Rates of successful pregnancy following three spontaneous losses (repeated miscarriages) are

Rates of successful pregnancy following three spontaneous losses (repeated miscarriages) are
a. Very poor
b. Slightly worse than those in the baseline population
c. No different from those in the baseline population
d. Just under 50%
e. Good unless cervical incompetence is diagnosed

Answer:

Physiological changes in pregnancy: uterus and cervix - Extended matching question

Physiological changes in pregnancy: uterus and cervix - Extended matching question

A Oestradiol
B Prostaglandins
C Progesterone
D Cortisol
E Collagenase
F Prolactin
G Human chorionic gonadotrophin (HCG)
H Adrenocorticotrophic hormone (ACTH)
I Oxytocin

For each description below, choose the SINGLE most appropriate answer from the above list of options. Each option may be used once, more than once, or not at all.

1 Levels approximately 15 times higher in third trimester than in non-pregnant state.
2 Induces the process of cervical remodelling.
3 Regulates local uterine blood flow through endothelial effects.
4 Utilized in triple test.
5 Released from posterior pituitary gland.

Answers:

Treatment Of High BP in Pregnancy

A 32-year-old woman who is 22 weeks’ pregnant is admitted to the maternity ward and found to be hypertensive with a BP of 180/100 mmHg. This is her first pregnancy and it is otherwise uncomplicated. She has no other relevant medical history and her urinalysis is normal, as is renal and liver function.

Question
Which of the following should not be used to control her BP?

A Hydralazine
B Methyldopa
C Labetalol
D Ramipril
E Amlodipine

Answer:

Post Coital Bleeding - Case Discussion

History
An 18-year-old woman is referred with postcoital bleeding. It has occurred on approximately seven occasions over the preceding 6 weeks. Generally it has been a small amount of bright red blood noticed a few hours after intercourse and lasting up to 2 days. There is no associated pain.
Her last menstrual period started 3 weeks ago and she bleeds for 4 days every 28 days. Her periods were previously quite heavy but are now lighter since she started the combined oral contraceptive pill (COCP) 6 months ago. There is no history of an abnormal discharge or offensive odour and she has no dyspareunia.
She has had three sexual partners and has been with her current partner for 10 months. She has never been diagnosed with any sexually transmitted infection and has never had a smear test. She had an appendectomy at the age of 7 years and was diagnosed with epilepsy in childhood but has been off all medication for 8 years.

Examination
The abdomen is soft and non-tender. Speculum examination reveals a florid reddened area symmetrically surrounding the external cervical os with contact bleeding. The uterus is normal sized, anteverted and non-tender. There is no cervical excitation and the adnexae are unremarkable.

Questions
• What is the differential diagnosis?
• What further investigations would you perform for this woman?
• If your investigations are negative what is the likely diagnosis and how would you manage the woman?

Case Discussion:

Case Discussion - A Woman Presenting for Preconceptional Counseling ...

Mrs B, 24 years old had a previous baby with Down syndrome who is now one year old.She is desirous of further childbearing but is apprehensive about similar problem in the next baby and has come for preconceptional counseling. The karyotype of the affected child showed Trisomy 21 (47,XY).

Approach to the Case: 

Points to be asked in History
• Age of the mother at delivery
• Period of gestation at which the pregnancy was registered
• First trimester scan for nuchal translucency
• Whether first or second trimester screening was done
• Second trimester anomaly scan
• Pregnancy outcome: Miscarriage, stillborn or live born

She mentions that her first pregnancy was a spontaneous conception. She sought antenatal care at 20 weeks of pregnancy. She had a term delivery at a hospital of a small for gestational age baby. The baby had mongoloid facies and a ventricular septal defect was diagnosed. The baby had delayed milestones and on investigations the baby was diagnosed with Trisomy 21.

What recurrence risk would you attribute to this lady?
Down’s syndrome cases result from nondisjunction, translocation or mosaic. With a pregnancy complicated by trisomy 21 from nondisjunction, the woman has 1% risk of having a pregnancy with trisomy in subsequent pregnancy. This risk pertains unless her age related risk exceeds it. Because of this risk, she would be offered invasive prenatal diagnosis. Parental karyotype is not indicated in this
couple.

What is the incidence of Down syndrome in general population?
Down’s syndrome occurs in 1 in 800 to 1 in 1000 newborns

Regarding chromosomal aberrations in spontaneous miscarriages...

