If a patient presents with PROM at 27 weeks of gestation, her management plan would have to include:

1) Cervical swabs to rule out infection
2) Commencement of prophylactic antibiotics such as erythromycin until results from the swabs are available
-If only normal vaginal flora are seen, prophylactic antibiotics can be stopped.
3) Administration of glucocorticoid- usually for 48 hours to promote maturity of the fetal lung and lower the chance of intracranial bleeding if the foetus has to be delivered prematurely
4) Transfer to a healthcare centre that has neonatal intensive care facilities to ensure if intensive care is needed post-delivery, the healthcare staff are prepared
5) Blood profile (particularly white cell count) and inflammatory markers (CRP) to look for any signs of chorioamnionitis
6) CTG assessment every 2-3 days. Abnormalities found on the CTG tracing are often the first evidence of problems such as a subclinical chorioamnionitis
7) Tocolysis with tocolytics such as IV salbutamol or nifedipine if contractions start before the course of glucocorticoid therapy is finished. Post-glucocorticoid therapy, tocolysis would not be often employed since there is a risk of masking contractions that occur due to an infection. In those cases, it is better to deliver the baby rather than to prolong the pregnancy. If there is no infection, the management plan should aim to prolong the pregnancy and delay delivery of a very premature baby.

Majority of the lymph from the ovaries drain into the para-aortic lymph nodes.

According to the laboratory reports, patient has developed urinary tract infection and should be treated with one week course of oral antibiotics.
As the patient is pregnant, antibiotics like cephalexin, co-amoxiclav and nitrofurantoin must be considered as these are safe during pregnancy.

Due to this Patient’s allergic history to penicillin, cephalexin can be considered as the best option. Risk of cross allergy would have been higher if the patient had any history of anaphylactic reactions to penicillin.

In Australia, Amoxicillin is not recommended to treat UTI due to resistance.Tetracyclines also should be avoided during pregnancy due to its teratogenic property.

The lower vagina drains to the inguinal nodes where as the upper vagina drains to the internal and external iliacs

The occurrence of migraine in women is influenced by hormonal changes throughout the lifecycle. A beneficial effect of pregnancy on migraine, mainly during the last 2 trimesters, has been observed in 55 to 90% of women who are pregnant, irrespective of the type of migraine.

For treatment of acute migraine attacks, 1000 mg of paracetamol (acetaminophen) preferably as a suppository is considered the first choice drug treatment. The risks associated with use of aspirin (acetylsalicylic acid) and ibuprofen are considered to be small when the agents are taken episodically and if they are avoided during the last trimester of pregnancy.

Paracetamol 500 mg alone or in combination with metoclopramide 10 mg are recommended as first choice symptomatic treatment of a moderate-to-severe primary headache during pregnancy.

P wave = Atrial depolarisation
QRS complex = Ventricular depolarisation
T wave = Ventricular repolarisation
U wave = repolarisation of the interventricular septum

Oestrogen is secreted by the corpus luteum and is responsible for the proliferation of the endometrium to prepare it for the implantation of the zygote.

Up to 20% of women have been found to have Group B streptococcus (GBS). GBS is considered a normal flora of the gastrointestinal tract. GBS infection is generally asymptomatic although some women might end up having a UTI. Infants born to mothers who are colonised with GBS during labour are at a higher risk of developing early-onset GBS infection. If a pregnant woman develops a UTI due to GBS, it is suggestive of significant GBS colonisation. IV penicillin would be the drug of choice and is to be administered to the mother during labour which would provide sufficient protection for the foetus and would be effective enough. If penicillin is unavailable, ampicillin is a reasonable alternative. If a patient has penicillin allergy, vancomycin can be used. If not for penicillin, roughly 50% of babies delivered vaginally to women who are GBS positive would be colonised with the organism and out of this percentage, 1-2% can go on to develop a severe infection such as septicaemia and meningitis which could often be fatal.

IM penicillin can be administered to the newborn immediately post-delivery would be an effective prophylaxis in most cases but one should not wait until signs of infection are present to give the injection. Many newborns would still have an immature immune system which could cause some to die. Hence, it is more suitable to treat all women who tested positive during labour and the newborn as well if any signs of infection do appear. The majority of babies don’t need antibiotic treatment if their mother has been treated.

T-Helper cells type 2 increase during pregnancy. They secret cytokines IL-4,5,9,10 and 13.

