The normal functional bladder capacity is around 400-600ml. First urge to void is typically felt when the bladder is approximately 150ml full.

Maximum levels of progesterone are detected at day 21 of 28 days in the menstrual cycle, assuming that ovulation has occurred at day 14. A value of >30nmol/l indicates an ovulatory cycle.

The clinical picture, unusually high LH-to-FSH ratio (which should ordinarily be around 1:1), and higher androgens but normal DHAS all point to polycystic ovarian syndrome (PCOS). DHAS is an indicator of adrenal androgen production; when normal, it rules out adrenal hyperandrogenism. Several drugs have been used to treat PCOS-related hirsutism. Contraceptives were the most often used medications for many years; they can decrease hair growth in up to two-thirds of individuals. They work by decreasing ovarian steroid production and increasing hepatic-binding globulin production, which binds circulating hormones and lowers metabolically active (unbound) androgen concentrations. Clinical improvement, on the other hand, can take up to 6 months to show.
Medroxyprogesterone acetate, spironolactone, cimetidine, and GnRH agonists, all of which decrease ovarian steroid synthesis, have also shown potential. GnRH analogues, on the other hand, are costly and have been linked to severe bone demineralization in some patients after only 6 months of treatment. Given the efficacy of pharmacologic medications and the ovarian adhesions that were usually linked with this surgery, surgical wedge resection is no longer regarded as an appropriate therapy for PCOS.

Patient mentioned in the case has developed thyrotoxicosis during pregnancy. TSH level should be tested, and if the result shows any suppressed or elevated TSH level, then it is mandatory to check for free T4 level.

Gestational diabetes (GDM) occurs in 2–9 per cent of all pregnancies. Screening for diabetes in pregnancy can be justified 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 specificity for gestational diabetes. Urinary glucose is unreliable, and most screening tests now rely on blood glucose estimation, with an oral 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. The women should be tested as soon as possible after booking if there is a history of GD.

The nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome. Pregnancy is a state of increased requirement of macro and micronutrients, and malnourishment or inadequate dietary intake before and during pregnancy, can lead to adverse perinatal outcomes. Many nutritional interventions have been proposed for pregnant mothers. These include multiple micronutrients (MMN), iron/folate, balanced protein energy, calcium, zinc and folic acid supplementation.

Abnormal uterine bleeding is a relatively common disorder which may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions. However, the patient who is younger than 30 years of age will rarely be found to have a structural uterine defect. Once pregnancy, hematologic disease, and renal impairment are excluded, administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs.

Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problem or for older women. Oestrogen would only increase the problem, which is usually due to anovulation with prolonged oestrogen secretion, producing a hypertrophic endometrium.

Ovulation occurs in the mid stage of the menstrual cycle, usually 36 hours after the LH surge. It is this LH surge which is necessary for the ovulation to occur.

Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.

The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic
henodeoxycholic acid level ratio. The elevation of aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.

Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta- Mild elevation of gamma glutamyl transferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.

Venous thromboembolic disease (VTE) is the most common cause of direct maternal death in the UK. In the most recent triennium, there were 41 fatalities, giving a maternal mortality rate of 1.94 per 100 000 – more than twice that of the next most common cause, pre-eclampsia. As pregnancy is a hyper coagulable state. There are alterations in the fibrinolytics and thrombotic pathways. There is also an increased production of clotting factors during pregnancy.

Meconium first appears in the fetal ilium at 10-16 weeks.

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 normal range for a term baby is pH: 7.18 – 7.38, and preterm pH: 7.14 – 7.4. A pH below 7.1 therefore indicates acidosis.

Her T-score puts her in the osteopenic range. The presence of fragility fractures is more important in the osteoporotic patient. Olecranon fracture is not a typical fragility fracture.

Any new onset of hypertension associated with proteinuria after 20 weeks of gestation in a previously­ normotensive woman is referred to as Preeclampsia.
Most commonly found risk factors for pre-eclampsia are:
– Preeclampsia in a previous pregnancy
– Family history of preeclampsia
– a prior pregnancy with poor outcome like placental abruption, IUGR, fetal death in utero, etc
– An interdelivery interval greater than 10 years
– Nulliparity, increases risk by 8 times
– Pre-existing chronic medical conditions or chronic hypertension
– pre-existing or gestational Diabetes
– chronic Renal disease
– Thrombophilias g. protein C and S deficiency, antithrombin Ill deficiency, or Factor V Leiden mutation
– Antiphospholipid syndrome
– Systemic lupus erythematous
– Maternal age greater than or equal to 40 years
– Body Mass Index (BMI) greater than 30 kg/m2
– Multiple pregnancy
– Raised blood pressure at booking
– Gestational trophoblastic disease
– Fetal triploidy

Maternal age between 18 and 40 years is found to be associated with a decreased risk for developing preeclampsia, and not an increased risk.
NOTE– Previously, age 16 years or younger was thought to be a risk factor for developing preeclampsia; however, recent studies conducted had failed to establish any meaningful relationship between the two.

Classifications of Pregnancy Signs:
Presumptive signs — possibility of pregnancy
Probable signs — most likelihood of indicating pregnancy
Positive signs — confirmation of pregnancy
Auscultation of fetal heart is the only positive sign amongst the rest of the answers.

Breast infections can be associated with superficial skin or an underlying lesion. Breast abscesses are more common in lactating women but do occur in nonlactating women as well.

The breast contains breast lobules, each of which drains to a lactiferous duct, which in turn empties to the surface of the nipple. There are lactiferous sinuses which are reservoirs for milk during lactation. The lactiferous ducts undergo epidermalization where keratin production may cause the duct to become obstructed, and in turn, can result in abscess formation. Abscesses associated with lactation usually begin with abrasion or tissue at the nipple, providing an entry point for bacteria. The infection often presents in the second postpartum week and is often precipitated in the presence of milk stasis. The most common organism known to cause a breast abscess is S. aureus, but in some cases, Streptococci, and Staphylococcus epidermidis may also be involved.

The patient will usually provide a history of breast pain, erythema, warmth, and possibly oedema. Patients may provide lactation history. It is important to ask about any history of prior breast infections and the previous treatment. Patients may also complain of fever, nausea, vomiting, purulent drainage from the nipple, or the site of erythema. It is also important to ask about the patient’s medical history, including diabetes. The majority of postpartum mastitis are seen within 6 weeks of while breast-feeding

The patient will have erythema, induration, warmth, and tenderness to palpation at the site in question on the exam. It may feel like there is a palpable mass or area of fluctuance. There may be purulent discharge at the nipple or site of fluctuance. The patient may also have reactive axillary adenopathy. The patient may have a fever or tachycardia on the exam, although these are less common.

Incision and drainage are the standard of care for breast abscesses. If the patient is seen in a primary care setting by a provider that is not comfortable in performing these procedures, the patient may be started on antibiotics and referred to a general surgeon for definitive treatment. Needle aspiration may be attempted for abscesses smaller than 3 cm or in lactational abscesses. A course of antibiotics may be given before or following drainage of breast abscesses.

Research suggests the risk of having preeclampsia again is approximately 20%, however experts cite a range from 5% to 80% depending on when you had it in a prior pregnancy, how severe it was, and additional risk factors you may have. If you had preeclampsia during your first pregnancy, you may get it again. HELLP is related to preeclampsia and about 4 to 12 percent of women diagnosed with preeclampsia develop HELLP. HELLP syndrome can also cause complications in pregnancy, and if you had HELLP in a previous pregnancy, regardless of the time of onset, you have a greater risk for developing it in future pregnancies.

In premenopausal women, watchful waiting usually involves monitoring for symptoms (pelvic pain or pressure) and repeating the pelvic ultrasound after six to eight weeks. If the ovarian cyst does not enlarge or if it resolves during the period of watchful waiting, it does not usually require surgical removal. Some premenopausal women will be advised to take a birth control pill during this time to help prevent new ovarian cysts from developing.

