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.

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

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

Endometrial cancer is one of the most common gynaecological malignancies present in postmenopausal women, with a peak incidence between the ages of 60-89. Factors associated with endometrial cancer include obesity, hypertension and diabetes. Full staging for endometrial cancer is surgical, including several other radiologic investigations. According to FIGO staging classifications:
Stage 1 indicates a tumour confined to the uterine body
Stage 2 indicates the invasion of the cervical stroma
Stage 3 indicates local and regional spread, where the tumour invades the serosa in stage 3A, spreads to the vagina and parametrium in stage 3B, and metastasizes to the pelvic or para-aortic lymph nodes in stage 3C.
Stage 4 indicates tumour invasion on the bladder or bowel mucosa, or distant metastasis.

Early decelerations: a result of increased vagal tone due to compression of the fetal head during contractions. Monitoring usually shows a symmetrical, gradual decrease and return to baseline of FHR, which is associated with a uterine contraction.

Patient’s presentation is classic for uterine rupture, were she developed sudden abdominal pain followed by cessation of contractions, termination of urge to push and vaginal bleeding.
Abdominal examination shows no fetal cardiac activity and signs of fluid collection like fluid thrill and shifting dullness. The fluid collected will be blood, which usually enters the peritoneum after the rupture of the uterus. In such patients vaginal examination will reveal a range of cervical dilatation with evidences of cephalopelvic disproportion.
Anterior lower transverse segment is the most common site for spontaneous uterine rupture. Patient in the case presenting with tachycardia and hypotension is in shock due to blood loss and will require urgent resuscitation.

Placenta previa presents with painless bleeding from the vagina and Placental abruption will present with painful vaginal bleeding with tender and tense uterine wall, however, in contrary to that of uterine rupture, uterine contractions will continue in both these cases.

Shoulder dystocia is more likely to present in a prolonged labour with a significant delay in the progress of labour. However, in this case, there is no mention of shoulder dystocia.

Disseminated intravascular coagulation (DIC) is a condition which is causes due to abnormal and excessive generation of thrombin and fibrin in the circulating blood which results in bleeding from every skin puncture sites. It results in increased platelet aggregation and consumption of coagulation factors which results in bleeding at some sites and thromboembolism at other sites. Placental abruption, or retained products of conception in the uterine cavity are the causes for DIC.

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%.

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 Fallopian tubes, also known as, uterine tubes, and salpinges, are two very fine tubes lined with ciliated columnar epithelia, leading from the ovaries of female mammals into the uterus, via the uterotubal junction.

In severe cases of hyperemesis, complications include vitamin deficiency, dehydration, and malnutrition, if not treated appropriately. Wernicke encephalopathy, caused by vitamin-B1 deficiency, can lead to death and permanent disability if left untreated. Additionally, there have been case reports of injuries secondary to forceful and frequent vomiting, including oesophageal rupture and pneumothorax.

Electrolyte abnormalities such as hypokalaemia can also cause significant morbidity and mortality. Additionally, patients with hyperemesis may have higher rates of depression and anxiety during pregnancy.

Chickenpox or varicella is a contagious disease caused by the varicella-zoster virus (VZV). The virus is responsible for chickenpox (usually primary infection in non-immune hosts) and herpes zoster or shingles (following reactivation of latent infection). Chickenpox results in a skin rash that forms small, itchy blisters, which scabs over. It typically starts on the chest, back, and face then spreads. It is accompanied by fever, fatigue, pharyngitis, and headaches which usually last five to seven days. Complications include pneumonia, brain inflammation, and bacterial skin infections. The disease is more severe in adults than in children.

Primary varicella infection during pregnancy can also affect the foetus, who may present later with chickenpox. In pregnant women, antibodies produced as a result of immunization or previous infection are transferred via the placenta to the foetus. Varicella infection in pregnant women could spread via the placenta and infect the foetus. If infection occurs during the first 28 weeks of pregnancy, congenital varicella syndrome may develop. Effects on the foetus can include underdeveloped toes and fingers, structural eye damage, neurological disorder, and anal and bladder malformation.

Prenatal diagnosis of fetal varicella can be performed using ultrasound, though a delay of 5 weeks following primary maternal infection is advised.

Antivirals are typically indicated in adults, including pregnant women because this group is more prone to complications.

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

Lymphatic drainage of the bladder is to the common iliac nodes via the internal iliac nodes.

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

Polycystic kidney disease (PKD) can either be autosomal dominant or recessive. The autosomal dominant variant is more common in adult PKD however, the recessive pattern is more common in infantile PKD.

The tests listed can all be performed during the work-up of a woman with secondary amenorrhoea. They are useful in that they cam diagnosis the most likely cause for the amenorrhoea as well as guide the treatment required if the patient wanted to become pregnant. Of these, the hormone test best able to predict a poor response to ovulation-induction therapy is the follicle-stimulating hormone (FSH) assay. If there are high levels of FSH, most of the ovulation-induction therapies are ineffective, although the rare spontaneous pregnancy can occur.

To maximise the chance of pregnancy in patients with elevated FSH levels, the most effective technique is an ovum donation from a young woman. The ovum would be fertilised in the laboratory and transferred to the uterus of the woman with the high FSH level after administering hormonal preparation of her uterus.

