REVIEWER

FOR WRITTEN EXAMINATION IN OBSTETRICS AND GYNECOLOGY

1.For patients with primary amenorrhea and complaining of cyclic pelvic pain,with palpable
mass anterior to the rectum (hematocolpos-blood in the vaginal canal/hematometra-blood in the
uterine cavity) THINK OF imperforate hymen or transverse vaginal septum. In imperforate
hymen there is a bulging mass at the introitus with no hymenal rim BUT in transverse vaginal
septum you can visualize the hymen and you can insert the cotton pledget halfway the vaginal
canal.HOW TO MANAGE: Excision of the septum (transvers vaginal septum) or cruciate
incision-hymenotomy/excision of the hymen-hymenectomy(impeforate hymen)

Basic knowledge on Reproductive tract anomalies:

1.Mullerian Duct (paramesonephric duct) t-fallopian tubes, uterus, cervix and upper third of
vagina

2.mesonephric(wolffian)-urinary system

*Therefore-urinary tract must be evaluated in cases of anomalies in the reproductive tract. Other
organs to be evaluated are auditory,palate, inguinal area(hernia)

3.Urogenital sinus-lower third of vagina

*Complete canalization of the vagina is complete at 20 weeks AOG

4.Sinovaginal bulb-hymen

Mullerian Abnormalities:

1.Agenesis of the Mullerian Duct-Mayer Rokitansky Kuster Hauser(MKRH) Syndrome

2.unilateral maturation- unicornuate

3.Absent midline fusion- didelphys

4.defective canalization –septate uterus

2.In postmenopausal patient with signs of estrogen stimulation like spinbarkeit/ferning and has
ovarian newgrowth THINK OF Granulosa cell tumor.This is also a consideration if you have
precocious puberty and ovarian newgrowth at the same time.WHY? because this tumor is
hormonally active in secreting ESTROGEN

3.The EARLIEST SIGN of ovulation or progesterone effect in endometrium is BASAL

VACUOLATION.This is due to glycogen vacuoles accumulation.(Glycogen accumulates in the
basal portion of the glandular epithelium)
Basic Knowledge in Ovulatory /Endometrial cycle:

Ovulatory-Follicular(estrogen-estradiol /luteal phase-progesterone)

Endometrial cycle-proliferative/secretory phase

1.Estrogen –causes endometrial proliferation. The glands are tubular,increasing amount of

stroma,mitosis,edema and glandular proliferation

*Endometrial dating is not possible during this time because the cycle length is vairable

2.Progesterone-stop endometrial growth ,no more glandular mitosis, formation of glycogen

vacuoles, edematous stroma with continued enlargement of spiral arterioles,excessive coiling and
relative stasisàmenstruation

*Basalis Layer-remains to become the new endometrium in the next cycle

*What will maintain the lifespan of the corpus luteumàbeta HCG (pregnancy)

4.What decidua is NOT present in early pregnancy ?DECIDUA VERA because it is only
formed on the latter part (14-20 weeks)when decidua capsularis(covers the conceptus) meet
decidua parietalis(covers the uterine cavity)

5.Do you know that the most common reason for fetal death due to cord accident is due to
LONG CORD

BASIC KNOWLEDGE ON CORD

Ave length- 40-70 cm long

Short cord-<32 cms IUGR, congenital malformations, fetal distress,two fold risk of fetal death

Long cord->100 cms-cord entanglement, prolapse, anomalies, acidemia and demise

2 ARTERIES 1 VEIN

1 single umbilical artery-congenital anomalies(targeted ultrasound and fetal 2 d

echocardiography)

Velamentous insertion of the cord –umbilical vessels spread within the membrane at a distance
from the margin which may lead to compression ,fetal hypoperfusion and acidemia

Furcate insertion-rare ,central insertion with loss of Wharton jelly as it insert the placenta with
the amnion sheath covering .Prone to twisting, compression and thrombosis.

Delayed cord clamping -2-3 cms from fetal abdomen ,delayed clamping up to 60 secs or after
cessation of pulsation .BENEFITS; increase total iron stores, decrease anemia
6.Patient complaining of fever, arthralgia, maculopapular rash and postauricular
lymphadenopathy,THINK OF RUBELLA.Test for rubella IgG and IgM.If rubella IgG is
positive and Ig M is negative it means that the patient is PROTECTED.If Ig M is positive she is
INFECTED.High Avidity Ig G –will differentiate past infection or a recent infection.

FETAL EFFECTS:CONGENITAL ANOMALIES

0-12 weeks -90%

13-14 weeks 54%,

end of second trimester-25%

Sensorineural deafness-most common single defect

MMR vaccination-contraindicated during pregnancy

7.The most common cause of MALE PSEUDOHERMAPHRODITISM IS ANDROGEN

INSENSITIVITY SYNDROME due to aromatase deficiency WHILE the most common cause of
FEMALE PSEUDOHERMAPHRODITISM IS CONGENITAL ADRENAL HYPERPLASIA
due to secretion of DHEA and DHEAS by the adrenal glands.

1.MALE PSEUDOHERMAPHRODITISM: MALE BUT THE EXTERNAL GENITALIA

LOOKS FEMALE BECAUSE OF LACK OF ANDROGEN

DESCRIPTION:.CHROMOSOME XY,NO UTERUS NO OVARIES BUT WITH

INCOMPLETE MUSCULINIZATION OF THE EXTERNAL GENITALIA

2.FEMALE PSEUDOHERMAPHRODITISM-FEMALE BUT WITH SIGNS OF

MUSCULINIZATION OF THE EXTERNAL GENITALIA DUE TO EXCESSIVE
ANDROGEN

DECRIPTION: KARYOTYPE XX,WITH UTERUS AND OVARIES,CLITORAL

HYPERTROPHY,LABIOSCROTAL FOLD

REMEMBER THAT TESTOSTERONE CAN BE PRODUCED BY OVARIES AND

ADRENAL GLAND THUS TO IDENTIFY ADRENAL GLAND AS THE CULPRIT
REQUEST FOR DHEA/DHEAS

8.In a patient who presents with hydrothorax, ascites and solid ovarian tumor ,THE MOST
COMMON OVARIAN TUMOR IS FIBROMA.This is the so called MEIGS syndrome.The
tumor is solid on ultrasound but BENIGN. Another tumor that is also SOLID on ultrasound and
benign with signs of hyperestrogenism/functional ,THINK of Thecoma .Management for both
will be oophorectomy. To rule out malignancy, frozen section must be done .If malignant, the
complete management will be PFC ,THBSO ,omentectomy, BLND,PALS(older patient with
children).For young patient,PFC, salpingooophorectomy,omentectomy,BLND,PALS

9.For iron supplementation 30 mg if hemoglobin is 12 gms/dl, for twin pregnancy double the
iron to 60 mg but for hemoglobin of 8 gms use IRON sucrose IV.Blood transfusion is only
recommended if patient is for surgery or symptomatic

Basic on Iron:

Total iron content of normal adult woman-2-2.5 grams

1000 mg iron is required for normal pregnancy

Requirement after mid pregnancy-6-7 mg/day.

The most common cause of anemia in pregnancy are iron deficiency anemia and anemia due to
blood loss.

DIAGNOSIS OF IRON DEFICIENCY ANEMIA:

1.hypochromic, microcytic red cells

2. decrease serum ferritin

3.no stainable bone marrow iron

*MCV will differentiate iron deficiency anemia(normal) from thallasemia(LOW less than 75)

After treatment with iron the reticulocyte count will increase but not that marked due to
hypervolemia during pregnancy

10.BASIC ON ULTRASOUND: Using TVS the Gestational sac is seen at 5 weeks and FHT at 6
weeks. It is expected the FHT must be present if the embryo is 25 mm in transvaginal ultrasound.
Thus if embryo is >25 mm with no FHT diagnosis is embryonic demise. If on ultrasound the
MSD is 1.1 cm with no embryo and repeated after 2 weeks with same findings- Diagnosis is
blighted ovum or anembryonic pregnancy. Management is wait for spontaneous expulsion

TRANSABDOMINAL ULTRASOUND: Gestational sac is seen at 6 weeks and fetal heart

activity at 7 weeks.

REMEMBER: Have 2 ultrasound done 2 weeks apart before you commit that the pregnancy is
anembryonic (blighted) or there is embryonic demise

Fetal aging by ultrasound is MORE accurate during first trimester with a difference of 7-10 days
to actual age of gestation. The best parameter used to determine AOG during FIRST trimester is
crown rump length,
SECOND trimester-Biparietal diameter, THIRD trimester –femoral length.For estimation of fetal
weight use the ABDOMINAL CIRCUMFERENCE

11.For GDM/OVERT DM it is recommended that CONGENITAL ANOMALY SCAN BE

DONE ON THE SECOND TRIMESTER (18-24 weeks )

Diagnosis of GDM/OVERT DM(Williams 24th edition)

FBS-126 ,RBS-200,HGb A1C-6.5 (OVERT)

GESTATIONAL DM

FBS = <105 and 2 hr postprandial <120 (diet)

FBS= >105 2 hour postprandial >120 (INSULIN)

Congenital anomalies are more common in Overt than in gestational DM.The other
complications are almost similar in the two conditions. What will indicate uncontrolled Blood
sugar clinically: CBG monitoring: Target values (FBS = <93(WHO)or 95 mgs/dl,1st hr =<140
mgs /dl,2nd hr-120 mg/dl ,polyhydramnios or increasing weight of both mother and baby above
normal

INSULIN IS THE ONLY treatment allowed for Diabetes during pregnancy. However ,recently
metformin and glyburide are already recommended as safe drugs during pregnancy.

12.BASIC ON ANATOMY:

DIAGNOSIS OF COMMON PROBLEMS OF THE GENITAL TRACT:

Hematoma at the skin and subcutaneous tissue after CS-superficial epigastric vessels

Hematoma underneath the rectus abdominis specially seen in Maylard incision-inferior “deep”
epigastric vessels

Direct Inguinal hernia-seen along Hesselback triangle bounded by inferior epigastric,inguinal

ligament,rectus abdominis

Masses seen at 5 or 7 oclock position of the labia –Think of Bartholins duct cyst

Masses at the line of episiotomy- inclusion or epithelial cyst,if with accompanying pain during
menses-think of endometriosis of the scar .Management-excision

Management during pregnancy-none unless infected(antibiotics/marsupialization) or

obstructing birth canal(Aspiration)
 Non pregnant Bartholins Abscess-antibiotics ,marsupialization) ,Bartholins cyst 40 yrs
old and above-excision to rule out malignancy

Muscles cut during episiotomy:Bulbocavernosus,transverse perineal muscles,external anal

spincter,pubococcygeus(deep)

Hematoma/abscess in the ischioanal fossa in the posterior triangle may extend to the other side
of the pelvis

Ligaments of the uterus:

Round ligament-anterior and inferior to the fallopian tube, supplied by sampson artery ,covered
by mesoteres and terminate in the labia majora

Infundibulopelvic ligament or suspensory ligament of the ovary-where ovarian artery passes and
it suspends the ovary and fallopian tubes

Broad ligament-winglike peritoneum at the sides of the uterus covering the fallopian
tubes(mesosalpinx),ovary(mesovarium),round ligament(mesoteres).Uterine arteries passes thru
this ligament.

Transverse cervical ligament/cardinal/mackendroth-BEST support of the uterus

Uterosacral ligaments-posterior uterus to the sacrum. Usually involved in

endometriosis(thickening/nodulations/shortening)

NERVE SUPPLY:

Uterine contractions are transmitted thru T10-L1,cervix and upper part of birth canal-S2-
S4,lower part of birth canal and perineum-pudendal nerve

13.For patient with missed abortion ,since cervix is closed prostaglandin like misoprostol or
dinoprostone ,foley catheter or laminaria (hygroscopic dilators) can be used to open the cervix
and start oxytocin drip. After expulsion do completion curettage

14. The ideal time to do prophylactic cerclage in patient with incompetent os(cervical
insufficiency-new nomenclature) is 14-18 weeks .Why at this time? because we have to rule out
chromosomal anomalies after the first trimester. HOWEVER IF THE CERVIX is already open
do the cerclage right away(Rescue or emergent cerclage). Patients with incompetent os have
recurrent late abortion with shortening of the cervical length <25mm or with cervical funneling.

