The incubation period of CMV is 3-12 weeks.

Promethazine or Cyclizine are 1st choice options for management of nausea and vomiting in pregnancy according to NICE. Prochlorperazine is also appropriate 1st line.

Breakthrough bleeding, breast tenderness, nausea, bloating, amenorrhea, hypertension, venous thromboembolic disease, increased risk of cervical cancer with decreased risk of ovarian & endometrial cancer, liver disorders like hepatic adenoma and increase in triglycerides due to estrogen component are the common side effects & risks of using combination oral contraceptives.

Patient in the given case mentioned symptoms of primary dysmenorrhea, which is recurrent lower abdominal pain associated with menstruation. Combination estrogen-progestin oral contraceptive pills (OCPs) are considered as the first-line treatment for dysmenorrhea in sexually active patients as OCPs help to reduce pain by thinning the endometrial lining, reducing prostaglandin release and by decreasing uterine contractions.
Nausea, bloating and breast tenderness, are considered as the early side effects of OCPs and will usually improve with continued use. The most common side effect is breakthrough bleeding which is usually associated with lower estrogen doses and other adverse effects caused by the pills include hypertension, increased risk of cervical cancer and venous thromboembolism. Although common perception considers weight gain as a side effect, several studies have shown that no significant weight gain is associated with OCPs, particularly with low-dose formulations.  Considering this, the patient should be reassured that her weight gain is not associated with regular use of OCPs.

In patients who are not sexually active, nonsteroidal anti-inflammatory drugs are considered as the first-line treatment for primary dysmenorrhea. As stopping contraception will increase this Patient’s risk of unintended pregnancy this is not advisable to her.

Switching the patient to a copper intrauterine device (IUD) will decrease systemic side effects, but as its inflammatory reaction in the uterus may increase pain symptoms, copper IUD is not recommended for patients with dysmenorrhea.

As Medroxyprogesterone will increase body fat and decrease lean muscle mass resulting in weight gain is not a good option for this patient. Also medroxyprogesterone due to its risk of significant loss of bone mineral density, is not recommended for adolescents or young women. So it can be used in this age group only if other options are unacceptable.

Presence of estrogen component is the main reason behind the side effects of combination OCPs. Progesterone-only pills have relatively fewer side effects but as they do not inhibit ovulation, they are less effective for treating dysmenorrhea and for contraception.

Combination oral contraceptive pills are the first-line therapy for primary dysmenorrhea in sexually active patients.  Its side effects include breakthrough bleeding, hypertension, and increased risk of venous thromboembolism. Researches proves that weight gain is usually not an adverse effect of OCPs.

A sample for fetal blood pH can be taken during the labour. The mother should be lying in a left lateral position.

Prolactin levels rise steadily during pregnancy during which time it promotes mammary growth (along with the other hormones mentioned below). Oestrogen and progesterone inhibit lactogenesis and it is only with the loss of these placental steroid hormones at term that Prolactin exhibits its lactogenic effect.

The gestational sac is typically visible from 31 days gestation by transvaginal ultrasound and a week later (38 days) on transabdominal ultrasound.

In the management of a miscarriage, after the completion of 7-14 days of expectant management, the woman is advised to take a pregnancy test after 3 weeks. In case of a positive result she is to return for further care.

The luteinizing hormone (LH) surge during ovulation causes: Increases cAMP resulting in increased progesterone and PGF2 production PGF2 causes contraction of theca externa smooth muscle cells resulting in rupture of the mature oocyte

1st Arch = Trigeminal V2 & V3 (CN V) 2nd Arch = Facial (CN VII) 3rd Arch = Glossopharyngeal (CN IX) 4th and 6th Arches = Vagus (CN X)

Vascular spiders or angiomas, are of no clinical significance during pregnancy as these are common findings and are form as a result of hyperestrogenemia associated with normal pregnancies. These angiomas, as they will resolve spontaneously after delivery, does not require any additional workup or treatment.
Reassurance to the patient is all that is required in this case.

