Retarded skeletal growth resulting in small for gestational age babies are the usual outcomes of an untreated vitamin D deficiency in pregnancy.

Symptoms associated with maternal vitamin D deficiency during pregnancy are:
– Hypocalcemia in newborn.
– Development of Rickets later in life.
– Defective tooth enamel.
– Small for gestational age due to its effect on skeletal growth
– Fetal convulsions or seizures due to hypocalcemia.

In Cushing’s syndrome there is excess cortisol. Causes are broadly divided into 2 types: ACTH dependent disease: excess ACTH from the pituitary (Cushing’s disease), ectopic ACTH-producing tumours or excess ACTH administration. Non-ACTH-dependent: adrenal adenomas, adrenal carcinomas, excess glucocorticoid administration. The recommended diagnostic tests for the presence of Cushing’s syndrome are 24-hour urinary free cortisol, 1 mg overnight dexamethasone suppression test and late-night salivary cortisol. There are several other tests that may also be performed to find the cause. ACTH and cortisol measured together may show if this is ACTH dependent or not. MRI pituitary and CT abdo and pelvis may show if tumour is the cause.

Tranexamic acid is an antifibrinolytic drug which is one of the treatment options in menorrhagia i.e. heavy menstrual bleeding. It acts by binding to the receptor sites on plasminogen thus preventing plasmin from attaching to those receptors thus inhibiting plasminogen activation.

If pharmaceutical treatment is appropriate NICE advise treatments should be considered in the following order:

1. levonorgestrel-releasing intrauterine system (LNG-IUS) provided at least 12 months use is anticipated
2. tranexamic acid or NSAIDs* or combined oral contraceptives (COCs) or cyclical oral progestogens
3. Consider progesterone only contraception e.g. injected long-acting progestogens

*When heavy menstrual bleeding (HMB) coexists with dysmenorrhoea NSAIDs should be preferred to tranexamic acid. Also note NSAIDs and tranexamic are appropriate to use if treatment needed pending investigations.

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 uterus is divisible into two portions. The portion above the isthmus is termed the body, and that below, the cervix. The uterine cervix is the narrow inferior segment of the uterus, which projects into the vaginal cavity. It is a fibromuscular organ lined by a mucous membrane and measures approximately 3cm in length and 2.5cm in diameter. The cervix is continuous at its superior margins with the body of the uterus and at its inferior margins with the vagina.

Vaginismus is an uncontrollable painful spasm of the pelvic muscles and vaginal exit that this patient has. It’s mainly caused by psychological factors. It’s important to distinguish it from frigidity, which indicates a lack of sexual desire, and dyspareunia, which is characterized as pelvic and/or back pain or other discomfort linked with sexual activity. Endometriosis, pelvic adhesions, and ovarian neoplasms are all common causes of dyspareunia. Vaginismus pain can be psychogenic, or it might be caused by pelvic diseases like adhesions, endometriosis, or leiomyomas. Organic vulvar or pelvic reasons (such as atrophy, Bartholin gland cyst, or abscess) are extremely rare, hence vaginismus is mostly treated with psychotherapy.

Cardiotocography (CTG) helps to record the heartbeat of the foetus in parallel to measuring the contractions of the mother’s uterus, this is the most appropriate tool to assess this patient’s condition.

BP over 159/109 is classed as Severe. NICE guidance advises admission and treatment with oral Labetalol as 1st Line. Patient should have BP checked QDS and shouldn’t be discharged until BP is below 159/109

Detrusor contraction is via Parasympathetic innervation of pelvic splanchnic nerves (S2-4). This also causes relaxation of the internal urethral sphincter Note contraction and relaxation of the external urethral sphincter is under somatic control.

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.

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.

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.

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

SLE is a type III hypersensitivity reaction

There are over 100 genotypes of HPV including several other high risk HPV types. HPV 16 and 18 are responsible for 70% of cases of HPV related cancers. HPV is thought to induce cancer via onco-proteins. The primary onco-proteins are E6 and E7 which inactivate two tumour suppressor proteins, p53 (inactivated by E6) and pRb (inactivated by E7)

Sinciput means the head is neither flexed nor extended. It is the area between forehead and crown and in this case the anterior fontanel is the presenting part.

Most common risk factors for spontaneous abortion are considered to be:
– Age above 35 years.
– Smoking.
– High intake of caffeine.
– Uterine abnormalities like leiomyoma, adhesions.
– Viral infections.
– Thrombophilia.
– Chromosomal abnormalities.
Conditions like subclinical thyroid disorder, subclinical diabetes mellitus and retroverted uterus are not found to cause spontaneous abortions.
The term retroverted uterus is used to denote a uterus that is tilted backwards instead of forwards.

The external carotid develops from the 1st arch. The common and internal carotid develop from the 3rd arch.

The condition should be an X-linked recessive condition, as it affects only male offspring. Duchene muscular dystrophy is an X-linked recessive condition. Cystic fibrosis is an autosomal recessive disorder. Spina bifida is a multifactorial condition. Down syndrome is caused by trisomy of chromosome 21. Spinal muscular atrophies are inherited in an autosomal-recessive pattern.

