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.

The best next step in her management is a colposcopy.

Patients diagnosed with high-grade lesions (CIN 2 or 3) or adenocarcinoma in situ (AIS) during pregnancy should undergo surveillance via colposcopy and age-based testing (cytology/HPV) every 12-24 weeks.

Cone biopsy and long loop excision of the transformation zone (LLETZ biopsy) are not recommended if the lesion extends up the canal and out of the vision of the colposcope.
It is not necessary to terminate the pregnancy.

Because repeat colposcopic examination during pregnancy offers all of the information needed, the repeat Pap smear is best done after the pregnancy has ended.

Unless colposcopy indicates aggressive cancer at an earlier time, the ultimate therapy required is usually not decided until the postpartum visit.

An assessment of amniotic fluid in pregnancy can be done by taking ultrasound measurements of the depth of amniotic fluid pockets. The combination of the measurements in four quadrants is called the amniotic fluid index (AFI), one of the major determinants of the biophysical profile which predicts pregnancy outcome. An AFI of less than 5 cm, or less than the 5th percentile is defined as oligohydramnios while an AFI of more than 25 cm is considered polyhydramnios.

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

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

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

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

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.

Leiomyomas uterine (fibroids)
Clinical features:
Menses that are heavy and last a long time, symptoms of pressure, pelvic discomfort, constipation, frequency of urination, complications during pregnancy, fertility problems, loss of pregnancy, premature birth, uterus enlargement and irregularity

Workup:
Ultrasound

Treatment:
Asymptomatic: monitoring
Surgical intervention, hormonal contraception

This patient has uterine leiomyomata, or fibroids, which are benign smooth muscle (myometrial) tumours that are very prevalent in adult women (up to 25%). These tumours can expand the endometrium’s surface area, the uterus’ overall size and thickness, and compress adjacent structures; nevertheless, some individuals have no symptoms and are identified by chance during a physical examination or imaging (as in this patient’s CT scan after a car accident).
Heavy, prolonged menses are among the indications for uterine leiomyomata treatment (particularly if associated with anaemia).
Pelvic discomfort that persists (e.g., dyspareunia).
Symptoms in abundance (e.g., pelvic pressure, hydronephrosis, constipation).
Recurrent miscarriages.
Medical or surgical treatment options are available for patients with these clinical characteristics (e.g., myomectomy).

This woman had mild menses and no pelvic discomfort or mass symptoms while having many big intramural and pedunculated leiomyomata (e.g., no ureter compression). There is no need for extra treatment in persons with asymptomatic fibroids. Only observation and reassurance are required.
In the treatment of symptomatic fibroids, a combination of oral contraceptive pills and progestin-containing intrauterine devices can be utilised, although they are not required in the management of asymptomatic fibroids. Furthermore, this patient has a minimal risk of unwanted pregnancy (e.g., monogamous, same-sex relationship), and the hazards of these contraceptives (e.g., venous thromboembolism, uterine perforation) outweigh the benefits.

GnRH agonist therapy (e.g., leuprolide) is a treatment for symptomatic uterine fibroids that works by inhibiting pulsatile FSH and LH production in the hypothalamus, lowering oestrogen levels. Low oestrogen levels cause a temporary reduction in leiomyoma size, which helps with heavy menses and bulky symptoms. Because long-term usage of GnRH agonists is linked to an increased risk of osteoporotic fractures, they are only administered preoperatively.

Tranexamic acid is a nonhormonal medicinal medication that reduces heavy menstrual bleeding by preventing fibrin breakdown (i.e., an antifibrinolytic drug). This patient’s menses are light.
Uterine leiomyomata (fibroids) are benign myometrial tumours that can produce a range of symptoms but are often identified by chance. Heavy menstrual blood, pelvic pain, and bulk symptoms are all indications for treatment. Patients with asymptomatic fibroids merely need to be monitored and reassured.

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

Fat necrosis is a benign (non-cancerous) breast condition that can develop when an area of fatty breast tissue is injured. It can also develop after breast surgery or radiation treatment.

There are different stages of fat necrosis. As the fat cells die, they release their contents, forming a sac-like collection of greasy fluid called an oil cyst. Over time, calcifications (small deposits of calcium) can form around the walls of the cyst, which can often be seen on mammograms. As the body continues to repair the damaged breast tissue, it’s usually replaced by denser scar tissue. Oil cysts and areas of fat necrosis can form a lump that can be felt, but it usually doesn’t hurt. The skin around the lump might look thicker, red, or bruised. Sometimes these changes can be hard to tell apart from cancers on a breast exam or even a mammogram. If this is the case, a breast biopsy (removing all or part of the lump to look at the tissue under the microscope) might be needed to find out if the lump contains cancer cells. These breast changes do not affect your risk for breast cancer.