If a cyst decreases in size or does not change, the ultrasound is often repeated at regular intervals until your healthcare provider is certain that the cyst is not growing. If the cyst resolves, no further testing or follow-up is required.
Surgery may be recommended in the following situations:
– A cyst is causing persistent pain or pressure, or may rupture or twist.
– A cyst appears on ultrasound to be caused by endometriosis and is removed for fertility reasons.
– Large cysts (>5 to 10 cm) are more likely to require surgical removal compared to smaller cysts. However, a large size does not predict whether a cyst is cancerous.
– If the cyst appears suspicious for cancer. If you have risk factors for ovarian cancer or the cyst looks potentially cancerous on imaging studies, your healthcare provider may recommend surgery.
– If the suspicion for ovarian cancer is low but the cyst does not resolve after several ultrasounds, you may choose to have it removed after a discussion with your healthcare provider. However, surgical removal is not usually necessary in this case.

At about 8-12 weeks gestation, normal physiological herniation of the fetal bowel occurs. The midgut protrudes into the base of the umbilicus, and undergoes a 90-degree anticlockwise rotation. When the abdominal cavity enlarges enough to fit the developing midgut, the intestines undergo another 180-degree rotation before returning to the abdominal cavity.

The normal fetal heart rate ranges from 120-160 beats per minute in the uterine period.

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.

The following cardiovascular changes occur during pregnancy:
– Blood volume slowly increases by 40-50%
– Heart rate rises by 15 beats/min above baseline
– Stroke volume increases by 25-30%
– Cardiac output increases by approximately 30-50%
– Systemic vascular resistance (SVR) decreases by 20-30%
– Diastolic blood pressure consequently decreases between 12 and 26 weeks but increases again to pre-pregnancy levels by 36 weeks.
As most of the changes occur in the first 12 weeks of gestation cardiac problems are likely to present in early pregnancy

A rectovaginal swab taken for Group B streptococci culture should be done in women presenting with threatened preterm labour

If labour is establishes, intrapartum antibiotic prophylaxis for Group B streptococci should be commenced and continued until delivery. In cases were labour is not establish, prophylaxis for Group B streptococci should be ceased and should be re-established only if the culture is found to be positive, that too at the time of onset of labour.

Strategies acceptable for reducing early onset Group B streptococci sepsis includes universal culture-based screening using combined low vaginal plus or minus anorectal swab at 35-37 weeks gestation or a clinical risk factor based approach.

No additional prophylaxis is recommended irrespective of Group B streptococci carriage, for elective cesarean section before the commencement of labour. However, if a woman who commences labour or has spontaneous rupture of the membranes before her planned Caesarean section is screened positive for Group B streptococci, she should receive intrapartum antibiotic prophylaxis while awaiting delivery.

Although there is little direct evidence to guide this practice, consideration of the above mentioned evidences it is recommendation that, every women with unknown Group B streptococci status at the time of delivery should be managed according to the presence of intrapartum risk factors.
All women at increased risk of early onset Group B streptococci sepsis must be offered an intrapartum antibiotic prophylaxis with IV penicillin-G or ampicillin.

With the high level of sensitivity and specificity of current tests to measure hCG in serum and urine, pregnancy can now be diagnosed before the time of the first missed menstrual period- For current serum hCG assays, the low threshold for detection is 10-25 IU/L, while for urine assays it is 25-50 IU/L, which corresponds to approximately the seventh day after conception. Because the levels of hCG in the blood and urine are very similar, the tests are equivalent. Urine testing may reveal a positive result as early as 3-4 days after implantation. By the time of the expected menstrual period, the test will be positive 98% of the time- If a test is negative more than 1 week after the expected time of the menstrual period, it is almost certain the patient is not pregnant. To cover these rare instances where a woman has a low hCG and conceived later than expected, the test should be repeated in 1 week for a definitive result.

Since ectopic pregnancy is not a life-threatening problem for the mother until 2 months after conception, a patient with a negative urine hCG does not require ultrasonography to exclude ectopic pregnancy. Patients with a suspected ectopic pregnancy and a negative urine hCG should be followed closely, as early laparoscopic intervention can improve the chances of future fertility.

This is VIN. Smoking is a risk factor. It is also more common in immunocompromised patients.

Although a dilatation and curettage (D&C) is frequently recommended as part of a woman’s menorrhagia examination.
D&C is not indicated in a woman who had a normal hysteroscopy and laparoscopy only two years ago, and who experienced comparable symptoms when not taking the OCP in the past, especially after the age of 40.
The Filshie clips should not be removed because they will not improve the symptoms.

Although an endometrial ablation or possibly a hysterectomy may be required in the future to address the symptoms, the first line of treatment should be a nonsteroidal anti-inflammatory drug (NSAID), which will reduce the loss in up to half of the women treated.

Firstline medical management of PCOS is with clomiphene.

Ovulation Disorders

WHO Group I : Hypothalamic pituitary failure (Stress, anorexia, exercise induced)
Management:
Increase BMI if <19 kg/m2
Reduce exercise if high levels
Pulsatile GnRH or Gonadotrophins with LH activity to induce ovulation

WHO Group II : Hypothalamic-pituitary-ovarian dysfunction (PCOS)
Management:
Weight reduction if BMI >30
Clomiphene/Clomiphene (1st line)
Metformin (1st line)
Clomiphene & Metformin (1st/2nd line)
Laparoscopic drilling (2nd line)
Gonadotrophins (2nd line)

WHO Group III : Ovarian failure
Management:
Consider IVF with donor eggs

Contraindications to tocolysis in preterm labor are as follows:
– Gestational age > 34 weeks or <24 weeks
– Labor is too advanced with an advanced cervical dilation of >4 cm
– Abnormal CTG suggesting a non-reassuring fetal status
– Lethal fetal anomalies
– Intrauterine fetal demise
– Suspected fetal compromise
– Significant antepartum hemorrhage, such as placental abruption/ active vaginal bleeding with hemodynamic instability
– Any suspected intrauterine infections like chorioamnionitis
– Maternal hypotension
– Pregnancy-induced hypertension/ eclampsia/ pre-eclampsia
– Placenta previa
– Placental insufficiency
– Intrauterine growth retardation
– Maternal allergy to specific tocolytic agents or cases where tocolytics are contraindicated due to specific comorbidities like in case of cardiac disease, were beta agonists cannot be administered.

As there are nonpulmonary morbidities associated with preterm birth, fetal pulmonary maturity, known or suspected, is not an absolute contraindication for tocolysis. These fetuses could potentially benefit from prolongation of pregnancy and from the nonpulmonary benefits of glucocorticoid therapy.

When cervical dilation is greater than 3 cm inhibition of preterm labor is less likely to be successful. In such cases Tocolysis can be considered when the goal is to administer antenatal corticosteroids or to safely transport the mother to a tertiary care center.

Maternal hypothyroidism which is usually treated with thyroxine is not a contraindication to suppression of labor.

Thee good news in regard to incontinence after childbirth is that there are many treatment options. Some common treatment options are listed below.

Food and drinks such as coffee, citrus, spicy foods and soda can all irritate the bladder. Cutting back on or eliminating these foods may help improve incontinence symptoms. Keeping weight within a healthy BMI range, and/or focusing on losing pregnancy weight, can also help with bladder control.

Kegels strengthen the pelvic floor, giving more control over urinary urges. Pelvic floor physical therapy can also help build muscle memory and strength. The abdominal muscles, hip muscles and pelvic floor muscles work together when a woman performs strengthening exercises like Kegels. Physical therapists identify areas of weakness in those muscle groups to help a woman build a strong core and pelvic floor.

The bladder is a muscle that should be regularly strengthened. Scheduling urination times and then gradually increasing the amount of time in between urination can increase bladder strength.

Percutaneous tibial nerve stimulation is a nonsurgical treatment for overactive bladder and a form of neuromodulation therapy. During PTNS treatments, a doctor places a slim needle in the ankle where the tibial nerve is located. The needle delivers electrical impulses to the tibial nerve, which sends signals to the sacral nerves in the spine that control bladder and pelvic floor function. Over time, these pulses block nerve signals that are not working properly to lessen urinary incontinence symptoms.

Evaluating lifestyle factors. Excessive coughing due to smoking or being overweight can put unnecessary strain on the pelvic floor muscles. Certain drugs such as antidepressants and antihistamines can also have an impact on urinary incontinence.
Pessary. A pessary is a device inserted into the vagina to provide support for vaginal tissues, in turn, aiding in bladder incontinence.