Rhesus positive mothers should not get anti-D. They have Rhesus antigens and the anti-D would result in maternal blood being bound and removed from her circulation. The danger is to children born to mothers who are rhesus negative. As the mother may develop antibodies against Rhesus positive fetal blood. Therefore if the baby is Rhesus negative then there is no risk of alloimmunisation (sensitisation)

OCPs which contain oestrogen and progesterone are contraindicated in women who have migraines associated with a neurological deficit or aura (pins and needles in this case). In such cases, the alternative would be Implanon (etonogestrel), however, there are mixed reviews and opinions regarding whether or not there is a decreased efficacy in heavier women. The absolute contraindication for Implanon is active breast cancer. Therefore, the best advice for her case would be some form of barrier contraceptive.

When choosing a COCP (combined oral contraceptive pill), it is recommended that a formulation containing 20-30ug of ethinyl oestradiol is chosen. The progestogen part is responsible for prevention of conception and can be norgestrel or any other progestogens although the formulations containing norgestrel tend to be cheaper than more novel progestins such as cyproterone acetate as well as drospirenone. If the patient is known to have issues with excessive fluid retention, OCPs that has drospirenone would be the most suitable. However, if the patient is suspected to have PCOS, the best choice would be one that contains cyproterone acetate.

Pelvic inflammatory disease (PID) refers to acute and subclinical infection of the upper genital tract in women, involving any or all of the uterus, fallopian tubes, and ovaries; this is often accompanied by involvement of the neighbouring pelvic organs. It results in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or tubo-ovarian abscess.

Lower abdominal pain is the cardinal presenting symptom in women with PID. The abdominal pain is usually bilateral and rarely of more than two weeks’ duration. The character of the pain is variable, and in some cases, may be quite subtle. The recent onset of pain that worsens during coitus or with jarring movement may be the only presenting symptom of PID. The onset of pain during or shortly after menses is particularly suggestive.

Other non-specific complaints include urinary frequency and abnormal vaginal discharge.

Ovarian cyst, uterine leiomyoma, appendicitis or ectopic pregnancy do not present with fever and vaginal discharge although tenderness is noted in appendicitis and ectopic pregnancy. Therefore, these options do not explain the patient’s symptoms.

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.

Phosphate and ammonia are the major urinary buffers

Immediate treatment for infants with suspected meconium aspiration syndrome is to clear/suction the airway. Intubation and tracheal toileting have remained a matter of debate till the most recent times. All neonates at risk of MAS who show respiratory distress should be admitted to a neonatal intensive care unit and monitored closely. The treatment is mainly supportive and aims to correct hypoxemia and acidosis with the maintenance of optimal temperature and blood pressure.

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.

Functional closure of the ductus arteriosus is neonates is completed within the first few days after birth. It normally occurs by the 12th postnatal week. It has been suggested that persistent patency of DA results from a failure of the TGF-B induction after birth. Due to increased arterial pO2, constriction of the DA occurs. In addition to this on inflation the bradykinin system is activated with cause the smooth muscles in the DA to constrict. A decrease in the E2 prostaglandin is also an important factor as raised levels have been indicated in keeping the patency of the DA.

ALP can rise to up to 3 times the normal non-pregnant value in the 3rd trimester. All of the other tests above typically decrease during pregnancy.

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

Raised pressure with the pelvis can cause a number of nerve entrapment syndromes. This is entrapment of the lateral cutaneous nerve of the thigh (or lateral femoral cutaneous nerve) also known as Meralgia Paraesthetica. Pregnancy is a risk factor. Shingles can effect this nerve but the rash would usually present itself within 14days.

