AFI involves measuring the depth of amniotic fluid pockets in all 4 quadrants.
Oligohydramnios AFI< 5cm or deepest amniotic fluid pocket < 2cm
Polyhydramnios AFI > 25cm or deepest amniotic fluid pocket > 8cm

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).

There are four types pelvic shapes:
1) Android pelvis: it has a larger inlet and smaller outlet along with small posterior sagittal diameter, prominent ischial spines and has a two finger arch.
2) Gynecoid pelvis: it has a transverse or nearly a circular ellipse and it is the most favourable for delivery.
3) Anthropoid pelvis: the brim is an anteroposterior ellipse.
4) Platypelloid pelvis: in this type the pelvic brim is kidney shape

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

Significant puerperal pyrexia is defined as a temperature of 38ºC or higher on any two of the first 10 days postpartum, exclusive of the first 24 hours. A mixed flora normally colonizes the vagina with low virulence. Puerperal infection is usually polymicrobial and involves contaminants from the bowel that colonize the perineum and lower genital tract. Following delivery, natural barriers to infection are temporarily removed and therefore organisms with a pathogenic potential can ascend from the lower genital tract into the uterine cavity. Placental separation exposes a large raw area equivalent to an open wound, and retained products of conception and blood clots within the uterus can provide an excellent culture medium for infection.

Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity.

Although acyclovir should be given, this patient is in the 3rd trimester so the course should continue until delivery. Dose will be 400mg TDS unless disseminated disease. If this is a primary HSV infection (This should be confirmed by lesion swabs to confirm HSV infection and bloods to check no antibody response i.e. evidence previous infection) then C-section is indicated.

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.

Chromosomal abnormalities are the most common cause of first trimester miscarriage and are detected in 50-85% of pregnancy tissue specimens after spontaneous miscarriage.

Precocious puberty can be defined as secondary sexual characteristics that occur before the age of 8 years in females and 9 years in males. In 80-90% of individuals it is idiopathic. Other causes include CNS anomalies and tumours, increased exposure to sex hormones/steroids, pituitary gonadotrophin secreting tumours and ovarian tumours etc.

Acute fatty liver of pregnancy occurs in 1-10000 pregnancies and presents as jaundice with abdominal pain. The maternal mortality is around 20%

The aim of pre-pregnancy counselling is to achieve the best possible glycaemic control before pregnancy and to educate diabetic women about the implications of pregnancy. Patient information leaflets about pregnancy should make clear the risks of pregnancy in diabetes, and include advice to take high dose (5 mg) folic acid pre-conception and for the first 12 weeks.

Most types of HRT increase the risk of breast cancer. But the risk is higher for those using combined HRT, which uses both oestrogen and progestogen. Vaginal oestrogens are not linked to an increased risk of breast cancer, whereas tibolone is. Taking HRT for 1 year or less only slightly increases breast cancer risk. However, the longer you take HRT the greater the risks are, and the longer they last.

Evidence is insufficient to conclude that long-term oestrogen therapy or hormone therapy use improves cardiovascular outcomes.

HRT containing oestrogen alone increases risk of endometrial cancer. However, this is not the case when using combined HRT.

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 chorionic plate represents the fetal surface of the placenta, which in turn is covered by the amnion. The amnion is composed of a single layered epithelium and the amnionic mesenchyme, an avascular connective tissue. The amnionic mesenchyme is only weakly attached to the chorionic mesenchyme and can easily be removed from the delivered placenta. The chorionic mesenchyme contains the chorionic vessels that are continuous with the vessels of the umbilical cord. Within the mesoderm of secondary villi, haematopoietic progenitor cells develop and start to differentiate. At about day 20 post-conception, first placental blood cells and endothelial cells develop independent of the vascular system of the embryo proper.13 14 The development of first placental vessels transforms the respective villi into tertiary villi.

The contents of the inguinal canal is the ilioinguinal nerves, the round ligament of uterus in the females and the spermatic cord with its contents in males.

