Thyroid function in pregnancy is altered in two ways; the circulating levels of the thyroid binding proteins are increased, resulting in an increase in the total circulating levels of thyroid hormones (but a slight fall in the free component).

This woman suffers from a classic migraine with focused neurological symptoms. The use of any OCP preparation containing oestrogen in such patients is strictly prohibited. Androgenic consequences of progesterone include hirsutism, acne, and weight gain. Progesterone of any sort (norgestrel, drospirenone, cyproterone, etc.) should be avoided by a lady of her size; consequently, a barrier approach such as male condoms is the best option.

It is recommended that formulations containing 20-30 mcg ethinylestradiol be evaluated first when choosing a combined oral contraceptive pill (COCP). The progesterone component can be norgestrel, drospirenone, cyproterone, and so on; however, norgestrel-containing formulations are less expensive and more accessible to patients.

For specific cases, the type of progesterone should be considered:
– Patients who have unpleasant fluid retention and weight gain as a side effect of COCPs may be administered drospirenone (Yaz®. Yasmin®)-containing preparations.
– Drospirenone inhibits the production of mineralocorticoids and does not cause fluid retention. It may even be linked to a small amount of weight reduction.
– A preparation containing cyproterone acetate is preferable if the patient has suspected polycystic ovarian syndrome (PCOS).

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

Apoptosis is described as programmed cell death. The cell release certain proapoptotic mediators that regulate this cell death.

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.

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.

Endometriosis is a chronic gynaecologic disease characterized by the development and presence of histological elements like endometrial glands and stroma in anatomical positions and organs outside of the uterine cavity. The main clinical manifestations of the disease are chronic pelvic pain and impaired fertility. The localization of endometriosis lesions can vary, with the most commonly involved focus of the disease the ovaries followed by the posterior broad ligament, the anterior cul-de-sac, the posterior cul-de-sac, and the uterosacral ligament.

The clinical presentation of the disease differs in women and may be unexpected not only in the presentation but also in the duration. Clinicians usually suspect and are more likely to diagnose the disease in females presenting with the typical symptomatology such as dyspareunia, namely painful sexual intercourse, pelvic pain during menstruation (dysmenorrhea), pain in the urination (dysuria), defecation (dyschezia), and/or infertility. The pain is usually characterized as chronic, cyclic, and progressive (exacerbating over time). Furthermore, some women suffering from endometriosis experience hyperalgesia, a phenomenon, when even with the application of a nonpainful stimulus, an intolerable painful reaction is released. This condition indicates neuropathic pain.

Tenderness on vaginal examination, palpable nodules in the posterior fornix, adnexal masses, and immobility of the uterus are diagnostically indicating findings of endometriosis.

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.

Free T3 (FT3) and free T4 (FT4) levels are slightly lower in the second and third trimesters. Thyroid-stimulating hormone (TSH) levels are low-normal in the first trimester, with normalization by the second trimester.

Lymphatic vessels from the vagina drain from the parts of the vagina as follows:
• Superior part: to the internal and external iliac lymph nodes.
• Middle part: to the internal iliac lymph nodes.
• Inferior part: to the sacral and common iliac nodes.

20% of the patients with breast cancer will have hypercalcemia.

Micturition is defined as a process of expelling urine from the body. It is caused by the reflex contraction of detrusor muscle. Urinary bladder is a hollow muscular organ which can store 400-600ml of urine until it is expelled from the body. The first urge to urinate is felt when the bladder is filled with around 150ml of urine. The reflex action is initiated when the stretch receptors located in the bladder wall are stimulated. The afferent fibres pass to the pelvic splanchnic nerves to the 2nd, 3rd, and 4th sacral segments and some pass through the hypogastric plexus to the first and second lumbar segments of the spinal cord. Efferent pathways from the 2nd, 3rd, and 4th sacral segments leave the cords and through the splanchnic nerves and inferior hypogastric plexus supplies the smooth muscle of the bladder i.e. detrusor muscle. Detrusor muscle contracts and the sphincters are relaxed.

The transabdominal ultrasound uses a frequency of 3.5-7 MHz emitted from a transducer. Transvaginal 5-7.5 MHz (post bladder void.

Cardiotocography (CTG) helps to record the heartbeat of the foetus in parallel to measuring the contractions of the mother’s uterus, this is the most appropriate tool to assess this patient’s condition.

The World Health Organisation defines the maternal mortality ratio as the number of maternal deaths during a given period per 100,000 live births during the same period. This measure indicates the risk of death in a single pregnancy.

A ruptured ectopic pregnancy is the most probable diagnosis. As she is in shock (tachycardia and hypotension) immediate laparotomy is needed.

