All of the conditions that comprise fetal alcohol spectrum disorders stem from one common cause, which is prenatal exposure to alcohol. Alcohol is extremely teratogenic to a foetus. Its effects are wide-ranging and irreversible. Although higher amounts of prenatal alcohol exposure have been linked to increased incidence and severity of fetal alcohol spectrum disorders, there are no studies that demonstrate a safe amount of alcohol that can be consumed during pregnancy. There is also no safe time during pregnancy in which alcohol can be consumed without risk to the foetus. Alcohol is teratogenic during all three trimesters. In summary, any amount of alcohol consumed at any point during pregnancy has the potential cause of irreversible damage that can lead to a fetal alcohol spectrum disorder.

In general, diagnoses within fetal alcohol spectrum disorders have one or more of the following features: abnormal facies, central nervous system abnormalities, and growth retardation.

Arcuate means ‘bow shaped’ and there are different arcuate lines in anatomical terms. Regarding the pelvic brim this is composed of the arcuate line of the ilium, pectineal line and prominences of sacrum and pubic symphysis (as demonstrated in the images below). As can be seen the arcuate line is a smooth rounded border on the internal surface of the ilium inferior to the iliac fossa and Iliacus. Image sourced from Wikipedia Note: The pelvic outlet is also called the inferior aperture. The pelvic brim is the superior aperture

Glucagon release is inhibited by increased blood glucose, ketones, free fatty
acids, insulin, raised urea levels and somatostatin. Glucagon is produced by alpha cells of the pancreas and increases the plasma glucose level by stimulating glycogenolysis and gluconeogenesis.

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.

Small teeth with faulty enamel is more associated with fetal alcohol syndrome (FAS).

In FAS, the most common orofacial changes are small eyelid fissures , flat facies, maxillary hypoplasia, short nose, long and hypoplastic nasal filter, and thin upper lip. The unique facial appearance of FAS patients is the result of changes in 4 areas: short palpebral fissures, flat nasal bridge with an upturned nasal tip, hypoplastic philtrum with a thin upper vermillion border, and a flat midface. Other facial anomalies include micrognathia, occasional cleft lip and/or palate and small teeth with defective enamel.

Vulva is defined by the area which is located outside the female vagina and comprises of the labia majora, labia minora, clitoris, mons pubis and Bartholin glands. It is supplied by the vestibula branch of pudental artery.
Inferior hemorrhoidal artery supplies the lower part of the rectum.
Femoral artery is the continuation of external iliac artery and supplies most of the leg.

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)

Fat necrosis may occur following a traumatic injury to the breast. The lump is usually firm, round, and painless.

Oxytocin binds to G-protein-coupled receptors and requires Magnesium and cholesterol for this process to occur.

Women with polycystic ovary syndrome (PCOS) have a 2.7-fold increased risk for developing endometrial cancer. A major factor for this increased malignancy risk is prolonged exposure of the endometrium to unopposed oestrogen that results from anovulation.

Additionally, secretory endometrium of some women with PCOS undergoing ovulation induction or receiving exogenous progestin exhibits progesterone resistance accompanied by dysregulation of gene expression controlling steroid action and cell proliferation.

Other risk factors include nulliparity, early menarche and late menopause, obesity and family history of endometrial cancer. Which rules out all the other options.

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.

There are a few differential diagnoses to think of in a patient that presents such as this one. Pre-eclampsia, cholecystitis, and fatty liver could all cause pain and tenderness, but cholecystitis would not normally cause the hypertension and proteinuria seen in this patient and neither would acute fatty liver of pregnancy. The more likely explanation is pre-eclampsia which must always be considered in the presence of these symptoms and signs. This process is particularly severe in the presence of pain and tenderness under the right costal margin due to liver capsule distension.

Chronic renal disease could cause the hypertension and mild proteinuria seen, but it would not usually produce the pain and tenderness that this patient has unless it was complicated by severe pre-eclampsia.

Biliary cholestasis does not usually produce pain.

There is an increase risk of developing carcinoma of the uterus, if the endometrium shows hyperplasia with atypia. The standard surgery is total hysterectomy with bilateral salpingectomy which can be performed abdominally or laparoscopically If the disease is grade 1-2 and less than 1B i.e. less than 50% invasion of the uterine body.

Adenomyosis or dysfunctional uterine haemorrhage are the most likely causes of heavy periods.
Because she refuses to have a hysterectomy or endometrial ablation, hormonal therapy must be administered in addition to the iron therapy she is already receiving.
Any of the choices could be employed, but using therapy only during the luteal phase of the cycle in someone who is virtually surely ovulating (based on her typical monthly cycles) is unlikely to work.

