Bacterial vaginosis is a common infection of the vagina caused by the overgrowth of atypical bacteria, most commonly Gardnerella vaginalis, a gram indeterminate bacteria, which is also a facultative anaerobe. Patients often complain of foul-smelling fishy discharge and dysuria. In diagnosing BV, a swab is taken for microscopy, often revealing clue cells. Of the other organisms listed in the options, Neisseria is an obligate anaerobe, while Chlamydia trachomatis is an obligate intracellular aerobe. Treponema Pallidum is an aerophilic bacteria and Mycoplasma hominis is a pleomorphic parasitic bacterium.

An ultrasonography is performed for confirmation, as well as for the evaluation of maternal pelvis, fetal size and viability in cases were breech presentation is suspected on manual examination. As there is a chance for spontaneous correction of breech presentation into cephalic during 36 to 37 weeks, this should be considered in every future visit. The chances for spontaneous version reduces to 25% if breech position persists beyond this period of time.

It an external cephalic version should be offered to all women with breech presentation, provided there are no contraindications or indication for cesarean delivery due to other reasons.

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.

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

Remember the inferior rectal artery supplies the anus. The middle rectal artery is the principle supply to the lower 1/3 rectum. The rectal arteries do form an anastomosis.

First stage of the labour starts with the contractions of the uterus. With time, the no. of contractions, its duration and intensity increases. It ends once the cervix is fully dilated.

In most cases reported, puerperal hematomas arise due to bleeding lacerations related to operative deliveries or episiotomy, and in rare cases from spontaneous injury to a blood vessel in the absence of any laceration/incision of the surrounding tissue. Vulval, vaginal/paravaginal area and retroperitoneum are considered the most common locations for puerperal hematomas.

Most puerperal hematomas are diagnosed based on the presence of characteristic symptoms and physical examination findings:
VuIvar hematoma usually presents as a rapidly developing, severely painful, tense and compressible mass which is covered by skin of purplish discoloration. A vulvar hematoma can also be an extension of a vaginal hematoma which was dissected through a loose subcutaneous tissue into the vulva.
Vaginal hematomas often present with rectal pressure, were hemodynamic instability caused due to bleeding into the ischiorectal fossa and paravaginal space are the first signs and can result in hypovolemic shock. In these cases a large mass protruding into the vagina is often found on physical examination.
Retroperitoneal hematomas are asymptomatic initially and extend between the folds of broad ligament. Patients suffering will often present with tachycardia, hypotension or shock due to the significant accumulated of blood in the retroperitoneal space. Unless the hematoma is associated with trauma, patients will not present with pain, only signs will be a palpable abdominal mass or fever.

Treatment of hematoma depends mostly on the size and location:
Non-expanding hematomas which are <3cm in size can be managed conservatively with analgesics and application of ice packs. An expanding hematoma or those greater than 3cm is managed effectively with surgical exploration under anesthesia, were an incision is made to evacuate the hematoma. The surgical site should not be sutured and vagina is often packed for 12-24 hours, an indwelling urinary catheter also may be indicated. In the given case, patient presents with a large haematoma (>3cm) which needs surgical excision and evacuation.

Aspiration of the hematoma is not an appropriate treatment. If surgical intervention is indicated excision and evacuation is the preferred option, followed by vaginal packing for 12-24 hours.

Administration of warfarin should be avoided throughout pregnancy and especially during the first and third trimesters as it have the ability to cross placenta. Intake of warfarin during 6-12 weeks of gestation can results in fetal warfarin syndrome which is characterized by the following features:
– A characteristic nasal hypoplasia
– Short fingers with hypoplastic nails
– Calcified epiphyses, namely chondrodysplasia punctata, which is evident on X-ray as stippling of the epiphyses.
– Intellectual disability
– Low birth weight

As these effects are usually dose dependent, recent estimates shows that the risk of fetal warfarin syndrome is around 5% in babies of women who requires warfarin throughout pregnancy.
Later exposure as after 12 weeks, is associated with symptoms like central nervous system anomalies, including microcephaly, hydrocephalus, agenesis of corpus callosum, Dandy-Walker malformation which is presented with complete absence cerebellar vermis and enlarged fourth ventricle, and mental retardation, as well as eye anomalies such as optic atrophy, microphthalmia and Peter anomaly (anterior segment dysgenesis).
Those newborns exposed to warfarin in all three trimesters there will be blindness and other complication of exposed to warfarin in neonates include perinatal intracranial and other major bleeding episodes.

Upon penetration, if all is normally occurring, the process of egg-activation occurs, and the oocyte is said to have become activated. This is thought to be induced by a specific protein phospholipase c zeta. It undergoes its secondary meiotic division, and the two haploid nuclei (paternal and maternal) fuse to form a zygote.

