Nadin OBS

‫ﻫﺪﻳﺔ‬
Gynecology & Obstetrics ‫ﻣﺠﺎﻧﻴﺔ‬

For undergraduates
Notes on the Board of

Dr.Nadine's Lectures 3 rd Edition
2021
Notes of Dr. Nadine Alaa Sherif Written by:

Professor of Obstetrics & Gynecology Reem Abdelhakim
Faculty of Medicine – Cairo University House officer
www.nadine-alaa-sherif.weebly.com
This work is dedicated to the soul of my father,
my beloved mother, my unique brother, and …
All the future doctors, whom I truly believe in
their creativity, intentions and potentials .


Nadine Alaa Sherif
2
Page
Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com
Website YouTube channel Telegram channel Facebook Page
3
Page
List of Abbreviations
AFI : Amniotic Fluid Index LEEP : Loop Electrosurgical Excision Procedure SIDS : Sudden infant death syndrome
AIS : Androgen insensitivity syndrome LGV: Lymphogranuloma Venereum SMB: Submento-bregmatic
ASCUS : Atypical squamous cells of undetermined LLETZ : Large loop excision of the transformation zone SMM : Submucous myoma
significance LMA : Left Mento Anterior SMV: Submento-vertical
AUB : Abnormal Uterine Bleeding LMWH : Low Molecular Weight Heparin SOB: Suboccipito-bregmatic
BAD : Bis-acromial diameter LNG-IUD : Levonorgestrel - Intrauterine Device SOF : Suboccipito-frontal
BCT : Benign cystic teratoma LOA : Left Occipito Anterior SP: Symphysis Pubis
BL : Broad Ligament LPD : Luteal phase defect TD : Tubal Disconnection
BLM : Broad ligament myoma LSA : Left scapula -anterior TDF : Testicular differentiation factor
BMD: Bimastoid diameter LSIL : Low grade squamous intraepithelial lesion TENS : Transcutaneous Electrical Nerve Stimulation
BPD : Biparietal diameter MA : Mento-anterior TOA : Tubo-ovarian abscess
BTD : Bitrochanteric diameter / Bitemporal diameter MCL : Midclavicular line TOC : Tuboovarian cyst
BVs : Blood vessels MCT : Malignant cystic teratoma TOT : Transobturator tape
CIA : Common Iliac Artery MDIF : Mullerian duct inhibiting factor TVT : Tension-free vaginal tape
CILNs : Common Iliac Lymph notes MH : Metropathia haemorrhagica UAE: Uterine artery embolisation
DMA : Direct Mento Anterior MP : Mento-posterior UG : Umbilical Grip
DO : Detrusor overactivity MRKH : Mayer Rokitansky Küster Hauser syndrome VaIN : Vaginal intraepithelial neoplasia
DOA : Direct Occipito Anterior MSAFP : Maternal serum Alpha Fetoprotein VIN : Vulvar intraepithelial neoplasia
DOP : Direct Occipito Posterior MSH : Melanocyte stimulating hormone VVF : Vesicovaginal fistula
DZT : Dizygotic Twin MST: Malignant solid teratoma
EH : Endometrial Hyperplasia MTX : Methotrexate
EILNs : External Iliac Lymph nodes MV: Mento-vertical
EMA-CO : Etoposide , Methotrexate, Actinomycin – D , MZT : Monozygotic Twin
Cyclophosphamide , Oncovin NT : Nuchal Translucency
FCA : Fetal congenital anomalies NTD : Neural Tube Defect
FG : Fundal Grip OF: Occipito-frontal
FL: Fundal Level OGTT : Oral Glucose Tolerance test
GI : Granuloma Inguinale OHSS: Ovarian hyperstimulation syndrome
HIFU:High Intensity Focused Ultrasound PAPP-A : Pregnancy Associated Plasma Protein A
HPL : Human Placental Lactogen PCT : Post coital test
HSIL : High grade squamous intraepithelial lesion PE : Preeclampsia
HSM : Hepatosplenomegaly PEB : Premenstrual Endometrial Biopsy
IAP: Intra abdominal pressure PG: Primigravida / Pelvic Grip
II LNs : Internal iliac lymph nodes POI : Premature ovarian insufficiency
II vessels : Internal Iliac vessels POP: Pelvic Organ Prolapse
IIA : Internal iliac artery PPC : Post Partum Care
IIV : Internal iliac vein PROM : Premature Rupture of membranes
IPHge : Intra Peritoneal Hemorrhage PUL : Pregnancy of Unknown Location
IUI : Intrauterine insemination ROD : Right Oblique Diameter
IUP : Intraurethral pressure ROM : Rupture of membranes
IVP: Intravesical pressure RSA : Right scapula – anterior
4
Page
Index
Gynecology Obstetrics
Physiology of menstrual cycle -------------------------------------------- 7 Abortion -------------------------------------------------------------------------------------------- 40
Ectopic pregnancy -------------------------------------------------------------------------------- 41
Amenorrhoea ---------------------------------------------------------------- 8 GTDs & Vesicular mole ------------------------------------------------------------------------ 42
Puberty & Menopause ---------------------------------------------------- 9 Anatomy of female pelvis & fetal skull ------------------------------------------------------- 43
Anovulation , PCO , Hirsuitism & Hyperprolactinemia ------------ 10 Mechanism of Normal Labour ---------------------------------------------------------------- 44
Management of Normal Labour --------------------------------------------------------------- 45
Infertility -------------------------------------------------------------------- 11 Partogram ------------------------------------------------------------------------------------------- 46
Fibroid ---------------------------------------------------------------------- 12 Occipito posterior / Face & Brow presentations --------------------------------------------- 47
Endometriosis & Adenomyosis ---------------------------------------- 13 Breech presentation ----------------------------------------------------------------------------- 48
Shoulder presentation ---------------------------------------------------------------------------- 49
AUB ------------------------------------------------------------------------- 14 Multi fetal gestation ------------------------------------------------------------------------------ 50
Contraception -------------------------------------------------------------- 15 Abnormal labour --------------------------------------------------------------------------------- 51
Pelvic Organ Prolapse & RVF ------------------------------------------ 16 Bleeding in late pregnancy (APHge) ----------------------------------------------------------- 52
Obstetric Trauma -------------------------------------------------------------------------------- 53
Urinary Incontinence ------------------------------------------------------ 17 Complications of 3rd stage of labour ---------------------------------------------------------- 54
Scheme for oncology------------------------------------------------------ 18 Assessment of fetal wellbeing ------------------------------------------------------------------ 55
Endometrial Carcinoma -------------------------------------------------- 19 SGA & LGA --------------------------------------------------------------------------------------- 56
Premature Rupture of Membranes ------------------------------------------------------------- 57
Cancer Cervix -------------------------------------------------------------- 20 Amniotic fluid disorders ----------------------------------------------------------------------- 58
Benign Ovarian Tumours ------------------------------------------------- 21 Prematurity & Postmaturity -------------------------------------------------------------------- 59
Malignant Ovarian Tumours --------------------------------------------- 22 Hypertension with pregnancy ------------------------------------------------------------------ 60
RH isoimmunization ---------------------------------------------------------------------------- 61
Non neoplastic ( functional ) cysts of the ovary ---------------------- 23 GIT disorders with pregnancy ----------------------------------------------------------------- 62
Malignant vulval tumours ------------------------------------------------ 24 UTI , Venous thromboembolism , PE & Seizures with pregnancy ----------------------- 63
Malignant vaginal tumours ---------------------------------------------- 25 DM with pregnancy ------------------------------------------------------------------------------ 64
Anemia , Cardiac diseases & Thyroid disorders with pregnancy ---------------------------- 65
Lower genital tract infections -------------------------------------------- 26 Fetal & neonatal asphyxia ----------------------------------------------------------------------- 66
Acute PID ------------------------------------------------------------------ 27 Fetal birth injuries --------------------------------------------------------------------------------- 67
Chronic PID --------------------------------------------------------------- 28 Analgesia & Anesthesia in labour ------------------------------------------------------------- 68
Induction of abortion & IOL ------------------------------------------------------------------- 69
STDs ----------------------------------------------------------------------- 29 Puerpurium & puerpural sepsis ------------------------------------------------------------- 70-71
Benign conditions of the vulva & vagina ------------------------------ 30 Instrumental delivery & Episiotomy ---------------------------------------------------------- 72
Anatomy of female genital tract ----------------------------------- 31 - 34 CS --------------------------------------------------------------------------------------------------- 73
Prenatal diagnosis of congenital anomalies ------------------------------------------------- 74
Normal sexual development -------------------------------------------- 35 Fertilization, implantation & placenta formation --------------------------------------------- 75
Developmental abnormalities of female genital system ------------- 36 Diagnosis of pregnancy , placenta , cord ------------------------------------------------------- 76
Endoscopy in Gynecology ----------------------------------------------- 37 Physiological changes during pregnancy------------------------------------------------------ 77
ANC ------------------------------------------------------------------------------------------------ 78
Operative Gynecology --------------------------------------------------- 38 High risk pregnancy , Maternal mortality ----------------------------------------------------- 79
5
Page
Clinical History taking 81-86

GYNECOLOGY
6
Page
Physiology of menstrual cycle
NB:
Hypothalamus : GnRH * 2 Cell theory:
theca & granulosa
OVULATION
cells for E2
synthesis
(pulsatile)
( steroidogenesis ).
Pituitary : FSH / LH * Other catalysts as

Inhibin - - FSH
LH Activin ++FSH
FSH
* PGs of secretory
FSH endometrium &
12
LH dysmenorrhea
36 hrs Progesterone
Ovary: E2 / P Follicular
Estrogen
Luteal
* PMS & ovulation
( PRG effect )
E2
PRG
Theca cells ++ E2
Androstendione
Cholesterol Aromatase
Granulosa enzyme 18-24 mm Corpus luteum Corpus albicans
cells Dominant follicle
PRG
Endometrium : Glands
5 – 8 mm
proliferative secretory Superficial

Active
Intermediate
Basal layer
Watery
Cervix: Mucus Viscid
Excessive ++WBCs
+ve spinbarkeit +ve Fern -ve spinbarkeit -ve Fern
Vagina: Cells E2 PRG

0 / 30 / 70 0 / 70 / 30 (Maturation index)
7
Page
basal / intermediate / superficial basal / intermediate / superficial

genital 1ryAmenorrhea TDF 2ry Amenorrhea Clinical approach to
MD ridge XY
MDIF a case of amenorrhea
urogenital sinus - Pregnancy 1) History
In the presence of In abscence of - Uncontrolled endocrinal
ry 2) Examination
2ry sexual characters 2 sexual characters disorders as thyroid / DM / External genitalia
( ‫ ؞‬presence of E2 ) ( ‫ ؞‬abscence of E2 ) cushing 2ry sexual characters
- Kallmann syndrome
- Drugs 3) US
Hypothalamus - Psychological (presence or abscence of uterus)
GnRH
4) Hormonal
++ FSH ‫ ؞‬ovarian causes
- Sheehan syndrome ( PPHge ) ( hypergonadotrophic hypogonadism )
- Empty sella syndrome
Ant. Pituitary - Prolactinoma ( ↑ ICT ) -- FSH ‫ ؞‬hypothalamic /
FSH / LH Pituitary causes
( hypogonadotrophic hypogonadism )
- (XO) Turner
- PCO N FSH ‫ ؞‬PCO
Ovary - POI (& resistant ovary syndrome) ( eugonadotrophic hypogonadism )
‫ ؞‬E2 E2
E2 / PRG
5) Specific :
- (XX) Mullerian agenesis - Pregnancy test
- (XY) AIS - Karyotyping
- Asherman syndrome - Ashermann syndrome ( curettage ) - CT brain
- Laparoscopy
- Cx atresia
- Transverse vag septum - Hysteroscopy
- Imperforate hymen - Thyroid profile
- PRL level
Treatment of the cause Surgical
Medical Withdrawal
8
Page
Induction of ovulation / or regulation of menses by COPs

Puberty (11-12yrs) Menopause (51-52 yrs)
( Non reproductive reproductive ) ( Reproductive non reproductive )
Due to maturation of pulsatility of hypothalamus Due to depletion of follicles
Normal sequence of pubertal changes: --E2
1) Growth spurt -- SHBG ++ FSH
++ Free Testosterone --Inhibin
2) Thelarche
3) Pubarche ( Adrenarche ) Clinical manifestations:
4) Menarche 1) Atrophy of urogenital system
5) Axillarche * Vulva : gaping
Abnormal puberty * Vagina : dryness , dyspareunia (ttt : give local E2 cream) / infection
* Cx * Uterus : ET < 5mm
Precocious Delayed * Breast * Urethra / bladder : infection / SUI
< 8 years * Ligaments : POP
( as 1ry amenorrhea 2) HOT FLUSHES ttt : HRT
but due to familial / 3) Mood changes: insomnia / change in libido
constitutional )
4) Skin : loss of collagen
5) Remote complications:
True (common) Pseudo (rare) * CVS manifestations ++LDL / --HDL
‫ ؞‬axis is present only peripheral hormones * Osteoporosis ++ osteoclasts / -- osteoblasts
‫ ؞‬ovulation occurs NO axis ‫ ؞‬NO ovulation Management:
Constitutional CNS lesion Isosexual heterosexual 1) Reassurance
( mostly ) ( Rarely ) ( ‫ ؞‬++E2 ) ( ‫ ؞‬++Androgen) 2) Change life style : exercise / stop smoking / dietary habits
ttt: GnRHa till ttt of cause Eg: 3) Prophylactic : Ca++ / Vit D
certain age Drugs Drugs 4) Annual screening program: TVS / Pap smear / Mammography
E2 secreting T. Androgen secret. T. Lipid profile / DEXA
Hypothyroid CAH
5) ttt of complications : Osteoporosis
Inv & ttt of the cause Biphosphonate ( once weekly )
Investigations for all : SERM BUT ++ hot flushes
1) History to detect cause (drug intake ) Phytoestrogen BUT weak
2) US : to detect any tumors HRT BUT Ca breast / Ca endometrium / ++CVS
3) Hormonal profile : for levels of E2 , FSH , androgen ‫ ؞‬CI : H/O Breast ca / AUB / DVT / Active liver disease
9
Page
4) Specific for suspected lesion eg : CT Brain Forms : continuous E/P , Cyclic E/P , E only in TAH
Anovulation PCO(obesity) Hirsutism
( commonest cause of anovulation )
{ = hypogonadism } * Stein & Leventhal 1935 ( obesity / Hirsutism / Infertility )
( ↑ androgen dependent sexual hair )
Et: Idiopathic ( commonest )
Def: Cong. * Rotterdam criteria 2012
Ovarian causes ( eg PCO )
Stress ( anovulation / hyperandrogen / US necklace appearance )
Et: І) HYPO Adrenal causes ( ↑ DHEA )
Drugs ( 2 out of 3 to diagnose PCO )
Hypothalamus ↓↓ OBESITY Androgenic drugs
gonadotrophs ++Leptin ++ GnRh pulse & frequency Diagnosis : History ( drug intake )
prolactinoma ‫ ؞‬++ LH ( maintained ) For the Lab (total & free testosterone /
empty sella ++ androgen Hirsutism cause DHEA)
sheehan - - aromatase more free androgen US ( ovaries / adrenal )
Ant. Pituitary - - E2 - - SHBG
Ttt: ttt of cause ( if present )
Turner ІІІ) HYPER Anovulation unopposed E EH hair removing techniques
POI ↑↑ gonadotrophs
++ Resistance to insulin NIDDM drugs:
PCO ± gonadotrophs
Ovary ІІ) EU Peripheral conversion of androstendione to E1 ‫ ؞‬++ E * Antiandrogen (cimetidine)
* OCPs (Cyproterone acetate)
Diagnosis: Diagnosis : * -- 5 α reductase (spironolactone)
Symptoms 1) Complaint : ( symptoms & signs ) Testosterone DHT ( more potent)
Regular cycles
2) Labs: ↑LH / FSH - ↑ androgen - ↑ E1 - ↓ PRG
Spasmodic dysmenorrhea
3) US: Adam’s criteria
Hyperprolactinemia
Premenstrual mastalgia
( ↑ prolactin level > 29 ng / ml)
Midcycle pain ( necklace appearance + dense stroma)
Presented by galactorrhea BUT not all cases of
Midcycle spotting 4) laparoscopy : Oyster shell appearance galactorrhea are associated with ↑ prolactin
Midcycle discharge ( large / loss of ovulation stigma ) Et : Physiological
Signs & Inv BBT
Folliculometry Treatment : Side effect of medication
Pituitary causes Micro < 1cm
PRG level ( D21) 1) loss of weight + insulin sensitization : ( metformin ) Macro > 1cm
Hypothalamic causes
LH urinary kits 2) ttt of complaint eg :
PEB Hypothyroid (‫↑ ؞‬TRH é PRL like effect)
If Irregular cycles OCPs
Diagnosis : History ( drugs / thyroid )
Ttt: of cause If Hirsutism see later Lab (PRL level )
Induction of Ovulation CT , MRI brain
CC If Infertility induction of ovulation Ttt: Cause Microadenoma : medical
10
Macroadenoma : surgical
HMG (FSH ± LH) CC / HMG – HCG ( better recombinant FSH to ↓ OHSS) Drugs: Bromocryptine(dopamine agonist)
Page
Ovarian drilling in PCO 3) ×× Last resort ×× (ovarian drilling ) Cabergoline