Danazol is prone to cause serious adverse effects (virilization), especially when used for a long period of time.
GnRH agonists would cause amenorrhoea but are more likely to cause substantial menopausal symptoms, and the °fa contraceptive pill (OCP) is generally best avoided in someone using hypertension medication.

Treatment with norethisterone throughout the cycle is likely to be the most successful of the treatments available.
If a levonorgestrel-releasing intrauterine device (Mirena®) had been offered as an alternative, it would have been acceptable.

Cells adapt to external stressors in a variety of ways. A cell can either undergo hypertrophy or hyperplasia to overcome the stress, or atrophy if unable to overcome the stress. Metaplasia occurs when fully differentiated cell lines transform into another fully differentiated cell type to adapt to a new external environment. The replacement of columnar epithelium of the cervix to a stratified squamous epithelium occurs in the squamocolumnar transformation zone in response to the exposure of an everted ectocervix to the acidic pH of the vagina at puberty and first pregnancy. Carcinoma in situ is thought to involve the immature metaplastic cells in this region.

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.

The Pudendal nerve divides into inferior rectal, perineal and dorsal nerve of the clitoris (or penis in males). The dorsal nerve of clitoris supplies sensory innervation to the clitoris. The perineal branch supplies sensory innervation to the skin of the labia majora and minora and the vestibule.

In the foetus, the hypogastric artery ascends along the side of the bladder, and runs upward on the back of the anterior wall of the abdomen to the umbilicus, converging toward its fellow of the opposite side. Having passed through the umbilical opening, the two arteries, now termed umbilical, enter the umbilical cord, where they are coiled around the umbilical vein, and ultimately ramify in the placenta.

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.

Patient in the given case is nine weeks pregnant, and she has been exposed to a herpes zoster rash because she is working as a hospital nurse and has no prior history of chickenpox.
The most appropriate next step in this case would be checking for Varicella-Zoster IgG antibodies which assures immunity to varicella infections. If VZV IgG is present no further action is needed, but if VZV IgG antibodies are absent, then she will need Varicella Zoster Immunoglobulins within ten days from the exposure to shingles.

Desogestrel only POPs work mainly by inhibiting ovulation. Cerazette Is the only brand in this list which belongs to this group.

Types of Progesterone Only Pills

1. Traditional (e.g. Femulen®, Micronor®, Norgeston®)

Main mode of action: thickening cervical mucus preventing sperm entry at neck of womb and may also cause anovulation but this effect variable and unreliable

2. Desogestrel (e.g. Cerazette®)

Main mode of action: inhibition of ovulation and also cause thickening of cervical mucus

During the early fetal life, oogonia proliferate by mitosis. They enlarge to form primary oocyte before birth. No primary oocyte is form after birth. The primary oocyte is dormant is the ovarian follicles until puberty. As the follicle matures, the primary oocyte completes its first meiotic division and gives rise to secondary oocyte. During ovulation the secondary oocytes starts the second meiotic division but is only completed if a sperm penetrates it. This 1st and 2nd meiotic division is known as ootidogenesis.

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.

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.

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

An underlying disease is only found in 17 % of cases in mild polyhydramnios. In contrast, an underlying disease is detected in 91 % of cases in moderate to severe polyhydramnios. The literature lists the following potential aetiologies: fetal malformations and genetic anomalies (8–45 %), maternal diabetes mellitus (5–26 %), multiple pregnancies (8–10 %), fetal anaemia (1–11 %), other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios.

The bony pelvis is made up of a girdle with a central canal. The rim that surrounds the upper opening of the canal is called the pelvic inlet, while the lower rim is the called the pelvic outlet. The pelvic outlet is diamond-shaped and is bounded posteriorly by the tip of the sacrum, and anteriorly by the pubic symphysis, with its lateral boundaries being the ischial tuberosities and the sacrotuberous ligament.

Luteal phase is always fixed to 14 days. In this patient, ovulation will occur between days 12-15. Sexual encounter must be ceased until 24-36 hours before day 15 (day 17). The start date of abstinence, calculated by decreasing 6 days (life span of the sperm) from the earliest possible day of ovulation (12-6=6). Hence from day 6-17, sexual encounter must be avoided.

Oxytocin binds to the G protein coupled receptors that triggers the IP3 mechanism leading to an elevated intracellular calcium ion.

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.