The major constituents of breast milk are lactose, protein, fat and water. However, the composition of breast milk is not constant; early lactation differs from late lactation, one feed differs from the next, and the composition can even change
during a feed. Artificial infant formulas cannot therefore be identical to breast milk. In addition to IgA, breast milk contains small amounts of IgM and IgG and other factors such as lactoferrin, macrophages, complement and lysozymes

Lichen Sclerosis is a destructive inflammatory condition that effects the anogenital region of women. It effects around 1 in 300 women. It destroys the subdermal layers of the skin resulting in hyalinization of the skin leading to parchment paper appearance of the skin. It is associated with vulval cancer and it is estimated that the risk of developing vulval cancer after lichen sclerosis is around 3-5%.

Oxygenation of fetal blood occurs in the placenta before it returns in the umbilical vein which joins the left branch of the portal vein. It bypasses the capillaries of the liver by going through the ductus venosus, which is obliterated after birth and becomes the ligamentum venosum. The oxygenated blood enters the inferior vena cava and is transported to the right atrium and
then through the patent foramen ovale to the left atrium and on to the left ventricle. From the left ventricle, the blood flows into the aorta and through the fetal vascular network. Blood returning from the head of the foetus passes through the superior vena cava to the right atrium and straight on to the right ventricle and pulmonary artery. However, it does not enter the pulmonary
circulation, being short-circuited by the ductus arteriosus to the aorta. Aortic blood is carried via the umbilical arteries back to the placenta for reoxygenation. At birth, the three short circuits, the ductus venosus, foramen ovale and ductus arteriosus, close.

This woman has signs and symptoms suggestive of cervical insufficiency, whose clinical features include pelvic pressure, premenstrual-like cramping and backache with increased vaginal discharge. Usually these symptoms will persist for several days to weeks.
Cervical insufficiency is seen between 14 – 20 weeks of gestation, which is presented as soft effaced cervix, with minimal dilation on physical examination and a 4 cm dilated and more than 80% effaced cervix will be the clinical presentation in a more advanced case.

Placental abruption presents with painful vaginal bleeding, whereas Placenta Previa presents as painless vaginal bleeding. Both cases will lead to shock but will not show any features of cervical insufficiency.

Anaemia, polyhydramnios, large for gestational age uterus and severe hyperemesis gravidarum are the commonly associated symptoms of a twin pregnancies.

New menstrual cycle after an abortion is expected to be presented with cervical dilation however signs of effacement will not be present along with it.

Misoprostol is not as effective as oxytocin but may be used if Oxytocin is not available e.g. home birth Recommended doses of Oxytocin For vaginal deliveries: 5 iu or 10 iu by intramuscular injection. For C-section: 5 iu by IV injection

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.

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

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

The 1st stage of wound healing is haemostasis. Even in incised wounds a small haematoma forms. Here the clotting cascade is activated by tissue factor and endothelial cells resulting in activation of platelets. This results in platelet aggregation and the laying down of a fibrin mesh that is cross linked and holds the platelets in place.
Wound healing is typically divided into phases:
1. Haemostasis Phase
2. Inflammatory phase
3. Proliferation phase
4. Remodelling phase

The progestogen-only pill (POP) is a contraceptive option for women who have high blood pressure either induced by use of combined oral pills or due to other causes; as long as it is well controlled and monitored. Combined oral contraception (COC) and Depo-Provera have been implicated in increased cardiovascular risk following use. High blood pressure has been theorized to be the critical path that leads to this increased risk. POP is the recommended method for women who are at risk of coronary heart disease due to presence of risk factors like hypertension.

Stopping OCP will risk in the patient getting pregnant. Cessation of oestrogen usually reverses the blood pressure back to normal, Hence, all other options are incorrect.

Congenital Herpes Simplex Virus infection may cause high levels of morbidity and mortality in neonates. Risk of infection with HSV 1 and 2 is highest within 6 weeks of delivery and is transferred to the neonate via maternal secretions at birth. Affected babies can present as skin manifestations, CNS infection, or disseminated infection, which carries an 85% risk of mortality if left untreated. Treatment with high dose antivirals such as acyclovir can help decrease the case mortality rate to 30% in cases of disseminated infection.

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.

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.

Major vessel injury is the most important potential complication when undertaking laparoscopy. It’s incidence is 0.2/1000. Bowel Injury is more common at 0.4/1000

In pregnancy, term refers to the gestational period from 37 to 41+6 weeks. Preterm births occur between 24 and 36+6 weeks. Only 1% of women who go into PROM have risk of having serious neonatal infections.