If the FSH level is normal, ovulation-induction therapy is usually effective. For these patients, correction of thyroid function will be necessary if the thyroid function is not normal. Dopamine agonist therapy is indicated if the prolactin level is elevated. Clomiphene or gonadotrophin therapy can be used where the luteinising and oestradiol levels are low, normal, or minimally elevated.

Patient’s symptoms and signs are suggestive of round ligament strain, which is a normal finding during pregnancy, especially in the 2nd trimester, and it does not require any medical intervention.

Round ligament is a rope-like fibromuscular band which extends from the anterolateral aspect of uterus anteriorly between the layers of the broad ligament, and passing through the deep inguinal ring into the inguinal canal.
A sharp, sudden spasm in the right iliac fossa which lasts for a few seconds which is usually triggered by sneezing, coughing, laughing and rolling over in bed are the common presentations of a round ligament pain.

Ectopic pregnancy and rupture of ectopic pregnancy are two unlikely diagnosis in this patient as she is in the second trimester of her pregnancy, whereas both the mentioned conditions occur during the first trimester.

Although appendicitis presents with pain in right iliac fossa, the pain is not causes by coughing or sneezing. Also, there will be other symptoms like tenderness and rebound tenderness in right iliac fossa in case of appendicitis.

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.

The yolk sac increases in size up until the 10th week reaching a maximum diameter of 6mm in normal pregnancy. After the 10th week the yolk sac will gradually disappear. It is usually sonographically undetectable by 20 weeks. A yolk sac greater than 6mm diameter is suspicious of failed pregnancy.

The BPP is performed in an effort to identify babies that may be at risk of poor pregnancy outcome, so that additional assessments of wellbeing may be performed, or labour may be induced or a caesarean section performed to expedite birth.

The transabdominal ultrasound uses a frequency of 3.5-7 MHz emitted from a transducer. Transvaginal 5-7.5 MHz (post bladder void.

If a mother has been abusing drugs during antenatal period, there are some contraindications to discharge her baby home. These conditions includes:
– excessive weight loss, which is greater than ten percent of birth weigh
– suspected baby neglect or abuse
– suspected domestic violence
– a court order preventing baby from being discharged home or if there is requirement for further assessment of withdrawal symptoms.

A 2-3 percentages weight loss during the early neonatal period is considered to be a normal finding and is therefore not considered as a contraindication to discharge the baby home.

Clinical decision making which contraceptive regimen is optimal for an individual woman with epilepsy is one of the most challenging tasks when taking care of women with epilepsy. The bidirectional interactive potential of antiepileptic drugs (AEDs) and hormonal contraceptives needs to be taken into account. Enzyme inducing (EI)-AEDs may reduce the contraceptive efficacy of hormonal contraceptives.

If combined oral contraceptives (COCs) are used in combination with EI-AEDs, it is recommended to choose a COC containing a high progestin dose, well above the dose needed to inhibit ovulation, and to take the COC pill continuously (“long cycle therapy”). But even with the continuous intake of a COC containing a higher progestin dose contraceptive safety cannot be guaranteed, thus additional contraceptive protection may be recommended.

Progestin-only pills (POPs) are likely to be ineffective, if used in combination with EI-AEDs.

Subdermal progestogen implants are not recommended in patients on EI-AEDs, because of published high failure rates.

Depot medroxyprogesterone-acetate (MPA) injections appear to be effective, however they may not be first choice due to serious side effects (delayed return to fertility, impaired bone health).

The use of intrauterine devices is an alternative method of contraception in the majority of women, with the advantage of no relevant drug–drug interactions. The levonorgestrel intrauterine system (IUS) appears to be effective, even in women taking EI-AEDs. Likelihood of serious side effects is low in the IUS users.

Clomiphene and/or Metformin are 1st line agents. Weight loss in the setting of subfertility is advised if BMI >30 kg/m2

Neisseria Gonorrhoeae is a Gram negative diplococci.

Both the female hormones, namely progesterone and oestrogen as well as the male hormones or androgens are lipid soluble. The common precursor of these is cholesterol.

The Inguinal Canal
– Anterior wall: formed by the external oblique aponeurosis throughout the length of the canal; its lateral part is reinforced by muscle fibres of the internal oblique.
– Posterior wall: formed by the transversalis fascia; its medial part is reinforced by pubic attachments of the internal oblique and transversus abdominis aponeuroses that frequently merge to variable extents into a common tendon—the inguinal falx (conjoint tendon)—and the reflected inguinal ligament.
– Roof: formed laterally by the transversalis fascia, centrally by musculo-aponeurotic arches of the internal oblique and transversus abdominis, and medially by the medial crus of the external oblique aponeurosis.
– Floor: formed laterally by the iliopubic tract, centrally by gutter formed by the infolded inguinal ligament, and medially by the lacunar ligament.

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.

Intrahepatic cholestasis of pregnancy can affect both mother and foetus, however it is more harmful for the foetus. Amongst foetuses, there is an increased risk of perinatal mortality, meconium aspiration, premature delivery and post partum haemorrhage. Exact cause of fetal death cannot be predicted accurately but it is not related to intra uterine growth retardation or placental insufficiency. The liver can be affected in the mother leading to generalized pruritis but no evidence of fetal hepatic dysfunction has been found.

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