There are 3 stages of labour. The 1st stage of labour starts from labour contractions till the time the cervix is fully dilated. Stage 2 is from complete cervical dilatation until the baby is born. The 3rd stage is from the birth of the baby, until the time the placenta is expelled.

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.

According to the Royal College of Obstetrics and Gynaecology guidelines for abortion care it advises dual antibiotic regimes for antibiotic prophylaxis.
Metronidazole 1g per rectum or 800 mg orally can be given before or at the time of the abortion in women who have tested negative for Chlamydia trachomatis infection.

Alternatively, Doxycycline (100mg oral, twice daily for 7 days) or Azithromycin 1g stat doses should be given in addition to metronidazole to be effective against Chlamydia trachomatis anaerobes.

Hyaline degeneration is the most common form of fibroid degeneration. Fibroids:
Risk Factors
– Black Ethnicity
– Obesity
– Early Puberty
– Increasing age (from puberty until menopause)
Protective Factors
– Pregnancy
– Multiparity

Desogestrel only POPs work mainly by inhibiting ovulation. Cerazette Is the only brand in this list which belongs to this group.

Types of Progesterone Only Pills

1. Traditional (e.g. Femulen®, Micronor®, Norgeston®)

Main mode of action: thickening cervical mucus preventing sperm entry at neck of womb and may also cause anovulation but this effect variable and unreliable

2. Desogestrel (e.g. Cerazette®)

Main mode of action: inhibition of ovulation and also cause thickening of cervical mucus

Dysplasia has 4 microscopic characteristics:
Anisocytosis (unequal cell size)
Poikilocytosis (abnormal cell shape)
Hyperchromatism (pigmentation)
Mitotic figures (increased cells currently dividing)

Hyperplasia and hypertrophy is characterised by increase in cell number and increase in cell size respectively, whereas atrophy means decrease in cell size.
Metaplasia is characterised by change of one form of cell to another type e.g. changes of columnar epithelium to squamous epithelium.

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.

Testing for GD should use the 2 hour 75g oral glucose tolerance test (OGTT) to test for GD in women. Testing women who have had GD in a previous pregnancy: early self monitoring of blood glucose OR a 75 g 2 hour OGTT as soon as possible after booking (whether in the first or second trimester) and a further 75 g 2hour OGTT at 24-28 weeks if the results of the first OGTT are normal. Testing women with risk factors for GD: 75g 2 hour OGTT at 24-28 weeks

Monitoring after treatment for HSIL includes:
– colposcopy and cervical cytology at 4 to 6 months followed by HPV typing at 12 months and annually until a negative test is obtained on 2 subsequent check ups.
-2 yearly screening interval can be done afterwards.

This patient has a regular and long menstrual period. The most crucial thing in this case is to rule out anovulation.
Serum progesterone concentration is the best test for detecting ovulation.
Ovulation has occurred if the level is greater than 20nmol/L.
This test should be performed 3 to 10 days prior to the start of the next anticipated period.

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.

The contents of the broad ligament:
Fallopian tubes
Ovarian artery
Uterine artery
Ovarian ligament
Round ligament of uterus

The ultrasound used a frequency of 3.5-7 MHz emitted from a transducer.

This is typical appearance of molar pregnancy. This used to be referred to as ‘snowstorm sign’ as with older poorer resolution ultrasound the anechoic species looked like a snowstorm.