Surgical treatment options can help support the pelvic floor and may be recommended for women who have completed childbearing and have not had success with conservative therapy.

The pudenal nerves has three branches, namely the inferior rectal, perineal and the dorsal nerve of the clitoris. The perineal nerve has two branches: The superficial perineal nerve gives rise to posterior scrotal or labial (cutaneous) branches, and the deep perineal nerve supplies the muscles of the deep and superficial perineal pouches, the skin of the vestibule, and the mucosa of the inferior most part of the vagina. The inferior rectal nerve communicates with the posterior scrotal or labial and perineal nerves. The dorsal nerve of the penis or clitoris is the primary sensory nerve serving the male or female organ, especially the sensitive glans at the distal end.

Varicella or chickenpox, is a highly contagious disease caused by primary infection with varicella-zoster virus (VZV) which can result in maternal mortality or serious morbidity. The virus which remains dormant in the sensory nerve root ganglia following a primary infection can get reactivated to cause a vesicular erythematous skin rash along the dermatomal distribution known as herpes zoster, ‘zoster’ or ‘shingles’. Though rare the risk of acquiring infection from an immunocompetent individual with herpes zoster in non-exposed sites like thoracolumbar regions can also occur. As the viral shedding will be greater, a disseminated zoster or exposed zoster (e.g. ophthalmic) in an individual or localised zoster in an immunosuppressed patient should be considered very infectious.

In industrialised countries, over 85 % of women in childbearing age are immune to varicella zoster virus (VZV), however, women from tropical and subtropical areas are more susceptible to chickenpox in pregnancy as they are more likely to be seronegative for VZV IgG. Up to 10% cases of VZV in pregnancy are complicated with Varicella pneumonia, whereas perinatal varicella/ chickenpox carries a 20 to 30 % risk of transmitting infection to the neonate. Studies on maternal varicella infection from 12-28 weeks gestation suggests a 1.4% risk of fetal varicella syndrome (FVS) whose subsequent abnormalities include:
– Skin scarring (78%)
– Eye abnormalities (60%)
– Limb abnormalities (68%)
– Prematurity and low birthweight (50%)
– Cortical atrophy, intellectual disability (46%)
– Poor sphincter control (32%)
– Early death (29%)

In the case mentioned above, patient had developed chickenpox rashes in her 2nd trimester and presented to you at day 2 of illness. Her varicella IgM came back positive along with a negative IgG indicating that she is not being immunized and that she is currently having active varicella infection. The best management in this case will be to reassured and allowed patient to be monitored at home. As there is no underlying lung disease, she is not immunocompromised and she is a non-smoker, so antiviral therapy is not required.

Generally, for pregnant women with chickenpox if they present within 24 hours of onset of rash and are in 20+0 weeks of gestation or beyond oral aciclovir should be prescribed. However, the use of acyclovir before 20+0 weeks should be considered carefully as Aciclovir is rated category B3 (Pregnancy and Breastfeeding, eTG, January 2003, ISSN 1447-1868) and should only be prescribed if its potential benefits outweigh the potential risks caused to the fetus, with informed consent in pregnant women who present within 24 hours of onset of varicella rash. If the patient is immunocompromised or if there are respiratory symptoms, a haemorrhagic rash or persistent fever for more than six days it is advisable to use intravenous acyclovir. On the other hand, to prevent secondary bacterial infection of the lesions, symptomatic treatment and hygiene should also be advised and unless there is significant superimposed bacterial infection antibiotics are not required.

If the pregnant woman has had a significant exposure to chickenpox or shingles, and is not immune to VZV , she should be offered VZIG as soon as possible or at the very latest within 10 days of the exposure. However, since Varicella zoster immunoglobulins (VZIG) has no therapeutic benefit in already developed cases of chickenpox, it should not be given to the context patient who have already developed active rashes of chickenpox with serology showing positive IgM positive and negative IgG indicating primary infection.

At least five weeks after primary infection a detailed fetal ultrasound must be done checking for any anomalies and ultrasounds should be repeated until delivery; and consider a fetal MRI if any abnormalities are found. In cases were if ultrasound is found to be normal, VZV fetal serology and amniocentesis are not useful and is not routinely advised.

The femoral triangle is bounded superiorly by the inguinal ligament which forms the base of the triangle, medially by the lateral border of the adductor longus and laterally by the sartorius muscle.

GI Tract initially forms via gastrulation from the endoderm of the trilaminar embryo around week 3. It extends from the buccopharyngeal membrane to the cloacal membrane. Later in development there are contributions from all three germ cell layers.

Normally, there will be a slight raise in prolactin level throughout pregnancy even despite estrogen stimulating and progesterone inhibiting prolactin secretion.

Serum alkaline phosphatase levels will be increased in pregnancy due to placental ALP.

During the first trimester of pregnancy there is a physiological mechanism by hCG causing cross-stimulation of the TSH receptors and as a result of this the concentration of thyroid stimulating hormone (TSH) normally decreases. During second trimester TSH concentration will again return back to its pre-pregnancy levels and then rises slightly by the third trimester. However, most of the changes still occur within the normal non-pregnant range, and the serum free T3 and T4 concentrations remain unchanged throughout pregnancy. But the total concentrations, which include both free and protein-bound fractions, elevates significantly due to an increase in the circulating binding globulins.

Iron binding capacity reflects transferrin, a protein used for iron transportation, which is a globulin found in the beta band on electrophoresis. To counteract the reduction of plasma iron during pregnancy both transferrin and iron binding capacity are elevated during this period.

When compared to the non-pregnant level, cortisol levels are been elevated up to three times than normal.

The rectus sheath is formed by the decussation and interweaving of the aponeuroses of the fl at abdominal muscles. The external oblique aponeurosis contributes to the anterior wall of the sheath throughout its length. The superior two thirds of the internal oblique aponeurosis splits into two layers (laminae) at the lateral border of the rectus abdominis; one lamina passing anterior to the muscle and the other passing posterior to it. The anterior lamina joins the aponeurosis of the external oblique to form the anterior layer of the rectus sheath. The posterior lamina joins the aponeurosis of the transversus abdominis to form the posterior layer of the rectus sheath.

The Australasian Diabetes in Pregnancy Society recommends a 50 or 75 g glucose challenge at 26–28 weeks in all pregnant women. An OGTT should be performed if the test result is abnormal: 1 hour values after a 50 or 75 g glucose challenge exceeding 7.8 or 8.0 mmol/L respectively.

If a woman has had gestational diabetes, a repeat OGTT is recommended at 6–8 weeks and 12 weeks after delivery. If the results are normal, repeat testing is recommended between 1 and 3 years depending on the clinical circumstances.

It is usual to experience heavy, continuous bleeding around the time of menarche.
Haemoglobin and ferritin levels are used to determine the severity of bleeding and its impact on the haemoglobin level.
These analyses do not pinpoint the source of the problem, but they do pinpoint its consequences.
A haematologic reason, such as thrombocytopenia, acute leukaemia, or a coagulation/bleeding issue, affects about one-third of girls with pubertal menorrhagia (e.g. von Willebrand disease).
A complete blood examination and a bleeding
lotting profile are required to rule out these illnesses.
The results of a haemoglobin estimation or a ferritin level evaluation are insufficient, and the results of dilatation and curettage (D&C) or magnetic resonance imaging (MRI) will rarely reveal the reason for the bleeding.

Normal menstrual blood loss is about 40-45 ml. More than 80 ml per period is defined as heavy menstrual bleeding.

This patient is towards the end of the first stage of labour and is having complications. Labour is divided into 3 stages. The first stage begins at regular uterine contractions and ends with complete cervical dilatation at 10 cm. It has a latent phase and an active phase- The active phase is usually considered to have begun when cervical dilatation reaches 4 cm. So this patient is in the active phase of the first stag- The second stage begins with complete cervical dilatation and ends with the delivery of the foetus. The third stage of labour is the period between the delivery of the foetus and the delivery of the placenta and fetal membranes.