Mastectomy, axillary node dissection and radiation therapy are all management options for malignancy which this patient doesn’t have.

The T10 spinal segment provides the sympathetic nerve fibres that innervate the testes

The Sella turcica is composed of three parts:
1. The tuberculum sellae (horn of saddle): a variable slight to prominent median elevation forming the posterior
boundary of the prechiasmatic sulcus and the anterior boundary of the hypophysial fossa.
2. The hypophysial fossa (pituitary fossa): a median depression (seat of saddle) in the body of the sphenoid that accommodates the pituitary gland (L. hypophysis).
3. The dorsum sellae (back of saddle): a square plate of bone projecting superiorly from the body of the sphenoid.
It forms the posterior boundary of the Sella turcica, and its prominent superolateral angles make up the posterior clinoid processes.

Girls with Turner’s syndrome (45,X) are not at risk for malignancy. Patients with feminizing testicular syndrome with XY chromosome composition and patients with mixed gonadal dysgenesis are at risk for malignancy, and bilateral gonadectomy is performed.

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

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

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

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

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

Prostaglandin E1 and E2 help maintain the patency of the DA during pregnancy. PGE2 is by far the most potent and important. It is produced in large quantities by the placenta and the DA itself.

This patient most likely has preeclampsia, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein, blood pressure monitoring, and laboratory evaluation that includes haemoglobin, haematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid- A peripheral smear and coagulation profiles also may be obtained- Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate.

→ Ultrasonography should be done to assess for fetal intrauterine growth restriction, but only after an initial laboratory and fetal evaluation.
→ It is not necessary to start this patient on antihypertensive therapy at this point. An obstetric consultation should be considered for patients with preeclampsia.
→ Delivery is the definitive treatment for preeclampsia- The timing of delivery is determined by the gestational age of the foetus and the severity of preeclampsia in the mother. Vaginal delivery is preferred over caesarean delivery, if possible, in patients with preeclampsia.

This woman has mixed incontinence, which includes signs and symptoms of both stresses and urges incontinence. The urge, on the other hand, irritates her. Bladder training would be the most appropriate management approach to investigate first for women with urge incontinence as the most troublesome symptom. The objectives are:
– Using a bladder diary to establish a baseline
– Creating a voiding schedule
– Over a long period, gradually increase the voiding interval in increments of 2- 5 minutes, to void every 3 hours.
– Other important strategies to consider are lifestyle changes like reducing fluid intake, losing weight, and avoiding diuretics-producing foods and beverages (e.g., alcoholic beverages, caffeine, etc).

When urge incontinence does not respond to physical or behavioural therapy, anticholinergics along with ongoing bladder training are an alternative. A 4- to 6-week trial is employed. At six months, risk and benefit are weighed to see if treatment should be continued for those who react. Patients should be informed about anticholinergic side effects such as dry mouth and constipation, as well as how to control them.

Anterior colporrhaphy is a treatment for cystocele that involves repairing the front vaginal wall. It can help people with urine incontinence. If you don’t have a cystocele, bladder neck suspension is the best option.
Retropubic bladder suspension is a more intrusive surgery for treating stress urinary incontinence in patients who haven’t responded to less invasive treatments like pelvic floor exercise.

The most essential initial conservative therapy to explore for patients with real stress incontinence and mixed (both stress and urge) urine incontinence when stress incontinence is the more prominent symptom is pelvic floor muscle exercise (e.g. Kegel exercise). For urge incontinence, more difficult training can be applied.

Shoulder dystocia occurs when the anterior or posterior fetal shoulder impacts on the maternal symphysis or sacrum and may require additional manevours to release the shoulders after gentle downward traction has failed. The most common injury that can occur, is to the brachial plexus due to lateral flexion of the head during traction. This may cause a neurological disability, Erb’s Palsy ( injury to C5 and C6 of the brachial plexus) in which there is a less than 10% chance that this injury would be permanent.

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

The following treatment regimes are recommended for the treatment of Chlamydia in Pregnancy: Erythromycin 500mg four times a day for 7 days or Erythromycin 500 mg twice a day for 14 days or Amoxicillin 500 mg three times a day for 7 days or Azithromycin 1 gm stat (only if no alternative, safety in pregnancy not fully assessed) The following treatment regimes are recommended for the treatment of Chlamydia in NON-PREGNANT patients: Doxycycline 100mg bd for 7 days OR Azithromycin 1gm orally in a single dose NOTE: Doxycycline and Ofloxacin are contraindicated in pregnancy

The most common causative agent found in female urinary tract infections is Escherichia Coli. E. Coli is a bacteria found in the environment and the human gastrointestinal system. Other common causes of UTI include Klebsiella sp, Proteus sp and various Enterococci.

Genetically, patients suffering from androgen insensitivity syndrome are 46XY. They are males but insensitive to male hormones i.e. androgens.