Pregnancy is considered as a hypercoagulable state with an increased risk for the development of conditions like deep venous thrombosis (DVT) and pulmonary embolism (PE). Among these two PE is the considered the most significant cause for maternal death in Australia.
A pregnant women with venous thromboembolism should be treated with heparin as warfarin is contraindicated. Warfarin should be avoided throughout pregnancy and especially during the first and third trimesters of pregnancy as it crosses the placenta. Intake of warfarin at 6-12 weeks of pregnancy can results in fetal warfarin syndrome which is characterised by:
– A characteristic nasal hypoplasia
– Short fingers with hypoplastic nails
– Calcified epiphyses, namely chondrodysplasia punctuta which is evident by stippling of epiphyses on X-ray.
– Intellectual disability
– Low birth weight
Recent studies show that the risk of fetal warfarin syndrome is around 5 % more in babies of women who require warfarin throughout pregnancy and the risk is always dose dependent.
Later exposure to warfarin, as in after 12 weeks, is mostly associated with central nervous system anomalies like microcephaly, hydrocephalus, agenesis of corpus callosum, Dandy-Walker malformation which is characterised by complete absence of cerebellar vermis along with enlarged fourth ventricle and mental retardation. Eye anomalies such as optic atrophy, microphthalmia, and Peter anomaly which is the dysgenesis of the anterior segment are also found in association. Newborns exposed to warfarin in all three trimesters are prone to present with blindness. Other complications found in neonates exposed to warfarin are perinatal intracranial hemorrhage and other major bleeding episodes.

Warfarin is not secreted into the breast milk and is so safe to use during the postpartum period.

Only little volumes of urine are lost when her intra-abdominal pressure is elevated during coughing, laughing, jumping, and straining, which is the only symptom associated with real stress incontinence.
The other reactions are significantly more compatible with a detrusor instability diagnosis (also called urge incontinence).
If she had incontinence throughout pregnancy, it would have been stress in nature, which is what her current incontinence is.

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.

Urethral syndrome is characterized by dysuria and pyuria in the presence of a negative culture for uropathogens. Frequency and urgency are often absent. The infecting organism is typically Chlamydia trachomatis although other organisms such as Urea plasma urealyticum and Mycoplasma species may be involve- Effective medication choices include doxycycline, ofloxacin, levofloxacin, and macrolides such as erythromycin and azithromycin.

-Amoxicillin
lavulanate  and cephalexin  are incorrect. These would cover gram-positive bacteria but it would not cover gram-negative bacteria nor bacteria without a cell wall, which are the most common causes of this condition.
– Metronidazole is best for treating anaerobic infections and protozoa such as trichomonas vaginalis, it would not be the best for treating this condition, given the most likely causes.
-Pyridium is a phenazopyridine often used to alleviate the pain, irritation, discomfort, or urgency caused by urinary tract infections. While it would be beneficial for symptomatic relief, it is unlikely to completely resolve this patient’s condition, given her recent history.

Despite the fact that this question includes many true-false options, the knowledge examined is particularly essential in the treatment of women who have genital herpes.
It answers many of the questions that such women have regarding the disease, how it spreads, how it may be controlled, and how it affects an unborn or recently born child.
All of these issues must be addressed in a counselling question.
Currently, the most prevalent type of genital herpes is type 1, while in the past, type 2 was more common, as confirmed by serology testing.
Type 2 illness is nearly always contracted through sexual contact, but it can go undetected for years.
Acyclovir can be taken during pregnancy, and there are particular reasons for its usage.
Neonatal herpes is most usually diagnosed when the newborn has no cutaneous lesions, and past genital herpes in the mother is protective against neonatal infection, although not always.
Where the genital infection is the initial sign of the disease rather than a relapse of earlier disease, neonatal herpes is far more frequent.
Many patients and doctors are unaware that, while the original infection might be deadly, it is usually asymptomatic.
This explains how the illness spreads between sexual partners when neither has had any previous symptoms of the disease.

Toxoplasma gondii is a protozoan parasite found in cat faeces, soil or uncooked meat. Infection occurs by ingestion of the parasite from undercooked meat or from unwashed hands. Spiramycin treatment can be used in pregnancy (a 3-week course of 2–3 g per day). This reduces the incidence of transplacental infection but has not been shown to definitively reduce the incidence of clinical congenital disease. If toxoplasmosis is found to be the cause of abnormalities detected on ultrasound scan of the foetus, then termination of pregnancy can be offered.

Gardnerella vaginalis is one of the bacteria implicated in the development of bacterial vaginosis , many women (>50%) with this vaginal infection have no signs or symptoms, when these are present they are most often :
Vaginal discharge, grey, white or green, with a strong unpleasant odour
Strong vaginal odour and fishy smell after sex
Vaginal itching
Burning during urination
Vaginal bleeding after sex
Gardnerella vaginalis can also be responsible for serious infections (sepsis, wound infections) in locations other than those associated with the genital tract or obstetrics, these cases are very rare but have been reported, including in men.

