The anatomy of the inguinal canal is of surgical importance. In the male, the inguinal canal carries the spermatic cord, ilioinguinal nerve and important blood vessels, while in females the inguinal canal holds the round ligament, ilioinguinal nerve and blood vessels. The floor of the inguinal canal is made of the inguinal ligament (a thickened portion of the inguinal ligament), while the posterior wall is made of the transversalis muscle. The anterior wall is made of the external oblique aponeurosis, and the roof is made up of fibres of the internal oblique, transversus abdominis and its aponeurosis, and the conjoint tendon. This means that the anterolateral support structure of the inguinal canal would be the fibres of the internal oblique.

Induction of labour is appropriate approximately 24 hours after rupture of the membranes.

As the time of onset of fever is the 4th day of postpartum and absence of uterine tenderness on exam makes infection of vaginal laceration the most likely cause of this presentation.

Exquisite uterine tenderness will be experienced in case of endometritis and symptoms are expected to start much earlier like by 2-3 days of postpartum.

UTI is often expected on days one or two of postpartum, also there are no urinary symptoms suggestive of UTI

Breast engorgement usually develops by 7th -2st day of postpartum and in the given case it’s too soon for it to occur.

As it is expected during the first 2 hours postpartum, Atelectasis is unlikely to be the cause of symptoms in the given case.

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.

Domperidone and metoclopramide are D2 dopamine receptor antagonists. They are primarily used to promote gastric motility. They are also known as galactagogues and they promote the production of milk. Cabergoline and bromocriptine are prolactin inhibitors and they reduce milk production.

This is stage 2B.

2010 FIGO classification of cervical carcinoma
0 – Carcinoma in situ
1 – Confined to the cervix (diagnosed microscopy)
1A1 – Less than 3mm depth & 7mm lateral spread
1A2 – 3mm to 5mm depth & less than 7mm lateral spread
1B1 – Clinically visible lesion or greater than A2 & less than 4 cm in greatest dimension
1B2 – Clinically visible lesion, Greater than 4 cm in greatest dimension 2 Invades beyond uterus but not to pelvic wall or lower 1/3 vagina
2A1 – Involvement of the upper two-thirds of the vagina, without parametrical invasion & Less than 4cm
2A2 – Greater than 4 cm in greatest dimension
2B – Parametrial involvement
3 – Extends to Pelvic side wall or lower 1/3 vagina or hydronephrosis
3A – No pelvic side wall involvement
3B – Pelvic side wall involved or hydronephrosis
4 – Extends beyond true pelvis
4A – Invades mucosa bladder and rectum
4B – Distant Metastasis

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 pelvic skeleton is formed posteriorly (in the area of the back), by the sacrum and the coccyx and laterally and anteriorly (forward and to the sides), by a pair of hip bones. Each hip bone consists of 3 sections, ilium, ischium, and pubis.

Patients suffering from androgen insensitivity syndrome have 46XY chromosomes. Due to insensitivity to androgens, they have female characteristics e.g. scant pubic or body hairs, enlarged mammary glands, and a small penis.

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

In pregnancy, progesterone is produced by the corpus luteum followed by the placenta- Exogenous progesterone will not lead to withdrawal bleeding. In ovarian failure as well as pituitary failure, no oestrogen stimulation of the endometrium exists, and progesterone cannot cause withdrawal bleeding. With Mullerian agenesis, there is no endometrium. Polycystic ovarian syndrome has an abundance of circulating oestrogen, so the endometrium will proliferate.

→ In pregnancy progesterone withdrawal will not occur since the corpus luteum is producing progesterone- The placenta will take over, starting at 7 weeks, and will be the sole producer of progesterone by 12 weeks.
→ In ovarian failure no oestrogen will be produced; no proliferation of the endometrium will occur.
→ Pituitary failure is an incorrect answer because without gonadotropin stimulation, there will not be enough oestrogen to stimulate the endometrial lining.
→ Mullerian agenesis is an incorrect answer – there is no uterus, thus no bleeding.

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

The best antibiotic of choice for empirical treatment of a urinary tract infection (UTI) during pregnancy is cephalexin. Nitrofurantoin and amoxicillin-clavulanate are second and third in-line respectively.
Patients allergic to penicillin, which is manifested as a rash can also be safely treated with cephalexin. But cephalosporins are not recommended if the presentation of allergic reaction to penicillin was anaphylactic, instead they should be treated with nitrofurantoin.

NOTE– Asymptomatic bacteriuria, such as >10 to power of 5 colony count in urine culture of an asymptomatic woman in pregnancy, should best be treated with a one week course of antibiotics, followed by confirming the resolution of infection via a urine culture repeated 48 hours after the completion of treatment.

Amoxicillin without clavulanate is recommended only in cases were the susceptibility of the organism is proven.

Macrolides like clarithromycin are usually not recommended for the treatment of UTI.

Aminoglycosides are coming under category D drugs should be avoided during pregnancy, unless there is a severe indication of gram negative sepsis.

Tetracycline, due to their potential teratogenic effects, are contraindicated in pregnancy.

Breast milk contains around 4% fat, 7% sugar and 1% proteins. The rest is water and minerals.