Fat necrosis is often a result of a trauma or surgery. In fat necrosis the enzyme lipase releases fatty acids from triglycerides. The fatty acids combine with calcium to form soaps. These soaps appear as white chalky deposits which are firm lumps with no associated discharge. The given case has a bruise which indicates prior trauma.

pre-eclampsia is defined as hypertension of at least 140/90 mmHg recorded on at least two separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24 hour collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the sixth postpartum week.

The pudendal nerve provides sensory innervation to regions of the anus, the perineum, the labia and the clitoris in women. The nerve is formed from the ventral rami of the S2-S4 sacral spinal nerves. The nerve is paired, each innervating the left and the right side of the body. Pudendal nerve blocks are indicated for analgesia of the second stage of labour, repair of an episiotomy or perineal laceration, and for minor surgeries of the lower vagina and perineum.

Clomiphene and/or Metformin are 1st line agents. Weight loss in the setting of subfertility is advised if BMI >30 kg/m2

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

Osteogenesis imperfect is an autosomal dominant condition. All the rest of the options are autosomal recessive conditions.

The pudendal nerve provides sensory and motor innervation to regions of the anus, the perineum, the labia and the clitoris in women. The nerve is formed from the ventral rami of the S2-S4 sacral spinal nerves. The nerve is paired, each innervating the left and the right side of the body. The nerve gives the following branches in females: the inferior anal nerve, the perineal nerve and the dorsal nerve of the clitoris.

Skin signs during pregnancy may include: dark spots on the breasts, nipples and inner thighs, melasma (chloasma), linea nigra, stretch marks, acne, spider telangiectasis and varicose veins.

Cord entanglement, a condition unique to MoMo pregnancies, occurs in 42 to 80% of the cases and it has been traditionally related to high perinatal mortality. Umbilical cord entanglement is present in all monoamniotic twins when it is systematically evaluated by ultrasound and colour Doppler. Perinatal mortality in monoamniotic twins is mainly a consequence of conjoined twins, twin reversed arterial perfusion (TRAP), discordant anomaly and spontaneous miscarriage before 20 weeks’ gestation. Expectantly managed monoamniotic twins after 20 weeks have a very good prognosis despite the finding of cord entanglement. The practice of elective very preterm delivery or other interventions to prevent cord accidents in monoamniotic twins should be re-evaluated.

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.

HB gower 1 is the predominant embryonic haemoglobin when the foetus is 6 weeks old and is replaced by adult haemoglobin by the age of 5 months post natally.

Immediate treatment for infants with suspected meconium aspiration syndrome is to clear/suction the airway. Intubation and tracheal toileting have remained a matter of debate till the most recent times. All neonates at risk of MAS who show respiratory distress should be admitted to a neonatal intensive care unit and monitored closely. The treatment is mainly supportive and aims to correct hypoxemia and acidosis with the maintenance of optimal temperature and blood pressure.

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).

Postcoital bleeding refers to spotting or bleeding unrelated to menstruation that occurs during or after sexual intercourse. It can be a sign of serious underlying pathology and is usually alarming for patients. About one-third of patients also have abnormal uterine bleeding that is not associated with coitus and about 15 percent have dyspareunia. The most serious cause of postcoital bleeding is cervical cancer. About 11 percent of women with cervical cancer present with postcoital bleeding. The patient should undergo cervical cancer screening according to local guidelines. Postcoital bleeding is not an indication for cervical cytology if previous screening tests are up-to-date and normal.

Cervical screening and liquid based cytology are superior to transvaginal ultrasound.

Coagulation profile can be done if cytology is normal to rule out bleeding diathesis.

Tranexamic acid can be considered once malignancy is ruled out and cause of bleeding has been established.

The Uterine artery typically arises from the anterior branch of the internal iliac artery. It crosses the ureter ANTERIORLY. It is the primary source of arterial supply to the uterus and its branches anastomose with branches of the ovarian and vaginal arteries.

As the most likely diagnosis, this woman meets diagnostic criteria for premenstrual syndrome (PMS).
Affective and physical symptoms that begin one week before menstruation and end four days after menstrual flow begins are diagnostic criteria for premenstrual syndrome. The symptoms must be present for at least three menstrual cycles and must not occur during the preovulatory period.
It’s critical to note that these symptoms are not caused by any medical or psychological condition, medications, drugs, or alcohol.

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent tears, and a lack of interest in daily activities. To put it another way, emotional impairment is the most prominent trait.

This woman does not meet the diagnostic criteria for PMDD because she only has psychological symptoms of irritation and anxiety, as well as physical symptoms of headache and breast soreness (five symptoms).