Mycoplasma Hominis is one of the organisms involved in the pathogenesis of BV but it appears normal on wet mount.

Candida presents with white cottage cheese like discharge.

Chlamydia is not seen on wet mount and produces clear vaginal discharge.

Trichomonas shows clue cells on wet mount.

The anal sphincters are responsible for closing the anal canal to the passage of faeces and flatus. The smooth muscle or involuntary internal sphincter sustains contraction to prevent the leakage of faeces between bowel movements and is innervated by the pelvic splanchnic nerves, which are a branch of the spinal segment 4. The external sphincter is made up of skeletal muscle and can therefore contract and relax voluntarily. Its innervation comes from the inferior rectal branch of the pudendal nerve, and the perineal branch of S4 nerve roots.

A pH value below than 7.18 indicates acidosis which can result in hypoxic brain injury. In order to prevent brain injury, immediate delivery of the foetus should be planned. The normal range for a term baby is pH: 7.18 – 7.38, preterm pH: 7.14 – 7.4.

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

Endometriosis is found in about one-third of women undergoing laparoscopy for chronic pelvic pain. Published studies show a diagnostic delay of 8.5 years from onset of symptoms to the eventual diagnosis of endometriosis!

This means that women can suffer for 8.5 years before a diagnosis of endometriosis is made, and appropriate interventions are carried out.

All other options are true statements about endometriosis.

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.

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.

Engagement means when the fetal head enters the pelvic brim/inlet and it usually takes place 2 weeks before the estimated delivery date i.e. at 38 weeks of pregnancy.

B-HCG levels almost double every 48 hours. A B-HCG levels of less than 5 mIU/ml is considered negative and anything above 25 is considered positive. As the foetus was not visualized on ultrasound in the uterus, there is possibility that this might be an ectopic pregnancy. But since the B-HCG levels also continued to fall the pregnancy becomes non-viable.

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.

There are no interactions between the combined oral contraceptive pill, progesterone-only pill, medroxyprogesterone injections or levonorgestrel implants and the AEDs valproic acid (sodium valproate), vigabatrin, lamotrigine, gabapentin, tiagabine, levetiracetam, zonisamide, ethosuximide and the benzodiazepines. So she can use COCP along with Sodium valproate.

An ultrasound of the foetal spine at 16-18 weeks of gestation is the most appropriate assessment (correct answer).

Ultrasound performed at 11-12 weeks of gestation can diagnose anencephaly, another neural tube defect, however; any vertebral column defect is unlikely to be detected.

In most cases of neural tube defects in the foetus, elevations will be noted in maternal alpha-fetoprotein levels at 12 to 15 weeks. However, it may not be possible to detect all such abnormalities and a confirmed diagnosis cannot be made.

Additionally, elevations in alpha-fetoprotein levels do not always correlate to the presence of foetal neural tube defects.

Nuchal translucency scans do not detect neural tube defects. They are performed to identify the risk of chromosomal abnormalities in the foetus.

Polycystic ovary syndrome (PCOS) is a condition in which the ovaries produce an abnormal amount of androgens, male sex hormones that are usually present in women in small amounts. The name polycystic ovary syndrome describes the numerous small cysts (fluid-filled sacs) that form in the ovaries. However, some women with this disorder do not have cysts, while some women without the disorder do develop cysts.

The symptoms of PCOS may include:
– Missed periods, irregular periods, or very light periods
– Ovaries that are large or have many cysts
– Excess body hair, including the chest, stomach, and back (hirsutism)
– Weight gain, especially around the belly (abdomen)
– Acne or oily skin
– Male-pattern baldness or thinning hair
– Infertility
– Small pieces of excess skin on the neck or armpits (skin tags)
– Dark or thick skin patches on the back of the neck, in the armpits, and under the breasts

The so-called Laurence-Moon-Biedl syndrome is a fairly rare condition characterized by six cardinal signs, namely obesity, atypical retinitis pigmentosa, mental deficiency, genital dystrophy, polydactylism and familial occurrence.