A 24-year-old woman has had three first-trimester spontaneous miscarriages.
Which of the following statements concerning chromosomal aberrations in miscarriages is true?
a. 45,X is more prevalent in chromosomally abnormal term babies than in abortus products
b. Approximately 20% of first-trimester spontaneous abortions have chromosomal abnormalities
c. Trisomy 21 is the most common trisomy in abortuses
d. Despite the relatively high frequency of Down syndrome at term, most Down fetuses abort spontaneously
e. Stillbirths have twice the incidence of chromosomal abnormalities as live births

Answer:

Regarding Gravidity and Parity...

Regarding Gravidity and Parity...

A G1 P0
B G4 P2
C G0 P0
D G3 P3
E G2 P1
F G1 P2
G G6 P0
H G5 P2
I G1 P1
J G3 P1
K G4 P3
L G2 P0

For each description below, choose the SINGLE most appropriate answer from the above list of options. Each option may be used once, more than once, or not at all.

1 A woman currently pregnant who has had a previous term delivery.
2 A woman not currently pregnant who has had one previous termination, one early miscarriage and one stillbirth at 36/40.
3 A woman who attends for pre-conception counselling, never having been pregnant.
4 A woman currently pregnant with twins who has had one previous early miscarriage.
5 A woman not currently pregnant who previously had a twin delivery at 28/40.

Answers:

A 43 year old woman with heavy and painful periods for last 2-3 years....

A 43-year-old woman is referred from her general practitioner (GP) with painful periods. She says that her periods have always been quite heavy and painful but that in the last 2–3 years they have become almost unbearable. She bleeds every 24 days and the period lasts for 7–9 days with very heavy flow from day 2 to day 6. The pain starts approximately 36 h before the onset of the bleeding and lasts until about day 5. The pain is constant, dull and severe, such that she cannot do any housework or any social activities during this time. Her GP has prescribed paracetamol and mefenamic acid in combination, which she says ‘takes the edge off ’ but does not fully relieve the symptoms.
She has had four normal deliveries and her husband had a vasectomy several years ago.
There is no history of intermenstrual or postcoital discharge and she has no abnormal discharge. Her smear history is normal, the most recent being 18 months ago. She takes citalopram for depression but currently reports her mood as fine. She does not drink alcohol or smoke.

Examination
The abdomen is soft and there is vague tenderness in the suprapubic area. The cervix appears normal. On bimanual palpation the uterus is approximately 10 weeks size, soft and bulky. She is tender on palpation but there is no cervical excitation, adnexal tenderness or adnexal masses.

Investigations: 
Transvaginal ultrasound report: there is asymmetrical uterine enlargement, with a thickened posterior uterine wall. There are ill-defined cystic spaces within the posterior myometrial wall. There is an indistinct myometrial–endometrial border. Both ovaries appear normal in size and morphology.

• What is the likely diagnosis?
• How would you further investigate and manage this woman?

Case Discussion:

A 59 Year Old Woman presents With An Episode Of Postmenopausal Bleeding...

Clinical History
A 59-year-old woman awoke with blood on her nightdress, which was bright red but not heavy. There were no clots of blood and there was no associated pain. The bleeding has recurred twice since in similar amounts.
Her last period was at the age of 49 years and she has had no other intervening bleeding episodes. She suffered hot flushes and night sweats around the time of her menopause, which have now stopped. She is sexually active but has noticed vaginal dryness on intercourse recently.
She has always had normal cervical smears, the last one being 7 months ago. She had two children by spontaneous vaginal delivery and had a laparoscopic sterilization at the age of 34 years. She has never used hormone-replacement therapy (HRT). She takes atenolol for hypertension and omeprazole for epigastric pain.

Examination
She is slightly overweight. Abdominal examination is normal. The vulva and vagina appear thin and atrophic and the cervix is normal. The uterus is small and anteverted and with no palpable adnexal masses.
An outpatient endometrial biopsy is taken at the time of examination and sent for histological
examination.Endometrial biopsy report shows atrophic endometrium with no evidence of inflammation, hyperplasia or malignancy.
A transvaginal ultrasound is normal and shows an endometrial thickness of < 5 mm.

Case Discussion:

A 24-year-old woman presents with the absence of periods for 9 months.... Case Study

A 24-year-old woman presents with the absence of periods for 9 months. She started her periods at the age of 13 years and had a regular 28-day cycle until 18 months ago. The periods then became irregular, occurring every 2–3 months until they stopped completely.
She has also had headaches for the last few months and is not sure if this is related. She has a regular sexual partner and uses condoms for contraception. She has never been pregnant. There is no previous medical history of note.
She works as a primary school teacher and drinks approximately 4 units of alcohol per week. She does not smoke or use recreational drugs. She jogs and swims in her spare time.
Examination
The woman is of average build. The blood pressure and general observations are normal.
The abdomen is soft and non-tender and speculum and bimanual examination are unremarkable.