Management of PROM:
60% of patients with PROM will go into labour within 24 hrs
Induction is appropriate if >34 weeks gestation and more than 24 hours post rupture when labour hasn’t started.
If < 34 weeks, induction of labour should not be carried out unless there are additional obstetric indications e.g. infection

During pregnancy, anaemia increases more than fourfold from the first to third trimester. It is a well established fact that there is a physiological drop in haemoglobin (Hb) in the mid trimester. This physiological drop is attributed to increase of plasma volume and hence decrease of blood viscosity lead to better circulation in placenta.

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 (cribriform fascia at the saphenous opening) Trasversalis fascia forms part of the roof of the inguinal canal

This is a patient that recently gave birth and is still breastfeeding presenting with dyspareunia. The most likely cause would be a thin atrophic vaginal epithelium. This is very common presentation and is due to the low oestrogen levels due to the prolactin elevation from breastfeeding.

An unrecognised and unsutured vaginal tear should have healed by this time and should not be causing issues.

Endometriosis tends to resolve during a pregnancy, but if this was the issue, it would have caused dyspareunia prior to pregnancy.

Vaginal infective causes of dyspareunia, such as monilial or trichomonal infections, are rare in amenorrhoeic 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.

Urge incontinence is involuntary pee loss accompanied by a strong desire to urinate. The most common cause of urge incontinence is detrusor or bladder dyssynergia, which is characterized by an involuntary contraction of the bladder during urine distension.

Bladder training, eliminating excess coffee and fluid intake, biofeedback, and pharmacological therapy are all options for treating urge incontinence. Treatment with anticholinergic medicines (oxybutynin chloride), -sympathomimetic agonists (metaproterenol sulphate), Valium, antidepressants (imipramine hydrochloride), and dopamine agonists (Parlodel) has proven successful if conservative approaches fail.

The detrusor muscle will be relaxed by these pharmacologic drugs. Oestrogen therapy may improve urine control in postmenopausal women who are not on oestrogen replacement therapy. Kegel exercises can help women with stress urinary incontinence strengthen their pelvic musculature and improve bladder control.

The levels of oestradiol (E2), progesterone, and prolactin (PRL) are all elevated during early pregnancy. However these elevations cannot be solely relied on to determine if pregnancy has occurred since increased levels of these hormones can also occur in pathologic states in non-pregnant women or, in some cases, even during menstrual cycles.

The levels of follicle stimulating hormone (FSH) are suppressed in pregnancy because of the elevated E2 and progesterone levels.

The correct answer is elevated levels of luteinising hormone (LH). This is because the beta sub-units of LH and human chorionic gonadotrophin (hCG) are almost identical and therefore, hCG is measured as LH in almost all LH assays (correct answer).

The LH levels can be slightly raised in polycystic ovarian syndrome; however, it is unlikely that the levels would increase above 30 mIU/mL in this condition.

The mid-cycle levels of LH can go up to 100-150 mIU/mL. If the levels are more than 200 mlU/mL, it usually indicates pregnancy.

In a postmenopausal woman, the ovaries should not be palpable; if they are, it should raise the concern that an ovarian malignancy is present. Before one would perform an operative evaluation, radiologic assessment should be done.

– Although this is an accepted regimen for oestrogen replacement therapy, the palpable ovaries need to be evaluated to rule out malignancy.
– Dual photon densitometry will give a reliable measure of bone density. Again, however, the palpable ovary is the first thing that needs to be worked up.
– Although surgical exploration may be warranted, initial workup of the adnexal mass should include an ultrasound along with tumour markers. A CT scan may also be warranted.

Occipitomental diameter is the greatest diameter of the fetal scalp and runs from chin to the prominent portion on the occiput. It measure about 12.5cm in diameter.

Androgen insensitivity (testicular feminization) syndrome is a rare inherited form of male pseudo hermaphroditism that occurs in phenotypically normal women with adequate breast development, normal external genitalia, a vagina of variable depth, absent uterus, and sparse or absent pubic hair and axillary hair. Testosterone levels are normal or elevated.

Radiotherapy causes ionisation, primarily of water. This leads to hydroxyl and other free radicals being generated. Free radicals are highly reactive and cause DNA damage to cells via their reactions with them. Free radicals are relatively short lived and eventually form stable compounds. The DNA damage leads to cellular death.

Serum progesterone has been proposed as a useful test to distinguish a viable pregnancy from a miscarriage or ectopic pregnancy. Low progesterone values are associated with miscarriages and ectopic pregnancies, both considered non-viable pregnancies, and high progesterone concentrations with viable pregnancies. A single progesterone measurement for women in early pregnancy presenting with bleeding or pain and inconclusive ultrasound assessments can rule out a viable pregnancy. The probability of a non-viable pregnancy was raised from 62.9% to 96.8%.

Ovarian insufficiency is a failure of the ovary to function adequately in a woman younger than 40 years, in its role either as an endocrine organ or as a reproductive organ. In women aged 40 years or older, the expected physiologic decline of ovarian function that takes place with aging is termed perimenopause or the menopausal transition.
Medical treatment of patients with primary ovarian insufficiency should address the following aspects:

Ovarian hormone replacement
Restoration of fertility
Psychological well-being of the patient

It is not appropriate to give this patient contraceptive pills since she desires pregnancy.