Froehlich syndrome is characterized by increased or excessive eating that leads to obesity, small testes, and a delay in the onset of puberty. It is also common for children with Froehlich syndrome to experience the delay in physical growth and the development of secondary sexual characteristics.

Cushing’s syndrome is a disorder that occurs when your body makes too much of the hormone cortisol over a long period of time. Cortisol is sometimes called the “stress hormone” because it helps your body respond to stress. Cortisol also helps. maintain blood pressure. regulate blood glucose, also called blood sugar.

Pseudohypoparathyroidism is characterized by short stature, a round face, short neck, and shortened bones in the hands and feet. Intelligence usually ranges from low normal to mentally retarded. Headaches, weakness, tiring easily, lethargy, cataracts and blurred vision or hypersensitivity to light may also be present.
This patient’s condition can only be explained by PCOS.

Placenta previa typically presents with painless bright red vaginal bleeding usually in the second to third trimester. Although it’s a condition that sometimes resolves by itself, bleeding may result in serious complications for the mother and the baby and so it should be managed as soon as possible.

Maternal exposure to dietary factors during pregnancy can influence embryonic development and may modulate the phenotype of offspring through epigenetic programming. Folate is critical for nucleotide synthesis, and preconceptional intake of dietary folic acid (FA) is credited with reduced incidences of neural tube defects in infants.

This infant will most likely be diagnosed as having fetal hydantoin syndrome, which occurs due to an in utero exposure to antiepileptic drugs like phenytoin, carbamazepine, valproate etc. 

Multiple antiepileptics, due to their ability to cross placenta, have teratogenic effects which will result in low folate and high oxidative metabolite levels in the fetus. This likely combined effect results deformities like cleft lip and palate, wide anterior fontanelle, distal phalangeal hypoplasia and cardiac anomalies like pulmonary stenosis, aortic stenosis etc in the fetus. There will be developmental delay and poor cognitive outcomes as a result of neural tube defects and microcephaly associated with this. Therefore, prior to conception, those patients who require antiepileptics for seizure control during pregnancy should titrate it to the lowest dose and must started on high-dose (4 mg) folic acid supplementation to minimize the risk of such congenital malformations.

Fetal alcohol syndrome commonly presents with microcephaly and midfacial hypoplasia, but is not association with cleft lip or palate.

Cocaine use during pregnancy can be associated with preterm delivery, abruptio placentae and fetal growth restriction; but there is no evidence to prove its association with congenital defects.

Fetal renal failure with associated oligohydramnios that results in pulmonary hypoplasia, growth restriction, and limb defects are the complications associated with the use of lisinopril and other angiotensin-converting enzyme inhibitors during pregnancy; but it does not cause cleft lip or palate.

Most infants with congenital syphilis are asymptomatic at birth and those with symptoms typically have rhinitis or “snuffles, hepatomegaly and a maculopapular rash none of which are seen in this patient.

Fetal hydantoin syndrome results from the in-utero exposure to antiepileptic drugs like phenytoin, carbamazepine etc and is usually presented with microcephaly, a wide anterior fontanelle, cleft lip and palate, and distal phalangeal hypoplasia.

After ovulation, the dominant follicle turns into a corpus luteum and begins to secrete progesterone. To confirm ovulation, serum progesterone or its metabolite in urine, can be measured. A single serum progesterone level >3 ng/ml in mid‐luteal phase has been used to retrospectively detect ovulation.

The incidence of monozygotic twins is constant worldwide (approximately 4 per 1000 births). Approximately two thirds of twins are dizygotic.

Wound healing typically undergoes different stages that include haemostasis, inflammation, proliferation and remodelling. The phases are often shortened when healing occurs by primary intention such as in a surgical wound. Remodelling, which is the major strengthening phase, takes about 3 weeks, while it takes a total of 12 weeks to reach maximum tensile strength.