This patient meets the diagnostic criteria for premenstrual syndrome.
Affective and somatic symptoms over the five days before menses in each of the three previous menstrual cycles are diagnostic criteria for premenstrual syndrome.
Affective symptoms include:
– Depression.
– Anger outbursts.
– Irritability.
– Anxiety.
– Confusion.
– social withdrawal.
Somatic symptoms include:
– breast tenderness
– abdominal bloating
– headache and swelling of extremities.
Symptoms normally disappear within four days of menstruation and are present even when no medical therapy, drugs, or alcohol are used.

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome marked by intense melancholy, emotional lability with frequent crying, loss of interest in daily activities, reduced focus, exhaustion, sleeplessness, and a sense of being overwhelmed or out of control.
Symptoms must have been present for the majority of the previous 12 months, interfering with daily activities.

The diagnoses of generalised anxiety disorder and depression alone are doubtful.

The juxtaglomerular apparatus is the main site for the production of renin. It plays an important role in the regulation of the blood pressure. These structures are mainly located in the cortex of the kidneys.

In early pregnancy Progesterone is produced by the corpus luteum.. This organ is fundamental for pregnancy maintenance until the placenta (syncytiotrophoblast) takes over its function at the 7-9th week of gestation, just after the expression of major histocompatibility complex antigens is suppressed in extra-embryonic fetal tissue.

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

Human Papillomavirus has been is implicated in the development of genital warts as well as, head and neck, anogenital and cervical cancers, with the most important high-risk strains being 16 and 18. Over 50% of women worldwide are thought to possess antibodies against various strains of HPV after natural infection. Many infections are asymptomatic and are cleared within 2 years. Several vaccines have been formulated against HPV, one of which is Gardasil, a quadrivalent vaccine against HPV types 6,11, 16,18.

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.

Pain upon movement of the cervix with the health care provider’s gloved fingers is suggestive of an inflammatory process of the pelvic organs. CMT, when present, is classically found on bimanual examination of the cervix and uterus. While CMT is often associated with pelvic inflammatory disease, it can be present in other disease entities such as ectopic pregnancy, endometriosis, ovarian torsion, appendicitis, and perforated abdominal viscus.

PID is not a singular disease entity but describes a spectrum of disease. It is an upper genital tract infection, which may affect the uterus, fallopian tubes, ovaries, and peritoneum. PID can begin as cervicitis, progress to endometritis, followed by involvement of the fallopian tubes as pyosalpinx, and ultimately involve the ovary as a tubo-ovarian abscess (TOA). The two most common causative pathogens are N. gonorrhoeae and C. trachomatis although the infection is often polymicrobial.

Documentation of infection with either of these two organisms must be done by cervical swabs for culture.

Transvaginal ultrasound or CT scan can be done to confirm diagnosis however the absence of findings in these investigations doesn’t rule out the possibility of PID.

Urinalysis can be done to exclude urinary tract infection, one of the possible differential diagnosis for PID.

Thyroid stimulating hormone has no role in the diagnosis of PID.

Tetracycline is classified as a broad spectrum antibiotic. It is a bacteriostatic inhibitor of protein synthesis acting at the ribosomal level. Tetracycline binds to the 30s ribosomal subunit preventing the binding of the aminoacidic charged T-RNA to the ribosome-mRNA complex.

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

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

TORCH infections are responsible for perinatal complications. CMV is the most common amongst them. Primary infection often produces no symptoms or mild non-specific flu-like symptoms in the mother. The diagnosis is often made after abnormalities are seen in the foetus on ultrasound scan. The main features seen in an affected foetus are FGR, microcephaly, ventriculomegaly, ascites or hydrops. Some foetuses which are infected may not show any features on ultrasound, but may later be found to have neurological damage such as blindness, deafness or developmental delay. The neonate can also be anaemic and thrombocytopenic, with hepatosplenomegaly, jaundice and a purpureal rash.