This patient’s contractions seem adequate and yet the fetal heart tone with baseline 80/min and absent variability suggests fetal distress. This is category III of the fetal heart rate pattern because the baseline rate is < 110/min with absent variability. It is usually predictive of abnormal acid-base status. The recommended actions are maternal position change and oxygen administration, discontinuation of labour stimulus such as oxytocin, treatment of possible underlying conditions, and expedited delivery.
→ Magnesium sulphate infusion is mainly used to prevent eclamptic seizures and despite no evidence of its effectiveness as a tocolytic agent, it is used sometimes to reduce risks of preterm birth.
→ Fetal scalp pH monitoring would help determine if there is indeed an acidosis and should be done before deciding whether a Caesarean section is necessary, but maternal position change and oxygen administration should be done first.
→ Ultrasonography may be used for preinduction cervical length measurement or if the active stage has already started- It is considered more accurate than digital pelvic exam in the assessment of fetal descent; however, at this point maternal position change and oxygen administration should be done first.
→ Immediate Caesarean section would be done if fetal scalp pH monitoring revealed a pH < 7.20. At this point, the best next step is maternal position change and oxygen administration.

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.

The diagnosis of functional ovarian cyst is made when the cyst measures more than 3 cm and rarely grows more than 10 cm. It appears as a simple anechoic unilocular cyst on USS. It is usually asymptomatic. If it is symptomatic then laparoscopic cystectomy should be performed.

Antiepileptic, phenytoin more so than topiramate are inducers of cytochrome P450. They should not be given with COCPs. The metabolism of oestrogen and progestogen is increased by anti-epileptic drugs that induce cytochrome P450 leading to a loss of contraceptive effect.

Puerperal sepsis is defined as sepsis occurring after birth until 6 weeks postnatal. The most common cause of puerperal sepsis is Group A streptococcus. Until 1937, puerperal sepsis was the major cause of maternal mortality. The discovery of sulphonamides in 1935 and the simultaneous reduction in the virulence of the haemolytic streptococcus resulted in a dramatic fall in maternal mortality.

The most probable cause of her presentation is a mixed infection with Chlamydia trachoma and vaginal pathogens.

Her most likely diagnosis is pelvic inflammatory disease (PID) as suggested by a purulent vaginal discharge alongside a fever which indicates a systemic infection.

The most common causative organisms in PID after sexual activity are chlamydia and gonorrhoea, of which chlamydia has a much higher prevalence.

Chlamydia has also been shown to be present in about 15% of subjects who underwent pregnancy termination with no constant sexual partner.

PID occurring after a gynaecologic surgical procedure is most commonly a result of mycoplasma or vaginal pathogens.

Extreme headache, vision defects, such as blurring of the eyes, rib pain, sudden swelling of the face, hands or feet are all consistent with pre-eclampsia. Women with the mentioned symptoms should have their blood pressure checked immediately. They should also be checked for proteinuria.

Diarrhoea is not related to pre-eclampsia. Pruritus would be more related to pregnancy cholestasis. Meanwhile, bruising and abnormal LFTs are common in complicated pre-eclampsia but not in an uncomplicated one.

The most common hereditary cancer in the breast ovarian cancer syndrome accounts for 90% of the hereditary cancers. It is due to mutations in the BRCA 1 and BRCA 2 genes, most commonly the BRCA 1 gene accounting for 70% life time risk of breast cancer and 40% life time risk of ovarian cancer.

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.

Paracetamol is safe to take during pregnancy and has shown no harm to unborn children during studies. It is the treatment of choice for mild to moderate pain during pregnancy.

During the 5th week, the neural crest cells migrate along each side of the spinal cord where they form ganglions located dorsolateral to the aorta. Some of these cells migrate ventrally and form neurons in the preaortic ganglia as the celiac and mesenteric ganglia.

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.

In post menopausal women the thickness of the endometrium should be 4mm or less or women on tamoxifen is should be less than 5mm. If it is more than this the patient should be worked up for endometrial carcinoma.

1 in 150 is the cut off. Where pre-natal screening shows a risk of 1 in 150 or greater invasive testing is typically offered.

Rubella virus is the only member of the genus Rubivirus and is a type of Togavirus (Togaviridae). It is a single stranded RNA virus. Note for the exam if you are unsure – most RNA viruses encountered in clinical practice are single stranded. The exception is rotavirus which is dsRNA virus. RNA viruses that use DNA during their replication are classed as retroviruses (HIV is an example)

Pregnancy is the most common cause of secondary amenorrhea worldwide. As a result, the first thing to check in every woman of reproductive age who has amenorrhea is a urine pregnancy test.
Once pregnancy has been ruled out, an ultrasound or measuring FSH and LH may be done to assess the condition (if required).
FBC is used to track clozapine side effects such as neutropenia and agranulocytosis. It is not recommended for the assessment of amenorrhea.

The patient could be suffering from pre-eclampsia. A BP of 140/100 with proteinuria should be admitted immediately for observation and if the symptoms do not improve then managed immediately. According to the NICE guidelines BP should be monitored 4 times daily. A BP of 140/90 to 149/99 mmHg is classed as mild hypertension. Without proteinuria this can be monitored once weekly and the patient can be discharged.

Boundaries of the Femoral Triangle:
Superior: Inguinal ligament
Medial: Medial border of the adductor longus
Lateral: Medial border of the sartorius
Floor: Pectineus, Adductor longus and Iliopsoas muscles
Roof: Fascia Lata

Bacterial vaginosis (BV) is a clinical condition characterized by a shift in vaginal flora away from Lactobacillus species toward more diverse bacterial species, including facultative anaerobes. The altered microbiome causes a rise in vaginal pH and symptoms that range from none to very bothersome. Future health implications of BV include, but are not limited to, increased susceptibility to other sexually transmitted infections and preterm birth. Fifty to 75 percent of women with BV are asymptomatic. Symptomatic women typically present with vaginal discharge and/or vaginal odour. The discharge is off-white, thin, and homogeneous; the odour is an unpleasant fishy smell that may be more noticeable after sexual intercourse and during menses.

Barr body is an inactive and non functioning X chromosome found in female somatic cells and is presents with a rim around the nucleus

Traditional POP main mode of contraceptive action: thickening of cervical mucus Desogestrel-only POP main mode of contraceptive action is inhibition of ovulation Cerazette® is the only Desogestrel-only POP in the options above. Other desogestrel brands include: Aizea® Cerelle® Nacrez® The other POPs listed are considered traditional POPs and have the following compositions: Norgeston® – Levonorgestrel 30 mcg Micronor® & Noriday® – Norethisterone 350 mcg Femulen® – Ethynediol diacetate 500 mcg

When the red cells are coated with immune IgG antibody, the cells do not agglutinate but when anti-IgG antiserum is added to these sensitized cells visible agglutination occurs. This is known as a positive direct coombs test.

Atosiban is a modified form of oxytocin that is administered by intravenous infusion for 2–48 hours.

The biochemical and mechanical effects of progesterone and the enlarging uterus are responsible for some changes in lung function during pregnancy.

Progesterone increases the sensitivity of the respiratory centre to arterial carbon dioxide while also causing hyperaemia in the airway leading to nasal obstruction. As a result, minute ventilation and tidal volume increase by 50% to allow greater arterial oxygen saturation.

The enlarging uterus displaces the diaphragm upwards, and also limits the movement of the thoracic cage, thereby decreasing the functional residual capacity (FRC) and the expiratory reserve volume (ERV) by 20%.

Functional Expiratory Volume in 1 second (FEV1) and Forced Vital Capacity (FVC) remain unchanged in pregnancy.

Breakthrough bleeding, or spotting, refers to when vaginal bleeding occurs between menstrual cycles. It may look like light bleeding or brown discharge.

Spotting is the most common side effect of birth control pills. It happens because the body is adjusting to changing levels of hormones, and the uterus is adjusting to having a thinner lining.

Taking the pill as prescribed, usually every day and at the same time each day, can help prevent bleeding between periods.

All other options are incorrect as this is a common side effect and will resolve on its own.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Weighted cones or topical steroids can be used as adjuvants but are not sufficient when used alone.

Tension free vaginal tape and Burch’s colposuspension are considered for patients who fail to respond to conservative management strategies.

Before considering invasive procedures, a cervical smear must first be performed. Antibiotics can only be given when inflammation has been confirmed and culture results have identified the organism causing the inflammation. Endometrial ablation, colposcopy and vaginal US are all invasive procedures that are not relevant in the immediate management of this patient.