TYPES OF CERCLAGE:

a. Mc Donalds- purse string suture, starting at 12 o clock, avoid puncturing 3 and 9 oclock
(blood supply of the cervix).Remove at term and deliver vaginally
 b. Shirodkar- suture is buried underneath the mucosa and patient is delivered by CS. This is
more difficult to do and bloody

15.Patient with Endometrial polyp will complain of intermenstrual spotting/profuse bleeding .

BASED ON THE ultrasound findings a single feeding vessel to differentiate it with submucous
myoma.

Patient must undergo either SALINE INFUSION SONOGRAPHY FOR CONFIRMATION OF

DIAGNOSIS OR HYSTEROSCOPY (DIAGNOSTIC/THERAPEUTIC) for diagnosis and
resection of polyp. If the submucous myoma is big more than 4 cms and not resectable right
away may give GnRh first for 4-6 months to shrink the size prior to resection. The most common
submucous myoma that will cause infertility is the Type 1 fundal . Type 0-totally in the cavity,
Type 1->50% in the cavity, Type 2-<50% in cavity

16.Amenorrhea,abdominal pain and vaginal bleeding ARE THE Classic TRIAD of ECTOPIC
pregnancy. REMEMBER that the B HCG discriminatory index is 1500 iu, WHICH MEANS AT
THIS LEVEL gestational sac must be seen on TVS. For NORMAL INTRAUTERINE
pregnancy the DOUBLING time of Beta HCG is 48 hours. On ultrasound ,no intrauterine
gestational sac, with a mass at the adnexa with a ring of fire pattern. SO IF THE BETA HCG is
1700 and no gestational sac on TVS,WHAT IS THE DIAGNOSIS?

How to manage ectopic pregnancy?

Depends of the age , parity ,desire for future pregnancy ,ruptured and the hemodynamic
instability

1.Medical-methotrexate ( unruptured, less than 3 cms, < than 6weeks AOG, no fetal heart beat, B
HCG less than 1500).Disadvantage: close monitoring of the size of mass and B HCG

2.Laparoscopy-hemodynamically stable/laparotomy-ruptured and not stable

Salpingectomy-ruptured or unruptured ( not desirous of pregnancy)

Salpingotomy-incised ,removed the products and suture the incision

Salpingostomy-< than 2 cms, incised ,remove the products and leave it open

* Heterotopic pregnancy-one intrauterine and another pregnancy in ectopic site

*Most common site of EP- ampulla, earliest to rupture-isthmic, rupture at a more advanced
AOG and more bloody –interstitial(where there is joining of uterine and ovarian supply)
17.REMEMBER THAT THE FOLLOWING DRUGS ARE CONTRAINDICATED IN

PREGNANT PATIENTS: Isoretinoin, phenytoin, ACE inhibitors(kidneys),

ofloxacin(bones),chloramphenicol(gray baby syndrome),tetracycline(yellowish discoloration of
teeth).

Sulfamethoxasole is contraindicated in the late second and third trimester because of

hyperbilirubinemia in newborn and nitrofurantoin causes hyperbilirubenemia in G6PD

18.ANTIPHOSPHOLIPID ANTIBODY SYNDROME

Clues: Suspected if patient had history of embryonic demise, fetal death and pre eclampsia

Diagnosis: Lupus anticoagulant, anticardiolipin, anti beta 2 glycoprotein

TREATED with Heparin and aspirin

19.CONTRACTION STRESS TEST IS TEST OF UTEROPLACENTAL FUNCTION.

Stimulate contractions by nipple stimulation or use oxytocin and must attain 3 contractions in 10
minutes with >25 mmhg uterine pressure

POSITIVE -persistent late deceleration in more than 50 % of the tracing

NEGATIVE-NO late deceleration observed

SUSPICIOUS-Occassional late deceleration

HYPERSTIMULATORY-Late deceleration but with too frequent uterine contractions less than 2
mins

UNSATISFACTORY-LESS than 3 contractions in 10 minutes

20.LEOPOLDS MANEUVER:

LM1- fundal grip(what occupies the fundus)

LM2-lumbar/umbilical grip(what occupies the flanks)

LM3-pawlik grip(what occupies the lower uterine segment)

LM4-pelvic grip(where is the cephalic prominence-if same side as the back (face),opposite of the
back(vertex)

*What maneuver is the examiner facing the patient legs?

CARDINAL MOVEMENTS OF LABOR

a.Engagement-biparietal diameter/greatest transverse diameter passes the inlet

Asynclitism-lateral deflection of the sagittal suture either anterior or posterior

a. anterior asynclitism-anterior parietal bone presents and sagittal suture is deflected to

the sacrum
b. posterior asynclitism-posterior parietal bone presents and sagittal suture is deflected
towards the symphysis pubis

b.Descent-first requisite for the birth

c.Flexion-suboccipitobregmatic diameter(9.5 cms) replaces the large occipitofrontal

diameter(11.5 cms)

d.Internal rotation-movement toward the anterior portion underneath the symphysis pubis

*This is the one not completed in POT,POP

e. extension- the movement facilitated by Ritgens maneuver

f. external rotation(restitution) rotating back to ischial tuberosity whether left or right

g.expulsion

21.On IE if you palpate the orbital ridge ,anterior fontanel and root of the nose the presentation is
BROW. HOW WILL YOU DIFFERENTIATE FACE AND BREECH?

FACE-Leopolds IV-cephalic prominence is on the same side as back in contrast to vertex and on
IE the bony protuberance(malar prominence is in triangular relationship with the
opening(mouth).If you insert your finger inside the opening ,baby will suck it

Mentum anterior-delivered vaginally .NSD or forceps

Mentum posterior-if will not rotate during internal rotation -CS

BREECH-Leopolds 1- round ballotable mass,Leopolds 3-irregular large soft ,nodular body

IE: Bony protuberance (ischial tuberosity ) is in line with the opening which is the
anus .If you insert your finger in the opening ,you will get meconium

1.Frank breech- thighs are flexed over the abdomen and legs are extended-BEST candidate for
vaginal delivery AND PINARDS is performed to deliver the feet

2.Complete breech-thighs are flexed and legs are flexed-REMEMBER :you don’t do PINARDS
in this type of breech BUT JUST GRASP THE FEET
3.Incomplete or footling-one or both thighs is /are extended-NOT a candidate for vaginal
delivery because it does not dilate cervix to full dilatation and high risk for cord prolapse.YOU
ALSO DON’T DO PINARDS IN THE TECHNIQUE but JUST GRASP THE FEET

TYPES OF VAGINAL DELIVERY:

1.Spontaneous breech delivery- spontaneous delivery with no assistance from the obstetrician

2.Partial breech delivery-wait for spontaneous delivery till the navel and assist delivery thereafter

3.total breech delivery-assist the delivery from feet upwards

Maneuvers in breech delivery:

1.Pinards-lateral deflection of the thigh ,press on popliteal fossa and deliver the legs

2.Loveset-press on the antecubital fossa to flex the arm and sweep it from face to chest

3.Maureceu smellie veit Maneuver-press with two fingers(index and middle) the maxilla while
the other hand at the suboccipital area to flex the head

4.Prague –use for baby in breech in supine position to deliver the head.Grasp the feet while the
other hand support the body and pulling the feet towards maternal abdomen

WHAT TO DO IN ENTRAPPED HEAD?

1.use pipers forceps-long blade and shank

2.durhsens incision-2,10 and add 6 if not yet successful

3.symphysiotomy

22.PREGNANT WITH MYOMA:

It is expected that the size will increase especially during the first trimester of pregnancy because
of the hormones ESTROGEN AND PROGESTERONE.

During the second trimester-increase in size or no change, while in the third trimester-no change
or may even decrease in size..

DO NOT OPERATE MYOMA DURING PREGNANCY BECAUSE IT IS BLOODY. In

patient who complains of pain THINK OF DEGENERATION and the most common is
CARNEOUS OR RED degeneration which can be treated with pain relievers. Myoma can cause
abortion,preterm labor ,p previa, abruptio placenta, tumor previa if located in the lower segment
or cause atony post partum .THUS IF PATIENT HAS big myoma and she has completed her
reproductive career CS HYSTERECTOMY CAN BE DONE.
NON PREGNANT:

For NON PREGNANT patient, the most common degeneration of myoma is hyaline
degeneration due to decrease in blood supply when the myoma outgrows its blood supply.In post
menopausal patient,the expected degeneration is calcific degeneration because of the absence of
hormones but it the mass increases in size during menopause think of sarcomatous degeneration.

Management of myoma in non pregnant patient depends of the following:

1.size if the uterus is 14 weeks size or more

2.patient is symptomatic-bleeding,urinary and bowel symptoms

3.infertility/recurrent pregnancy loss

Myomectomy for young/desirous of pregnancy or hysterectomy for patient that has completed
her reproductive career. For myomectomy-a transverse incision is recommended because of less
bleeding. GnRh can be given for 4 months prior to myomectomy for huge myoma to save the
uterus. GnRh if given will down regulate the secretion of FSH and LH thus no estrogen and
progesterone.However, remember that the initial dose will have an initial flare, meaning it is
stimulatory at the first dose. In GnRh antagonist there is no initial flare and the effect is an
outright inhibitory effect but this is very expensive.

OTHER DRUGS TO DECREASE THE SIZE OF MYOMA

ARE:COC,DMPA,PROGESTINS,LNG IUS

23.Accessory lobe of the placenta(placenta succenteriata)- is usually associated with retained

placenta post partum.CHECK THE PLACENTA !!!Follow the blood vessels from the cord to the
edge.If you noticed there is interruption in the course of blood vessels ,the possibility is there.

Infarction-seen in hypertension

Chorioangioma- more than 5 cms leads to AV shunting leading to fetal anemia and hydrops

Tumors metastatic to placenta-melanomas,leukemia,lymphoma and breast cancer

24.For patients with vulvar hematoma post partum:

CLUES:they will complain of vulvar pain or difficulty of urination,hypotension or pallor.

Most common in the labia majora because of the vestibular bulb located at the labia majora. If
located at the deep perineal space ,it may extend to the broad ligament and patient will have to
undergo exploration.
The size cut off is 6 cms. Less than 6 cms and non expanding observe but if the size is more than
6 cms or the size is expanding,-

INCISED/LIGATE BLEEDERS, SUTURE THE CAVITY,TRANSFUSE BLOOD IF NEEDED

AND GIVE ANTIBIOTICS.

WHAT BLOOD VESSELS ARE INVOLVED?

Vulvar hematoma- pudendal artery

Upper third of the vagina- cervico vaginal branch of the uterine artery/vaginal artery

Middle third-middle rectal artery

Lower third-internal pudendal artery

25.POST OPERATIVE FISTULA, POST TAHBSO-WHO ARE AT RISKS?

Patient who had severe adhesions, extensive manipulation, large tumors, malignancy. HOW TO
EVALUATE PATIENTS? Methylene blue dye test thru IFC and look for blue colored dye
spilling in the OPERATIVE SPONGE inside the vaginal vault-Diagnosis is VESICOVAGINAL
FISTULA.

IF NEGATIVE:GIVE THE PATIENT RIFAMPICIN-orange colored URINE spillage will be

seen in the OPERATIVE SPONGE inside the vagina-DIAGNOSIS IS URETEROVAGINAL
FISTULA;

HOW TO PREVENT FISTULA DURING OR:

a.Dissection along the plain

b.Use Metz instead of blunt dissection

c.avoid cauterization of the bladder

d.Correct anemia/build up nutrition of patient

e.Ureteral stenting prior to difficult surgery to avoid injury

26.POST PARTUM METRITIS: CLUES: vaginal bleeding,abdominal pain ,fever,foul smelling

discharge, cervix tender on wriggling,uterus and adnexa are tender.WHAT IS THE SINGLE
MOST IMPORTANT PREDISPOSING FACTOR?ROUTE OF DELIVERY ,most common in
CS.There are other factors involved like no of IE ,anemia, PROM, prolonged labor, internal
monitoring low socioeconomic status and meconium stained AF.

Diagnostics:CBC platelet,urinalysis, gram stain culture of discharge, blood culture, TVS,CT

MRI if indicated, coagulation studies if with sepsis
Management:Clindamycin ,gentamycin plus ampicillin if with sepsis/enterococcal

Clinda Aztreonam,extended spectrum penicillin,cephalosporin,vancomycin added if with

S aureus ,Ampicillin +gentamycin+metronidazole,carbapenem

27.ABRUPTIO PLACENTA:CLUES:vaginal bleeding, abdominal pain,woody or tetanic

contraction of the uterus with difficulty hearing the FHT.WHAT IS THE MOST COMMON
RISK FACTOR?PRIOR ABRUPTIO .HYPERTENSION IS JUST SECOND ON THE LIST.