Reported cure rates for an episode of acute BV vary but have been estimated to be between 70% and 80%. Unfortunately, more than 50% of BV cases will recur at least once within the following 12 months. Because the aetiology of BV is still not entirely understood, identifying the cause of recurrent cases is challenging. Reinfection may play a role in explaining recurrent BV, but
treatment failure is a more likely contributor. There are several theories that try to explain recurrence and persistent symptoms. The existence of a biofilm in the vagina is one such theory and is the subject of ongoing research. Biofilms occur when microorganisms adhere to surfaces. G vaginalis, one of the primary organisms

BV is not a sexually transmitted infection. The antibiotic of choice to treat BV is Metronidazole. Reassurance is not acceptable as a means of treatment.

Cholesterol is the common precursor for progesterone and androgen production.

Vitamin B1 deficiency can lead to Wernicke’s encephalopathy. Alcoholics are at particular risk. In obstetrics all women with hyperemesis gravidarum should receive thiamine supplementation to prevent Wernicke’s.

The risks of breast and cervical cancers are increased in women who use oral contraceptives, whereas the risks of endometrial, ovarian, and colorectal cancers are reduced.

Women who have used oral contraceptives for 5 or more years have a higher risk of cervical cancer than women who have never used oral contraceptives. The longer a woman uses oral contraceptives, the greater the increase in her risk of cervical cancer.

One study found a 10% increased risk for less than 5 years of use, a 60% increased risk with 5–9 years of use, and a doubling of the risk with 10 or more years of use. However, the risk of cervical cancer has been found to decline over time after women stop using oral contraceptives.

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

Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity include inhibition of trophoblastic function and differentiation, activation of complement pathways at the maternal–fetal interface, resulting in a local inflammatory response and, in later pregnancy, thrombosis of the uteroplacental vasculature. This patient should be offered referral to a specialist clinic as she has had recurrent miscarriages. Low dose aspirin is one of the treatment options to prevent further miscarriage for patients with antiphospholipid syndrome.

A brow presentation in a nulliparous woman is associated with high risk of obstructed labour and the need for delivery by Caesarean section.

Brow presentation occurs when the presenting part of the fetal head is the part between the orbital ridge and anterior fontanelle.

In multiparous women, the indications differ as vaginal manipulation or spontaneous flexion to a vertex presentation or extension to a face presentation can occur after full cervical dilatation.

Early fetal heart decelerations are indicative of a mild abnormality on cardiotocograph (CTG). It does not indicate obstructive labour or need for delivery by Caesarean section.

The slow descent of the fetal head can be controlled subsequently by good uterine contractions and allow for vaginal birth.

Prolonged labour can cause maternal fever, but that in isolation is not an indication for Caesarean section.

Caput and head moulding are associated with a ‘tight fit’ of the fetal head in the pelvis, but does not contraindicate vaginal birth.

Streptococcus pyogenes, also known as group A beta-haemolytic streptococcus, is the organism responsible for scarlet fever. The bacteria is found in secretions from the nose, ears or the skin, and infections may be preceded by wounds, burns or respiratory infections. Symptoms may include a sore throat, fever, a red skin rash and cervical lymphadenopathy. Untreated scarlet fever in children and adolescents can lead to rheumatic fever, or post-streptococcal glomerulonephritis.

Endometriosis is defined as the presence of normal endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Approximately 30-40% of women with endometriosis will be sub fertile. About one third of women with endometriosis remain asymptomatic. When they do occur, symptoms, such as the following, typically reflect the area of involvement:
– Dysmenorrhea
– Heavy or irregular bleeding
– Pelvic pain
– Lower abdominal or back pain
– Dyspareunia
– Dyschezia (pain on defecation) – Often with cycles of diarrhoea and constipation
– Bloating, nausea, and vomiting
– Inguinal pain
– Pain on micturition and/or urinary frequency
– Pain during exercise

Pregnancy, appendicitis, ureteral colic and ruptured ectopic pregnancy all do not present with dysmenorrhea, pain on defecation and dyspareunia. Presence of a non tender, soft abdomen also rules out these conditions.