There is no evidence that Danazol or Metformin would improve ovarian follicle function.

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

Spinnability (or Spinnbarkeit), which measures the capacity of fluids to be drawn into threads, represents an indirect measurement of the adhesive and elastic properties of mucus.

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.

The Vaginal artery, like the Uterine artery is typically a branch of the Internal Iliac artery. It can sometimes arise as a branch of the Uterine artery so it is important to read the question (if the stem stated it CAN arise from the Uterine artery then that would be true)

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.

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

Visual disturbances although very common during pregnancy are not a normal sign. Physicians should have a firm understanding of the various ocular conditions that might appear pregnancy or get modified by pregnancy. In addition, it is very important to be vigilant about the rare and serious conditions that may occur in pregnant women with visual complaints. Prompt evaluation may be required and the immediate transfer of care of the patient may help saving the lives of both the mother and the baby.

The Leydig cells contain receptors to the luteinizing hormone which in turn is responsible for the production of testosterone. This circulates in the body predominantly bound to transport proteins and to a lesser extent to albumin.

The Rhesus status of a mother is important in pregnancy and abortion. The exposure of an Rh-negative mother to Rh antigens from a positive foetus, will influence the development of anti-Rh antibodies. This may cause problems in subsequent pregnancies leading to haemolysis in the newborn. Rh Anti RhD- globulin is therefore given to non-sensitised Rh-negative mothers to prevent the formation of anti-Rh antibodies within 72 hours following abortion. Anti RhD globulin is not useful for already sensitized, or RhD positive mothers.

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.

Lymphatic drainage of the breast.
The lateral two thirds of the breast drains into the axillary lymph nodes. This constitute about 75% of the lymphatic drainage of the breast. The medial third of the breast drains into the parasternal lymph nodes and these communicate with the ipsilateral lymph nodes from the opposite breast. The superior part of the breast drains into the infraclavicular lymph nodes and inferior part drains into the diaphragmatic lymph nodes.

Vaginal spotting, malodorous vaginal discharge and no signs of trauma like lacerations are the clinical features of vaginal foreign bodies in prepubertal girls. The most common object found as foreign body is toilet paper and its management includes warm irrigation and vaginoscopy under sedation/anesthesia.

Common cause of vulvovaginitis in prepubertal girls are vaginal foreign bodies. Although other objects like small toys, hair bands, etc can be occasionally found, the most common vaginal foreign body is toilet paper. Symptoms like malodorous vaginal discharge, intermittent vaginal bleeding or spotting and urinary symptoms like dysuria are caused due to the chronic irritation caused by the foreign body (the whitish foreign body in this case) on the vaginal tissue.

An external pelvic examination is performed with the girl in a knee-chest or frog-leg position in cases of suspected vaginal foreign body. An attempt at removal, after application of a topical anesthetic in the vaginal introitus, using vaginal irrigation with warm fluid or a swab can be done in case of an easily visualized small foreign body like toilet paper. In cases were the age of the girl or the type of foreign body prohibit adequate clinical evaluation the patient should be sedated or given a general anesthesia for examination using a vaginoscope and the foreign body should be removed.

In cases where child abuse or neglect is suspected Child Protective Services should be contacted. Vaginal or rectal foreign bodies can be the initial presentation of sexual abuse; however in otherwise asymptomatic girls with no behavioral changes, urinary symptoms and vulvar or anal trauma, presence of toilet paper is not of an immediately concerning for abuse.

To evaluate pelvic or ovarian masses CT scan of the abdomen and pelvis can be used; but it is not indicated in evaluation of a vaginal foreign body.

Patients in there prepubertal age have a narrow vaginal introitus and sensitive hymenal tissue due to low estrogen levels, so speculum examinations should not be performed in such patients as it can result in significant discomfort and trauma.

Topical estrogen can be used in the treatment of urethral prolapse, which is a cause of vaginal bleeding in prepubertal girls. This diagnosis is unlikely in this case as those with urethral prolapse will present with a beefy red protrusion at the urethra and not a material in the vagina.

Prepubertal girls with retained toilet paper as a vaginal foreign body will present with symptoms like malodorous vaginal discharge and vaginal spotting secondary to irritation. Initial management is topical anaesthetic application and removal of foreign body either by vaginal irrigation with warm fluid or removal with a swab.

A miscarriage is defined as the spontaneous loss of a pregnancy before the age of viability at 24 weeks in the UK. An inevitable miscarriage occurs with the usual symptoms of a miscarriage such as menstrual-like cramping, vaginal bleeding and a dilated cervix. The gestational sac has ruptured but products of conception have not been passed. The products of conception will eventually pass.

A missed miscarriage is described as a loss of pregnancy without vaginal bleeding, loss of tissue, cervical changes or abdominal pain. During a scan, a fetal heartbeat is not observed, and the gestational sac may be small.

A threatened miscarriage is when the cervix dilates and uterine bleeding is seen; the pregnancy could still be viable.