The clinical features of endometriosis include dyspareunia, dysmenorrhea, dysuria, dyschezia as well as infertility. Pain is characteristically long-term, cyclic (often occurring the same time as menses) and can get progressively worse over time. Laparoscopy remains the standard for diagnosis. There are many cases in which endometriosis is only discovered at the time of the workup for infertility.

Luteal phase occurs after the ovulation. Luteal defect means that the luteal phase is shorter than 10 days and women will find it difficult to sustain the pregnancy. There is decreased progesterone, LH and FSH production in this case.

This is a case of a woman who presented with cyclical breast pain that is on an OCP and with a family history of breast cancer. Those with a family history of breast cancer in more than one blood relative (parent, sibling, grandparent) have a significantly higher chance of developing breast cancer than women with no family history. Regular six-monthly clinical review and yearly mammographic screening, with or without ultrasound screening, should start at least five years before the age of the diagnosis in the blood relatives.

The consensus now is that any additional risk of breast cancer from the oestrogen in the oral contraceptive pill (OCP) is less than the risk of unwanted pregnancy when using alternative, and perhaps less effective, contraception. Thus, the patient would not be advised to stop the OCP.

With two blood relatives that developed breast cancer before the age of 50, this patient is in a high-risk group of developing breast cancer. Even so, 50% of such high-risk women will not develop a breast cancer in their lifetime. There are specialised familial cancer screening clinics are available for high-risk women where genetic testing can be discussed further. Women at high risk may electively have a bilateral subcutaneous mastectomy performed prophylactically which will bring the risk of breast cancer development to an irreducible minimum.

CA-125 is the tumour marker specific for ovarian carcinoma.

An ectopic pregnancy is definitely present in this patient. An extrauterine pregnancy is referred to as an ectopic pregnancy. The fallopian tube accounts for 96% of ectopic pregnancies, but other sites include the cervical, interstitial (also called cornual; a pregnancy located in the proximal segment of the fallopian tube that is embedded within the muscular wall of the uterus), hysterotomy (caesarean) scar, intramural, ovarian, or abdominal. Furthermore, multiple gestations may be heterotopic in rare situations (including both a uterine and extrauterine pregnancy). Diabetes mellitus is not considered a risk factor for the development of an ectopic pregnancy.

Risk factors for ectopic pregnancy are summarized below:
High Risk: (Risk factors & Odds ratio)
Previous ectopic pregnancy 2.7 to 8.3
Previous tubal surgery 2.1 to 21
Tubal pathology 3.5 to 25
Sterilization 5.2 to 19
IUD – Past use 1.7 – Current use 4.2 to 16.4
Levonorgestrel IUD 4.9
In vitro fertilization in current pregnancy 4.0 to 9.3

Moderate:
Current use of oestrogen/progestin oral contraceptives 1.7 to 4.5
Previous sexually transmitted infections (gonorrhoea, chlamydia) 2.8 to 3.7
Previous pelvic inflammatory disease 2.5 to 3.4
In utero diethylstilbesterol (DES) exposure 3.7
Smoking – Past smoker 1.5 to 2.5 – Current smoker 1.7 to 3.9
Previous pelvic/abdominal surgery 4.0
Previous spontaneous abortion 3.0

Low:
Previous medically induced abortion 2.8
Infertility 2.1 to 2.7
Age ≥40 years 2.9
Vaginal douching 1.1 to 3.1
Age at first intercourse <18 years 1.6
Previous appendectomy 1.6

Shortly after the Morula enters into the uterus, approximately on the 4th day after fertilization a fluid filled cystic cavity appears in the morula and transforms the morula into a blastocyst.

Foetal movements often become apparent at about 18-20 weeks gestation. This phenomenon is also called quickening. The Foetal movements continue to increase in frequency and force until 32 weeks where they plateau. Foetal movements can be used to monitor the wellbeing of the foetus, alerting the mother and healthcare providers to a problem.

The WHO defines maternal death as female death from any cause related to pregnancy or its management, including childbirth or within 42 days of termination of pregnancy. This is irrespective of the duration or site of the pregnancy.

The ovarian arteries are considered the main blood supply for the ovaries. The ovarian arteries usually arise from the lateral aspect of the abdominal artery, though in some instances they may arise from the renal or iliac arteries.

Ureters are muscular tubes that run from the kidneys to the urinary bladder. It is lined by transitional epithelium.

The corpus luteum is formed from the granulosa cells of the mature follicle. The structure functions as a transient endocrine organ which secretes mainly progesterone with additional secretion of oestradiol and inhibin, which serve to suppress FSH levels. In the event of no pregnancy, the corpus luteum stops producing progesterone and degenerates into the corpus albicans.

Shoulder dystocia occurs when the bisacromial diameter, which is the breadth of the shoulders, exceed the diameter of pelvic inlet. This typically results in a bony impaction of the anterior shoulder against the maternal symphysis pubis, instead of an arrest at the pelvic inlet. Brachial plexus palsies including Erb’s palsy is the most common foetal injury associated with shoulder dystocia.

It is not hyper-extension but the hyper-flexion of maternal legs tightly on her abdomen, called as McRoberts manoeuvre, which facilitates delivery during shoulder dystocia. This technique is effective as it increases the mobility of sacroiliac joint during pregnancy, which allows the rotation of pelvis and thereby facilitating the release of fetal shoulder.
If this manoeuvre does not succeed, another technique called suprapubic pressure is done where an assistant applies pressure on the lower abdomen and gently pulls the delivered head. This technique is useful in about 42% of cases with shoulder dystocia.

Maternal diabetes mellitus and foetal macrosomia both are a risk factor for shoulder dystocia.

Administration of epidural anaesthesia during labour increases the possibility of shoulder dystocia.

Risk of shoulder dystocia may increase with Oxytocin augmentation also.

Signs of shoulder dystocia:
– Difficulty with delivery of the face and chin
– The head remaining tightly applied to the vulva or even retracting (turtle-neck sign)
– Failure of restitution of the fetal head
– Failure of the shoulders to descend
Upon identifying shoulder dystocia additional help should be called and McRoberts manoeuvre (flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen) should be performed first. Fundal pressure is associated with uterine rupture and should not be used.

The internal anal sphincter is innervated by the splanchnic nerves. Sympathetic nerve supply from the inferior hypogastric plexus (for contraction) and parasympathetic supply from nervi erigentes (for relaxation).

Depot medroxyprogesterone acetate and the combination contraceptive vaginal ring are the most effective hormonal contraceptives for obese women because they do not appear to be affected by body weight. Women using the combination contraceptive patch who weight 90 kg may experience decreased contraceptive efficacy. Obese women using oral contraceptives may also have an increased risk of pregnancy.

Her most likely diagnosis would be an ovarian carcinoma. Any palpable adnexal mass in a post-menopausal woman is a red flag for an ovarian malignancy and should be assumed so until proven otherwise.

Endometrial cancer typically presents with a post-menopausal bleed and although there might be uterine enlargement, an adnexal mass is generally absent.

It is very rare for follicular cysts to develop following menopause and it is uncommon for post-menopausal women to have a benign ovarian tumour, which is more common in younger women. A degenerating leiomyoma would be unlikely in this case, especially since her pelvic examination three years ago was normal (no history of leiomyoma noted).

According to the RCOG greentop guidelines, a women who have underdone chemotherapy for GTD are advised not to conceive for 1 years after completion of the chemotherapy.

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.

The patient’s condition can be described as a normal progress of labour. The scenario shows a normal descent of the head in the pelvic cavity, with a favourable position, and occurring within an hour of the second stage of labour. A normal second stage of labour in a nulliparous individual occurs at a maximum of two hours, which is consistent with this patient. Hence, there is no delay in the second stage.

There is evident progress of labour in this patient, hence, obstructed labour or cephalopelvic disproportion is ruled out.

No signs of maternal distress such as tachycardia or pyrexia is described in this patient.