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.

Endometrial ablation is primarily intended to treat premenopausal women with heavy menstrual bleeding (HMB) who do not desire future fertility. Women who choose endometrial ablation often have failed or declined medical management.

Absolute contraindications to endometrial ablation include pregnancy, known or suspected endometrial hyperplasia or cancer, desire for future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal. In general, endometrial ablation should be avoided in patients with congenital uterine anomalies, severe myometrial thinning, and uterine cavity lengths that exceed the capacity of the ablative technique (usually greater than 10-12 cm).

The postpartum period begins soon after the baby’s delivery and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state.

Bloody vaginal discharge (lochia rubra) is heavy for the first 3-4 days, and slowly it becomes watery in consistency and colour changes to pinkish-brown (lochia serosa). After the next 10-12 days, it changes to yellowish-white (lochia alba). Advise women to seek medical attention if heavy vaginal bleeding persists (soaking a pad or more in less than an hour). Women with heavy, persistent postpartum bleeding should be evaluated for complications such as retained placenta, uterine atony, rarely invasive placenta, or coagulation disorders. Endometritis may also occur, presenting as fever with no source, maybe accompanied by uterine tenderness and vaginal discharge. This usually requires intravenous antibiotics. This also should be explained and advise the mother to seek immediate medical attention.

Choriocarcinoma spreads hematogenously.

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.

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

Complete abortion is defined as a ‘complete’ passage of all conception products.

The first day of the last menstrual period and findings on any prior ultrasounds should be determined to establish the gestational age and location of the pregnancy. An abdominal exam should be performed to assess for peritoneal signs that might indicate a ruptured ectopic pregnancy or extra-uterine extension of a septic abortion. Lastly, a pelvic exam is central to the evaluation of suspected miscarriage. It should include both speculum-facilitated visualization of the cervix and a bimanual examination to assess for cervical motion tenderness that may indicate a septic abortion or an adnexal mass that may herald ectopic pregnancy.

Early pregnancy loss takes many different forms. In missed abortion, there is asymptomatic or ‘missed’ death of the embryo or foetus without sufficient uterine contractions to push out the products of conception. In contrast, threatened abortion is characterized by symptomatic, ‘threatened’ expulsion of the products of conception, yet the cervical os remains closed, and the embryo or foetus remains viable.

Although there is a lack of consensus, complete abortion is often defined as the absence of a gestational sac on ultrasound with an endometrial stripe thickness of less than 30 mm.

In this case, the fundus height appears to be smaller than the suggested dates of gestation. However, this is uncertain as the exact gestation dates are not known. Head-sparing intrauterine growth restriction needs to be excluded or managed appropriately if detected.

The best initial management step would be to perform an ultrasound examination (correct answer). This would enable complete assessment of the foetus and all the measurable parameters can be determined. This would aid in identifying any discrepancy in size of the abdomen, limbs and head, and the liquor volume (amniotic fluid index) could be evaluated.

If asymmetrical growth restriction was detected via ultrasound examination, further evaluations such as cardiotocography (CTG) and umbilical arterial wave form analysis by Doppler could be initiated.

Additionally, foetal movement counting could then be commenced and evaluation of foetal lung maturity by amniocentesis could be considered.

If the ultrasound was normal (no evidence of asymmetrical growth restriction, normal amniotic fluid), repeat ultrasound should be performed after two weeks to evaluate the foetal growth.

If normal growth is observed on the repeat ultrasound, the estimated due date can be calculated (assuming normal foetal growth around the 50th percentile for the population).

Presentation in the given case is classic for premature rupture of membranes (PROM) which was probably caused due to trauma during intercourse.
Premature rupture of membrane (PROM) is defined as the rupture of embryonic membranes before the onset of labor, regardless of the age of pregnancy. If occured before 37 weeks of gestation, it is termed as preterm PROM (PPROM.)

A sudden gush of watery fluid per vagina is the classic presentation of rupture of the membranes (ROM), regardless of gestational age, however nowadays many women presents with continuous or intermittent leakage of fluid or a sensation of wetness within the vagina or on the perineum. Presence of liquor flowing from the cervical os or its pooling in the posterior vaginal fornix are considered as the pathognomonic symptom of ROM. Assessment of fetal well-being, the position of the fetus, placental location, estimated fetal weight and presence of any anomalies in PROM and PPROM are done with ultrasonographic studies.

Retained semen will not result in the findings mentioned in this clinical scenario as it have a different appearance.

Infections will not be a cause for this presentation as it will be associated with characteristic features like purulent cervical discharge, malodorous vaginal discharge, etc. Pooling of clear fluid in the posterior fornix is pathognomonic for ROM.