Rheumatoid arthritis and its prognosis during pregnancy are highly unpredictable, as the disease can improve in 75% of the cases and gets worse in 25%. During conception and pregnancy, it is advisable to avoid those rheumatoid arthritis medications which possess high risk in causing congenital disabilities. Most common such contraindicated remedies include methotrexate and leflunomide.
Drugs like Prednisone, Non-steroidal anti-inflammatory drugs and TNF inhibitors are also not considered safe during pregnancy, so if required these should be used under specialist supervision.

Sulfasalazine and Antimalarials such as hydroxychloroquine are safe and can be used without much complications during pregnancy. In this given case, the patient should be advised to stop methotrexate and to continue sulfasalazine during pregnancy.

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.

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.

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)

The normal fetal heart rate is between 110-150 bpm.

The neck of the bladder is surrounded by the internal sphincter. It is supplied by the sympathetic and parasympathetic nerves of the splanchnic nerve. Parasympathetic stimulation causes the detrusor muscle to contract and the internal urethral sphincter to relax. It Is predominantly by the parasympathetic nerves S2-S4. Relaxation of the bladder is caused by inhibiting the sacral parasympathetic preganglionic neurons and exciting the lumbar sympathetic preganglionic neurons. Remember SYMPATHETIC is for STORAGE and PARASYMPATHETIC is for PEEING.

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

Warfarin inhibits Vitamin K dependent clotting factors. These include factors 2,7,9 and 10.

The number of stillbirths and deaths in the first week of life per 1000 births.
According to WHO the perinatal period commences at 22 completed weeks (154 days) of gestation and ends seven completed days after birth.

This patient with a previous history of pre-eclampsia and obesity is at high risk for developing pre-eclampsia.

A daily intake of 1000mg of calcium is observed to be helpful in reducing the incidence of any hypertensive disorders and preterm labour.

Vitamin A should always be avoided during pregnancy as it is fetotoxic.

All other options are incorrect.

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.

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.

Pyelonephritis is the most common serious medical problem that complicates pregnancy. Infection is more common after midpregnancy, and is usually caused by bacteria ascending from the lower tract. Escheria coli is the offending bacteria in approximately 75% of cases. About 15% of women with acute pyelonephritis are bacteraemia- A common finding is thermoregulatory instability, with very high spiking fevers sometimes followed by hypothermia- Almost 95% of women will be afebrile by 72 hours. However, it is common to see continued fever spikes up until that time- Thus, further evaluation is not indicated unless clinical improvement at 48-71 hours is lacking. If this is the case, the patient should be evaluated for urinary tract obstruction, urinary calculi and an intrarenal or perinephric abscess. Ultrasonography, plain radiography, and modified intravenous pyelography are all acceptable methods, depending on the clinical setting.

The pelvic floor or diaphragm is composed of Coccygeus and Levator Ani. Levitator Ani is composed of 3 muscles: puborectalis, pubococcygeus and iliococcygeal. Although Piriformis assists in closing the posterior pelvic outlet it is not considered a component of the pelvic floor

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.

HPV 16 and 18 are responsible for 70% of cases of HPV related cancers. They are considered the most important high risk genotypes of HPV. As well as cervical cancer they are associated with cancers of the oropharynx and anogenital region.

There are over 100 genotypes of HPV including several other high risk HPV types. Gardasil® is a quadrivalent vaccine against HPV Types 6, 11, 16, and 18

HPV genotypes 6 and 11 are low risk and cause anogenital warts.

Typically 70% of HPV infections are cleared within 1 year and 90% are cleared within 2 years

The Conjoint tendon AKA Inguinal falx reinforces the posterior wall of the inguinal canal. The inguinal ligament is part of the floor.
The aponeurosis of external oblique is the major component of the anterior wall with fibres of internal oblique reinforcing the lateral part

The changes seen in breast tissue with the menstrual cycle are accentuated during pregnancy. Deposition of fat around glandular tissue occurs, and the number of glandular ducts is increased by oestrogen, while progesterone and human placental lactogen (hPL) increase the number of gland alveoli. Prolactin is essential for the stimulation of milk secretion and during pregnancy prepares the alveoli for milk production. Although prolactin concentration increases throughout pregnancy, it does not then result in lactation since it is antagonized at an alveolar receptor level by oestrogen.