REMEMBER!!! NEGATIVE ULTRASOUND DOES NOT RULE ABRUPTIO.BASIS FOR

DIAGNOSIS IS STILL CLINICAL SIGNS AND SYMPTOMS.MOST DREADED
COMPLICATION IS DIC thus COAGULATION PROFILE IS PART OF THE WORK UPS.IN
REMOTE AREA WITH NO LABORATORY CLOT OBSERVATION TEST IS AN
ALTERNATIVE

MANAGEMENT OF ABRUPTIO DEPENDS ON THE CONDITION OF MOTHER AND

BABY.IF MATERNAL OR FETAL CONDITION IS AT STAKE BECAUSE VAGINAL
DELIVERY IS NOT IMMINENT DO CS!!FOR VAGINAL DELIVERY-DO IMMEDIATE
AMNIOTOMY.WHY!!!

a. hasten delivery

b.decrease the bleeding

c.decrease the egress of thromboplastin

CASE A: WITH SIGNS OF ABRUPTIO ,CTG WITH LATE DECELERATION,CERVIX 4

CMS ,WHAT IS THE MANAGEMENT?

CASE B:ABRUPTIO PLACENTA,FETUS IS DEAD,MOTHER IS BLEEDING

PROFUSELY,CERVIX 1 CM OPEN

CASE C:ABRUPTIO PLACENTA: FETUS IS DEAD , MINIMAL BLEEDING,CERVIX 6

CMS OPEN ?

DURING CS YOU WILL NOTICE THAT THE UTERUS IS BLUISH WITH HEMATOMA.
This is called as Couvelaire uterus or uteroplacental apoplexy and this is not an indication for
hysterectomy unless there is atony.

28.PLACENTA PREVIA:CLUES: painless vaginal bleeding, no uterine contractions, soft uterus

FHT can be heard. Diagnosis is by Pelvic ultrasound, the most accurate is transvaginal rather
than transabdominal, transperineal. BUT DO GENTLE SPECULUM EXAMINATION FIRST
,YOUR PATIENT MIGHT BE HAVING LESIONS (ex. Polyp, myoma, erosions)THAT
CAUSE THE BLEEDING.
MANAGEMENT IS EXPECTANT!! It means if the AOG is still preterm Give steroids to
accelerate surfactant production, tocolytic if with contractions or to allow steroids to have its
effect ,correct anemia. If there is a probability of delivery less than 32 weeks , give MgSo4 for
neuroprotection. Repeat ultrasound must be done at 35 weeks for the final localization of the
placenta. If still placenta previa and the AOG reaches 37 weeks DO CS especially for placenta
previa totalis, Placenta previa partialis and low lying less than 2 cms from the internal os(90%
will bleed during labor).More than 2 cms from the os ,trial of labor and CS is only done if with
profuse bleeding.

29.ABNORMAL ADHERENCE OF THE PLACENTA:WHAT IS THE PATHOLOGY? Due to

absence of the NITABUCHS LAYER at the basalis layer of the decidua

Adherent-placenta Accreta

Invades- Increta

Penetrates-Percreta(up to serosa or bladder)

CLUES:placenta previa in a previous CS or hysterotomy scar, previous D and C ,smoking as

risk factors

Diagnosis by Ultrasound:

PLACENTA PREVIA ON Ultrasound(BASES)

• PLACENTAL LAKES, ABSENCE OF SONOLUSCENT SPACE,AND ON

DOPPLER PENETRATION OF BLOOD VESSELS ON THE MYOMETRIUM

MANAGEMENT:

Classical Cesarean with Hysterectomy without removal of the placenta/PREPARE BLOOD

QUESTION: In CS hysterectomy at what level can you injure the ureter? WHY? Clamping of
the Uterine arteries, because the ureter is posteromedial in relation to the uterine artery

OPTION FOR PATIENTS WITH NO BLOOD PREPARED: Do not remove the placenta
,LEAVE it behind ,GIVE METHOTREXATE, AND RE EXPLORE PATIENT ONCE WITH
BLOOD READY

30.WHAT IS HELLP SYNDROME? HEMOLYSIS ,ELEVATED LIVER ENZYMES,LOW

PLATELETS

THIS is indicative of severity and an indication for TERMINATION OF PREGNANCY

HOW WILL YOU TERMINATE? DEPENDS ON THE FETAL STATUS/INDUCIBILITY OF
CERVIX(BISHOPS SCORE).If BISHOP SCORE IS NON INDUCIBLE,4 OR LESS -NON
INDUCIBLE AND DO CS

COMPONENTS OF BISHOP SCORE:

Score Dilatation Effacement Station Consistency Position

0 closed 0-30 -3 firm posterior

1 1-2 40-50 -2 medium midposition

2 3-4 60-70 -1 soft anterior

3 >5 >80 +1+2 - -

CERVICAL RIPENING/AND OR LABOR INDUCTION

• Mechanical-Transcervical catheter
• Hygroscopic cervical dilators
• Prostaglandin E1 100ug oral or 25 ug vaginal misoprostol
• Prostaglandin E2-Dinoprostone 10 mg

INDUCTION/AUGMENTATION:

• Oxytocin 1 amp of 10 u in liter(Low dose protocol-0.5-1.5mu/min every 15-40

min interval.HIGH dose-4.5-6 mu/min every 15 min)
• Prostaglandin E1 100ug oral or 25 ug vaginal misoprostol

31.POSTPARTUM HEMORRHAGE: BLOOD LOSS OF MORE THAN 500 CC IN NSD or

MORE THAN 1 LITER IN CS.

• UTERINE ATONY- the most common cause of EARLY POSTPARTUM

HEMORRHAGE(less than 24 hrs postpartum),WHILE RETAINED PLACENTA is the
most common cause of LATE POSTPARTUM HEMORRHAGE(>24 hours
postpartum).

ATONY CLUES: vaginal bleeding, uterus SOFT AND BOGGY ,PALPATED ABOVE NAVEL

IF THE UTERUS IS WELL CONTRACTED, WHAT IS THE DIAGNOSIS????????

THINK OF LACERATIONS,DO SPECULUM LOOK FOR THE BLEEDERS,SUTURE AND

LIGATE
 • WHAT ARE THE RISKS FACTORS FOR ATONY?

PRIMIPARITY/MULTIPARITY

LABOR ABNORMALITIES EX: PROLONGED LABOR

OVERDISTENDED UTERUS(HYDRAMNIOS, MULTIFETAL,MACROSOMIA)

INDUCTION /AUGMENTATION OF LABOR

• WHAT IS THE MANAGEMENT FOR ATONY?

1.Bimanual uterine compression

2.Uterotonics
agents(oxytocin/methyergometrine/misoprostol(E1)/dinoprostone(E2)/carboprost(F2)

REMEMBER:DONT GIVE METHYL ERGOMETRINE AND CARBOPROST TO

ASTHMATIC/HYPERTENSIVE PATIENTS

OXYTOCIN BOLUS IS NOT GIVEN AS IV BOLUS BECAUSE IT CAUSES

HYPOTENSION

3.Double IV line/prepare blood/IFC ,alert anesthesiologist/oxygen inhalation

4.Explore the vagina cervix for lacerations /uterus for retained placenta

5.uterine packing /balloon tamponade (IFC-80 ml of water)

IF UNRESPONSIVE, EXPLORE PATIENT

-NOT DESIROUS OF PREGNANCY: HYSTERECTOMY

• TOTAL HYSTERECTOMY- IF WITH STABLE VITAL SIGNS

• SUBTOTAL IF UNSTABLE AND THERE IS A NEED TO SHORTEN THE
OPERATIVE TIME

-DESIROUS OF PREGNANCY:BE CONSERVATIVE

Uterine artery ligation

Uterine compression suture or Brace compression- ex.B-Lynch, Cho

Internal iliac artery ligation or hypogastric artery ligation ( Branches : umbilical,

superior vesical,obturator ,vaginal,inferior vesical,middle rectal,internal pudendal)

Angiographic embolization
 Pelvic umbrella pack

BUT IF THE ABOVE CONSERVATIVE MANAGEMENT FAILED AND MATERNAL

CONDITION IS IN JEOPARDY :DO HYSTERECTOMY

32.PROM-rupture of membranes prior to onset of labor. If the AOG is less than 37 weeks the
term used is PPROM. If the patient is in early labor- SROM

RISKS FACTORS:

1.INFECTION/HOW?: MOST COMMON: Bacterial endotoxinàincreased tumor necrosis

factor/interleukinàIncreased PGàuterine contractions; Released of proteases causes weakening
of membranes ,release of fetal CRH which will stimulate prostaglandin secretion

2.Low socioeconomic status

3.BMI-less than 19.8

4.Nutritional deficiencies

5.Cigarette smoking

6.Multifetal gestation

MANAGEMENT OF PPROM:

1.Grp. B streptococcus infection prophylaxis is recommended for patients with AOG-24 weeks
onward

Antibiotic of choice: Pen G 5 million then 2.5-3 mil every 4 hrs till delivery

Alternative:ampicillin 2 gms IV then 1 gm every 4 hrs or 2 gms every 6 hrs till delivery

PENICILLIN ALLERGIC: cefazolin/clindamycin/vancomycin

2.Corticosteroid for lung maturity-24-33 weeks BUT recently based on CPG can still be given
for less than 37 weeks AOG

3.Tocolytics-only used to allow time for the corticosteroid to have an effect

4.Less than 24 weeks- expectant /or induction/counselling ONLY

REMEMBER THAT YOU HAVE TO GIVE MGSO4 FOR NEUROPROTECTION OF

PRETERM INFANTS if AOG is 24-31 weeks
34.What TOCOLYTIC is recommended in the following cases ?

• DIABETES- CALCIUM ANTAGONIST/MGSO4

Don’t give BETA AGONIST LIKE TERBUTALINE/ISOXUPRINE-causes an increased blood

sugar.

• HEART DISEASE-MGSO4

DON’T GIVE BETA AGONIST/CALCIUM ANTAGONIST CAUSES TACHYCARDIA

33.Posterm/prolonged-42 completed weeks AOG. Postmature refers to clinical features of

postmaturity after delivery like the following:

Wrinkled patchy peeling skin,long thin body,open eyed,unusually alert,old,worried

WHAT ARE THE DANGERS?

Placental dysfunction/fetal distress/oligohydramnios/thickly meconium stained AF/fetal

growth restriction/macrosomia

How to manage?

41 weeks choose between fetal surveillance vs induction of labor

How to induce?

Prostaglandins for ripening/labor induction-PGE2(dinoprostone),PG E1-misoprostol,

Mechanical:

1.hygroscopic dilators(laminaria)

2.foley catheter

3.membrane stripping

How to do the surveillance?

NST ,sonographic evaluation of AF, BPS twice weekly

41 weeks –induce if there is hypertension, decreased fetal movements, oligohydramnios

Uncomplicated :

42 weeks –Induced if with fetal compromise, oligohydramnios, cervix favorable

WHAT WILL DETERMINE INDUCIBILITY OF THE CERVIX? BISHOP SCORE

Components:

1.Dilatation

2.effacement

3.station

4.cervical consistency

5.cervical position

SCORE OF 9-SUCCESSFUL

SCORE-4 OR LESS-NON INDUCIBLE

34.Ovarian cyst in complication: CLUES: hypogastric heaviness with on and off pain, Internal
examination :with palpable cystic to doughy mass on the adnexal area which is tender on
palpation.

WHAT ARE THE POSSIBLE COMPLICATIONS?

1.Torsion- the most common especially for dermoid cyst because it is usually heavy and floats in
the abdomen due to its sebum content, on IE usually located anterior to the uterus

2.Rupture- especially for endometrioma /corpus luteum cyst . Clues for rupture: sign of
peritoneal irritation-abdominal pain,with abdominal tenderness,muscle guarding and
hypovolemia

3.infection- patient will present with pain, fever and leucocytosis

How to manage case of ovarian cyst with torsion?

If NECROTIC and preservation not feasible –salpingooophorectomy

If NOT NECROTIC grossly ,DETORSION and observe for revascularization and DO

oophorocystectomy. Previous belief of embolism during detorsion is NOT significant.