Infertility
female
male unexplained
Ovarian Tubal & Peritoneal Endometrial & Uterine Cervical
* Anovulation
Etiology
* Smoking Kallmann * PID * Polyp / septum

Hypothalamic Drugs
* DM stress * Surgery * SMM Ab _____
Pituitary
* Varicocele * Endometriosis * Ashermann
Ovary PCO
* Symptoms of ovulation
* H/O operations Regular cycles * H/O fever
Symptoms
* Infections / tumor Spasmodic dysmenorrhea * Discharge Abnormal

* Bleeding
* Trauma PMS * Pain discharge ? _____
* Amenorrhea
* Impotence Midcycle spot * H/O abdominal /
* PM ejaculation Pain pelvic surgeries
Discharge
* Semen analysis
* BBT chart
Signs & inv.
( Azo /oligo / terato /

* Folliculometry * TVS
Asthenospermia ) * HSG
* LH urinary kits * HSG PCT ? Laparoscopy
* Hormones * Laparoscopy
* Day 21 PRG > 5mg * Hysteroscopy
* Doppler US
* PEB
* Testicular biopsy
* Stop smoking * Ttt of the cause
* Vitamins & * Induction of ovulation * Tuboplasty / Polypectomy
ttt
Antioxidants * CC ( oral tabs ) adhesiolysis Septum resection IUI IVF / ICSI