PMDD diagnostic criteria include:
Symptoms and their timing
A) At least 5 symptoms must be present in the final week before menses, improve within a few days after menses, and become mild or non-existent in the week after menses in the majority of menstrual cycles.
Symptoms
B) At least one of the symptoms listed below must be present:
1) Affective lability that is noticeable (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
2) Excessive irritation, wrath, or interpersonal conflicts
3) Depressed mood, hopelessness, and self-depreciating thoughts
4) Severe anxiety, tension, and/or a sense of being tense or on edge
C) In addition to the symptoms listed in criterion B, one (or more) of the following symptoms must also be present to reach a total of five symptoms.
1) Loss of enthusiasm for customary activities
2) Subjective concentration problems
3) Lethargy, fatigability, or a noticeable lack of energy
4) Significant changes in appetite, such as binge eating or specific food desires
5) Insomnia or hypersomnia
6) A feeling of being overwhelmed or powerless
7) Physical signs and symptoms include breast discomfort or swelling, joint or muscle pain, bloating, or weight gain.
Severity
D)The symptoms are linked to clinically substantial distress or interfere with employment, school, regular social activities, or interpersonal relationships.
E) Think about other mental illnesses. The disturbance isn’t only a sign of another disorder, like major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
Confirmation of the condition
F)Prospective daily ratings throughout at least two symptomatic cycles should be used to confirm Criterion A. (although a provisional diagnosis may be made prior to this confirmation)
Other medical explanations are ruled out.
G) The symptoms aren’t caused by the physiological consequences of a substance (e.g., drug misuse, medication, or other treatment) or a medical condition (e.g., hyperthyroidism).
The severity of the symptoms cannot be explained by normal menstrual physiology.
Generalized anxiety disorder and depression are improbable diagnoses because these symptoms are temporally tied to menstrual cycles.

The ischial spine is the anatomical landmark for assessing the station of the fetal head and also placing pudendal nerve blocks. (the pudendal nerve runs posterior to the ischial spine). The ischial spine can be palpated approximately 8cm into the vagina, at 4 and 8 o’clock.

This patient presents with signs and symptoms similar to clinical features of placental abruption.

Any trauma during the last trimester of pregnancy could be dangerous to both mother and fetus. By force of deceleration, motor vehicle accidents can result in placental separation. Also when subjected to strong acceleration-deceleration forces such as those during a motor vehicle crash uterus is thought to slightly change its shape. Since the placenta is not elastic and amniotic fluid is not compressible, such uterine distortion caused due to acceleration-deceleration or direct trauma will result in abruptio placentae due to shear stress at the utero-placental interface.

A painful, tender uterus which is often contracting is characteristic of placental abruption and the condition will lead to maternal hypovolemic hypotension and consequent fetal distress which is presented as fetal bradycardia and repetitive late decelerations. Vaginal bleeding, abdominal pain, contractions, uterine rigidity with tenderness, and a nonreassuring fetal heart rate (FHR) tracing are the clinical features diagnostic of abruption. However, a significant abruption can occasionally be asymptomatic or associated with minimal maternal symptoms in the absence of vaginal bleeding. Therefore the amount of vaginal bleeding is not always an appropriate indicator to the severity of placental abruption, this is because, in cases bleeding could be very severe or it may be concealed in the form of a hematoma in between the uterine wall and the placenta.

Sharp or blunt abdominal trauma can lead to uterine rupture or penetrating injury, since there is no reported abdominal trauma to the patient, uterine rupture is less likely to happen in this case. Severe abdominal pain with tenderness, cessation of contractions and loss of uterine tone are the most common symptoms characteristic of Uterine rupture. It will also be associated with mild to moderate vaginal bleeding along with fetal bradycardia or loss of heart sound. In this case uterus will be less tense and tender in comparison to placental abruption

Symptoms like low blood pressure, tachycardia and fetal bradycardia can be justified by ruptured spleen and liver laceration, but not the tense, tender and contracting uterus.

The diagnosis of placenta previa cannot be considered with the given clinical picture as it presents with sudden, painless bleeding of bright red blood and there will not be any uterine tenderness.

The Bishop score is a system used by medical professionals to decide how likely it is that you will go into labour soon. They use it to determine whether they should recommend induction, and how likely it is that an induction will result in a vaginal birth.

Cohort studies are the most appropriate study design to study the prognosis of a disease. A group of patients with the same condition are chosen and their baseline information is taken. The group is then followed up over time to see which patients live or die.
Case-control studies can also be useful where a group of individuals that have survived a condition are compared with cases of those who have died. Prognostic factors that distinguish the two groups are identified. This method, however, is limited by bias and the accuracy of medical information present.

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