The treatment of asphyxia starts with the correct perinatal management of high-risk pregnancies. The management of the hypoxic-ischemic new-borns in the delivery room is the second fundamental step of the treatment. Low Apgar scores and need for cardiopulmonary resuscitation at birth are common but nonspecific findings. Most new-borns respond rapidly to resuscitation and make a full recovery. The outcomes for new-borns who do not respond to resuscitation by 10 minutes of age are very poor, with a very low probability of surviving without severe disability. Resuscitation in room air is advised for term new-borns, since the use of 100% oxygen is associated with worse outcomes compared to the use of room air.

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.

Multiple studies have identified several risk factors for uterine atony such as polyhydramnios, fetal macrosomia, twin pregnancies, use of uterine inhibitors, history of uterine atony, multiparity, or prolonged labour.

The incubation period of varicella is 10-21 days.

At the 36‑week appointment, all pregnant women should be seen again. At this appointment: measure blood pressure and test urine for proteinuria; measure and plot symphysis–fundal height; check position of baby; for women whose babies are in the breech presentation, offer external cephalic version (ECV)

The placenta is important for regulating feto-maternal blood circulation, ensuring that the two circulatory systems do not come into direct contact. The placenta receives 70-80% of the uterine blood flow into the decidual spiral arteries where nutrient, waste and gaseous exchange with fetal blood takes place via the villous core fetal vessels. Deoxygenated blood arrives at the placenta via two uterine arteries while oxygenated, nutrient-rich blood is circulated back to the foetus via a single umbilical vein. The pressure in the umbilical vein is about 20 mmHg.

Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications.

Most mature cystic teratomas can be diagnosed at ultrasonography (US) but may have a variety of appearances, characterized by echogenic sebaceous material and calcification.

Follicular cysts are simple fluid-filled cysts and never have calcifications.

Mucinous cystadenoma usually develop in the third to fifth decades of life and typically cause vague symptoms, such as increasing abdominal girth, abdominal or pelvic pain, emesis, fatigue, indigestion, constipation, and urinary incontinence However, calcifications are not usually seen.

Brenner tumour is also a benign epithelial ovarian tumour but it is solid, occurring most often in women over 50 years of age.

Serous cystadenoma also does not show calcifications.

Preeclampsia prevention
Preeclampsia is defined as a new-onset hypertension along with other features like proteinuria &/or end-organ damage at >20 weeks of gestation.
Patients with the following histories are at high risk for preeclampsia:
– Those with prior history of preeclampsia
– Those with chronic kidney disease
– Those with chronic hypertension
– Those with diabetes mellitus
– Multiple gestation
– Autoimmune disease
Patients belonging in the following criteria are at moderate risk for preeclampsia:
– Obesity
– Advanced maternal age
– Nulliparity

Preeclampsia is considered as the leading cause for maternal and fetal morbidity and mortality. This is due to its increased risk for complications such as stroke, placental abruption and disseminated intravascular coagulation. It is most likely caused due to abnormal vasoconstriction and increased platelet aggregation, which thereby results in placental infarction and ischemia. The condition can be effectively prevented by the administration of low-doses of aspirin at 12 weeks of gestation.

Patients with predisposing factors, such as chronic kidney disease, chronic hypertension and a history of preeclampsia, particularly with severe features or at <37 weeks gestation as in this patient, are at higher risk for developing preeclampsia.
In high risk patients, the only therapy proven to decrease the risk of preeclampsia is a daily administration of low-dose aspirin, as it inhibits platelet aggregation and helps in preventing placental ischemia. Treatment is initiated at 12 – 28 weeks of gestation, optimally before 16 weeks and is continued till delivery.

Betamethasone is a drug used to accelerate fetal lung maturity in patients who are prone to imminent risk of preterm delivery before 37 weeks of gestation. In this case, if the patient develops pre-eclampsia requiring an urgent preterm delivery betamethasone will be indicated.

High-doses (4 mg) of folic acid is indicated in patients with high risk for a fetus with neural tube defects, as in those who have a history of any prior pregnancies affected or those patients who use any folate antagonist medications. In the given case patient is at average risk and requires only a regular dose of 0.4 mg which is found in most prenatal vitamins.

Intramuscular hydroxyprogesterone is indicated in pregnant patients with prior spontaneous preterm delivery due to preterm prelabor rupture of membranes, preterm labor, etc to decrease the possible risk for any recurrence. In patients who underwent preterm delivery due to other indications like preeclampsia with severe features, fetal growth restriction, etc it is not indicated.

Vaginal progesterone is administered to decrease the risk of preterm delivery in patients diagnosed with a shortened cervix, which is usually identified incidentally on anatomy ultrasound scan done between 16 and 24 weeks of gestation. This patient is currently at her 14 weeks, so this is not advisable.

Patients at high risk for pre-eclampsia, like those with preeclampsia in a prior pregnancy, are advised to start taking a daily low-dose aspirin as prophylaxis for prevention of pre-eclampsia during pregnancy.

Endometrial hyperplasia with atypia is at high risk of progression to cancer and hysterectomy is indicated There is high risk of progression to cancer with endometrial hyperplasia with atypia and hysterectomy is indicated. Although weight loss would be beneficial this shouldn’t delay surgical management.

Antepartum haemorrhage presents with bleeding, which may or may not be accompanied by pain. Uterine irritability would suggest abruptio, however contractions are present which may be confused with uterine irritability and in this case, there are no signs of pre-eclampsia present.

Cephalo-pelvic disproportion exists when the capacity of the pelvis is inadequate to allow the foetus to negotiate the birth canal. This may be due to a small pelvis, a nongynecoid pelvic formation, a large foetus, an unfavourable orientation of the foetus, or a combination of these factors. Diagnosis of CPD may be made when there is failure to progress, but not all cases of prolonged labour are the result of CPD. Use of ultrasound to measure the size of the foetus in the womb is controversial, as these methods are often inaccurate and may lead to unnecessary caesarean section; a trial of labour is often recommended even if size of the foetus is estimated to be large.

Threatened abortion:
– Vaginal bleeding with closed cervical os during the first 20 weeks of pregnancy
– Occurs in 25% of 1st-trimester pregnancies
– 50% survival
More than half of threatened abortions will abort. The risk of spontaneous abortion, in a patient with a threatened abortion, is less if fetal cardiac activity is present.

Shoulder dystocia is a complication associated with fetal macrosomia and may result in neurological dysfunction. Fetal macrosomia is generally defined as birth weight – 4,000 g. It occurs in about 10% of pregnancies and one of the most important predictors of fetal macrosomia is previous macrosomic infant(s). The recurrence rate of fetal macrosomia is above 30%. Other risk factors are maternal diabetes, multiparity, prolonged gestation, maternal obesity, excessive weight gain, male foetus, and parental stature- Not all cases of fetal macrosomia lead to shoulder dystocia and the occurrence of this complication is only 0.5%-1% of all pregnancies.

To make clinical decision regarding management of the patient, it is important to understand that there are other factors that lead to shoulder dystocia, such as the mother’s anatomy. While statistics suggest that there’s a tendency to choose elective Caesarean delivery for suspected macrosomia, it is believed that most of procedures are unnecessary, as evidence has shown the number of complications are not reduce- Also while it is logical to consider induction of labour at the 37th week of pregnancy, it is associated with increased Caesarean deliveries because of failed inductions. The recommended course of action is watchful waiting till the patient goes in labour.

→ Induce labour at the 37th week of gestation is not the best course of action, as it is associated with high failure rate, which often leads to Caesarean delivery.
→ Schedule elective Caesarean delivery is considered unnecessary in patients who do not have diabetes. Statistics have shown no evidence that Caesarean delivery reduces the rate of complications.
→ Serial ultrasound for fetal weight estimation is incorrect. The strategies used to predict fetal macrosomia are risk factors, Leopold’s manoeuvres, and ultrasonography. Even when they are combined, they are considered inaccurate; much less ultrasonography alone.
→ At this point, blood glucose control in pregnancies associated with diabetes seems to have desired results in preventing macrosomia- A weight loss program is usually not recommended- Instead, expectant management should be considered.

There is a high risk of developing HELLP syndrome in pre-eclamptic patients. Considering that she is complaining of right upper quadrant pain, a LFT should be done immediately.

This is not an X-linked condition so the sex of the child makes no difference to the inheritance. Any child will have a 1 in 4 chance of having beta thalassaemia major.