A complete miscarriage occurs when all the products of conception are expelled from the uterus, bleeding has stopped, and the cervix has closed up after dilation. Recurrent miscarriages are described as spontaneous pregnancy loss of more than 2 to 3 consecutive times.

Literature review shows that bicornuate uterus is associated with increase risk of spontaneous abortion in about 36% of patients. There is also an increased risk of preterm birth, malpresentation and fetal growth retardation.

Threatened abortion consists of any vaginal bleeding during early pregnancy without cervical dilatation or change in cervical consistency. Usually, no significant pain exists, although mild cramps may occur. More severe cramps may lead to an inevitable abortion.

Threatened abortion is very common in the first trimester; about 25-30% of all pregnancies have some bleeding during the pregnancy. Less than one half proceed to a complete abortion. On examination, blood or brownish discharge may be present in the vagina. The cervix is not tender, and the cervical os is closed. No fetal tissue or membranes have passed. The ultrasound shows a continuing intrauterine pregnancy. If an ultrasound was not performed previously, it is required at this time to rule out an ectopic pregnancy, which could present similarly. If the uterine cavity is empty on ultrasound, obtaining a human chorionic gonadotropin (hCG) level is necessary to determine if the discriminatory zone has been passed.

Placenta previa is an antenatal complication occurring around the third trimester of pregnancy. The cervix is closed in this condition which rules out inevitable abortion and the patient has no history of passage of tissue, this rules out complete abortion. The patient has no history of fever or offensive vaginal discharge which makes septic abortion unlikely.

Clomiphene citrate is widely used in the induction of ovulation, especially in the treatment of anovulatory infertility and in conditions such as PCOS. The drug functions as a selective oestrogen receptor modulator, which acts in the hypothalamus to indicate low serum oestrogen levels. Reduced levels of negative feedback stimulate the secretion of GnRH from the hypothalamus, which in turn stimulate the production of gonadotropins (FSH and LH) from the anterior pituitary. These work to increase ovarian follicular activity.

The best next step is to order an ultrasound of the pelvis to locate the IUCD in the uterine cavity.

Once the device is located, appropriate advice can be given about the pregnancy proceeding.

Uterine sounding and hysteroscopy are contraindicated in the presence of a viable pregnancy due to risks of infection and abortion.

Pelvic X-ray is indicated if the device cannot be located during the pelvic ultrasound. It can show if the device is in the peritoneal cavity or has been expelled from the uterus. It should only be done after the pregnancy.

In cases where the device is in the peritoneal cavity, a laparoscopy is indicated for device removal.

Pregnancy termination is not indicated simply because of the presence of an intrauterine device (IUCD) in the uterus, unless other factors dictate that this is appropriate.

Adenomyosis is a disorder characterised by the presence of endometrial glands deep within the myometrium. It presents with increasing severe secondary dysmenorrhoea and increased in the flow of menstrual blood.

Most carcinomas spread primarily via lymphatic invasion. Renal cell is the exception spreading via the bloodstream.

The internal anal sphincter is innervated by pelvic splanchnic nerves

Remember patients with PCOS have elevated LH. COCPs suppress synthesis and secretion of FSH and the mid-cycle surge of LH, thus inhibiting the development of ovarian follicles and ovulation COCPs reduce hyperandrogenism as reduced LH secretion results in decreased ovarian synthesis of androgens. Furthermore they stimulate the liver to produce Sex Hormone Binding Globulin which leads to decreased circulating free androgens. Other mechanisms include reduction in adrenal androgen secretion and inhibition of peripheral conversion of testosterone to dihydrotestosterone and binding of dihydrotestosterone to androgen receptors

SPIKES protocol for delivering serious news to patients includes:
– Set the stage includes arranging for a private, comfortable setting space, introduce patient/family & team members, maintain eye contact & sit at the same level and schedule appropriate time interval & minimize space for interruptions.
– Perception: Use open-ended questions to assess the patient’s/family’s perception of the medical situation.
– Invitation: should ask patient/family how much information they would like to know and remain cognizant of their cultural, educational & religious issues.
– Knowledge:
Warn the patient/family that serious news is coming, Speak in simple & straightforward terms, stop & check whether they are understanding.
– Empathy: Express understanding & give support when responding to emotions
– Summary & strategy: Summarize & create follow-through plan, including end-of-life discussions if applicable.

The ultrasound findings of severe growth restriction, bilateral choroid plexus cysts, clenched fists, and a large ventricular septal defect are consistent with trisomy 18, the second most common autosomal trisomy, which results in fetal loss or neonatal death in the majority of cases.  In this case, the physician is to deliver a very serious news to the patient who is presenting for a routine visit, believing her pregnancy was normal.  When serious news is unexpected, it is especially important to prepare the patient and determine how the patient would like to receive the results.
The physician is supposed to provide a comfortable setting and must ask patient’s permission to share the results. This allows the patient to respond with her preference and avoids making assumptions about whom, if anyone, she would like to be present with.  For example, some patients may prefer to defer discussion of the results until a major support person (eg, husband, mother) is present. In addition to establish patient’s preferred setting, physician should determine how much information the patient would like to receive. Some patients will prefer a detailed medical information about diagnosis and prognosis, whereas others may prefer to have time to process the news emotionally and receive further information later.  The SPIKES protocol (Setting the stage, Perception, Invitation, Knowledge, Empathy, and Summary/strategy) is a six-step model that can guide physicians in delivering serious news to patients.