Congenital cytomegalovirus infections are the most common cause of sensorineural hearing loss in babies. Cytomegalovirus infection during the perinatal period can be transferred to the foetus especially if the primary infection is during pregnancy. In babies born with congenital CMV about 10-15% are symptomatic, while 10-15% of those who are asymptomatic will develop symptoms in life. Some of the features of CMV infection include sensorineural hearing loss, visual impairment, cerebral palsy, microcephaly and seizures. Other causes of infective congenital sensorineural hearing loss include: Rubella, HIV, Herpes Simplex Virus, Measles, Varicella Zoster virus, Mumps and West Nile Virus.

Ovulation in the menstrual cycle usually occurs over 4 days. There is an increase in basal body temperature at the time of ovulation due to the effect of progesterone.

A high Day 21 progesterone level indicates ovulation and the release of an egg.

Dysmenorrhea is described as painful menstruation. The symptoms start at the time of ovulation and persist till menstruation.

During childbearing the vagina and perineum are prone to lacerations that may involve the skin or can extend into the anal sphincter complex. It is important to be able to identify obstetric and anal sphincter injuries to provide adequate care and prevent complications. In the classification of obstetric tears according to RCOG guidelines:

First degree tear: injury to the perineal skin and/or the vaginal mucosa
Second degree tears: Injury to perineum involving perineal muscles but not the anal sphincter.
Third-degree tear: Injury to perineum involving the anal sphincter complex:
Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn.
Grade 3b tear: More than 50% of EAS thickness torn.
Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn.
Fourth-degree tear: Injury to perineum involving the anal sphincter complex (EAS and IAS)
and anorectal mucosa.

Treatment with Clomiphene should not exceed 6 months.

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).

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

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.

When the palpated uterine size is in discrepancy with the expected size based on the duration of amenorrhoea, it can have several causes including reduced fluid volume or fetal growth (both of which are more common when there is fetal malformation), or miscalculated age of gestation as a result of wrong dates or actual ovulation occurring at a later date than expected. Reduced fluid volume and fetal growth are the most likely aetiologies during the third trimester of pregnancy, unlike in this patient at 20 weeks age of gestation.

Premature rupture of membranes is less likely the cause when there is negative vaginal fluid loss like this patient.

The most likely cause in this case is that ovulation did not occur as expected, especially when the patient ceased her OCPs during this period. In some instances, ovulation can occur 2 weeks later in about 50% of women, 6 weeks later in 90%, and may still not occur 12 months later in 1% of women.

The other listed statements are unlikely to explain the discrepancies in dates and the observed uterine size in this patient.

The GI tract forms from the endoderm. The endoderm grows laterally and then ventrally finally folding on its self to form the gut tube.

To help protect babies during this time when they are most vulnerable, women should get the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) during each pregnancy.

Pregnant women should receive Tdap anytime during pregnancy if it is indicated for wound care or during a community pertussis outbreak.
If Tdap is administered earlier in pregnancy, it should not be repeated between 27 and 36 weeks gestation; only one dose is recommended during each pregnancy.

Optimal timing is between 27 and 36 weeks gestation (preferably during the earlier part of this period) to maximize the maternal antibody response and passive antibody transfer to the infant.
Fewer babies will be hospitalized for and die from pertussis when Tdap is given during pregnancy rather than during the postpartum period.

The lumbar plexus is formed via contributions from the T12-L4 spinal cord segment. The plexus is responsible for the motor and sensory innervation of portions of the lower extremities and some parts of the lower abdomen and pelvis. Nerves arising from the plexus include the Iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, femoral nerve, obturator, and nerve to the lumbosacral trunk.

Women aged 25-49 years living in England are routinely recalled for screening every three years. Women receive their first invitation for cervical screening at 25 years of age. They are not invited earlier as changes in the young cervix can be normal and result in unnecessary treatment. Provided the smears remain negative and there are no symptoms to suggest cervical cancer, the routine recall is three years for women aged 25-49 years. Women aged 50-64 years old are routinely recalled for a smear every five years. After the age of 65 years, women are only screened if they have not had a smear since the age of 50 years (including those who have never had a smear) or those who have had recent abnormal smears. This is because due to the natural history and progression of cervical cancer, it is highly unlikely that women over 65 years old will go on to develop the disease. 

Thyroxine requirement during pregnancy will increases by 25 to 30 percent, which is seen as early as fifth week of pregnancy.

Children born to those women whose hypothyroidism was inadequately treated during pregnancy, are at higher risk for developing neuropsychiatric impairments.

When a woman who is on thyroxine is planning to conceive, they are advised to increase their thyroxine dose by 30 percent at the time of confirmation of pregnancy.

During pregnancy TSH also should be monitored at every 8 to 10 weeks, with necessary dose adjustments.

Dose requirements of thyroxine will return to pre-pregnancy level soon after delivery and it will not change according to whether the mother is breastfeeding or not.

History of heavy menstrual bleeding and amenorrhoea favour the diagnosis of a fibroid uterus. All the given responses are causes for subfertility. Ectopic pregnancy presents with abdominal pain has an acute presentation. Endometriosis and adenomyosis usually don’t present with amenorrhoea or heavy bleeding respectively. PID presents with chronic pelvic pain and is not related to menstruation.

Mirena coil is used for contraception and for long term birth control. It causes stoppage of menstrual bleeding however, in a few cases there may be inter-menstrual spotting.

The uterine and vaginal arteries branch from the internal iliac artery. The ovarian artery branches direct from the aorta.