How to manage Ruptured endometrioma?

Oophorocystectomy if patient is still young and oophorectomy if already old

For infected ovarian tumor –oophorectomy

Diagnostic test to determine if ONG is malignant

1.Ultrasound- determine the sassone score (9 and above), IOTA simple rules ,Doppler studies to
determine intratumoral flow, Tumors markers(not sensitive and specific but may help)

B rules:

• Unilocular cyst
• Presence of solid component where the solid is less than 5mm
• Acoustic shadows
• Smooth multilocular tumor less than 100 in largest diameter
• No detectable blood flow on Doppler

M rules

• Irregular solid tumor

• Ascites
• At least 4 papillary structures
• Irregular multilocular solid tumor with a largest diameter of at least 100mm
• Very high color content on doppler

For Ovarian Tumor with solid component: THINK OF POSSIBLE MALIGNANCY-FROZEN

SECTION IS A MUST!!!!!

What if MALIGNANT?

Young and desirous of pregnancy-depends on the stage 1A -PFC, USO OMENTECTOMY

WITH LYMPH NODE DISSECTION

Old patient/not desirous of pregnancy regardless of stage or young patient with Stage 1B and
above- PFC,TAHBSO,OMENTECTOMY,BLND

35.HYPERTHYROIDISM IN PREGNANCY:

CLUES: SIGNS AND SYMPTOMS( palpitations/tachycardia/heat intolerance,loss of weight,

exophthalmos,thyromegaly,tremors,etc. )

LABORATORY RESULTS: Decreased TSH, high FT3 and FT4

MANAGEMENT DURING PREGNANCY: PROPHYLTHIOURACIL-inhibits conversion of

T3 and T4 and crosses the placenta less readily than methimazole(associated with
esophageal/choanal atresia,aplasia cutis if given during first trimester of pregnancy)

WHAT IS THE DANGER IF UNTREATED: THYROID STORM

WHAT ARE THE MANIFESTATIONS OF THYROID STORM?

Congestive heart failure,pulmonary hypertension,cardiomyopathy

MANAGEMENT OF THYROID STORM:

1.Thioamides-PTU 1000 mg po then 200 every 6 hrs

2.Propanolol 10-40 mg po every 4-6 hrs for heart rate control

3.Na iodide 500-1000 IV every 8 hrs or potassium iodide 5 gtt po every 8 or lugols solution 10
gtt every 8 hrs

For allergy to iodine: Lithium carbonate-300 mg po every 6 hrs

4.Dexamethasone 2 mg every 6 hrs or hydrocortisone 100 mg every 8 hrs for 24 hrs

WHAT ARE THE POSSIBLE PREGNANCY OUTCOME?

1.MATERNAL

Abortion , pre eclampsia, heart failure ,death

2.FETAL

Thyrotoxicosis prematurity,growth restriction,stillbirth,hypothyroidism,goiter

HYPOTHYROIDISM: High TSH and low FT3 FT4

Management:Levothyroxine

36.FATTY LIVER IN PREGNANCY:

IS THE MOST COMMON CAUSE OF LIVER FAILURE IN PREGNANCY

CLUES: SIGNS AND SYMPTOMS( nausea ,vomiting,anorexia,epigastric pain and progressive

jaundice),hypertension,proteinuria and edema

LABS:DECREASED:fibrinogen,albumin,cholesterol,clotting factors,platelets,

INCREASED;bilirubin,SGPT,WBC,LDH,

WHAT ARE THE COMPLICATIONS?

1.DUE to capillary leakageàHemoconcentration,kidney injury,edema,ascites

2.DUE to Hemoconcentrationàdecreased uteroplacental perfusion,fetal death

3.hypoglycemia,hepatic encephalopathy,coagulopathy
37.SYPHILIS IN PREGNANCY

CLUES: SIGNS AND SYMPTOMS DEPENS ON THE STAGE AND DURATION OF

ILLNESS

1.PRIMARY SY-chancre- SOLITARY,PAINLESS ulcer with raised ,red,border with smooth

base

2.SECONDARY-macular rash at the plantar and palmar surfaces, patchy alopecia,

flesh papules and nodules at the perineum (condyloma lata) fever, malaise, anorexia,
headache, myalgias and arthralgias

3.LATENT SY- no clinical manifestation after an untreated primary or secondary SY

4.TERTIARY/LATE SY-not seen in the reproductive age

WHAT IS THE DEFINITIVE DIAGNOSTIC TEST?- DARKFIELD EXAMINATION OR

DIRECT IMMUNOFLOURESCENT

VDRL/RPR ARE JUST SCREENING TEST WHICH NEEDS CONFIRMATION WITH

TREPONEMAL SPECIFIC TESTS LIKE TPHA/FTA-ABS/TPPA

WHAT WILL BE THE COMPLICATIONS?

1.Preterm delivery

2.congenital syphilis(hydrops,ascites,hepatomegaly,placental thickening,stillbirth)

MANNER OF TRANSMISSION TO FETUS?

1.Crosses the placenta(MOST COMMON)

2.Contact with lesions

MANAGEMENT:

Benzathine Penicillin-2.4 million units but MAY DEVELOP JARISCH HERXHEIMER

REACTION WHICH IS A FORM OF PENICILLIN ALLERGY

Clinical Manifestations: uterine contractions, decreased fetal movement and persistent late
decelerations

Management is desensitization or use alternative treatment like erythromycin, azithromycin or

cephalosporins.
38.HERPES GENITALIS IN CONTRAST WITH SYPHILIS

CLUES:

HSV 2 infectionàMULTIPLE papular eruption, itchy ,PAINFULàvesicular WHICH

WILL ULCERATE , with lymphadenopathy, Influenza like symptoms

HOW TO CONFIRM?

• VIROLOGICAL –PREFERRED TEST: cell culture and PCR

• SEROLOGICAL-ELISA

WHAT ARE THE POSSIBLE COMPLICATIONS?

Abortion. stillbirth, preterm labor, IUGR

Neonatal infection-mucocutaneous lesions, encephalitis

HOW TO MANAGE THIS PATIENT WITH HERPES INFECTION?

• ANTIVIRAL-acyclovir, famciclovir, valacyclovir.Valacyclovir is preferred for recurrent

herpes infection
• ORAL ANALGESIC OR ANESTHETIC
• IFC-urinary retention
• CESAREAN DELIVERY IS RECOMMENDED FOR PATIENT WITH ACTIVE
LESIONS AT THE GENITALIA OR PRODROMAL SYMPTOM DURING
LABOR.LESIONS AT THE BREAST OR OROPHARYNGEAL AREA IS NOT AN
INDICATION FOR CS.

WHY CS? BECAUSE 85% OF TRANSMISSION OCCURRED IN THE PERIPARTUM

PERIOD

BREASTFEEDING IS ALLOWED AS LONG AS THERE ARE NOLESIONS ON THE

BREAST

39.HUMAN PAPILLOMA VIRUS INFECTION

CLUES:fleshy warty outgrowth,with associated itchiness cause by HPV type 6 and 11 which
increases in number and size during pregnancy

Differential diagnosis:

Molluscum contagiosum( umbilicated center),condyloma lata(secondary syphilis),squamous

papillomatosis
TREATMENT DURING PREGNANCY?

1.trichloracetic or bichloracetic acid-80-90%

2.cryotherapy,laser,surgical excision

REMEMBER THE FOLLOWING ARE NOT USED DURING PREGNANCY

1.podophyllin

2.podofilox

3.imiquimod

4.interferon

5.sinecathechins

WILL YOU DO CS FOR PATIENT WITH HPV INFECTION?

NO,THIS DOES NOT DECREASE THE INCIDENCE OF LARYNGEAL PAPILLOMATOSIS

AND CS IS ONLY DONE FOR PATIENTS WITH HUGE WARTS THAT WILL
OBSTRUCT THE BIRTH CANAL OR MAY CAUSE SEVERE BLEEDING DURING
DELIVERY

HOW WILL YOU PREVENT HPV INFECTION?

VACCINATION- BUT IT IS CONTRAINDICATED DURING PREGNANCY BUT CAN BE

GIVEN IN A BREASTFEEDING MOTHER

Cervarix-bivalent(HPV 16.18)

Gardasil-quadrivalent(HPV 6,11,16,18)

Nonavalent-(6,11,16,18,31,33,45,52,58)

40.LABOR ABNORMALITIES:

REMEMBER THE FOLLOWING:

LATENT PHASE-(Preparatory Division) Preparatory phase when cervix dilates slowly and
effacing(0-4 cms)

Nullipara-20 hrs, Multipara-14 hrs

ACTIVE PHASE – (4-10 cms)

Acceleration phase –overall outcome of labor,

 Phase of maximum slope(Dilatational Division)-overall efficiency of
machine.THE PERIOD TO EXPECT DILATATION OF 1.2 CMS/HR in
nullipara and 1.5 cms /hr in multipara

Deceleration phase(Pelvic division)-fetopelvic relationship,THIS IS THE

PERIOD TO EXPECT HEAD DESCENT-1cm/hr in nullipara and 2cms/hr in
multipara

SECOND STAGE IS FROM FULL DILATATION TO DELIVERY OF THE BABY

NOW WHAT ARE THE ABNORMALITIES THAT YOU CAN ENCOUNTER AND HOW
WILL YOU MANAGE?

1. Prolonged latent phase- MORE THAN 20 hrs in NULLIPARA AND MORE THAN 14
HRS IN MULTIPARA
MANAGEMENT- therapeutic bed rest/sedation
2.Protraction disorders-MANAGEMENT: EXPECTANT AND SUPPORT
Protracted dilatation-less than 1.2 cms in nullipara and 1.5 in multipara(
DIAGNOSED ONLY:4cms onward)
Protracted descent-less than 1cm /hr and 2 cms /hr during deceleration phase
(DIAGNOSED ONLY :8 cms onward)

3. Arrest disorders-MANAGEMENT:CS FOR CPD,NO CPD OXYTOCIN

1.Prolonged deceleration- (FROM 8-9 CMS)

More than-3 hrs in nulli ,more than 1 hr in multi

2.Secondary arrest in dilatation-more than 2 hrs in both nulli and multi(CERVIX
SHOULD BE AT LEAST 6 CMS)
IN THE NEW GUIDELINES-4 HRS IS ALLOWED BEFORE DIAGNOSIS
3.Failure of descent –no descent from deceleration phase onward(HEAD DOES
NOT GO BEYOND ZERO) more than 2 hrs in nulli ,more than 1 hr in multi
*CPD INLET
4.arrest of descent-no descent for more than 1 hr in nulli and multi(HEAD GO
BEYOND ZERO)
*CPD MIDPLANE

WHEN TO DO CESAREAN SECTION?

2HRS –IF WITH NO EPIDURAL ,3 HRS IF WITH EPIDURAL

NEW GUIDELINES: ADD ADDITIONAL HR BEFORE DOING CS
BUT THE POWER OF UTERINE CONTRACTIONS MUST BE NORMAL AT 200
MONTEVIDEO UNITS
How to compute for Montevideo units:add the uterine pressure of uterine contractions in
the CTG for 10 mins

WHAT ARE THE CLUES FOR CPD?

1. Asynclitism-
ANTERIOR ASYNCLITISM (Naegeles Obliquity)-more of the anterior parietal
bone presents thus the sagittal suture moves towards the sacral promontory
POSTERIOR ASYNCLITISM(Litzman Obliquity)-more of the posterior parietal
bone presents thus the sagittal suture moves towards the symphysis pubis
2.Development of caput /molding/cephalhematoma
3.After rupturing the BOW the head did not descend or the cervix thickens
4.The head did not rotate-the head will normally rotate after engagement ,descent ,
flexion.
In persistent occiput posterior position-the diameter that will present is the
occipitofrontal(11.5 cms ) instead of the suboccipitobregmatic(9.5 cms),thus if baby is
relatively big there will be CPD. The internal rotation was the cardinal movement
involved probably due to a short transverse diameter and this is common in anthropoid
pelvis .
In persistent LOT the most common pelvis involved is platypelloid.

WHAT TYPE OF ABDOMINAL INCISION TO DO?