Urine leakage is common during the pregnancy, but it is not similar to the clinical scenario mentioned above.

Absence of findings like cervical dilation and bulging membranes on speculum exam makes cervical insufficiency an unlikely diagnosis in this case.

The biophysical profile is a composite test that collects 5 indicators of fetal well-being, including fetal heart rate reactivity, breathing movements, gross body movements, muscular tone, and quantitative estimation of amniotic fluid volume. The assessment of fetal heart rate is accomplished by performing a non-stress test, whereas the latter 4 variables are observed using real-time ultra-sonography.

With the use of warfarin, strict control of the INR is compulsory. After mitral valve replacement the INR should ideally be kept between 2.5-3.5. If the Ball and Cage or the Tilting Disc is used as a prosthetic valve then the target INR is 3.5, for bi-leaflets the target INR is 3.0 and for biological valves the target INR is 2.5.

The combination oral contraceptive pill is an unequivocal contraindication for this patient (migraine with aura). Progestogen-only contraception, such as etonogestrel implant, levonorgestrel intrauterine device, and depot medroxyprogesterone, should be offered to her.
There is no need for a neurologist’s assessment or a brain MRI because her migraines are managed with sumatriptan nasal spray.

Amniotic fluid volume begins to increase rapidly in the second and third trimester as the fetal kidneys continue to develop. By 35 weeks gestation the amniotic fluid volume reaches a maximum average of about 800 ml after which it decreases slightly to term.

Monitoring after treatment for HSIL includes:
– colposcopy and cervical cytology at 4 to 6 months followed by HPV typing at 12 months and annually until a negative test is obtained on 2 subsequent check ups.
-2 yearly screening interval can be done afterwards.

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.

Fibroadenoma usually occurs in younger women. These non-tender masses can be removed for aesthetic purposes. Breast cysts are common shifting masses inside the breast tissue more common in women over the age of 35.

An ectopic pregnancy is definitely present in this patient. An extrauterine pregnancy is referred to as an ectopic pregnancy. The fallopian tube accounts for 96% of ectopic pregnancies, but other sites include the cervical, interstitial (also called cornual; a pregnancy located in the proximal segment of the fallopian tube that is embedded within the muscular wall of the uterus), hysterotomy (caesarean) scar, intramural, ovarian, or abdominal. Furthermore, multiple gestations may be heterotopic in rare situations (including both a uterine and extrauterine pregnancy). Diabetes mellitus is not considered a risk factor for the development of an ectopic pregnancy.

Risk factors for ectopic pregnancy are summarized below:
High Risk: (Risk factors & Odds ratio)
Previous ectopic pregnancy 2.7 to 8.3
Previous tubal surgery 2.1 to 21
Tubal pathology 3.5 to 25
Sterilization 5.2 to 19
IUD – Past use 1.7 – Current use 4.2 to 16.4
Levonorgestrel IUD 4.9
In vitro fertilization in current pregnancy 4.0 to 9.3

Moderate:
Current use of oestrogen/progestin oral contraceptives 1.7 to 4.5
Previous sexually transmitted infections (gonorrhoea, chlamydia) 2.8 to 3.7
Previous pelvic inflammatory disease 2.5 to 3.4
In utero diethylstilbesterol (DES) exposure 3.7
Smoking – Past smoker 1.5 to 2.5 – Current smoker 1.7 to 3.9
Previous pelvic/abdominal surgery 4.0
Previous spontaneous abortion 3.0

Low:
Previous medically induced abortion 2.8
Infertility 2.1 to 2.7
Age ≥40 years 2.9
Vaginal douching 1.1 to 3.1
Age at first intercourse <18 years 1.6
Previous appendectomy 1.6

OCPs which contain oestrogen and progesterone are contraindicated in women who have migraines associated with a neurological deficit or aura (pins and needles in this case). In such cases, the alternative would be Implanon (etonogestrel), however, there are mixed reviews and opinions regarding whether or not there is a decreased efficacy in heavier women. The absolute contraindication for Implanon is active breast cancer. Therefore, the best advice for her case would be some form of barrier contraceptive.

When choosing a COCP (combined oral contraceptive pill), it is recommended that a formulation containing 20-30ug of ethinyl oestradiol is chosen. The progestogen part is responsible for prevention of conception and can be norgestrel or any other progestogens although the formulations containing norgestrel tend to be cheaper than more novel progestins such as cyproterone acetate as well as drospirenone. If the patient is known to have issues with excessive fluid retention, OCPs that has drospirenone would be the most suitable. However, if the patient is suspected to have PCOS, the best choice would be one that contains cyproterone acetate.

The principal screening test for detecting maternal HBV infection is the serologic identification of HBsAg. Screening should be performed in each pregnancy, regardless of previous HBV vaccination or previous negative HBsAg test results.

A test for HBsAg should be ordered at the first prenatal visit. Women with unknown HBsAg status or with new or continuing risk factors for HBV infection (e.g., injection drug use or a sexually transmitted infection) should be screened at the time of admission to a hospital or other delivery setting.

Interventions to prevent perinatal transmission of HBV infection include screening all pregnant women for HBV, vaccinating infants born to HBV-negative mothers within 24 hours of birth, and completing the HBV vaccination series in infants by age 18 months.

Warfarin is teratogenic if it is used in the first trimester. It causes bone defects and haemorrhages in the developing foetus.

The pudendal nerve is formed by sacral nerve roots S2, S3 and S4 almost immediately as they exit the spinal foramina. The pudendal nerve exits the pelvis via the greater sciatic foramen, travels behind the sacrospinous ligament before re-entering the pelvis via the lesser sciatic foramen. It is an important nerve to be aware of as it supplies sensation to the genitalia and can also be damaged/compressed at a number of places along its course. Image sourced from Wikipedia

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.

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.

This patient at 36 weeks of gestation likely had a generalized tonic-clonic seizure. A new-onset seizures in pregnancy can be due to either due to eclampsia which is pregnancy-specific or due to other non-obstetric causes like meningitis, intracranial bleeding etc.

In pregnant and postpartum women eclampsia is the most common cause for seizures which is classically associated with preeclampsia, a new-onset hypertension at ≥20 weeks gestation, with proteinuria and/or signs of end-organ damage. Although this patient has hypertension, absence of proteinuria and the additional findings like agitation, dilated pupils, hyponatremia and normal head CT scan are suggestive of another etiology. Patients with eclampsia will show white matter edema in head CT scan.

Amphetamine intoxication, which causes overstimulation of the alpha-adrenergic receptors resulting in tachycardia, hypertension and occasional hyperthermia, might be the cause for this patient’s seizures. Some patients will also have diaphoresis and minimally reactive, dilated pupils and severe intoxication can lead to electrolyte abnormalities, including significant hyponatremia (possibly serotonin-mediated) and resultant seizure activity.
Confirmation of Amphetamine intoxication can be done by a urine drug testing. it is essential to distinguishing between eclampsia and other causes of seizure in this case, as it will help to determine whether or not there is need for an emergency delivery.

Altered mental status and electrolyte abnormalities can be due to heat stroke, however, patients affected this way will have an elevated temperature of >40 C /104 F associated with hemodynamic instabilities like hypotension.

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a hypertensive disorder of pregnancy which can result in seizures (ie, eclampsia), but this patient’s hematocrit level is normal without any hemolysis, also patients with HELLP syndrome typically presents with a platelet count <100,000/mm3. Seizures and altered mental status in patients with prior splenectomy can be due to pneumococcal meningitis however, such patients will present with high fever and nuchal rigidity, making this diagnosis less likely in the given case. Amphetamine intoxication can present with hypertension, agitation, diaphoresis, dilated pupils, and a generalized tonic-clonic seizure due to hyponatremia, which is most likely to be the case here.

Ovarian cancer is a gynaecological cancer that commonly affects women over 40 years. Risk factors for ovarian cancer include: infertility, a family history of ovarian, breast or colorectal cancer. There are some protective factors, which include: high parity and breastfeeding, early age at menarche and late age at menopause, and combined oral contraceptives, and statins.

The five year survival of stage 1 ovarian cancer is 70-90%

There are many different reasons for performing a delivery by Caesarean section. The four major indications accounting for greater than 70 per cent of operations are: 1. previous Caesarean section 2. dystocia 3. malpresentation 4. suspected acute fetal compromise. Other indications, such as multifetal pregnancy, abruptio placenta, placenta praevia, fetal disease and maternal disease are less common. The chances of early postpartum haemorrhage are greatly reduced in C-section deliveries.

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

WHO guidelines
Semen volume: Greater than or equal to 1.5 ml
pH: Greater than or equal to 7.2
Sperm concentration: Greater than or equal to 15 million spermatozoa per ml
Total sperm number: 39 million spermatozoa per ejaculate or more
Total motility (% of progressive motility and nonprogressive motility): 40% or more motile or 32% or more with progressive motility
Vitality: 58% or more live spermatozoa
Sperm morphology (percentage of normal forms): 4% or more

The pudendal nerve arises from the S2-S4 nerve roots and it lies medial to the internal pudendal artery while exiting the pelvis via the greater sciatic foramen. It curves around the sacrospinous ligament and re-enters the pelvis via the lesser sciatic foramen and from there it runs medial to the ischial tuberosity over the obturator internus in the pudendal canal to the deep perineal pouch.