Investigations: 
Follicle-stimulating hormone  = 7 IU/L (normal on day 2-5 = 1–11 IU/L)
Luteinizing hormone  = 4 IU/L (normal on day 2-5 = 0.5–14.5 IU/L)
Prolactin   = 1800 mu/L (normal range = 90–520 mu/L)
Testosterone  = 1.8 nmol/L (normal range = 0.8–3.1 nmol/L)

A MRI scan of the head was done which revealed asymmetrical enlargement of pituitary gland,
representative of a small pituitary adenoma most likely a prolactinoma.

Case Discussion:

Hepatitis B and Pregnancy

A baby is born to a mother who is known to have chronic hepatitis B. The mothers latest results are as follows:
HBsAg Positive , HBeAg Positive
What is the most appropriate strategy for reducing the vertical transmission rate?
A. Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin
B. Give the newborn hepatitis B vaccine
C. Give the newborn hepatitis B immunoglobulin
D. Give the mother intravenous zidovudine during labour
E. Give the mother hepatitis B immunoglobulin shortly before birth + the newborn hepatitis B vaccine

Answer:

A Woman Presenting With Anemia Secondary to Heavy Periods - Case Study

History
A 30-year-old woman is referred from the hematologist, with anemia. She had been complaining of increasing tiredness and shortness of breath for 3 months, with frequent headaches.
Her periods occur every 24 days and the first day is generally moderate but the second to fourth days are very heavy. She uses tampons and sanitary towels together. She has no pain. Her last smear test was normal 2 years ago. She had no previous gynecological problems and takes no medication.

Examination
The woman is slim with pale conjunctiva. Abdominal, bimanual and speculum examination are unremarkable.

Investigations: 
Hemoglobin =  6.3 g/dL (Normal range = 11.7–15.7 g/dL)
Mean cell volume = 66 fL (normal = 80–99 fL)
Ferritin  = 9 μg/L (normal = 6–81 μg/L)
WBC count and platelets = within normal ranges
Total iron-binding capacity = (TIBC) 80 μmol/L (normal = 45–72 μmol/L)

Blood film: hypochromic microcytic red cells

Transvaginal ultrasound scan report (cycle day 4): the uterus is normal size and retroverted. The endometrium is smooth and thin measuring 3.1 mm. Both ovaries are normal.

Questions
• How do you interpret these findings?
• What is the likely underlying diagnosis?
• How would you manage this woman?

Answers And Discussion:

Abnormal Cervical Smear - case Study And Management

A 28-year-old woman attends the colposcopy clinic after an abnormal smear test. She is very anxious as she thinks that she might have cervical cancer. The smear is reported as ‘severe dyskaryosis’. She had a previous normal result at age 25 years.
She has not had any postcoital or intermenstrual bleeding. Her first sexual relationship started at the age of 14 years and she has had several partners since then. She lives with her current partner who she has been with for 3 years. She was diagnosed with genital herpes several years ago but has not had any attacks for at least 3 years.
She smokes 15–20 cigarettes per day and drinks only at the weekends.
She has an intrauterine contraceptive device in situ.

On Examination
The cervix is macroscopically normal. At colposcopy, acetic acid is applied and an irregular white area is apparent to the left of the os. Lugol’s iodine is applied and the same area stains pale while the rest of the cervix stains dark brown. A biopsy is taken.

Cervical biopsy report: the sample received measures 4 mm x 2 mm and contains enlarged cells with irregular nuclei consistent with CIN 3.

Questions
• How should this patient be managed?

Answer And Discussion:

Uterine Fibroid - Case Study

History
A 36-year-old African-Caribbean woman has noticed abdominal swelling for 10 months. She has to wear larger clothes and people have asked her if she is pregnant, which she finds distressing having been trying to conceive. She has no abdominal pain and her bowel habit is normal. She feels nauseated when she eats large amounts. She has urinary frequency but no dysuria or haematuria.
Her periods are regular, every 27 days, and have always been heavy, with clots and flooding on the second and third days. She has never received any treatment for her heavy periods.
She has been with her partner for 7 years and despite not using contraception she has never been pregnant.

Examination
The woman has a very distended abdomen. A smooth firm mass is palpable extending from the symphysis pubis to midway between the umbilicus and the xiphisternum (equivalent to a 32-week size pregnancy). It is non-tender and mobile. It is not fluctuant and it is not possible to palpate beneath the mass. On speculum examination it is not possible to visualize the cervix. Bimanual examination reveals a non-tender firm mass occupying the pelvis.