Achieving spontaneous pregnancy is rare in cases where a couple have been infertile with abnormal semen analysis (count <5million/mL and reduced motility), hence there is generally an indication for treatment. FSH injection usually would not be expected to improve the semen specimen. Rate of pregnancy would be much lower if at the time of intrauterine insemination, the total motile count is less 5 million. In this case, his count is 1 million. Pregnancy is likely to be achieved with donor sperm but as it would not contain the husband’s genetic material, it would be only considered later on once all other methods involving his own sperm have failed. Out of all the options, IVF would most likely result in a pregnancy, in which it allows the husband’s sperm to spontaneously fertilise the oocyte. Rate of pregnancy would roughly be 2% per treatment cycle. This rate would increase to roughly 20% if ISCI is also used.

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

The most common cause of maternal mortality is Cardiovascular deaths due to post partum bleeding followed by hypertensive disorders of pregnancy, sepsis and complications of labour.

After the release of the oocyte, the theca and the granulosa cells form the corpus luteum which undergoes extensive vascularization for continued steroidogenesis. Progesterone is secreted by the luteal cells and is synthesized from cholesterol. The luteal phase lasts for 14 days and if implantation does not occurs the corpus luteum starts to degenerate. As B-HCG produced by the implanted embryo maintains it and without it luteolysis occurs.

Oestrogen- and progesterone-containing oral contraceptives inhibit LH, which suppresses the FSH and LH levels, preventing follicular development and ovulation. Combined pills suppress FSH and LH throughout the cycle, inhibit endometrial proliferation, and produce a scanty cervical mucus. 

Yasmin has been linked to decreased fluid retention and weight gain as a side effect of COCs, which is why most women who experience this side effect prefer Yasmin®.
Due to its anti-mineralocorticoid properties, drospirenone, unlike earlier progestogens, is associated with no weight gain or even moderate weight loss.
Yasmin has a similar failure rate to other COCs. No evidence using Yasmin is linked to a lower risk of cervical cancer as a long-term side effect of COCs. Yasmin, like all COCs, can cause spotting and irregular bleeding in the first few months of use.
Drospirenone, a progesterone component, has antiandrogenic properties and is slightly more successful in treating acne, but the difference is not big enough to make it preferable in terms of acne therapy or prevention when compared to other COCs.

All of the options provided could cause amenorrhoea and therefore need to be evaluated.

The luteinising hormone (LH) level reported here is exceedingly elevated. A patient with polycystic ovarian syndrome (PCOS) is unlikely to have such a raised level, but it could be because of a LH-producing adenoma. Such tumours are, however, extremely rare.

Early pregnancy (correct answer) is the most likely cause of this woman’s elevated LH level. This would be due to the presence of beta human chorionic gonadotropin (hCG) hormone that is produced during pregnancy.

LH and beta-HCG both have similar beta-subunits and cross-reactions are commonly noted in LH assays.

The serum prolactin (PRL) level is at the upper end of the normal range and this correlates to the levels observed in the early stages of pregnancy.

The follicle-stimulating hormone (FSH) levels remain low during early pregnancy.

If her amenorrhea had been caused by stress from her recent marriage, the LH level would have been normal or low.

If the cause was premature ovarian failure, the FSH level would have been significantly higher.

Syphilis is a sexually transmitted disease which is caused by spirochete called treponema pallidum. It can be divided into three stages. i.e. primary, secondary and tertiary syphilis.
– Primary syphilis is characterized by chancre formation at the site of sexual contact.
– Secondary syphilis ranges from maculopapular lesions to scaly lesions, inguinal lymphadenopathy, condylomata lata and split papules at the corner of mouth.
– Tertiary syphilis is the late stage of syphilis which is characterized by gummas formation and general paresis along with signs and symptoms of visceral involvement.

Ilioinguinal nerve injury is one of the most common nerve injuries associated with pelvic surgery.

Fetal ultrasound scanning is considered an essential part of routine antenatal care with first trimester scans recommended for confirming viability, accurate estimation of gestational age and determining the number of foetuses. Fetal crown-rump length (CRL) is measured in early pregnancy primarily to determine the gestation age (GA) of a foetus and is most reliable between 9+0 to 13+6 weeks’ gestation, but not beyond.

The extrinsic pathway is activated by the tissue factor, which converts factor VII to VIIa which later on converts factors X and II to their activated form finally leading to the conversion of fibrinogen to fibrin fibres.

CAH leads to virilization of the female foetus. It occurs to an enzyme deficiency (21-hydroxylase). This results in a reduced levels of corticosteroids from being circulated resulting in hyperplasia of the adrenal glands and increased progesterone production. The CYP21A gene has been implicated in causes this deficiency.

During early pregnancy, hCG can be detected in the maternal serum as early as 6 to 8 days after fertilization. hCG levels are dynamically increased and doubled every 48 h in most normal pregnancies, and this pattern is similar in both in vivo or in vitro (IVF) conceptions.

The NICE guidelines on Hypertension in pregnancy define blood pressure in pregnancy as follows:
Mild hypertension: DBP=90-99 mmHg, SBP=140-149 mmHg. Moderate hypertension: DBP=100-109 mmHg, SBP=150-159 mmHg.
Severe hypertension: DBP=110 mmHg or greater, SBP=160 mmHg or greater.

Analysis of presentation shows the patient has developed hyperemesis gravidarum.
She is in early shock, presented as sinus tachycardia and hypotension, with ketonuria and requires immediate fluid resuscitation and anti-emetics. The first line fluid of choice is administration of normal saline 0.9%, and should avoid giving dextrose containing fluids as they can precipitate encephalopathy and worsens hyponatremia.

The most appropriate management of a pregnant patient in this situation is administration of metoclopramide as the first line and Ondansetron as second line antiemetic, which are Australian category A and B1 drugs respectively. The following also should be considered and monitored for:
1. More refractory vomiting.
2. Failure to improve.
3. Recurrent hospital admissions.

Steroids like prednisolone are third line medications which are used in resistant cases of hyperemesis gravidarum after proper consultation.

The biophysical profile is a composite test that collects 5 indicators of fetal well-being, including fetal heart rate reactivity, breathing movements, gross body movements, muscular tone, and quantitative estimation of amniotic fluid volume. The assessment of fetal heart rate is accomplished by performing a non-stress test, whereas the latter 4 variables are observed using real-time ultra-sonography.

Thyroid disease is the second most common endocrine disorder after diabetes in pregnancy. Thyroid disease poses a substantial challenge on the physiology of pregnant women and has significant maternal and fetal implications. Research shows during pregnancy, the size of the thyroid gland increases by 10% in countries with adequate iodine stores and by approximately 20% to 40% in countries with iodine deficiency. During pregnancy, thyroid hormone production increases by around 50% along with a similar increase in total daily iodine requirements.

The different changes occurring in thyroid physiology are as follow:
– An increase in serum thyroxine-binding globulin (TBG) leading to an increase in the total T4 and total T3 concentrations
– Stimulation of the thyrotropin (TSH) receptor by human chorionic gonadotropin (hCG) which increases thyroid hormone production and subsequently reduces serum TSH concentration.

Therefore, compared to the non-pregnant state, women tend to have lower serum TSH concentrations during pregnancy.
The need to adjust levothyroxine dose manifests itself as early as at 4-8 weeks of gestation, therefore justifying the adjustment of levothyroxine replacement to ensure that maternal euthyroidism is maintained during early gestation. Most of well-controlled hypothyroid pregnant women need increased dosage of thyroid hormone after pregnancy.

First stage: The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine contractions. A definition of active labour is having contractions more frequent than every 5 minutes, in addition to either a cervical dilation of 3 cm or more or a cervical effacement of 80% or more.

Second stage: fetal expulsion begins when the cervix is fully dilated, and ends when the baby is born.

Third stage: placenta delivery – The period from just after the foetus is expelled until just after the placenta is expelled is called the third stage of labour or the involution stage.

Anomalies of the cervico-uterus are widely diagnosed by HSG. The diagnostic value of HSG in the detection of anomalies varies, depending on the type of malformation.

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.

Corpus albicans is the regressed form of the corpus leuteum. It is formed when the corpus leuteum is engulfed by macrophages and a scar or fibrous tissue is formed, called the corpus albicans.