1.ABDOMINAL
a.transverse suprapubic-pfannensteil or maylard
Better cosmetic result(follows the langer lines),less postoperative pain,less
dehiscence,less hernia BUT with limited operative space , with more
hematoma,bleeding,neurological disruption
MAYLARD-transect the bellies of the rectus abdominis

b.midline vertical-
ADVANTAGES:easier to do,minimal blood loss,better operative space and can be
extended,does not transect the neurovascular structures.
DISADVANTAGES:poor cosmetic result,increased incidence of dehiscence and hernia
and postoperative pain
2.UTERINE INCISION(CESAREAN SECTION)
A.LOW SEGMENT CESAREAN SECTION:
a.vertical(Kronig)-Disadvantage; extension to bladder and vagina or extension upward
like a classical section
b.transverse(Kerr)-preferred because of the following advantages
 easier to repair, least likely to rupture, less bleeding, less adhesions to bowel and
omentum
Disadvantage:extension to uterine arteries. To prevent do U,J incision
B.CLASSICAL CS
Main disadvantage- uterine rupture even before labor
INDICATIONS:
1.Densely adherent bladder
2.myoma at the lower uterine segment
3.invasive ca cervix
4.anterior placenta previa
5.transverse lie of a large fetus or presenting as back down
6.fetus is very small esp.breech
7.poorly developed lower segment
8.Preterm/malpositioned multiple foetuses
9.marked obesity(included in 23rd ed of Williams)

CPD AT THE MIDPLANE IS DIFFICULT AND MAY END IN LACERATIONS

HOW ARE YOU GOING TO PREVENT THIS COMPLICATION?
1.Adequate incision,(J or U or T incision)
2.Push method-push the head in the vagina
3.Pull method wherein the legs are grasped and delivered by complete breech extraction
4.Do low vertical low segment incision
5.forceps extraction or vacuum of the head at the CS incision

41.NST-test of fetal well being while CST is a test of uteroplacental function

REACTIVE- 2 or more accelerations of 15 beats/min lasting for 15 secs or more in a 20
min observation but may be extended to 40 min in consideration to fetal sleep pattern

VARIABILITY IN CTG-BEST INDICATOR OF FETAL STATUS

ABSENT-Undetectable
MINIMAL-< OR EQUAL TO 5
MODERATE-6-25 BPM
MARKED-> 25 BPM
SINUSOIDAL-SMOOTH SINELIKE PATTERN-INDICATES FETAL
ANEMIA
• Doppler velocimetry- main usage is for IUGR
Umbilical artery-best predictor of perinatal outcome(Absent or reversed end diastolic
flow)
Middle cerebral artery-brain sparing effect at risk of death
 Ductus venosus

42.BIOPHYSICAL SCORING

COMPONENTS:NST, FETAL BREATHING,FETAL MOVEMENTS,FETAL TONE,

AMNIOTIC FLUID VOLUME

8/10 NORMAL AF-NORMAL NON ASPHYXIATED -NO INTERVENTION

8/10-DECREASED AFCHRONIC FETAL ASPHYXIA -DELIVER

6/10-POSSIBLE FETAL ASPHYXIA –ABNORMAL AF(DELIVER),

NORMAL AF MORE THAN 36 WEEKS INDUCIBLE CERVIXàDELIVER ,

IF LESS THAN 36 WEEKS ,UNINDUCIBLE CERVIX-REPEAT TEST IF 6 OR LESS-

DELIVER

4/10- PROBABLE FETAL ASPHYXIA REPEAT BPS SAME DAY AND IF 6 OR LESS
DELIVER

0-2 ALMOST CERTAIN OF FETAL ASPHYXIA- DELIVER.

43.FETAL SURVEILLANCE RESULTS?

• WHAT IS THE BEST INDICATOR OF FETAL STATUS

FETAL VARIABILITY

SIGNIFICANCE OF PERSISTENT LATE DECELERATION(DECELERATION OF >50 %

OF TRACING AFTER THE ACME OF UTERINE CONTRACTIONS)

UTEROPLACENTAL INSUFFICIENCY

MANAGEMENT: CESAREAN SECTION

SIGNIFICANCE OF SINUSOIDAL PATTERN (WAVY,SMOOTH SINE LIKE)

FETAL ANEMIA

MANAGEMENT;CESAREAN SECTION

SIGNIFICANCE OF VARIABLE DECELERATION (ABRUPT DECREASE IN FETAL

HEART RATE BEGINNING WITH THE ONSET OF CONTRACTION AND REACHING A
NADIR IN LESS THAN 30 SECS)

• IF ACCOMPANIED BY ABSENT VARIABILITY(Category 3)-CESAREAN

SECTION
 • IF WITH MINIMAL OR MODERATE VARIABILITY(Category 2)-INTERNAL
RESUSCITATION

1.Left lateral position

2.correct maternal hypotension

3.discontinue oxytocin

4. hydration

5.oxygen inhalation

6.tocolysis/amnioinfusion

SIGNIFICANCE OF EARLY DECELERATION- DECREASED IN FHR STARTING WITH

THE ACME OF CONTRACTION

HEAD COMPRESSION

MANAGEMENT: DO INTERNAL EXAMINATION AND ASSESS THE CERVIX

AND DESCENT

SIGNIFICANCE OF ABSENT OR REVERSED END DIASTOLIC FLOW(FETAL

COMPROMISE)

MANAGEMENT: CESAREAN SECTION

44.CORD PROLAPSE/FETAL BRADYCARDIA

WHAT TO DO PRIOR TO DELIVERY?

1.Push the presenting part up to prevent compression of cord

2.elevate the buttocks using pillow/bedpan or trendelenberg

3.insert catheter and inflate the bladder

4.give oxygen

HOW TO DELIVER? DEPENDS ON THE STATION OF THE PRESENTING PART

1.LSA STATION +4 TO +5-TOTAL BREECH EXTRACTION.START EXTRACTING

THE BABY FROM THE FEET UPWARDS.IF FRANK,WHAT IS FIRST PROCEDURE TO
DO ?______IF COMPLETE______WHAT IS THE ANESTHESIA?______WHEN TO
ADMINISTER ?_______
2.CORD PROLAPSE ,HIGHER STATION,NOT IN IMMINENT DELIVERY- CESAREAN
SECTION

MANAGEMENT OF BREECH

All types of breech presentation ,primigravid= CS

Frank/complete breech multipara=-partial breech extraction

Footling breech-CS but if in imminent delivery with cord prolapse-total breech extraction

45. OCCIPUT ANTERIOR ,STATION 4/5,WITH FETAL BRADYCARDIA-

MANAGEMENT?

FORCEPS EXTRACTION/VACUUM EXTRACTION

46. FOR PATIENTS WITH CARDIAC PROBLEM:

PROPHYLACTIC ANTIBIOTICS IS ONLY GIVEN TO CARDIAC DISEASE WITH

1.Prosthetic heart valve

2.prior endocarditis

3.unrepaired cyanotic heart disease or within 6 months from repair

4.valvulopathy

MANAGEMENT IS LOW OUTLET FORCEPS /VACUUM EXTRACTION UNDER

EPIDURAL ANESTHESIA

47.HOW WILL YOU KNOW THAT THE POWER OF UTERINE CONTRACTIONS

DURING LABOR IS ADEQUATE?

AT LEAST 200 MONTEVIDEO UNITS COMPUTED BY ADDING THE UTERINE

PRESSURE IN 10 MINUTES

WHAT WILL HAPPEN IF YOU WILL GIVE UTEROTONICS IN PROLONGED LABOR

WITH NORMAL MONTEVIDEO ?__________

47.Patient x 35 year old G2P1(0100)35 weeks AOG ,known hypertensive complains of

abdominal pain and vaginal bleeding. Uterus is woody with difficulty in palpating fetal parts and
no FHT.BP-90/60,HR-110/min. cervix closed uneffaced with profuse bleeding

WHAT IS THE DIAGNOSIS?____BASES?_______RISK FACTOR_______

WHAT IS THE MOST DREADED COMPLICATION?

WHAT WILL DETERMINE THE MANAGEMENT?

YOU DECIDED TO DO CS,AND AFTER THE DELIVERY OF THE DEAD BABY ,THE
UTERUS IS BLUISH WITH HEMATOMA FORMATION,WHAT IS THIS?_____HOW
WILL YOU MANAGE THE PATIENT?______

48.HEMATOMA /BLOOD SUPPLY/MANAGEMENT

Bleeding/hematoma at the vagina

1.upper vagina- cervico vaginal branch of the uterine artery/vaginal artery

2.middle third-middle rectal/inferior vesical

3.lower-internal pudendal

Vulvar hematoma-pudendal artery

Vulvar hematoma less than 6 cms not expanding –OBSERVE

Vulvar hematoma 6 cms or more or expanding-evacuate ,ligate bleeders,give the

antibiotics,AND REMEMBER REPLACE BLOOD LOSS.The amount of blood loss in
hematoma is 2x the amount of blood clots

Hematoma of the vulva is most common at the vestibular bulb located at the labia majora. If the
internal pudendal artery is involved at the deep perineal space, it has the tendency to extend to
the pelvic cavity thus an abdominal ultrasound or CT scan must be requested. Management if
present is exploration.

49.Patient with prolonged labor /or prolonged operation complaining of numbness of extremities
and foot drop the nerve involved is PERONEAL NERVE

Patient complaining of numbness of lateral thigh after Pfannenstiel .What is the nerve
involved? ILIOINGUINAL.What if the numbness is at mons pubis the nerve involved is
ILIOHYPOGASTRIC.

50.PLACENTA PREVIA/VASA PREVIA

CLUES: vaginal bleeding ,no uterine contractions, fetal heart can be heard easily

P.previa bleeding is maternal in origin while vasa previa is fetal

1.VASA PREVIA:

Seen in succenteriate /bilobed placenta, velamentous insertion of the cord.

DIAGNOSIS: CLINICAL: palpate tubular fetal vessel ahead of the presenting
part/ULTRASOUND/DOPPLER:CORD VESSELS inserting in the membranes above the
cervical os, LABS: Fetal hemoglobin DENATURATION (APT TEST)

MANAGEMENT: elective CS at 34-35 weeks to avoid rupture of fetal vessels

2.PLACENTA PREVIA

Placenta previa totalis/partialis(TOTALLY or PARTIALLY)

Marginalis-at the edge of the internal os

Low lying-2cm away from the internal os

PLEASE REMEMBER “TROPHOTROPISM”(PLACENTAL MIGRATION IS A

MISNOMER)-PLACENTAL GROWTH IS MORE TOWARDS THE UPPER SEGMENT
WITH GREATER UTERINE BLOOD FLOW

THUS:YOU HAVE TO REPEAT THE ULTRASOUND AT 34-35 WEEKS TO DETERMINE

THE FINAL PLACENTAL LOCATION

WHAT IS THE MOST COMMON RISK FACTOR ? PREVIOUS CS SCAR

CLINICAL CLUES: vaginal bleeding ,no pain,no uterine contractions,uterus is soft with no
difficulty palpating the fetal parts,fetal heart tone can be heard easily

WHAT IS THE BEST WAY TO DIAGNOSE? Pelvic ultrasound

WHAT IS THE MANAGEMENT?EXPECTANT

1.28 weeks AOG with vaginal bleeding,FHT-140/min, Pelvic ultrasound: Placenta previa
totalis on ultrasound.Hgb-10 gms/l.
• WHAT IS THE MANAGEMENT?
Bed rest, steroid, tocolytic only for the steroid to have its effect,repeat ultrasound at
34-35 weeks,oral iron BID

2.35 weeks AOG, placenta previa totalis with minimal bleeding ,with mild uterine
contractions ,haemoglobin 8 gms

• MANAGEMENT:

Bed rest ,tocolytic, IV sucrose, schedule for CS at 37 weeks

WHAT IF THE PATIENT IS BLEEDING PROFUSELY? Transfuse blood and Immediate

caesarean section

2. 36 weeks AOG, Low lying placenta 3 cms away from the internal os.
 WHAT IS THE MANAGEMENT?
Wait for spontaneous labor and CS is only done if patient bleeds during labor

51.PELVIC ORGAN PROLAPSE

STAGE 1:most distal portion more than 1 cm above the hymen

STAGE 2:most distal portion less than or equal to 1 cm above hymen

STAGE 3:most distal portion is more than 1 m but not farther than 2 cms from hymen

STAGE 4 : complete eversion

VAGINAL DELIVERY-MAJOR RISK FACTOR FOR POP

URINARY INCONTINENCE:

Leakage of urine when coughing/lifting heavy objects-STRESS

Leakage of urine when patient feels urinating-URGE

Leakage of urine when she feels the urge and coughing/lifting heavy objects-MIXED

(PREVIOUSLY TERMED AS GENUINE)

MANAGEMENT OF INCONTINENCE

1.KEGELS EXECISE(PFMT)-FIRST LINE OF TREATMENT FOR URINARY

INCONTINENCE.HOW IS IT DONE?contracting the pubococcygeus ,as if patient is urinating
and controlling the urinary stream , 8-12 times for 6-8 secs each and repeat in 3 sets

2.ESTROGEN

3.SURGICAL-transvaginal needle suspension(TVNS),transvaginal tape tape

ling(TVT),marshall marchetti krants ,burch procedure

POP MANAGEMENT

STAGE1/2-KEGELS OR LAP ASSISTED VAGINAL HYSTERECTOMY

STAGE 3/4 – VAGINAL HYSTERECTOMY/MAC CALL CULDOPLASTY/ANTERIOR

AND POSTERIOR COLPOPERINEORRHAPHY

FOR PATIENTS WHO ARE NOT GOOD CANDIDATE FOR OPERATION:PESSARY/LE

FORT OPERATION/GOODAL POWER(Colpocleisis)

FOR PATIENT WITH VAGINAL BLEEDING EITHER CERVICAL OR UTERINE MUST

BE EVALUATED FIRST TO RULE OUT MALIGNANCY.TVS-FOR ENDOMETRIAL
THICKNESS FOR MENOPAUSAL PATIENT.IF MORE THAN 5 MM DO ENDOMETRIAL
SAMPLING FIRST.IF CERVICAL EROSION-DO PUNCH BIOPSY/COLPO GUIDED
BIOPSY TO RULE OUT MALIGNANCY

FOR PATIENTS WHERE ADHESIONS ARE EXPECTED LIKE PREVIOUS

COMPLICATED OPERATION: ABDOMINAL TAHBSO WITH A AND P REPAIR

POST OPERATIVE:

Retain the catheter for 4-7 days and measure the residual urine after the removal

WHAT IS THE NORMAL RESIDUAL URINE?

Less than 150 or less than 1/3 of the voided urine. If more than the normal—Re insert
foleycatheter and give urecholine and antibiotics.

52.What is the reason for amenorrhea if the patient is under stress? This is a case of secondary
amenorrhea(the patient had previous history of menstruation) .The most common cause is
ANOVULATION

In stress/weight reduction- prolactin secretion inhibits the FSH and LH thus there is no
estrogen and progesterone secretion.

53.BREAST COMPLAINTS

Cyclic bilateral breast pain before menses/multiple cystic masses/plate of peas àFibrocystic
disease or mammary dysplasia

Stages:

1.Mazoplasia-(20 y/o)-pain at the upper outer quadrant

2.adenosis(30 y/o))0 2-10mm in diameter

3.cystic phase(40 y/o)-simple or complex cyst

DIAGNOSIS: Breast ultrasound, simple cyst(FNAB),complex cyst(core biopsy).At present ,the

BEST diagnostic procedure to rule out malignancy is CORE biopsy

MANAGEMENT:

1.Support bra

2.avoid methylxanthine

3.diuretics
4.OCP

5.danazol-TREATMENT IF SYMPTOMATIC

6.bromocriptine-DRUG OF CHOICE

7.primrose oil

FOR SOLID MASSES THE BEST DIAGNOSTIC TEST IS CORE NEEDLE BIOPSY AND IF
MALIGNANT TREAT THE PATIENT AS NON PREGNANT. Chemotherapy if necessary is
recommended after first trimester.

2.POST PARTUM BREAST COMPLAINTS

A.21 Y/O G1P1 COMPLAINING OF FEVER AND CHILLS WITH TENDER BREAST WITH
NO REDNESS:DIAGNOSIS=BREAST ENGORGEMENT

• ENCOURAGE BREAST FEEDING/BREAST PUMP/PARACETAMOL,COLD

COMPRESS

B. IF WITH REDNESS AND PAIN: DIAGNOSIS: MASTITIS

PATHOPHYSIOLOGY: SECONDARY TO STREPTOCOCCUS FROM BABYS MOUTH

• TREATMENT; CLOXACILLIN, CLINDAMYCIN,EXTENDED PENICILLIN

54.POSTPARTUM METRITIS

CLUES: Fever, vaginal bleeding or foul smelling discharge, abdominal pain with leucocytosis
15,000-30,000.

Single most important RISK FACTOR is the ROUTE OF DELIVERY(CS)

MANAGEMENT: GOLD STANDARD: clindamycin and gentamycin plus Ampicillin if with

suspected enterococcal or sepsis syndrome

IF PATIENT IMPROVES BUT STILL FEBRILE WITH OCCASSIONAL PAIN IN ONE OR

BOTH LOWER QUADRANTS , REQUESTS FOR CT/MRI BECAUSE WE MIGHT BE
DEALING WITH SEPTIC THROMBOPHLEBITIS WHICH CAN BE TREATED BY
ADDING HEPARIN TO ANTIBIOTIC TREATMENT

IF PATIENT DOES NOT IMPROVE AFTER 48-72 HRS OF ANTIBIOTICS WITH SIGNS
OF ACUTE ABDOMEN/ PERITONEAL IRRITATION—EXPLORE THE
PATIENT.DEFINITIVE MANAGEMENT IS PELVIC CLEAN UP
55.FAMILY PLANNING

1.Adolescent/young-Low dose OCP/ Progestin only pills(lynestrenol,desogestrel).

DONT GIVE 2.DMPA- has effects on bones

3. High dose OCP will further delay maturation of HPO axis

4. IUD-cause infection
5. IMPLANTS-SAME EFFECT AS DMPA

2.REPRODUCTIVE AGE GROUP WITH HEART DIASEASE-POP(ORAL/DMPA/LGN-

IUS/IMPLANTS)

DON’T PRESCRIBE:

A.IUD –RISK OF BACTERIAL ENDOCARDITIS

B.OCP-RISK OF THROMBOEMBOLISM

3.LIVER DIASEASE: BEST TO USE PATCH SINCE IT WILL BYPASS THE LIVER OR
YOU CAN USE IUD/BARRIER

4.BEST FAMILY PLANNING FOR PROMISCOUS PATIENT: CONDOM

56.VARICELLA INFECTION:

Critical period for neonatal complication:13-20 weeks

CONGENITAL Rubella Syndrome-chorioretinitis,micropthalmia,cerebral cortical

atrophy,IUGR,hydronephrosis,limb hypoplasia,cicatricial skin lesion

After 20 weeks –NO complications reported

CLUES: flu like symptoms, pruritic vesicular lesions, pneumonia(most common cause of death)

DIAGNOSIS:NAAT,(BEST),tzanck smear,tissue culture, direct fluorescent antibody

MANAGEMENT:VARIZIG

VACCINATION IS CONTRAINDICATED

57.PARVOVIRUS:

CLUES: Maybe asymptomatic, fever ,headache, flulike, erythroderma of the face giving a
slapped cheek

The most common cause of non immune hydrops presenting as anemia , fetal ascites/
hydrops/stillbirth à PARVOVIRUS
DIAGNOSIS:

Ig G and Ig M ,PCR(mother) and Doppler studies of the MCA for diagnosis of fetal anemia

58.MULTIFETAL PREGNANCY

CLUES: Exaggerated signs and symptoms , fundic height larger than expected ,multiple fetal
parts and two distinct heart beats

DIFFERENTIAL DX:H mole, polyhydramnios, pregnancy with myoma, pregnancy with ovarian
newgrowth, macrosomic baby, wrong dates

DIAGNOSIS; pelvic ultrasound number of fetuses, fetal heart rate chorionicity

T sign-monochorionic diamnionic,

Twin peak (lambda sign)-dichorionic diamnionic

REMEMBER THAT COMPLICATIONS ARE USUALLY SEEN IN MONOZYGOTIC

TWINS

0-4 DAYS- dichorionic,diamnionic

4-8 days-monochorionic,diamnionic

8-12 days-monochorionic,monoamnionic

>13 days-conjoined

TTTS-TWIN TO TWIN TRANSFUSION SYNDROME(SEEN ONLY IN MONOZYGOTIC

TWIN-)

1.DONOR-ANEMIC,IUGR,PALE

2.RECIPIENT-PHLETORIC,WITH CONGESTIVE HEART ,HYDROPIC

GROWTH DISCORDANCE

Formula= wt of large twin- wt of small twin divided by wt of large twin x 100

Abnormal if abdominal circumference is more than 20 mm in difference or 20% or more

discordancy

IF the weight of the first twin is 1250 and the other is 2300 ,is there a discordancy?

MANAGEMENT:
If 26-34 weeks in preterm labor= bed rest, tocolytic,steroids

Monoamnionic monochorionic placentation –elective CS at 34-35 weeks .Give steroids at 26-32

weeks

Other types of Monozygotic twins or dizygotic twin ,manner of delivery depends on the
presentation

a. Ceph-Ceph -NSD
WHAT TO DO AFTER THE DELIVERY OF THE FIRST OF TWIN
1.ascertain the presenting part of the second of twin and size
2.relationship to birth canal/station
3.moderate fundal pressure and when presenting is fixed in birth canal rupture the
BOW
4.repeat IE to ascertain if there is cord prolapse
5.if no contraction give oxytocin

WHAT IF AFTER THE DELIVERY OF THE FIRST OF TWIN ,THE SECOND OF

TWIN CONVERTS INTO TRANSVERSE ,WHAT ARE YOU GOING TO
DO?INTERNAL PODALIC VERSION-grasp the feet and deliver by complete
breech extraction

HOW WILL YOU DIFFERENTIATE IT TO EXTERNAL CEPHALIC VERSION?

External cephalic version-done at 36-37 weeks converting a breech to cephalic

b. Cephalic-Breech-option MULTI 1.NSD first of twin and total breech extraction of

second twin
Option 2 Cesarean section particularly for primigravida
c. malpresentation of any of the twin-CS

For breech cephalicàprone to interlocking of twins if allowed to undergo vaginal

delivery

4.triplets or more—caesarean section

FOR VAGINAL DELIVERY:

ANESTHESIA OF CHOICE IS EPIDURAL BUT IF UTERINE RELAXATION IS NEEDED

FOR MANIPULATIONàGIVE GENERAL ANESTHESIA-HALOGENATED
INHALATIONAL AGENTS
59.IMPORTANT POINTS TO REMEMBER

DO YOU KNOW THAT?

A. CONGENITAL ANOMALY SCAN IS DONE AT 18-20 weeks AOG

B. CERVICAL LENGTH OF <25MM IS THE BEST INDICATOR OF PRETERM LABOR

C. MENTUM POSTERIOR WHICH DID NOT ROTATE DURING LABOR MUST BE

DELIVERED BY CS

D. TRANSVERSE LIE –BACK DOWN(DORSO-INFERIOR) OR DORSO ANTERIOR MUST

BE DELIVERED BY CLASSICAL CS

E .PROM OF MORE THAN 6 HRS MUST BE GIVEN PROPHYLACTIC ANTIBIOTIC(PEN

G IS PREFERRED FOLLOWED BY AMPICILLIN)

H. MOST COMMON DIFFERENTIAL OF HPV IS SQUAMOUS PAPILLOMATOSIS

I.FOR WHITISH PATCH IN THE VULVA DIAGNOSED AS LICHEN SCLEROSUS ,THE

TREATMENT IS CLOBETASOL OR ANY TOPICAL STEROID

J. VULVAR CA 2 CMS IN DIAMETER WITH NO PALPABLE INGUINAL NODES THE

TREATMENT IS SKINNING VULVECTOMY

K.FOR PATIENT WITH CERVICAL CA AND HYDRONEPHROSIS THE TREATMENT IS

CHEMORADIATION,WHY?WHAT IS THE STAGE ?

J.IN CS HYSTERECTOMY THE INJURY TO THE URETER IS DURING LIGATION OF

UTERINE ARTERIES,WHILE FOR ENDOMETRIOMA IT IS DURING LIGATION OF
INFUNDIBULOPELVIC LIGAMENT AND IN CERVICAL MYOMA DURING CUTTING
AT THE CERVICO-VAGINAL JUNCTION.