Investigations
Haemoglobin = 6.3 g/dL ( normal = 11.7–15.7 g/dL)
Mean cell volume = 68 fL ( normal = 80–99 fL)

The pelvic ultrasound revealed a large uterine fibroid .

Case Discussion: 

Uterine Fibroid (Leiomyoma)
The woman has a large uterine fibroid (leiomyoma). This is causing menorrhagia and hence the microcytic anaemia from iron deficiency. It is also likely that the fibroid is accounting for her infertility history, although this warrants investigation as a separate
problem.
Fibroids are benign tumours of the myometrium which may be extrinsic (subserous) as in this case. Alternatively they may be intramural or submucosal (projecting into the endometrial cavity).

A 72 Year Old Woman With Shortness of breath and Abdominal Swelling ...

History
A 72-year-old woman has been admitted with shortness of breath. On further questioning she says she has been unwell for about 8 weeks. She has decreased appetite and nausea when she eats. She has lost weight but her abdomen feels swollen. She has generalized dull abdominal pain and constipation, which is unusual for her. There are no urinary symptoms.
She has always been healthy with no previous hospital admissions. She is a widow and did not have any children. Her periods stopped at 52 years and she has had no postmenopausal bleeding. She has never taken hormone-replacement therapy.
Examination
She appears pale and breathless on talking. Chest expansion is reduced on the right side, with dullness to percussion and decreased air entry at the right base. The abdomen is generally distended with shifting dullness. There is a mass arising from the pelvis. Speculum examination is normal, but on bimanual palpation there is a fixed left iliac fossa mass of about 10 cm diameter.

Investigations: 
Haemoglobin = 9.2 g/dL
CA-125 = 118 ku/L (normal <30ku/L)
Other routine blood work including liver function test and renal function was in normal range.

The Chest X ray shows An effusion on the right side and Ct scan of the abdomen and pelvis reveals a tumor on the left side and ascites.

Questions
• What is the likely diagnosis?
• How should this woman be further investigated?
• If the diagnosis is confirmed how should she be managed?

Answers And Discussion: 

Secondary Infertility Due To Premature Ovarian Failure..

History
A 37-year-old woman is seen in the clinic because of  secondary infertility. She had a daughter 13 years ago and a miscarriage 2 years later. She separated from her former husband and has now married again and is keen to conceive, especially as her new partner has no children.
Her last period started 45 days ago. She says that her periods are sometimes regular but at other times she has missed a period for up to 3 months. The bleeding is moderate and lasts up to 4 days. There is no history of pelvic pain or dyspareunia, and no irregular bleeding or discharge.
There is no medical history of note and she takes no regular medication.
Her partner is 34 years old and is also fit and healthy with no significant history of ill-health or medications.

Examination
There are no abnormal features on examination of either partner.

Investigations:
Day 3 follicle-stimulating hormone (FSH) = 11.1 IU/L ( normal on day 2-5 = 1–11 IU/L)
Prolactin = 305 mu/L (normal = 90–520 mu/L)
Day 21 progesterone = 23 nmol/L ( >30nmol/L if ovulation occurs)

Semen analysis report: normal volume, count, normal forms and motility.

Hysterosalpingogram report: the uterine cavity is of normal shape with a smooth regular outline. Contrast medium is seen to fill both uterine tubes symmetrically and free spill of dye is confirmed bilaterally.

Transvaginal ultrasound scan report: the uterus is anteverted with no congenital abnormalities, uterine fibroids or polyps visualized. Both ovaries are of normal morphology, volume and mobility. No follicles are noted.

Questions
• What is the cause of the infertility?
• What are the further investigation and management options?

Answers And Discussion

Primary Infertility Case Study

A 29-year-old woman and her partner are seen in the gynaecology outpatient clinic with primary infertility. They stopped using condoms 2 years ago and have had regular intercourse since then. The partner has no previous medical history of note.  He works as a manager in a hotel.
The woman also has no specific previous medical history except for an appendectomy aged 12 years. Her periods occur every 31 to 46 days and can be heavy at times but not painful. There is no intermenstrual or postcoital bleeding. She has always had normal smears and has never had any sexually transmitted infections. She takes no medications,

Examination
On examination her body mass index (BMI) is 29 kg/m2. She has slight acne on her face and her chest. There are no abdominal scars and the abdomen is non-tender with no masses palpable.
Speculum and bimanual examination are normal.