* IUI * HMG / HCG * IVF / ICSI Myomectomy
* ICSI IU adhesiolysis
IVF / ICSI:
1) Down regulation of pituitary by GnRHa ( or antagonist )
2) HMG / HCG Stimulation ( NB : OHSS )
3) Oocyte retrieval under anesthesia ( NB: Complications )
11
4) IVF / ICSI under the microscope
5) Max 2 embryos for transfer on day 2 , 3 or 5
Page
6) PRG Luteal support till end of 1st trimester ( if pregnancy occurs )
Fibroid (myoma , leiomyoma) Menorrhagia
• Definition : Benign tumour of smooth muscle fibers of the myometrium.
• Incidence : 25 % of ♀ in child bearing period !!! WOW
• Etiology : + + E2 eg ( Genetic / Racial / Nulligravida / Anovulation / Early menarche & Late menopause ….)
• Pathology : Gross ( site / size / shape / consistency / cut section / count )
Mic: < 10 mitotic figures / HPF * Hyaline ( commonest )
Pathological changes Atrophy * Cystic
( Uterine Sarcoma ): Necrosis * Fatty
* Rapid growth Infection * Calcification ( menopause )
* Rapid recurrence Degeneration * Red (Necro-biosis) commonest in pregnancy:
* Growth after menopause Malignant (very rare) incomplete necrosis
• Clinical picture : S: Asymptomatic / Menorrhagia ,unless SM fibroid polyp metrorrhagia / Pain / Mass /Infertility…
S: general anemia
abdominal mass ( can’t reach lower border ) interstitial
PV & Bimanual mass ( in weeks describe )
DD symmetrical / asymmetrical enlarged uterus
subserous
• Diagnosis : US : TVS ( TAS ) : Gold standard submucous
Hysteroscopy / Laparoscopy / HSG / MRI / CT / X-Ray…
• Treatment : Conservative: NO symptoms ‫ ؞‬NO ttt
EXCEPT : > 14wks / BLM / Infertility or RPL in SMM / Rapid recurrence / Growth after menopause
Medical: Antifibrinolytic eg Tranexamic acid
Venotonics eg Daflon
Hormonal ( Gestagens / GnRh agonist / OCPs )
Microinvasive techniques : UAE / lap. Myolysis / HIFU
Surgical (definitive ttt) : Myomectomy ( open / laparoscopic / hysteroscopic )
Hysterectomy ( open / laparoscopic / vaginal ? )
12Page
NB: Fibroid during pregnancy , Never to be removed , due to high vascularity & ++ E2 EXCEPT in certain conditions
Endometriosis PAIN Adenomyosis Menorrhagia
Def: presence of end. glands & stroma outside ut. cavity Def: presence of end. glands inside myometrium
‫ ؞‬uterus is clean ‫ ؞‬uterus is affected
Incidence: 10% of all ! 20% of ch.pelvic pain 30% of infertility
NB : Commonest cause of chronic pelvic pain is Idiopathic Etiology + theories: more in Multipara
Etiology: ++ E2 / white races (infiltration in myometrium during involution )
+ theories Sampson Retrograde menstruation
Halban Lymphatic theory
Meyer’s coelomic metaplasia theory
Immunologic & genetic theory
Pathology: site pelvic √√ Pathology : localized: DD Fibroid ( false capsule )
extrapelvic diffuse
size burn match uterus is grossly bulky & tender ( Halban sign )
endometrioma ( chocolate cyst )
Clinical picture : Clinical picture :
Type of patient: Type of patient:
Symptoms: PAIN / Infertility Symptoms: bleeding ( menorrhagia )
dysmenorrhea / dyspareunia (deep) / dyschezia / dysuria /ch. pelvic pain pain ( dysmenorrhea )
Signs : General Signs: General : anemia
Abdominal Abdominal : ± enlarged uterus
Local: PV & Bimanual fixed RVF PV & Bimanual: Halban sign (enlarged tender uterus)
endometrioma (adnexal mass ) Free adnexae
nodules in DP
DD of nodules in DP : Endometriosis / TB / Krükenberg
Inv: US : for endometrioma ( Ground glass appearance ) Inv: US ( TVS / TAS )
CA125: prognostic & follow up not diagnostic
Laparoscopy : gold standard
Ttt: depends on symptoms severity / will to preserve fertility Ttt:
Medical :analgesics ( NSAIDs) Symptomatic : Analgesics / haemostatics
Hormonal :continuous OCPs / continuous gestagens / GnRh a Hormonal : ( to↓↓menses )
Surgical : conservative : lap fulgration of endometriotic foci eg : OCPs / gestagens / mirena LNG-IUD
13
cystectomy of endometriomas > 4cm Definitive surgical ttt : TAH
Page
definitive : TAH & BSO
( most common) Atrophic
( most serious) EH / EC
After menopause
(postmenopausal bleeding )
AUB Before puberty mostly FB introduction
may be precocious puberty
Child bearing period