The pelvis is supported by a variety of ligaments. At term, these ligaments allow for variation in its structure such that the overall size of the pelvic cavity is increased in order to accommodate the upcoming foetus into the cavity.

In pregnancy, although it is a hypercoagulable state with an increase in clotting factors, the platelet count is decreased. Fibrinogen and erythrocyte sedimentation rate (ESR) may be both increased.

ADH and vasopressin are synthesized in the supraoptic and periventricular nuclei of the hypothalamus, they are eventually transported to the posterior pituitary where they are stored to be released later.

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.

Venous thromboembolism (VTE) during pregnancy and the postpartum window occurs at a 6-10-fold higher rate compared with age-matched peers and is a major cause of morbidity and mortality. Hypercoagulability persists for 6-8 weeks after delivery with the highest risk of PE being during the postpartum period. The lack of randomized trials in pregnant women leads to variability in practice, which are largely based on expert consensus or extrapolation from non-pregnant cohorts. The standard treatment of VTE in pregnancy is anticoagulation with low molecular weight heparin (LMWH), which like unfractionated heparin does not cross the placenta and is not teratogenic.

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

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.

This woman has developed non-specific symptoms of cervical insufficiency, is a painless dilation of cervix resulting in the delivery of a live fetus during the 2nd trimester or premature delivery.

The following has been identified as the risk factors associated with increased incidence of cervical insufficiency:
– Congenital disorders of collagen synthesis like Ehlers-Danlos syndrome.
– Prior cone biopsies.
– Prior deep cervical lacerations, which is secondary to vaginal or cesarean delivery.
-Müllerian duct defects like bicornuate or septate uterus.
– More than three prior fetal losses during the 2nd trimester

From the given options, alcohol abuse is the only one not associated with increased incidence of cervical insufficiency.

Clinical picture mentioned is indicative of hyperemesis gravidarum with resultant hypovolemia and pre-shock state, were patient needs urgent fluid resuscitation and intravenous antiemetic medications. The first-line fluid for resuscitation is normal saline (0.9% NaCl) and metoclopramide an antiemetic drug which is safe for use in pregnancy (category A).

Dextrose should be avoided in this situation as the sugar in the solution will leave behind a hypotonic fluid leading to severe hyponatraemic state which increases the risk for encephalopathy due to edema.

Ondansetron is considered as the second-line of antiemetic drug under category B1 which is used in situations like more refractory vomiting, when patient is not responding to metoclopramide and in cases of recurrent hospital admissions due to hyperemesis gravidarum.

Steroids such as prednisolone are considered as the third-line medication mostly used in resistant cases of hyperemesis gravidarum and should be used only after consulting an expert in the field.

This woman has experienced a septic abortion. Therefore the first step is commencement of intensive antibiotic treatment as soon as cervical swabs have been taken.

The next step is evacuation of the uterus. Curettage can be performed after a few hours, to extract any remaining infected products of conception from the uterine cavity.

The choice of antibiotics depends on the most likely microorganism involved. Therefore, prior to commencing any other procedure, it is vital to take cervical swabs for microscopic examination to guide further antibiotic therapy (correct answer).

If curettage is performed immediately there is a risk that the infection would spread.

However, if Clostridium welchii infection is suspected from the cervical smear (particularly if encapsulation of the microorganisms is present), then curettage should be performed immediately along with commencing antibiotic treatment.

Curettage can be delayed for up to 12-24 hours if other microorganisms are suspected; unless a significant increase in bleeding occurs.

Ergometrine is not essential as an immediate treatment measure as the patient is not bleeding heavily and reports that her bleeding has decreased. However, ergometrine is commonly given when curettage is performed.

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.