These statements do not allow the patient to choose how she receives the results and assume that she does not want her mother present.

This statement fails to prepare the patient for serious news and prematurely jumps to sharing results using technical, medical terminology that may be difficult for the patient to comprehend. This approach could also be upsetting to a patient undergoing a routine ultrasound who is not expecting anything abnormal.

This statement inappropriately determines when and with whom the patient should receive the results. Instead the patient should be asked how she prefers to receive the results.

While delivering unexpected, serious news, physicians should prepare the patient and determine how the patient prefers to receive the information.

Gestational trophoblastic disease (GTD) is a group of tumours defined by abnormal trophoblastic proliferation. Trophoblast cells produce human chorionic gonadotropin (hCG).

GTD is divided into hydatidiform moles (contain villi) and other trophoblastic neoplasms (lack villi). The non-molar or malignant forms of GTD are called gestational trophoblastic neoplasia (GTN).
Hydatidiform mole (HM) is associated with abnormal gametogenesis and/or fertilization. Risk factors include extremes of age, ethnicity, and a prior history of an HM which suggests a genetic basis for its aetiology.

GTD is best managed by an interprofessional team that includes nurses and pharmacists. Patients with molar pregnancies must be monitored for associated complications including hyperthyroidism, pre-eclampsia, and ovarian theca lutein cysts. Molar pregnancy induced hyperthyroidism should resolve with the evacuation of the uterus, but patients may require beta-adrenergic blocking agents before anaesthesia to reverse effects of thyroid storm. Pre-eclampsia also resolves quickly after the evacuation of the uterus. Theca lutein cysts will regress spontaneously with falling beta-HCG levels. However, patients must be counselled on signs and symptoms of ovarian torsion and ruptured ovarian cysts.

A single uterine evacuation has no significant effect on future fertility, and pregnancy outcomes in subsequent pregnancies are comparable to that of the general population, despite a slight increased risk of developing molar pregnancy again.

Luteo-placental shifts occurs around 6-8 week when the placenta takes over from the corpus luteum as the main producer of oestrogen and progesterone.

In a non pregnant adult female the cardiac output is 4.5L/min, by the 20 week of pregnancy the cardiac output increases by 40% to 6.3L/min. During early stages of labour it increases further still by 17% to 7.3L/min.

The 1st commonly presents as cephalic. Monozygotic (MZ) twins originate when a single egg is fertilized to form one zygote, which then divides into two embryos. Although they share the same genotype they are not phenotypically identical.

The most likely cause of her postcoital bleeding is cervical ectropion as suggested by her postcoital bleeding, normal pap smears and use of oral contraceptive pills.

Cervical ectropion is a benign condition that occurs as a result of overexposure to oestrogen. Here, glandular cells (the columnar epithelium) lining the endocervix, begin to grow on the ectocervix, leading to exposure of the columnar cells to the vaginal environment.

These columnar cells are prone to trauma and bleeding during coitus.

The Rubella virus, also known as German measles, is found in the Togavirus family and is a single-stranded RNA virus. The virus, which is acquired through contact with respiratory secretions, primarily replicates in the nasopharynx and lymph nodes, and produces a mild and self-limiting illness. Congenital infection, however, is associated with several anomalies including sensorineural deafness, cataracts and cardiac abnormalities.

Screening for gestational diabetes should be offered and performed between 24-28 weeks. It should be noted PCOS alone does not make screening essential. It is advised for PCOS patients who are overweight or if not overweight but has other risk factors (age >40, personal history of gestational diabetes or family history of type II diabetes). Screening is via a 2-hour post 75 g oral glucose tolerance test.

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

Stillbirth has many causes: intrapartum complications, hypertension, diabetes, infection, congenital and genetic abnormalities, placental dysfunction, and pregnancy continuing beyond forty weeks.

In 5% of normal-appearing stillborns, a chromosomal abnormality will be detectable. With an autopsy and a chromosomal study, up to 35% of stillborns are found to have a major structural pathology, and 8% have abnormal chromosomes. After a complete evaluation, term stillbirth remains unexplained about 30% of the time. The chance of finding a cause is impacted by the age of the foetus, the experience of the caregiver, and the thoroughness of the exam. Chromosome testing for aneuploidy should be offered for all stillbirths to confirm or to seek a cause of the stillbirth. Genetic amniocentesis or chorionic villus sampling before delivery offers the highest yield.