No adverse reactions in breastfed infants have been reported from maternal warfarin use during lactation, even with a dose of 25 mg daily for 7 days. There is a consensus that maternal warfarin therapy during breastfeeding poses little risk to the breastfed infant.

The most appropriate test for a hydatiform mole is serum beta hCG levels, which are consistently raised in these patients. The levels return to normal when the pregnancy is terminated.

Lichen sclerosus is characterized by hypopigmented atrophic plaque in the perineal region along with features of pruritis and dyspareunia.
It is more common in post menopausal women and on histology there is epidermal atrophy, inflammatory infiltrate in the dermis and basal layer degeneration.

Vitiligo is characterised by hypopigmentation but without any other symptoms.
Extramammary Paget’s disease is characterized by erythematous plaque located mostly in the perianal region but its histology is different.
Lichen simplex chronicus is a chronic scaly pruritic condition characterized by itchy papules and plaques plus lichenification and it mostly results from chronic irritation and itching of the area.

This woman at her 37 weeks of gestation, has developed multiple herpetic lesions over her genitals. In every case were the mother develops herpes simplex infection after 28 weeks of pregnancy, chances for intrapartum and vertical transmission of the infection to the neonate is considered to be very high.

Risk factors of intrapartum herpes simplex infection of the child includes premature labour, premature rupture of membrane, primary herpes simplex infection and multiple lesion in the genital area.

The most appropriate methods for managing this case includes:
– checking for herpes simplex infection using PCR testing of a cervical swab.
– starting prophylactic antiviral therapy for the mother from 38 weeks of gestation until delivery.
– preferring a cesarean section delivery if there are active lesions present in the cervix and/or vulva.

Cesarean delivery is advised in this case along with maternal antiviral therapy before delivery to minimise the risk of vertical transmission.

A serious complication with a miscarriage is DIC, a severe blood clotting condition and is more likely if there is a long time until the foetus and other tissues are passed, which is often the case in missed abortion.

Lamotrigine, a drug used to treat epilepsy, is less effective when taken with combined oral contraceptives. The oestrogen component of the pill decreases the circulating levels of Lamotrigine, increasing the risk of seizures. The combination is therefore classified as a UKMEC 3, as the risk of the drug combination may outweigh the benefit. As an alternative, the progesterone-only pill, depo progesterone, Mirena or the copper IUD may be considered as there is no restriction on concomitant use. Lamotrigine is not metabolised through cytochrome P450 like other antiepileptic drugs such as carbamazepine and phenytoin, neither is it an enzyme inhibitor.

Consideration of the risk of scar rupture is probably the most important consideration when determining whether delivery should be by elective Caesarean section or by trial of vaginal delivery.
Most published studies do not differentiate between scar dehiscence and rupture, however, analysis of observational and comparative studies indicates that the excess risk of uterine rupture following trial of labour compared with women undergoing repeat elective Caesarean section is considerably lower than 1 per cent (25/10000); indeed, some studies do not demonstrate any increased risk.

The risk of uterine perforation is 0.1% during therapeutic hysteroscopy.

With a history of MI, oestrogen and COCP should be avoided. Evening primrose is also not suitable for post-menopausal symptoms. Raloxifene is a SERM – these make hot flushes worse. Clonidine will help improve the hot flushes and the vasomotor symptoms.

Oogonium become Primary Oocyte via Growth/Maturation. This process is called oocytogenesis Primary Oocyte undergoes 2 meiotic divisions to become Ootids. This process is called Ootidogenesis Ootids differentiate into Ovum

Institute of Medicine Weight Gain Recommendations for Pregnancy: Recommends a gestational weight gain of 16.8–24.5 kg (37–54 lb) for women of normal weight, 14.1–22.7 kg (31–50 lb) for overweight women, and 11.3–19.1 kg (25–42 lb) for obese women.

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.

The mid-luteal progesterone sample should be taken 7 days before the expected period i.e. day 21 in a 28-day cycle or day 28 of a 35 day cycle

The woman is most probably suffering from eclampsia.
Magnesium sulphate (MgSO4) is the agent most commonly used for treatment of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia. It is usually given by either intramuscular or intravenous routes. The intramuscular regimen is most commonly a 4 g intravenous loading dose, immediately followed by 10 g intramuscularly and then by 5 g intramuscularly every 4 hours. The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump.

The 3rd arch gives rise to the Glossopharyngeal nerve.

Bacterial vaginosis (BV) is a common infection of the vagina caused by the overgrowth of atypical bacteria, most commonly Gardnerella vaginalis, a gram-negative rod. In diagnosing BV, a swab is taken for microscopy, often revealing clue cells. Clue cells are cells of the vaginal epithelium which are covered by adherent Gardnerella, giving them a distinctive look under the microscope. Though many are asymptomatic, some infected women complain of a greyish, foul-smelling vaginal discharge. Their vaginal fluid pH may also become more alkaline. BV does not however present with pyrexia, so the lady’s fever could be attributed to another cause as she is still a patient on the medical ward.

The risk factors for uterine carcinoma include obesity, diabetes, Nulliparity, late menopause, unopposed oestrogen therapy, tamoxifen therapy, HRT and a family history of ovarian or uterine carcinoma.

In a person who is infected by streptococcus (Group B) should be started on benzylpenicillin as soon as possible. In case of allergy vancomycin should be started at 1g every 12 hours. Tetracyclines should be avoided in pregnancy.

Taking into consideration that she had only missed one pill and that they were going to be stopped the next day anyway, the rate of pregnancy would be low; hence all of the responses would be acceptable and effective. However, the most appropriate step would be to initiate her hormone-free interval starting from the time she missed her pill i.e. 11pm the night before. This would make tonight the 2nd lactose pill day and hence she should commence the next course of hormone pills on the 5 nights from tonight. In doing this, her hormone-free period would be the usual length of 7 days. Although the risk of pregnancy is low after missing only one pill, this opposite occurs when the missed pill causes a longer than normal hormone-free duration between the end of the current cycle and the starting of the subsequent one.

The World Health Organisation defines the maternal mortality ratio as the number of maternal deaths during a given period per 100,000 live births during the same period. This measure indicates the risk of death in a single pregnancy.

Normal position of the foetus in relationship to the mother is always a longitudinal lie and a cephalic presentation. Transverse lie means that the baby is sideways. The foetus lies transverse till 26-28th week of gestation, after which it usually changes its position from transverse to a longitudinal lie with head down. A transverse lie can occur in conditions like grand multiparity, preterm foetus, placenta previa and pelvic contraction.

It utilizes the IgG class of the antibody.

Because of the high possibility of spontaneous resolution and the fact that if the cystic mass was verified ultrasonically, a conservative policy would almost probably be proposed for at least another six weeks, an ultrasound examination is not necessary at this time. If the cyst is still present at the six-week check, an ultrasound examination is required, as it is likely that the cyst is a benign tumour or possibly endometriosis. It’s quite improbable that it’s cancer.
Additional tests, such as computed tomography (CT) examination and potentially surgical removal or drainage, may be required in the future, although not at this time.
This cyst in a young lady is almost probably of physiological origin, especially given its size. The woman should be informed, but a follow-up examination is required. The most suitable next action is to return in six weeks, as the cyst is most likely physiologic and will most likely dissipate naturally by then. The following appointment should not take place during the same menstrual cycle.

When face presentation is diagnosed, around 60% of cases are in the mentum anterior position, 25% are mentum posterior and 15% are mentum transverse; most malpositions rotate spontaneously into mentum anterior. A vaginal birth at term is possible only if the foetus is in the mentum anterior position.

The half life of oxytocin is 5 mins, which is why is should be started as an infusion at a low rate.

The presentation is antepartum haemorrhage. Ultrasound should be performed to find the reason for bleeding and assess the fetal well being.

Women with medical conditions associated with increased risk for thrombosis generally should not use oestrogen-containing contraceptives.

The majority of evidence identified does not suggest an increase in odds for venous or arterial events with use of most POCs. Limited evidence suggested increased odds of VTE with use of injectables (three studies) and use of POCs for therapeutic indications (two studies, one with POCs unspecified and the other with POPs).

Discontinuing anticoagulants increases her risk of recurrent DVT.

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.

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.