an excess of androgens e.g. excess hair growth, acne etc.
2- Menstrual irregularities e.g. dysmenorrhea, oligomenorrhea, and amenorrhea.
3-The ovaries are polycystic if one ovary has 12 or more follicles or if the size of one or both ovaries has risen.

Low FSH, LH, and pituitary hormones are typically associated with hypothalamic dysfunction, however this is not the case here.
Similarly, with premature ovarian failure, FSH/LH levels rise while oestrogen levels decrease.

All of the other choices are incorrect.

In this pregnant patient with an antepartum haemorrhage at 37 weeks of gestation, her clinical presentation points to a placenta previa. Her bleeding has stopped, the uterus is of the expected size and non-tender, and the fetal head is still mobile above the pelvic brim which are all findings that would be consistent with a placenta praevia. An ultrasound examination would be done to rule-out or diagnose the condition.

An Apt test on the blood is necessary to ensure that this is not fetal blood that would come from a ruptured vasa praevia. Although this diagnosis would be unlikely since the bleeding has stopped. If there was a vasa praevia, there would be fetal tachycardia or bradycardia, where a tachycardia is often seen first but then bradycardia takes over late as fetal exsanguination occurs.

In a placental abruption with concealment of blood loss, the uterus would be larger and some uterine tenderness would be found on exam.

A cervical polyp could bleed after sexual intercourse and a speculum examination would be done to exclude it. However, it would be unlikely for a cervical polyp to cause such a large amount of blood loss. A heavy show would also rarely have as heavy as a loss of 200mL.

Pelvic Outlet Boundaries Anteriorly: Pubic arch Laterally: Ischial tuberosities Posterolaterally: Inferior margin of the sacrotuberous ligament Posteriorly: Tip of the coccyx Note: The pelvis outlet is also called the inferior aperture. The pelvic brim is the superior aperture

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

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

Sodium Valproate is known to be the most teratogenic when used in the first trimester of pregnancy. This antiepileptic increases the risk of congenital malformations including a 10-20 fold risk of neurodevelopmental defects. Though the use of antiepileptics should generally be avoided during pregnancy, carbamazepine, or newer drugs such as Lamotrigine are thought to carry less of a risk of teratogenicity.

The 3 main oestrogens are Estrone (E1) Oestradiol (E2) and Estriol (E3). Oestradiol is the predominant oestrogen during female reproductive years except during the early follicular phase when Estrone predominates. During pregnancy Estriol levels rise significantly and this becomes the dominant oestrogen during pregnancy. Ethinylestradiol and Mestranol are oestrogen found in COCP’s

LH surge occurs around ovulation and it is this LH surge which results in completion of the 1st meiotic division and ovulation occurs. It enhances the production of androgens and also luteinizes the granulosa cells.

Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity include inhibition of trophoblastic function and differentiation, activation of complement pathways at the maternal–fetal interface, resulting in a local inflammatory response and, in later pregnancy, thrombosis of the uteroplacental vasculature. This patient should be offered referral to a specialist clinic as she has had recurrent miscarriages. Low dose aspirin is one of the treatment options to prevent further miscarriage for patients with antiphospholipid syndrome.

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

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

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

All other options are incorrect.