High FSH and low E2 levels would be expected in menopause. FSH levels would be raised as her body attempts to stimulate ovarian activity and E2 would be low due to reduced ovarian function. The other options would be possible if she was younger, and if occurring with amenorrhea, would warrant further hormonal tests.

It is often challenging to interpret hormone test results close to the time of menopause, especially if the woman is still experiencing irregular menstruation, as remaining ovarian follicles might still produce oestrogen, causing both bleeding and FSH suppression. Elevation of FSH then can be seen again once the oestrogen level drops. Hence, the results would be influenced by the timing of blood sample collection. Once amenorrhea occurs more consistently, it would be easier to interpret the results.

Ovarian cancer is a gynaecological cancer that commonly affects women over 40 years. Risk factors for ovarian cancer include: infertility, a family history of ovarian, breast or colorectal cancer. There are some protective factors, which include: high parity and breastfeeding, early age at menarche and late age at menopause, and combined oral contraceptives, and statins.

Methotrexate is a folic acid antagonist. It inhibits dihydrofolate reductase (DHFR). DHFR catalyses the conversion of dihydrofolate to the active tetrahydrofolate which is required for DNA synthesis. It is either administered as a single intramuscular injection or multiple fixed doses.

The case presented points to a diagnosis of an autoimmune thyroiditis leading to hypothyroidism. The most common form of autoimmune hypothyroidism, Hashimoto’s, often presents with a goitre, positive for antibody tests against thyroid components i.e. anti-TPO and anti-thyroglobulin. Graves disease and toxic diffuse goitre are more likely to cause hyperthyroidism. While De-Quervain’s and endemic goitre may cause hypothyroidism, they don’t result in positive antibody tests.

The middle rectal artery arises from the anterior division of the internal iliac artery.

Lichen sclerosis (LS) is a benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes accompanied by symptoms of pruritus and pain.

Topical corticosteroids are the mainstay of therapy. Intralesional corticosteroid therapy is an additional option that is useful for the treatment of thick hypertrophic plaques that topical corticosteroids may not penetrate adequately.

Antibiotics or antifungals have no role in the treatment of LS since it’s not an infection.
Since histological diagnosis has already been made, there is no need to refer to dermatologist.
Surgical intervention is indicated for treatment of complications like adhesion and scarring.

Trichomoniasis is considered a sexually transmitted infection found both in men and women, and is caused by the flagellate protozoan Trichomonas vaginalis. The organism is mainly found in the vagina and the urethra. Though many infected women can be asymptomatic, they can also present with yellow frothy vaginal discharge, itching and vaginitis, dysuria or an offensive odour. About 20-30% of women with the infection however are asymptomatic. For the diagnosis of t. vaginalis in women, a swab is taken from the posterior fornix during speculum examination and the flagellates are detected under light-field microscopy. The recommended treatment for t. vaginalis during pregnancy and breastfeeding is 400-500mg of metronidazole twice daily for 5 -7 days. High dose metronidazole as a 2g single dose tablet is not advised during pregnancy. All sexual partners should also be treated and screened for other STIs.

Oxytocin activates phospholipase C to produce inositol 1,4,5-trisphosphate (IP3), which releases Ca2+ from intracellular stores. There are thought to be other mechanisms by which myometrium is stimulated by Oxytocin including increased sensitisation of the myometrium and increased calcium entry into cells. cAMP and Protein Kinase A inhibit myometrial contractility.

If abnormal cells are found high up in the cervical canal, it is critical to consider doing a cone biopsy to rule out any cervical malignancy. A cone-shaped section of the cervix containing the abnormal cells is removed under general anaesthesia.
Loop Electrosurgical Excision Procedure is a way of removing the abnormal cells from the cervix using a wire loop. First a speculum is inserted to open the vagina so the uterus can be seen. Then a solution is applied to the surface of the cervix to make the areas of abnormal cells easier to see. It is done under local anaesthesia.

Cone biopsy is the only acceptable option to rule out malignancy. Cryotherapy, chemotherapy and radiotherapy are management options once malignancy has been confirmed.

Dehydroepiandrosterone (DHEA) is a steroid hormone synthesised from cholesterol (via Pregnenolone) by the adrenal glands. The foetus manufactures DHEA, which stimulates the placenta to form oestrogen, thus keeping a pregnancy going. Production of DHEA stops at birth, then begins again around age seven and peaks when a person is in their mid-20s

The nuchal lucency measurement is the measure of the nuchal pad thickness. Children with down syndrome have an increased thickness of the nuchal pad. The risk of down’s syndrome increases with maternal age. The nuchal lucency test has an accuracy rate of 70%.

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.

TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. The signs and symptoms of trichomoniasis are present in this patient. Trichomonas vaginalis is the reason.
Increased vaginal discharge that is frothy, yellowish, and has an unpleasant odour are among the symptoms. It’s frequently linked to dyspareunia and dysuria. Normally, the genital area is red and painful.

In both men and women, trichomoniasis can cause preterm labour and raise the risk of infertility. Both the patient and the partner must be treated at the same time.