The episiotomy is a technique originally designed to reduce the incidence of severe perineal tears (third and fourth-degree) during labour. The general idea is to make a controlled incision in the perineum, for enlargement of the vaginal orifice, to facilitate difficult deliveries.

Below is the classification scale for the definitions of vaginal tears:
First degree involves the vaginal mucosa and perineal skin with no underlying tissue involvement.
Second degree includes underlying subcutaneous tissue and perineal muscles.
Third degree is where the anal sphincter musculature is involved in the tear. The third-degree tear can be further broken down based on the total area of anal sphincter involvement.
Fourth degree is where the tear extends through the rectal muscle into rectal mucosa.

Maternal blood volume expands during pregnancy to allow adequate perfusion of vital organs, including the placenta and foetus, and to anticipate blood loss associated with delivery. The rapid expansion of blood volume begins at 6–8 weeks gestation and plateaus at 32–34 weeks gestation. While there is some increase in intracellular water, the most marked expansion occurs in extracellular fluid volume, especially circulating plasma volume. This expanded extracellular fluid volume accounts for between 8 and 10 kg of the average maternal weight gain during pregnancy. Overall, total body water increases from 6.5 to 8.5 L by the end of pregnancy.

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.

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. Weight of the uterus increases from 50–60 g prior to pregnancy to 1000 g by term.

The female pelvic inlet tilts at an inclination that is about 60 degrees from the anatomical horizontal plane. This tilt is maintained by muscles and fascia. The pelvic outlet slopes at an angle of 15 degrees.

Gonorrhoea is a sexually transmitted disease that is caused by Neisseria gonorrhoea. It infects the mucous membrane of the genital tract epithelium in the endocervical and the urethral mucosa. Around 50% of the women are asymptomatic. However it presents as increase vaginal discharge, dysuria, proctitis and pelvic tenderness.

Hormones that are secreted into the circulation at one site but have effects on distal target organs are endocrine as is the case with the hormones above. Autocrine and Intracrine messengers act within the same cell. Exocrine glands secrete their products into ducts. Apocrine is a histological term used to describe some types of exocrine gland.

Clomiphene is a non-steroidal compound with tissue selective actions. It is used to induce ovulation in women who wish to become pregnant. It is a selective oestrogen receptor modulators.

Biochemical features suggest that this patient has polycystic ovary syndrome (PCOS). It is associated with signs and symptoms of hyperandrogenism (oligomenorrhea, irregular menstruation, hirsutism, hair loss, and acne) and elevated testosterone. PCOS patients are often overweight or obese, have insulin resistance (treated with Metformin) and an adverse risk profile for cardiovascular disease.

It blocks the voltage gated sodium channels and reduce the influx of sodium ions preventing depolarization of the membrane and blocking the conduction of the action potential. The affinity of the receptor site in the sodium channels depends on whether it is resting, open or inactive.

This patient has experienced polycystic ovarian syndrome-like symptoms.
At least two out of three of the following criteria must be met to diagnose polycystic ovarian syndrome:
1- Hyperandrogenism suggesting an excess of androgens e.g. excess hair growth, acne etc.
2- Menstrual irregularities e.g. dysmenorrhea, oligomenorrhea, and amenorrhea.
3-The ovaries are polycystic if one ovary has 12 or more follicles or if the size of one or both ovaries has risen.

Low FSH, LH, and pituitary hormones are typically associated with hypothalamic dysfunction, however this is not the case here.
Similarly, with premature ovarian failure, FSH/LH levels rise while oestrogen levels decrease.

All of the other choices are incorrect.

Miscarriage is a pregnancy that ends spontaneously before the foetus reaches the age of viability i.e. before 24 weeks of gestation. In a threatened miscarriage the USG findings are of a foetus present in the uterus and on speculum examination the cervical OS is closed, in an inevitable miscarriage the cervical OS is opened. In an incomplete miscarriage the uterus contains the retained products of conception and the cervical OS is open. complete miscarriage contains no retained products of conception and the cervix is closed as the bleeding as resolved.

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.

Cholestasis of pregnancy is associated with increased fetal morbidity and mortality and should be treated actively. The significance attached to pruritus in pregnancy is often minimal, but it is a cardinal symptom of cholestasis of pregnancy, which may have no other clinical features.