K.FOR YOUNG PATIENTS WITH DYSMENORRHEA, GNRH IS NOT THE FIRST LINE
OF TREATMENT.YOU CAN USE COC,PROGESTIN

L.THE CUT OFF SIZE FOR OPERATION OF ENDOMETRIOMA IS 4 CMS FOR

CYSTECTOMY.IF THE CUL DE SAC I S ALREADY OBLITERATED IT IS ALREADY
TOTALLY : STAGE 4 PELVIC ENDOMETRIOSIS.IF PARTIALLY OBLITERATED IT IS
STAGE 111

J. MANAGEMENT OF HSIL ON COLPO INVOLVING WHOLE DEPTH OF EPITHELIUM-

CONIZATION,LEEP/LLETZ,CONE BIOPSY

K. NEGLECTED TRANSVERSE LIE-(PROLAPSE OF ARM,WITH FETAL

DEATH,PATHOLOGIC RETRACTION RING)-CLASSICAL CS
L.MECHANISM OF MC ROBERT MANEUVER IN SHOULDER DYSTOCIA-
STRAIGTHENED THE SACRUM AND DRAWS SYMPHYSIS PUBIS UPWARD AND
DECREASE THE ANGLE OF PELVIC INCLINATION

60.IF THE SACRAL PROMONTORY IS EASILY REACHED AT 11.5 THE INLET IS

CONTRACTED-USUALLY SEEN IN PLATYPELLOID AND ANDROID PELVIS.THIE
DIAMETER MEASURED IS THE DIAGONAL CONJUGATE.HOW WILL YOU COMPUTE
FOR THE OBSTETRIC CONJUGATE?

SACRUM IS HALLOW, INTERSPINOUS DIAMETER IS LESS THAN 10

CMS,CONVERGENT SIDEWALLS ,NARROW SYMPHYSIS PUBIS THE CONTRACTION
IS AT THE MIDPLANE-(ANDROID,ANTHROPOID PELVIS)

IF THE DISTANCE BETWEEN BI ISCHIAL TUBEROSITY IS LESS THAN 8 CMS OR

CANT ACCOMMODATE THE CLOSED FIST THE CONTRACTION IS AT THE OUTLET

61.IN GYNECOLOGY DO YOU KNOW THAT?

A. THE FOLLOWING TUMORS ARE THE MOST COMMON ONG?

1.YOUNG PATIENTS ;BENIGN-Mature teratoma MALIGNANT: Dysgerminoma

2.OLDER PATIENTS: BENIGN-epithelial serous MALIGNANT; Epithelial,serous

FOR MENOPAUSAL PATIENT WITH ONG AND WITH SIGNS OF ESTROGEN

STIMULATION OR ONG IN CHILD WITH SIGNS OF PRECOCIOUS PUBERTY –
ALWAYS THINK OF GRANULOSA CELL TUMOR

FOR PATIENT WITH ONG AND GIT TUMOR AT THE SAME TIME- KRUKENBERG
TUMOR.MOST COMMON SOURCE IS THE STOMACH

B.TUMOR MARKERS

SEROUS CYSTADENOCARCINOMA-CA125,

MUCINOUS-CEA,

ENDODERMAL SINUS-ALPHA FETO PROTEIN,

HCG-CHORIOCA/DYSGERMINOMA,

ALPHA FETOPROTEIN-IMMATURE TERATOMAS,

INHIBIN/ESTROGEN-GRANULOSA CELL TUMOR,

GERM CELL TUMOR-LDH

62.VULVAR HEMATOMA- COMMON IN THE VULVA DUE TO THE VESTIBULAR
BULB BENEATH THE BULBOCAVERNOUS MUSCLES

63.MUSCLES CUT IN MEDIOLATERAL EPISIOTOMY-bulbocavernous muscles,transverse

perineal muscles ,pubococcygeus ,puborectalis

64.THE MAIN USAGE OF Doppler velocimetry if for IUGR by determining the flow at the
umbilical artery and middle cerebral artery. Although it can also be used in hypertension
prediction during the second trimester by the presence of diastolic notching

65.PELVIC INFLAMMATORY DISEASE:

CLUES: MINIMUM CRITERIA:lower abdominal pain, adnexal tenderness ,cervical motion

tenderness,

ADDITIONAL CRITERIA: TEMP >38,abnormal vaginal discharge, Increase WBC,ESR,CRP

lab documentation of chlamydia or gonorrhoea

DEFINITIVE CRITERIA: histopath of endometritis, TVS-tuboovarian complex, lap findings of

PID(VIOLIN STRING ADHESIONS-FITZ HUGH CURTIS /SALPINGITIS WITH
EXUDATES)

GOALS OF MANAGEMENT;resolution of symptoms and preservation of tubal function

CRITERIA FOR HOSPITALIZATION:

1.unsure diagnosis,cant rule out AP

2. too ill to tolerate oral treatment

3.tubo ovarian abscess

4.pregnancy

OUT PATIENT THERAPY:

Ceftriaxone 250 IM single dose or cefoxitin 2 gm IM and probenecid 1gm po single dose or third
gen cephalosporin(cefotaxime) PLUS doxycycline 100 mg BID x 14 days with or without
metronidazole 500 mg BID for 14 days

IN PATIENT;

REGIMEN A (community acquired infection)

Cefoxitin 2 gms every 6 or cefotetan 2gm every 12 hrs plus doxycycline 100 BID
REGIMEN B (abscess,IUD related infection,infection after diagnostic procedure)

Clindamycin 900 mg every 8 plus gentamycin 2mg/kg

ALTERNATIVE

Ampi-sulbactam 3 gms iv evry 6 plus doxycycline 100 bid

SURGICAL MANAGEMENT IS RESERVED FOR:

1.life threatening infections

2.ruptured tuboovarian abscess

3.laparosopic drainage of abscess

4.persistent masses in women who completed her reproductive career

5.removal of persistent symptomatic mass

LONG TERM COMPLICATIONS:

1.ectopic pregnancy

2.chronic pelvic pain

3.infertility( tubal obstruction,hindrance to ovum pick up)

FOR PATIENTS WITH HYDROSALPINX AND FOR IVF THEY RECOMMEND

BILATERAL SALPINGECTOMY OR CLIPPING AT THE UTEROCORNUAL REGION
BECAUSE IT SECRETES INFLAMMATORY SUBS THAT MAY AFFECT
IMPLANTATION.

66.INCREASE ALPHA FETO PROTEIN:

Done at 16-18 weeks .If > 2.5 MOM first thing to do is Ultrasound for congenital
anomaly screen especially neural tube defects

67.The fundic height is equivalent to AOG at 20-34 weeks(prenatal care chapter) and 18-32
weeks (IUGR chapter)

If the fundic height is smaller than in relation to AOG, think of IUGR or just a healthy small
fetus .Biometry studies should be done(BPD,abdominal circumference, femoral length,EFW) if
less than the 10th percentile .Repeat every 2 weeks.If all parameters are less than 10th percentile
but growing every 2 weeks-constitutionally small or small healthy baby. IF all parameters are not
growing-symmetric IUGR.IF BPD/FL are growing but not the AC-asymmetric IUGR
68.Hot flush is secondary to DECREASE estrogen,THUS THE best treatment is ESTROGEN

69.If patient has FRACTURE the treatment is ALENDRONATE (DON’T GIVE THIS IF
PATIENT HAS HOT FLUSH.THIS DRUG WILL AGGRAVATE HOT FLUSHES

70.Patient with late postpartum haemorrhage with minimal bleeding:Treatment is

prostaglandin/antibiotics

BUT if the patient is bleeding profusely or persistent despite of medical treatment: DO

CURETTAGE

71.In PPROM ,the MOST COMMON risk factor for uterine infection is the number of cervical
examination

72.The cause of massive haemorrhage in case of cornual pregnancy :ruptures late and it is the
area where the uterine artery meet the ovarian artery

73.OVARIAN CYST IN PREGNANCY-THE MOST COMMON IS CORPUS LUTEUM

CYST FOLLOWED BY DERMOID CYST

LESS THAN 5 CMS DON’T TOUCH

5-10 CMS-MONITOR SIZE

FOR OVARIAN NEWGROWTH THE INDICATION FOR EXPLORATION:

1.CYST EQUAL OR MORE THAN 10 CMS

2.WITH SOLID COMPONENTS

3.WITH PAPILLATIONS,THICK SEPTA ,NODULATIONS

BEST TIME TO EXPLORE:14-20 WEEKS :YOU MIGHT REMOVE THE CORPUS

LUTEUM AND THE DANGER IS ABORTION!!!!THE CORPUS LUTEUM IS THE
SOURCE OF PROGESTERONE SUPPLY IN EARLY PREGNANCY UNTIL SUCH TIME
THAT THE PLACENTA WILL TAKE OVER. THIS WILL ALSO GIVE TIME IF THE MASS
WILL DISAPPEAR AFTER THE FIRST TRIMESTER TO RULE OUT CORPUS LUTEUM
AND THE RISK THAT SURGERY MIGHT AFFECT THE PREGNANCY WILL BE
LOWER.

IF THERE IS A COMPLICATION LIKE TORSION OR RUPTURE AND YOU HAVE TO DO

EMERGENCY OPERATION IN LESS THAN 10 WEEKS AOGàGIVE PROGESTERONE
IM

74.POSTMENOPAUSAL BLEEDING: THE MOST COMMON CAUSE IS ATROPHIC

ENDOMETRIUM
PMB- ENDOMETRIAL THICKNESS LESS THAN 5 MM: DX: ATROPHIC
ENDOMETRIUM

MANAGEMENT:OBSERVE, IF PERSISTENT GIVE ESTROGEN/PROGESTIN

PMB-ENDOMETRIAL THICKNESS > 5 MM DO ENDOMETRIAL

SAMPLING(BIOPSY,CURETTAGE,HYSTEROSCOPIC BIOPSY)

HISTOPATH RESULT:

1.PROLIFERATIVE-GIVE PROGESTIN

2.SIMPLE HYPERPLASIA-PROGESTIN

3.COMPLEX HYPERPLASIA WITHOUT ATYPIA-PROGESTIN AND REPEAT BIOPSY IN

3-6 MONTHS OR HYSTERECTOMY IF WITH RECURRENT BLEEDING

4.COMPLEX HYPERPLASIA WITH ATYPIA-EHBSO OR HIGH DOSE PROGESTIN IF

NOT A GOOD CANDIDATE FOR OR

5.ENDOMETRIAL CA- EHBSO,WITH BILATERAL LYMPH NODE DISSECTION.PFC

AND OMENTECTOMY ARE ADDED FOR TYPES LIKE PAPILLARY SEROUS AND
CLEAR CELL ADENOCARCINOMA.WHAT COULD CONTRIBUTE TO POOR
PROGNOSIS: HIGH STAGE,POORLY DIFFERENTIATED,WITH LYMPHOVASCULAR
INVOLVEMENT,POSITIVE LYMPH NODES

75.ENDOMETRIAL MASS (SUBMUCOUS OR ENDOMETRIAL POLYP)

Endometrial polyp-single feeding vessel

Submucous myoma- type 0 the myoma occupies the whole cavity,

type 1-more than 50% in the cavity,

type 2-less than 50 % in the cavity

METHOD OF DIAGNOSIS:

1. SALINE INFUSION SONOGRAPHY-OUTLINE THE MASS AFTER DISTENDING

THE UTERINE CAVITY WITH NSS
2. HYSTEROSCOPY-DIRECT VISUALIZATION OF THE CAVITY
3. MRI HYPODENSITY(MYOMA)

MANAGEMENT OF POLYP:TCRP(transcervical resection of polyp or hysteroscopic resection)

MANAGEMENT OF SUBMUCOUS MYOMA:hysteroscopic resection of myoma or if more
than 3 cms give GNRH or progestin,or LNG IUS for 3-6 months then hysteroscopic resection

76.HYDATIDIFORM MOLE:

CLUES:amenorrhea ,vaginal bleeding, exaggerated nausea and vomiting, fundic height larger
than AOG,no FHT,signs of hyperthyroidism or preeclampsia

DIAGNOSTICS:cbc bld typing,,TVS-snowstorm pattern,beta HCG (>100,000),

chest xray, liver profile

DIFFERENCE BETWEEN COMPLETE AND PARTIAL?

COMPLETE-46 XX,NO FETAL TISSUES,MORE THAN 100,000 B- HCG,HIGH

INCIDENCE OF GTN,UTERUS LARGER THAN AOG,P57KIP 2 NEGATIVE

PARTIAL-69 XXY,XYY,UTERUS SMALLER THAN AOG,MISTAKEN AS MISSED

ABORTION,LOW INCIDENCE OF GTN,LOW BETA HCG,P57KIP2 POSITIVE

MANAGEMENT:YOUNG- SUCTION CURETTAGE(DON’T DO HYSTEROMETRY)

OLD OR COMPLETED REPRODUCTIVE CAREER-TAH

POSTEVACUATION SURVEILLANCE:

Initial HCG within 48 hrs postevacuation then every 1-2 weeks until normal

Then monthly until 6 months(RESOLUTION OF BETA HCG-7 WEEKS PARTIAL MOLE/9

WEEKS COMPLETE MOLE)

Avoid pregnancy in 6 months-CHOICE :ocp or progesterone(DMPA)

DON’T USE IUD,IT CAUSES PERFORATION,BARRIER AND OTHER METHODS-HIGH

FAILURE RATES

Chest xray-6months

PROPHYLACTIC CHEMOTHERAPY-METHOTREXATE (FIRST LINE)

,ACTINOMYCIN(GIVEN IF LIVER ENZYMES ARE HIGH)

PERSISTENT TROPHOBLASTIC DISEASE:CLUES:

1.RISK FACTORS-complete mole,old age,>100,000 beta HCG,larger uterine size,>6 cms theca
lutein cyst,slow decline of beta HCG
2.criteria for diagnosis:plateau of beta HCG,rise of beta HCG >10 percent ,beta HCG remains
detectable for 6months or more,histologic criteria of chorioca

PRIMARY TREATMENT:CHEMOTHERAPY

REPEAT CURETTAGE IS NOT DONE:RISK OF UTERINE PERFORATION,BLEEDING

AND INFECTION

CASE OF POSTPARTUM WITH PROLONGED BLEEDING MONTHS AFTER

DELIVERY,WITH BLUISH MASS IN THE VAGINA ,ENLARGED UTERUS ,THINK OF
CHORIOCARCINOMA.REQUEST FOR BETA HCG AND ULTRASOUND DON’T DO
BIOPSY OF THE MASS.IF PATIENT HAS NEUROLOGICAL MANIFESTATION OR
SIGNS OF LUNG METASTASIS REQUEST FOR CT SCAN.

MANAGEMENT; MULTIAGENT CHEMOTHERAPHY-EMACO,RADIATION IF WITH

BRAIN METS OR LUNG METS

77. PEDIATRIC PATIENTS MOST COMMON COMPLAINTS VULVOVAGINITIS

CLUES:vaginal discharge,irritation,pruritus

Why are children prone to infection?

Physiological reasons

1.lack of labial fats and pubic hairs

2.proximity of anus to introitus

3.lack of protective effect of estrogen

4.thin labia

5.alkaline or neutral ph

6.lack of glycogen and lactobacilli

Behavioural reasons:

1.poor perineal hygiene

2.scratch itch cycle

3.tight fitting clothes

CAUSES:

Bacterial/protozoal/mycotic/viral/physical-chemical/allergic/foreign body/uti
PLS REMEMBER THE CLUES:

PARASITISM-ENTEROBIUS –NIGHT ITCH AND YOU HAVE TO DO THE SCOTCH

TAPE TEST

FOREIGN BODY-FOR RECURRENT BLOODY FOUL SMELLING DISCHARGE-DO

VAGINOSCOPY UNDER ANESTHESIA.THE MOST COMMON FOREIGN BODY IS
SMALL WADS OF TOILET PAPER

HOW TO EXAMINE THE CHILD?

REMEMBER :Establish rapport, don’t restrain, explain the procedure,DEFER if non

cooperative ,NO draping, HOW TO EXAMINE THE EXTERNAL GENITALIA

MOTHERS LAP-0-2 YRS

FROG LEG-2-3 YRS

LITHOTOMY-4-5 YRS OR OLDER

EXAMINATION OF THE VAGINA-KNEE CHEST POSITION

RECTAL EXAMINATION MAY BE OMITTED UNLESS THERE IS VAGINAL

BLEEDING,PELVIC PAIN,FOREIGN BODY OR PELVIC MASS

MANAGEMENT:

1.improve perineal hygiene-anterior to posterior washing with legs wide apart

2.burrow solution for weeping lesions

3.avoid tight fitting clothes

4.zinc oxide/steroid cream

5.antibiotic-bacterial infection

6.mebendazole-pinworms

7.estrogen cream

LABIAL ADHESIONS-TREATMENT IS ESTROGEN CREAM DON’T SEPARATE IT

USING THE EXAMINERS HAND

LICHEN SCLEROSUS-pruritus,thinning of vulvar epithelium,skin dystrophy,lichenification of

skin,parchment like appearance,white in appearance.MANAGEMENT:STEROIDS-
CLOBETASOL
SARCOMA BOTYROIDES or ENDODERMAL SINUS TUMOR-RARE TUMOR IN
CHILDREN WHICH PRESENTS AS VAGINAL BLEEDING

78.INFERTILITY

FECUNDABILITY-NORMAL FERTILE 20% PER MONTH

INFERTILITY-INABILITY TO CONCEIVED IN 1 YEAR BUT FOR MORE THAN 35 YRS 6

MONTHS

THE MOST COMMON CAUSE OF INFERTILITY IS OVULATORY DYSFUNCTION

FOLLOWED BY MALE FACTOR

HOW WILL YOU KNOW THAT PT IS OVULATING?

1.regular predictable menses

2.progesterone of more than 10 ng/ml

3.BBT-indirect evidence/shortly after awakening/after at least 6 hrs of sleep/prior to

ambulating/sublingual temp

FOR WOMEN OLDER THAN 35 YEARS TEST FOR OVARIAN RESERVE

1.DAY 2FSH (>10 MIU/ML) ABNORMAL,>20 BAD PROGNOSIS)

2.DAY ESTRADIOL->70 pg/ml-decrease ovarian reserve

3.AMH or MIS(ANTIMULLERIAN HORMONE OR MULLERIAN INHIBITING SUBS)

<0.5 NG /MLDECREASE OVARIAN RESERVE .NORMAL = >2NG/ML-large cohort of

follicles in the ovaries

SEMEN ANALYSIS

ABSTAIN 2-3 days,clean wide mouth bottle,with in the laboratory.If collected at home must be
kept warm during transport

WHAT IS NORMAL?

VOLUME-1.5

SPERM CONCENTRATION-MILLION/ML-15
TOTAL NUMBER(MIL/EJACULATE)-39

TOTAL MOTILITY-40%

PROGRESSIVE MOTILITY-32%

NORMAL FORMS-4%

TUBAL PATENCY TEST:

1.hysterosalpingography-not advised if with salpingitis,done on day 7-10,give prophylactic

doxycycline 2 days prior to procedure.water soluble contrast medium is preferred over oil based
contrast media which causes more pain and granulomas.

2.Hysterosonosalpingography or SISH

FROM LH SURGE-SEXUAL CONTACT MUST BE 2-24 HRS LATER

MEDICAL TREATMENT OF ANOVULATION:

1.clomiphene-competes with estrogen,stimulates GnRh,increase FSH anf LH,causing oocyte

maturation

2.Metformin-ovulation induction in PCOS

3.rosiglitazone and pioglitazone

4..letrozole-inhibits estrogen secretion, negative feeback, increase FSH BUT it increase androgen
levels thus it increases FSH sensitivity. Short acting thus it does not cause thinning of
endometrium and thickening of cervical mucus seen in clomiphene

5.gonadotrophins indicated if estrogen level is low

WHAT WILL BE THE DANGER OF GONADOTROPHIN FOR OVULATION INDUCTION?

OHSS-ovarian hyperstimulation syndrome

CLUES;ascites,pleural effusion,electrolyte imbalance,thromboembolism

79.FAMILY PLANNING :REMEMBER THE FOLLOWING

OCP PROGESTERONE CONTENT:

1.ANDROGENIC SIDE EFFECTS

 a..ESTRANGES-noerthindrone, norethindrone acetate ,ethynodiol

b.gonanes-levanorgesterel,norgestrel,desogestrel,norgestimate

c.spirinolactone-drosperinone-antimeniralocorticoid,less androgenic-NO
WEIGHT GAIN AND LESS HEADACHE

2.cyproterone-antiandrogenic-GOOD FOR ACNE /PCO

CONTRAINDICATIONS FOR OCP

A.BREASTFEEDING

B.SEVERE CIRRHOSIS

C.DVT

D.DM WITH VASCULAR COMROMISE

E.HEADACHES WITH AURA

F.HPN/ISHEMIC HEART DISEASE

G.INFLAMMATORY BOWEL DISEASE

H.CIGARETTE SMOKER /MORE THAN 35 Y/O

WHAT WILL BE THE MANAGEMENT IF PATIENT FORGET TO TAKE A PILL AND

SHE DEVELOPS BREAKTHROUGH BLEEDING? DOUBLE THE PILLS

IF PATIENT HAS A FAMILY HISTORY OF DVT –YOU CAN USE THE LOW DOSE OCP

ACTIVE COMPONENT IN SPERMICIDE-NONXYNOL NINE

80. Clinical manifestations :amenorrhea, vaginal bleeding, foul smelling discharge ,fever and
abdominal pain

IE :with open cervix, (+) motion tenderness, uterus tender, adnexa tender bilaterally

Diagnosis:Abortion Incomplete, septic

Diagnostics:CBC ,urinalysis,gram stain,culture and sensitivity of discharge, abdominal xray-for

pneumoperitoneum,TVS-retained placenta,coagulation studies –dx DIC

Plan:Broad spectrum antibiotics to cover all types of organism

Pen G +aminoglycosides+metronidazole

Clindamycin+gentamycin
Broad spectrum cephalosporin+metronidazole

Carbapenem or extended penicillin,ticarcillin

If patient will not respond ,or with signs of acute abdomen: explore lap and total pelvic clean up

72.Pudendal block –sensory and motor block of the perineum for NSD or forceps by blocking
the anterior primary division of S2,3,4 except for the anterior part since it is supplied by
ilioinguinal and genitofemoral nerves.This block does not affect cervix,uterine contractions
which is innervated by sympathetic nerve T10-L2

Can be introduced transperineal or transvaginal using an IOWA trumpet and injected

inferior and medial of the ischial spines where pudendal nerve is located. In transperineal the
landmark is between the ischial tuberosities and anus.

Complications:

Lacerations, systemic complication if given intravenously, infection, hematoma, fetal injuries

,paresthesia, prolonged second stage due to loss of bearing down reflex

73. Patients with the following complaints after delivery, what nerve is involved?

Foot drop after a long time in lithotomy- Peroneal nerve

Numbness of the lateral thigh- obturator nerve

After a pfannensteil loss of sensation at suprapubic area- iliohypogastric nerve,

mons pubis, upper labia majora and medial upper thigh- ilioinguinal,

74.PELVIS

Linea terminalis separates the false from true pelvis

INLET: bounded by sacral promontory ,symphysis pubis and linea terminalis

Diagonal conjugate-inferior symphysis and sacral promontory (11.5 or more)

Obstetric conjugate-midportion of symphysis pubis to sacral promontory(10.5)

True conjugate-topmost of symphysis pubis and sacral promontory(11.5)

Greatest transverse diameter of the inlet-between two linea terminalis(13.5)

MIDPLANE

AP diameter of midplane-symphysis pubis to sacral bone (11.5 cms)

 Interspinous diameter-between two ischial spines-10 cms

OUTLET

APO-Symphysis pubis to tip of sacrum (11.5 cms)

IT-between two ischial tuberosities-(10 cms)

PELVIC TYPES

1.Gynecoid- all findings are normal

2.android- least favorable –all findings are abnormal

3.platypelloid- short AP but long transverse diameter. Usually seen in persistent occiput
transverse

4.anthropoid-short transverse ,long AP diameter.Usually seen in POP

Pure type of pelvis is RARE. Mixed Type of Pelvis is determined by the posterior segment and
the tendency is determined by the anterior segment

75.PRENATAL CARE:

Pregnancy test-positive by 8-9 days after ovulation.HCG is produced by syncitiotrophoblast and

doubling time is 1.5 to 2 days

Vaccination during pregnancy

Influenza,rabies,hepatitis B and A,Tdap

pneumococcus(asplenia,metabolic,renal,cardiac and pulmonary,smoker)

Varicella-within 4 days before or 2 days after delivery