The active infection can be treated with a single oral dose of metronidazole 2 g taken with food.
To avoid disulfiram-like symptoms, alcohol should be avoided during the first 24-48 hours after treatment.

DHEA is formed in the mother’s adrenal gland as well as the fetal adrenal glands. These weak androgens are transported by the blood to the placenta and are converted into oestradiol, estrone and estriol in the trophoblast.

Oxytocin is the primary stimulus for uterine involution following childbirth.

An elevation in serum PRL is associated with a variety of reproductive disorders, including amenorrhea, oligomenorrhea, anovulation and/or luteal phase defects with subsequent infertility.

The case above gives a classic presentation of preterm premature rupture of membranes(PPROM). In term or near term women rupture of membrane harbingers labor, so if ROM does not end up in established labor in 4 hours, is called as premature ROM (PROM). In other words, PROM is defined as ROM before the onset of labor and if it occurs before 37 weeks, the preferred term is PPROM. In both these scenarios treatment approach will be different.
A sudden gush of watery fluid per vagina, continuous or intermittent leakage of fluid, a sensation of wetness within the vagina or perineum are the classic presentation of rupture of the membranes(ROM), regardless of the gestational age. Pathognomonic symptoms symptoms of ROM are presence of liquor flowing from the cervical os or pooling in the posterior vaginal fornix.
PPROM is associated with many risk factors and some of them are as follows:
– Preterm labor
– Cord prolapse
– Placental abruption
– Chorioamnionitis
– Fetal pulmonary hypoplasia and other features of prematurity
– Limb positioning defects
– Perinatal mortality
Once the diagnosis is confirmed the following measures should be considered in the management plan:
a) Maternal corticosteroids
Adverse perinatal outcomes like respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis can be effectively reduced using corticosteroids. The duration of using neonatal respiratory support, in case of respiratory distress, can be significantly reduced by the administration of corticosteroids. If preterm labor is a concern in cases were gestational age is between 23•0d and 34•6d weeks or if preterm birth is planned or expected within the next 7 days corticosteroids are indicated.
Recommended regimens to the woman are IM betamethasone in two doses of 11.4 mg, given 24 hours apart and if betamethasone is unavailable, IM dexamethasone given 24 hours apart in two doses of 12 mg.
A single repeat dose of corticosteroid given seven days or more after the first dose is suggestive in cases were the gestational age is less than 32• 6d, if the woman is still considered to be at risk of preterm labor, up to 3 repeated doses can be considered.
Another option is Tocolysis using nifedipine and is indicated if the woman is in labor. This helps in cessation of labor for at least 48 hours, providing a window for corticosteroid to establish its effects. Tocolysis is not indicated in cases with absence of uterine contractions suggestive of labor.
It is appropriate to transfer this woman to a tertiary hospital after administering the first doses of corticosteroid and antibiotics. This ensures optimal neonatal care in case of premature delivery.
As the patient needs investigations and fetal monitoring along with close observation for development of any signs of infection and preterm labor, it is not appropriate to discharge this patient on oral antibiotics
Admitting to a primary care center without neonatal ICU (NICU) does no good to the outcome of this patient.

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

The best time to perform amniocentesis is at the gestational age of 15 weeks or more. There is increased risk of abortion, respiratory problems and fetal talipes if amniocentesis is performed before the gestational age of 14 weeks.

HELLP syndrome stands for haemolysis, elevated liver enzyme levels, and low platelet levels and is a very severe condition that can happen during pregnancy. Management of this condition requires immediate delivery of the baby.

The ischial spine is the anatomical landmark for assessing the station of the fetal head and also placing pudendal nerve blocks. (the pudendal nerve runs posterior to the ischial spine). The ischial spine can be palpated approximately 8cm into the vagina, at 4 and 8 o’clock.

Decreased pregnancy-associated plasma protein (PAPP-A) in the first trimester of pregnancy is an indication to carry out further diagnostic testing for Down syndrome.

Antenatal tests available for screening Down syndrome are divided into two types:
– Screening tests includes maternal serum screening and ultrasound which are safe to conduct with relatively low predictive values.
– Diagnostic tests like chorionic villous sampling and amniocentesis are confirmative but carries higher risk of miscarriage as 1 in 100 and 1 in 200 respectively.

a) Serum screening tests for Down syndrome during first-trimester includes:
1. Pregnancy-associated plasma protein (PAPP-A) will be decreased in case of Down syndrome.
2. Free ß-human chorionic gonadotropin (HCG) will be increased in cases of Down syndrome.
If these screening tests are combined with first-trimester ultrasound nuchal translucency, it is found to be more accurate than doing only one of these tests.

b) Second-trimester serum screening tests for identifying Down syndrome:
1.Alpha-fetoprotein will be decreased.
2.Unconjugated oestriol will be decreased.
3.Free ß-HCG will be increased
4.Inhibin A will be increased.
These tests combined with maternal age and ultrasound results will provide more accurate predictive values.