Investigations
 - Day 3 luteinizing hormone (LH) = 6.2 IU/L (Normal on day 2-5 = 0.5–14.5 IU/L)
 - Day 3 follicle-stimulating hormone = 3.1 IU/L (Normal on day 2-5 =1–11 IU/L)
 - Day 21 progesterone = 15 nmol/L (>30nmol/L if ovulation occurs)
 - A transvaginal ultrasound scan shows polycystic ovaries.

Questions
• What is the diagnosis?
• How would you further investigate and manage this woman?

Answers And Discussion

A 32 year Old woman presents with absent periods for 3 months......

A 32-year-old woman complains that she has not had a period for 3 months. Four home pregnancy tests have all been negative. She started her periods at the age of 15 years and until 30 years she had a normal 27-day cycle. She had one daughter by normal delivery 2 years ago, following which she breast-fed for 6 months. After that she had normal cycles again for several months and then her periods stopped abruptly. She was using the progesterone only pill for contraception while she was breast-feeding and stopped 6 months ago as she is keen to have another child. She reports symptoms of dryness during intercourse and has experienced sweating episodes at night as well as episodes of feeling extremely hot at any time of day.

There is no relevant gynaecological history.

The only medical history of note is that she has been hypothyroid for 10 years and takes thyroxine 100 μg per day.

She does not take any alcohol, smoke or use recreational drugs.

Examination findings are unremarkable

Investigations:
Haemoglobin  = 12.2 g/dL (normal = 11.7–15.7 g/dL)
Thyroid-stimulating hormone = 3.6 mu/L (normal = 0.5–7 mu/L)
Free thyroxine = 28 pmol/L (normal =  11–23 pmol/L)
Follicle-stimulating hormone = 45 IU/L
Luteinizing hormone = 30 IU/L
Prolactin  = 401 mu/L (normal = 90–520 mu/L)

Questions
• What is the diagnosis?
• What further investigations should be performed?
• What are the important points in the management of this woman?

Answers and Discussion

A 31 Year Old Woman Presents With Difficulty Conceiving....

A 31-year-old woman has been trying to conceive for nearly 3 years without success. Her last period started 7 months ago and she has been having periods sporadically for about 5 years. She bleeds for 2–7 days and the periods occur with an interval of 2–9 months. There is no dysmenorrhoea but occasionally the bleeding is heavy.
She was pregnant once before at the age of 19 years and had a termination of pregnancy.
She had a laparoscopy several years ago for pelvic pain, which showed a normal pelvis.
Cervical smears have always been normal and there is no history of sexually transmitted infection.
The woman was diagnosed with irritable bowel syndrome when she was 25, after thorough investigation for other bowel conditions. She currently uses metoclopramide to increase gut motility, and antispasmodics.
Her partner is fit and well, and has two children by a previous relationship. Neither partner drinks alcohol or smokes.

Investigations: 
Follicle-stimulating hormone = 3.1 IU/L ( Normal = Day 2–5 1–11 IU/L)
Luteinizing hormone = 2.9 IU/L ( Normal = Day 2–5 0.5–14.5 IU/L)
Day 21 progesterone = 12 nmol/L (>30nmol/L indicates ovulation)
Prolactin = 1274 mu/L ( Normal = 90–520 mu/L)
Thyroid-stimulating hormone = 4.1 mu/L ( Normal = 0.5–7 mu/L)

1. What is the diagnosis and its etiology?
2. How would you further investigate and manage this couple?

Answers And Discussion:

A 48-year-old woman presents with intermenstrual bleeding for 2 months

A 48-year-old woman presents with intermenstrual bleeding for 2 months. Episodes of bleeding occur any time in the cycle. This is usually fresh red blood and much lighter than a normal period. It can last for 1–6 days. There is no associated pain. She has no hot flushes or night sweats. She is sexually active and has not noticed vaginal dryness.
She has three children and has used the progesterone only pill for contraception for 5 years. Her last smear test was 2 years ago and all smears have been normal. She takes no medication and has no other relevant medical history.

Examination
The abdomen is unremarkable. Speculum examination shows a slightly atrophic-looking vagina and cervix but there are no apparent cervical lesions and there is no current bleeding.
On bimanual examination the uterus is non-tender and of normal size, axial and mobile. There are no adnexal masses.

Investigations: 
Haemoglobin 12.7 g/dL (Normal range 11.7–15.7g/dL)

Transvaginal ultrasound scan and hydrosonography is shows an endometrial polyp.

Questions
• What is the diagnosis and differential diagnosis?
• How would you further investigate and manage this woman?

Answers And Discussion: