Polycystic ovary syndrome (PCOS) is a condition in which the ovaries produce an abnormal amount of androgens, male sex hormones that are usually present in women in small amounts. The name polycystic ovary syndrome describes the numerous small cysts (fluid-filled sacs) that form in the ovaries. However, some women with this disorder do not have cysts, while some women without the disorder do develop cysts.

The symptoms of PCOS may include:
– Missed periods, irregular periods, or very light periods
– Ovaries that are large or have many cysts
– Excess body hair, including the chest, stomach, and back (hirsutism)
– Weight gain, especially around the belly (abdomen)
– Acne or oily skin
– Male-pattern baldness or thinning hair
– Infertility
– Small pieces of excess skin on the neck or armpits (skin tags)
– Dark or thick skin patches on the back of the neck, in the armpits, and under the breasts

The so-called Laurence-Moon-Biedl syndrome is a fairly rare condition characterized by six cardinal signs, namely obesity, atypical retinitis pigmentosa, mental deficiency, genital dystrophy, polydactylism and familial occurrence.

Froehlich syndrome is characterized by increased or excessive eating that leads to obesity, small testes, and a delay in the onset of puberty. It is also common for children with Froehlich syndrome to experience the delay in physical growth and the development of secondary sexual characteristics.

Cushing’s syndrome is a disorder that occurs when your body makes too much of the hormone cortisol over a long period of time. Cortisol is sometimes called the “stress hormone” because it helps your body respond to stress. Cortisol also helps. maintain blood pressure. regulate blood glucose, also called blood sugar.

Pseudohypoparathyroidism is characterized by short stature, a round face, short neck, and shortened bones in the hands and feet. Intelligence usually ranges from low normal to mentally retarded. Headaches, weakness, tiring easily, lethargy, cataracts and blurred vision or hypersensitivity to light may also be present.
This patient’s condition can only be explained by PCOS.

Haemoglobin decreases from 13.3 g/dL to 10.5 g/dL from the start of pregnancy i.e. First trimester till the 3rd trimester.

Raised pressure with the pelvis can cause a number of nerve entrapment syndromes. This is entrapment of the lateral cutaneous nerve of the thigh (or lateral femoral cutaneous nerve) also known as Meralgia Paraesthetica. Pregnancy is a risk factor. Shingles can effect this nerve but the rash would usually present itself within 14days.

Remember SYMPATHETIC is STORAGE PARASYMPATHETIC is PEEING

Women with medical conditions associated with increased risk for thrombosis generally should not use oestrogen-containing contraceptives.

The majority of evidence identified does not suggest an increase in odds for venous or arterial events with use of most POCs. Limited evidence suggested increased odds of VTE with use of injectables (three studies) and use of POCs for therapeutic indications (two studies, one with POCs unspecified and the other with POPs).

Discontinuing anticoagulants increases her risk of recurrent DVT.

Nausea, fatigue, breast tenderness, and increased frequency of urination are the most common symptoms of pregnancy, but their presence is not considered definitive as they are nonspecific symptoms which are not consistently found in early pregnancy, also these symptoms can occur even prior to menstruation.

In pregnancy a physical examination will reveal an enlarged uterus which is more boggy and soft, but these findings are not apparent until after 6th week of gestation. In addition, other conditions like adenomyosis, fibroids, or previous pregnancies can also result in an enlarged uterus which is palpable on physical examination.

An abdominal ultrasound will not demonstrate a gestational sac until a gestational age of 5 to 6 weeks, nor will it detect an ectopic pregnancy soon after a missed menstrual period, therefore it is not indicated in this patient.

A Doppler instrument will detect fetal cardiac action usually after 10 weeks of gestation.

A sensitive serum quantitative pregnancy test can detect placental HCG levels by 8 to 9 days post-ovulation and is considered as the most appropriate next step in evaluation of this patient.

Folate has been in the news because of its connection with a type of birth defect called neural tube defect. Studies have shown that women who have infants with neural tube defects have lower intakes of folate and lower blood folate levels than other women. Folate is needed early in pregnancy (before many women know they are pregnant) for normal neural tube development.

Many vegan foods including enriched bread, pasta, and cold cereal; dried beans; green leafy vegetables; and orange juice are good sources of folate. Vegan diets tend to be high in folate, however, to be on the safe side, women capable of becoming pregnant should take a supplement or use fortified foods that provide 400 micrograms of folate daily.

For the above mentioned reasons, all other options are incorrect.

Toxoplasma gondii, an intracellular protozoan, is the main causative agent for Toxoplasmosis. Though the primary host for the organism is the domestic cat, humans can become infected by eating undercooked meat of animals harbouring cysts, consuming water or food contaminated with cat faeces, or through maternal-fetal transmission. Toxoplasmosis can cause complications in pregnancy such as miscarriages and congenital infection which can lead to hydrocephalus, microcephaly, mental disability and vision loss.

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.

Menstrual cycle can be divided into the follicular phase and luteal phase. In the luteal phase, there is an increase in progesterone secretion and LH levels are low. If the ova is fertilized, it is implanted in the endometrium. In case of failure in fertilization, there is gradual decrease in progesterone and LH levels.

Sigmoid colon is part of the hindgut and the hindgut is innervated by the T12-L1 segment of the spinal nerves.

The mid-luteal progesterone sample should be taken 7 days before the expected period i.e. day 21 in a 28-day cycle or day 28 of a 35 day cycle

Oesophageal atresia of the foetus interrupts the normal circulation of the amniotic fluid. This causes polyhydramnios and subsequent distension of the uterus impacting proper expansion of the lungs. This would explain the difficulty breathing.

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.

ALP can rise to up to 3 times the normal non-pregnant value in the 3rd trimester. All of the other tests above typically decrease 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.

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.

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.

Turner syndrome patients present with primary amenorrhea, have non functional or streak ovaries and cant conceive. They are 45X genetically.

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.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Weighted cones or topical steroids can be used as adjuvants but are not sufficient when used alone.

Tension free vaginal tape and Burch’s colposuspension are considered for patients who fail to respond to conservative management strategies.

A serious complication with a miscarriage is DIC, a severe blood clotting condition and is more likely if there is a long time until the foetus and other tissues are passed, which is often the case in missed abortion.

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

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

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

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

This patient has a regular and long menstrual period. The most crucial thing in this case is to rule out anovulation.
Serum progesterone concentration is the best test for detecting ovulation.
Ovulation has occurred if the level is greater than 20nmol/L.
This test should be performed 3 to 10 days prior to the start of the next anticipated period.

Engagement means when the fetal head enters the pelvic brim/inlet and it usually takes place 2 weeks before the estimated delivery date i.e. at 38 weeks of pregnancy.

Uterine blood flow increases 40-fold to approximately 700 mL/min at term, with 80 per cent of the blood distributed to the intervillous spaces of the placentae, and 20 per cent to the uterine myometrium.

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.

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.

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.

Congenital Herpes Simplex Virus infection may cause high levels of morbidity and mortality in neonates. Risk of infection with HSV 1 and 2 is highest within 6 weeks of delivery and is transferred to the neonate via maternal secretions at birth. Affected babies can present as skin manifestations, CNS infection, or disseminated infection, which carries an 85% risk of mortality if left untreated. Treatment with high dose antivirals such as acyclovir can help decrease the case mortality rate to 30% in cases of disseminated infection.