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.

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

CMV effects 1 in 200 pregnancies of which 30% will transmit the virus to the foetus and of which 30% foetus will be effected.

It is less common for a girl of this age to develop fibroids, endometriosis and endometrial polyps, although these are all causes of severe dysmenorrhea. Chronic pelvic infection can be due to sexually transmitted disease but the history does not mention any previous episodes of pelvic pain or symptoms of infection such as fever. In this case, it is most likely that she has primary dysmenorrhea. Primary dysmenorrhea, in which no pathological cause can be identified, is believed to be due to the prostaglandins released by the secretory endometrium. If secondary dysmenorrhea is suspected, then endometriosis would be the most prominent cause.

While hysteroscopic and laparoscopic examinations are commonly done in adult women to rule out organic causes such as those mentioned earlier, in younger girls, they are usually only carried out if pain management with, for example, NSAIDs and the use of COCPs, have failed to either provide symptom relief or reduction.

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

Endometrial ablation is primarily intended to treat premenopausal women with heavy menstrual bleeding (HMB) who do not desire future fertility. Women who choose endometrial ablation often have failed or declined medical management.

Absolute contraindications to endometrial ablation include pregnancy, known or suspected endometrial hyperplasia or cancer, desire for future fertility, active pelvic infection, IUD currently in situ, and being post-menopausal. In general, endometrial ablation should be avoided in patients with congenital uterine anomalies, severe myometrial thinning, and uterine cavity lengths that exceed the capacity of the ablative technique (usually greater than 10-12 cm).

Tamoxifen and Raloxifene are drugs which acts as selective estrogen receptor modulators.
Their mechanisms of action are competitive inhibitor of estrogen binding and mixed agonist/antagonist action respectively.
Commonly indicated in prevention of breast cancer in high-risk patients. Tamoxifen as adjuvant treatment of breast cancer and Raloxifene in postmenopausal osteoporosis.
Adverse effects include:
– Hot flashes
– Venous thromboembolism
– Endometrial hyperplasia & carcinoma (tamoxifen only)
– Uterine sarcoma (tamoxifen only)
Adjuvant endocrine therapy is commonly used option for treatment of nonmetastatic, hormone-receptor-positive breast cancer; and the most commonly used endocrine agents include tamoxifen, aromatase inhibitors, and ovarian suppression via GnRH agonists or surgery.

Tamoxifen is a selective estrogen receptor modulator which is an estrogen receptor antagonist in the breast.  It is the most preferred adjuvant treatment for pre-menopausal women at low risk of breast cancer recurrence.  Tamoxifen is also a second-line endocrine adjuvant agent for postmenopausal women who cannot use aromatase inhibitor therapy due to intolerable side effects.
Tamoxifen acts as an estrogen agonist in the uterus and stimulates excessive proliferation of endometrium. Therefore, tamoxifen use is associated with endometrial polyps in premenopausal women, and endometrial hyperplasia and cancer in postmenopausal women. These effects will continue throughout the duration of therapy and resolves once the treatment is discontinued. Even with all these possible complications, benefits of tamoxifen to improve the survival from breast cancer outweighs the risk of endometrial cancer.

In postmenopausal women, tamoxifen has some estrogen-like activity on the bone, which can increase bone mineral density and thereby reduce the incidence of osteoporosis significantly.  However, tamoxifen is generally not a first-line agent for osteoporosis in treatment due to the marked risk of endometrial cancer.

Dysplasia of the cervical transformation zone is typically caused due to chronic infection by human papillomavirus, and tamoxifen has no known effects on the cervix.

Tamoxifen is not associated with any increased risk for adenomyosis, which is characterised by ectopic endometrial tissue in the myometrium.

Intimal thickening of the coronary arteries is a precursor lesion for atherosclerosis. Tamoxifen helps to decrease blood cholesterol level and thereby protect against coronary artery disease.

Tamoxifen is an estrogen antagonist on breast tissue and is used in the treatment and prevention of breast cancer, but it also acts as an estrogen agonist in the uterus and increases the risk of development of endometrial polyps, hyperplasia, and cancer.

CMV is the most common congenital infection causing sensorineural deafness.
10-15% of infected infants will be symptomatic at birth. A further 10-15% who are asymptomatic at birth will develop symptoms later in life. Transmission can also be via breastmilk and the incubation period for CMV is 3-12 weeks. Diagnosis of fetal CMV infection is via amniocentesis however this should not be performed for at least 6 weeks after maternal infection and not until the 21st week of gestation

Female infants are thought to be born with the total number of gametes they will posses in their lifetime. About 1 million healthy oocytes are present at birth. However, only about 300,000 of these oocytes survive to puberty, a number which continues to decline until all the oocytes are depleted triggering menopause.