The yolk sac increases in size up until the 10th week reaching a maximum diameter of 6mm in normal pregnancy. After the 10th week the yolk sac will gradually disappear. It is usually sonographically undetectable by 20 weeks. A yolk sac greater than 6mm diameter is suspicious of failed pregnancy.

Pregnant women with high-grade squamous intraepithelial lesions (HSIL) on cervical cytology should be evaluated with colposcopy. Principles of management of pregnant women include the following:
– An immediate diagnostic excisional procedure should NOT be performed.
– When colposcopy is performed during pregnancy:
– Endocervical sampling with a curette and endometrial sampling should NOT be performed, as there is a risk of disturbing the pregnancy; however, the endocervical canal may be sampled gently with a cytobrush.
– Cervical biopsy should be performed only if a lesion is present that appears to be high grade or suspicious for cancer.
– If the examination is unsatisfactory, repeating the colposcopy after 6 to 12 weeks should allow visualization of the entire squamocolumnar junction.

There is no indication for inducing abortion or performing a hysterectomy.

IUS or Intra Uterine System/Device releases progestin. The progestin thickens the cervix, preventing the sperm from penetrating the cervix, and it also causes the uterine lining to become thinner, preventing any implantation. IUS may also prevent excessive bleeding and can help women with fibroids.

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

Oxytocin stimulates the myoepithelial cells in the breast causing the milk production. It also helps augment contractions in labour and cause uterine involution after childbirth.

From the options given, option A is correct as primary pulmonary hypertension is considered a contraindication to pregnancy.
The patient should be educated about the possible risks and increased maternal mortality in such cases. This restriction is due to the fact that symptoms of Pulmonary hypertension gets worse during pregnancy which results in high maternal mortality.
Termination of pregnancy may be advisable in these circumstances mostly to preserve the life of the mother.
Sudden death secondary to hypotension is also a commonly dreaded complication among patients with pulmonary hypertension during pregnancy.

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.

Overt hypertension, developing in about 5% of Pill users, and increases in blood pressure (but within normal limits) in many more is believed to be the result of changes in the renin-angiotensin-aldosterone system, particularly a consistent and marked increase in the plasma renin substrate concentrations. The mechanisms for the hypertensive response are unclear since normal women may demonstrate marked changes in the renin system. A failure of the kidneys to fully suppress renal renin secretion could thus be an important predisposing factor. These observations provide guidelines for the prescription of oral contraceptives. A baseline blood pressure measurement should be obtained, and blood pressure and weight should be followed at 2- or 3-month intervals during treatment. Oral contraceptive therapy should be contraindicated for individuals with a history of hypertension, renal disease, toxaemia, or fluid retention. A positive family history of hypertension, women for whom long-term therapy is indicated, and groups such as blacks, especially prone to hypertensive phenomena, are all relative contraindications for the Pill.

COCs do not increase the risk of developing breast and endometrial cancer, Type 2 DM or breast fibroadenoma.

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.

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

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

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

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

Nerve Supply: L5 to S2 via Nerve to Piriformis
Origin: Sacrum
Insertion: Greater trochanter
Action: External rotation of hip
Blood Supply: Superior and Inferior gluteal arteries and lateral sacral arteries

If a cervical screening test reveals invasive squamous cell carcinoma or adenocarcinoma, refer the patient to a gynaecologist at a tertiary hospital right once for further treatment.
Colposcopy at a GP practice is not appropriate in these situations. When it comes to the prospect of cancer, reassurance isn’t enough.

Typically fetal movements become apparent by 18-20 weeks

Patient’s symptoms and signs are suggestive of round ligament strain, which is a normal finding during pregnancy, especially in the 2nd trimester, and it does not require any medical intervention.

Round ligament is a rope-like fibromuscular band which extends from the anterolateral aspect of uterus anteriorly between the layers of the broad ligament, and passing through the deep inguinal ring into the inguinal canal.
A sharp, sudden spasm in the right iliac fossa which lasts for a few seconds which is usually triggered by sneezing, coughing, laughing and rolling over in bed are the common presentations of a round ligament pain.

Ectopic pregnancy and rupture of ectopic pregnancy are two unlikely diagnosis in this patient as she is in the second trimester of her pregnancy, whereas both the mentioned conditions occur during the first trimester.

Although appendicitis presents with pain in right iliac fossa, the pain is not causes by coughing or sneezing. Also, there will be other symptoms like tenderness and rebound tenderness in right iliac fossa in case of appendicitis.

IgM rise is typically seen with acute infection. IgG is produced in response to infection but is produced later than IgM. IgG is also produced in response to vaccination. If IgG and IgM are negative the patient is susceptible to Rubella infection. If IgG +ve and IgM -ve the patient should be considered immune. If IgM +ve this suggests acute infection or false positive IgM (not uncommon)

Listeria Monocytogenes is a cause of congenital infection. The most common source of the bacteria is food, especially unpasteurised milk. Congenital listeriosis can lead to spontaneous abortions, premature birth and chorioamnionitis. At birth, neonates may present with septicaemia, respiratory distress and inflammatory granulomatosis. The case mortality rate for listeriosis is thought to be between 20-30%.