Placental abnormalities such as placenta previa and placenta accreta are the most common reasons for considering hysterectomy as an inevitable treatment option in postpartum hemorrhage.

Placental villi normally invade only the superficial layers of endometrial deciduas basalis, but when the invasion is too deep into the uterine wall, the condition is termed as placenta accreta, increta or percreta depending on the depth of invasion.
– When the villi invade the deeper layers of the endometrial deciduus basalis, but not the myometrium it is called as Placenta accreta. This is the most common type of decidual invasion and accounts for approximately 75% of the cases.
– When the villi invade the myometrium, but do not reach the uterine serosa or the bladder is called Placenta increta. This type accounts for nearly 15% of cases.
– In cases were the villi invades into the uterine serosa or the bladder is it called as Placenta percreta and this happens in 5% of cases.

Prior uterine surgery is the main risk factor for placenta accreta and the best management is elective cesarean hysterectomy.
postpartum hemorrhage can also be caused by conditions like genital lacerations, uterine atony, retained products of conception and uterine inversion. In most of these above mentioned cases, hysterectomy is not required and remains as the last resort in extremely desperate situations.

NOTE– Though uterine atony is the most common cause of postpartum hemorrhage, it is often manageable medically.

In patients who have an HbA1C value above 10%, it is better to postpone pregnancy until diabetes is under control. Also in those patients with type 2 diabetes mellitus, who are suffering from severe gastroparesis, those with advanced retinopathy, with severe diabetic renal disease and severe ischemic heart disease with uncontrolled hypertension pregnancy is contraindicated.

All the other options mentioned are incorrect.

Paroxetine is an SSRI used for hot flushes in women with contraindication for hormonal therapy.

Hormonal or other pharmacotherapy is usually needed for women with bothersome hot flashes. For most women with moderate to very severe hot flashes and no contraindications, we suggest MHT. Women with an intact uterus need both oestrogen and a progestin, while those who have undergone hysterectomy can receive oestrogen only. For women interested in MHT, the first step is to determine the potential risks for the specific individual.

The majority of perimenopausal and recently menopausal women are good candidates for short-term hormone therapy for symptom relief. However, for women with a history of breast cancer, coronary heart disease (CHD), a previous venous thromboembolic event (VTE) or stroke, or those at moderate or high risk for these complications, alternatives to hormone therapy should be suggested. For women with moderate to severe hot flashes who are not candidates for hormone therapy based upon their breast cancer, CHD, or VTE risk and for those who choose not to take MHT, we suggest nonhormonal agents. The agents most commonly used include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), antiepileptics, and centrally acting drugs.

Black Cohosh is found to be no more significant than placebo.
Long-term use of mefenamic acid is controversial and not recommended.

The five year survival of stage 1 ovarian cancer is 70-90%

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

It is essential to notice the important details mentioned in the case scenario. These would be the details about her menstruation, a smaller than dates uterus and an open cervix. A smaller than expected uterine size could be caused by her passing out some tissue earlier or it could be due to the foetus having been dead for some time. The finding of an open cervix would be in line with the fact that she had passed out some fetal tissue or it could signify that she is experiencing an inevitable miscarriage (while all fetal tissue is still kept within her uterus).

The likely diagnoses that should be considered for this case would be miscarriage (threatened, incomplete, complete and missed), cervical insufficiency, and ectopic pregnancy. A smaller than dates uterus and an open cervix makes threatened abortion an unlikely diagnosis. Her clinical findings could be expected in both an incomplete abortion and a complete abortion.
In ectopic pregnancy, although there would be a smaller than dates uterus, the cervical os would usually be closed. Cervical insufficiency is probable due to an open os but the uterine size would be expected to correspond to her dates, making it also less likely than a miscarriage.

Since she most likely has had a miscarriage (be it incomplete or complete), the next best step would be to do a per vaginal ultrasound scan which could show whether or not products of conception are still present within the uterine cavity. If present, it would be an incomplete miscarriage which would warrant a dilatation and curettage; if absent, it is a complete miscarriage so D&C would not be needed.

In view of her open cervix and 12 weeks of amenorrhea, there is no indication for a pregnancy test nor assessment of her beta-hCG levels. Cervical ligation would only be indicated if the underlying issue was cervical incompetence, which is not in this case.

The deep perineal pouch contains the external urethral sphincter, proximal urethra in females and membranous urethra in males, deep transverse perineal muscles and the glands of cowper.