Factor V Leiden is the most common congenital thrombophilia. Named after the Dutch city Leiden where it was first discovered. Protein C and S deficiencies are type 1 (Not type 2) thrombophilias Antiphospholipid syndrome is an acquired (NOT congenital) thrombophilia

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.

Pruritus of pregnancy is a common disorder, which occurs in 1 in 300 pregnancies, and presents as excoriated papules on extensor limbs, abdomen
and shoulders. It is more common in women with a history of atopy. Prurigo usually starts at around 25–30 weeks of pregnancy and resolves after delivery,
with no effect on the mother or baby. Treatment is symptomatic with topical steroids and emollients. It occurs due to derangement in the LFTs. 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.

Incontinence in women is typically related to dysfunction of the bladder or pelvic floor muscles, with such dysfunction often arising during pregnancy or childbirth, or at the time of menopause.

A pregnant woman may experience an increase in the size of the kidneys and ureter due to the increased blood volume and vasculature.
Later in pregnancy, the woman might develop physiological hydronephrosis and hydroureteronephrosis, which are normal.
There is an increase in glomerular filtration rate associated with an increase in creatinine clearance, protein, albumin excretion, and urinary glucose excretion.
There is also an increase in sodium retention from the renal tube so oedema and water retention is a common sign in pregnant women

The commonest foetal presentation in twin pregnancy is cephalic-cephalic.

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.

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.

On reflex liquid-based cytology, this patient had a cervical screening test that revealed HPV non-16 and 18 kinds, as well as a low-grade squamous intraepithelial lesion. In a year, she should be provided a cervical screening test. If HPV non-16/18 kinds are discovered in 12 months, she will need a colposcopy.

Combined oral contraceptives are a safe and highly effective method of birth control, but they can also raise problems of clinical tolerability and/or safety in migraine patients. It is now commonly accepted that, in migraine with aura, the use of combined oral contraceptives is always contraindicated, and that their intake must also be suspended by patients suffering from migraine without aura if aura symptoms appear.

Discontinuation of contraception could risk in pregnancy. Barrier methods can be used but aren’t as effective as pills.

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.

When considering immunoglobulins in neonates. There are only a few key points you are likely to be tested on. 1. IgA is resistant to stomach acid and found in large amounts in breast milk. 2. IgG is the only Ig that can cross the placenta so is key for passive neonatal immunity 3. When the neonate starts synthesising its own Ig it is IgM that is produced first.

Reduced fetal movements can be the first indication of possible fetal abnormalities. Movements are first perceived by the mother from about 18-20 weeks gestation, increase in size and frequency until 32 weeks gestation when they plateau at about 31 movements per hour. Investigations for reduced fetal heart rate include auscultation of the fetal heart rate using a handheld doppler device, and a cardiotocograph or ultrasound if the foetus is above 28 weeks gestation. About 70% of women who experience one episode of reduced fetal movement have uncomplicated pregnancies. They are advised to report to a maternal unit if another episode occurs.

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

A well contracted uterus excludes an atonic uterus. Delivery of large baby by a primigravida can cause cervical +/- vaginal tears which can lead to PPH.

Ultrasound findings in early pregnancy can help determine the viability of an intrauterine pregnancy. In the absence of a fetal heartbeat and no visible fetal pole, the mean gestational sac diameter should be measured. A sac diameter of less than 25mm on a transvaginal ultrasound scan is likely an indication of a miscarriage. In the presence of a fetal heartbeat, the crown-rump length should be less than 7mm according to NICE guidelines. Further scans are indicated 14 days later to confirm the diagnosis. The diagnosis of ‘pregnancy of uncertain viability’ is given in situations where there is inadequate ultrasound evidence to diagnose a miscarriage, such as a developing sac but no visualisation of a foetus with a heartbeat.
Ultrasound findings for partial molar pregnancy are an enlarged placenta with multiple diffuse anechogenic patches, while findings in a complete molar pregnancy include an enlarged uterus with multiple small anechogenic spaces (snowstorm appearance), or the bunch of grapes sign representing hydropic trophoblastic villi.

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

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

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

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

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