Polycystic kidney disease (PKD) can either be autosomal dominant or recessive. The autosomal dominant variant is more common in adult PKD however, the recessive pattern is more common in infantile PKD.

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.

Breast development occurs from the age of 9-13 at the onset of puberty. Delayed puberty is defined as the absence of breast development after the age of 13.

Oxytocin is responsible for the let down mechanism that occurs during breast feeding in which the myothelial cells contract and push the milk into the ductules.

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.

Dehydroepiandrosterone (DHEA) is a steroid hormone synthesised from cholesterol (via Pregnenolone) by the adrenal glands. The foetus manufactures DHEA, which stimulates the placenta to form oestrogen, thus keeping a pregnancy going. Production of DHEA stops at birth, then begins again around age seven and peaks when a person is in their mid-20s

Patient mentioned in the case has developed severe nausea and vomiting at the initial weeks of pregnancy. If the following clinical features are present, it confirms the diagnosis of hyperemesis gravidarum:
– Weight loss of more than 5% of pre-pregnancy weight
– Moderate to severe dehydration.
– Ketosis
– Electrolyte abnormalities.

Management of hyperemesis gravidarum include:
– Temporary suspension of oral intake, followed by gradual resumption.
– Intravenous fluid resuscitation, beginning with 2 L of Ringer’s lactate infused over 3 hours to maintain a urine output of more than 100 mL/h.
– Use of Antiemetics like metoclopramide, if needed.
– Oral administration of Vitamin B6.
– Replacement of electrolytes if required in the case.

Encouraging oral intake and sending this patient home without any intravenous hydration, is not considered the correct treatment option in this case.

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.

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 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)

Above mentioned patient presented with symptoms of premature rupture of membranes (PROM) which refers to membrane rupture before the onset of uterine contractions.

A sudden gush of clear or pale yellow fluid from the vagina is the classic clinical presentation of premature rupture of membranes. Along with this the patient also developed signs of infection like fever, tachycardia and sweating which is suggestive of chorioamnionitis.

Vaginal examination is never performed in patients with premature rupture of membrane, instead a speculum examination is the usually preferred method which will show fluid in the posterior fornix.

The following are the steps in management of premature rupture of membrane:
– Admitting the patient to hospital.
– Take a vaginal
ervical smears.
– Measure and monitor both white cell count and C- reactive protein levels.
– Continue pregnancy if there is no evidence of infection or fetal distress.
– In presence of any signs of infection or if CTG showing fetal distress it is advisable to induce labour.
– Corticosteroids must be administered if delivery is prior to 34 weeks of gestation.
– Give antibiotics as prevention and for treatment of infection.

The best regimen would be to have no intercourse in the follicular phase of the cycle and then commence it two days after a temperature rise of 0.3C and continue then onwards. When deciding the best contraceptive method, one has to consider two factors-the duration of survival of sperm in the uterus and body temperature in relation to ovulation. For this case, since her cycle length varies from 24 to 30 days, the earliest time in which ovulation would occur would be 14 days before her shortest cycle i.e. day 10. Intercourse has to be avoided from day 4 of her cycle just in case the current cycle is short because sperm can survive up to 6 days in the uterus. Day 4 would be the day her menses would end and as this couple avoids intercourse during her menstruation, there would be no intercourse during the follicular phase of her cycle.

During ovulation, her serum progesterone levels would start to increase, causing a 0.3°C to 0.4°C increase in her body temperature within 2-3 days of ovulating. This elevation in temperature would remain until close to when her period starts. The ovum can only be fertilised for roughly 24 hours after ovulation has taken place. Resuming sexual intercourse once her temperature has risen for 2 days would suggest that ovulation had already taken place 3-4 days earlier and so it is unlikely for pregnancy to occur.

Options that include intercourse during any part of her follicular phase is not correct. Hence, the only option that satisfies the above criteria would be intercourse avoidance during her follicular phase and to resume 2 days following a rise of 0.03°C in body temperature.

Menopause is defined as the cessation of menstruation for a period of 12 months. Premature menopause is defined as cessation of menstruation before the age of 40.

At the time of delivery, the most important signs of complete placental separation are lengthening of the umbilical cord, per vaginal bleeding and change in shape of uterus from discoid to globular shape. The uterus contracts in size and rises upward.