Ectopic pregnancy is a known complication of pregnancy that can carry a high rate of morbidity and mortality when not recognized and treated promptly. It is essential that providers maintain a high index of suspicion for an ectopic in their pregnant patients as they may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting. Ectopic pregnancy, in essence, is the implantation of an embryo outside of the uterine cavity most commonly in the fallopian tube.

Providers should identify any known risk factors for ectopic pregnancy in their patient’s history, such as if a patient has had a prior confirmed ectopic pregnancy, known fallopian tube damage (history of pelvic inflammatory disease, tubal surgery, known obstruction), or achieved pregnancy through infertility treatment.

Performance of laparoscopic surgery is safe and effective treatment modalities in hemodynamically stable women with a non-ruptured ectopic pregnancy.

Patients with relatively low hCG levels would benefit from the single-dose methotrexate protocol. Patients with higher hCG levels may necessitate two-dose regimens. There is literature suggestive that methotrexate treatment does not have adverse effects on ovarian reserve or fertility. hCG levels should be trended until a non-pregnancy level exists post-methotrexate administration.

Surgical management is necessary when the patients demonstrate any of the following: an indication of intraperitoneal bleeding, symptoms suggestive of ongoing ruptured ectopic mass, or hemodynamically instability. Women who present early in pregnancy and have testing suggestive of an ectopic pregnancy would jeopardize the viability of an intrauterine pregnancy if given Methotrexate. The patient may have a cervical ectopic pregnancy and would thus run the risk of haemorrhage and potential hemodynamic instability if a dilation and curettage are performed.

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

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

Ultrasound findings in early pregnancy can help determine the viability of an intrauterine pregnancy. In the absence of a fetal heartbeat and no visible fetal pole, the mean gestational sac diameter should be measured. A sac diameter of less than 25mm on a transvaginal ultrasound scan is likely an indication of a miscarriage. In the presence of a fetal heartbeat, the crown-rump length should be less than 7mm according to NICE guidelines. Further scans are indicated 14 days later to confirm the diagnosis. The diagnosis of ‘pregnancy of uncertain viability’ is given in situations where there is inadequate ultrasound evidence to diagnose a miscarriage, such as a developing sac but no visualisation of a foetus with a heartbeat.
Ultrasound findings for partial molar pregnancy are an enlarged placenta with multiple diffuse anechogenic patches, while findings in a complete molar pregnancy include an enlarged uterus with multiple small anechogenic spaces (snowstorm appearance), or the bunch of grapes sign representing hydropic trophoblastic villi.

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

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

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

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

This is a grade 1 prolapse

The drug of choice for eclampsia and pre-eclampsia is magnesium sulphate. It is given as a loading dose of 4g i/v over 5 minutes, followed by an infusion for the next 24 hours at the rate of 1g/hr. If the seizures are not controlled, an additional dose of MgSO4 2-4gm i/v can be given over five minutes. Patients with eclampsia or pre-eclampsia can develop any of the following symptoms: persistent headache, visual abnormalities like photophobia, blurring of vison or temporary blindness, epigastric pain, dyspnoea and altered mental status.

Endometrial tissue found within the myometrium is Adenomyosis. If endometrial tissue is found at a distant site to the uterus it is termed endometriosis. Fibroids are smooth muscle tumours (Leiomyoma’s) sometimes called myoma’s.

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.

This patient has got thrush or a fungal infection in the vaginal area. Candida infection is most likely based on the white discharge and itching. A vaginal clotrimazole antifungal treatment is required.

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.

Endometriosis is a condition in which the endometrial tissue lies outside the endometrial cavity. There are 4 theories which explain this. First is pathological hyperplasia resulting in menstrual regurgitation and implantation, second is the coelomic epithelium transformation, third is immunogical factors and the fourth is via the lymphatic or vascular spread.

Dermoid cysts and teratomas contain elements from multiple germ cell layers. They are often considered the same entity (even in medical texts) however a dermoid is composed only of dermal and epidermal elements. A teratoma has mesodermal and endodermal elements Mature teratomas are composed of well-differentiated derivations from at least 2/3 germ cell layers (i.e. ectoderm, mesoderm, and endoderm). They contain developmentally mature skin complete with hair follicles, sweat glands, sometimes hair, and sometimes sebum, blood, fat, bone, nails, teeth, eyes, cartilage, and thyroid tissue.

The half-life of Oxytocin is approximately 5 minutes
The half-life of Misoprostol is approximately 20-40 minutes
The half-life of Ergometrine is approximately 30-120 minutes