( Menorrhagia / Metrorrhagia / Contact bleeding / Perimenopausal bleeding )
1 Exclude 2 Exclude
Complications of Then do US Complications of

pregnancy absence of presence of contraception
(ie bleeding in 4 organic lesion organic lesion 3 ( IUD / Hormonal )
early pregnancy ) COEIN FIGO 2011 PALM
(β-HCG) Dysfunctional Structural
Polyp
Adenomyosis ttt
Systemic Local Leiomyoma of
(Ovulatory disorder) Malignancy cause
* Coagulation defect may lead to EH ( see later ) (cx / endometrium /
( blood diseases ) ( Metropathia Hemorrhagica ovary / vagina )
* Iatrogenic drugs é Swiss cheese apprearance )
( as anticoagulant )
* Non specific as: ttt Medical: Antifibrinolytics ( Tranexamic a.)
HTN or NSAID ( Mefenamic a.)
Liver troubles Hormonal: OCPs / Gestagens ( Cyclical )
Thyroid dysfunction LNG – IUD ( Mirena ) *Dysmenorrhea
D&C ( in acute attack to stop bleeding) 1ry spasmodic
ttt of cause Endometrial Ablation (NSAIDs / OCPs)
TAH ry
2 congestive
14
(ttt of the cause)
*PMS
Page
Contraception
Physiological Barrier IUD Hormonal Sterilization
*Physical
* safe period Condom ♂ / ♀ * Copper Oral IM subdermal Vag ring Patches * Female ♀
Types
* coitus interruptus Vag diaphragm * Silver E/P E/P Implants E/P E/P Tubal ligation
* lactation Cx cap * LNG (daily) (monthly) (3 years) (3wks) (weekly ( lap /open / vag)
*Chemical P P P for * Male ♂
spermicidals (daily) (3months) 3wks) Bilat vasectomy
Nonoxynol-9 non-stop
* Easy / Cheap * Easy / Cheap * Easy / Cheap / Available * Easy / Cheap * Permanent ?
* Available * Available * No systemic SE * Available
Benefit
* No systemic * No systemic SE * No hormonal CI * High efficacy 4 PRG ONLY

side effects * No hormonal CI * High efficacy * Regular cycles (with COCPs) contraceptives * High efficacy
* No hormonal CI * condom protects * Single decision *↓ menstrual amount (due to P content)
against STDs (Developing countries) ( Developed countries )
* Bleeding (menorrhagia) * Break through bleeding / ↓amount of menses
* Low efficacy
Side effects
* Low efficacy * Infection / Pain * Amenorrhea in P - nausea * Post ligation

* May cause Minor
* Need regular * Leucorrhea * HTN / Breast lesion SE
- bloating syndrome
allergic reaction - vomiting
cycles * Perforation / expulsion * Liver impairment
* Need - acne
* Need cultured * Missed IUD * Need compliance in daily pill intake
understanding - pigmentation
couples * Pregnancy on Top * DVT / - - lactation * Permanent
couple - weight gain?
* Ectopic pregnancy (use progesterone only)
* uterine anatomical * H/O of DVT
* Allergy to changes * H/O of Breast benign or malignancy Future desire for
* Irregular cycles
material * Infection * Coronary heart - migraine fertility
CI
* Uncultured
* Refusal of * Menorrhagia * Active liver impairment relative - smoker ( Undecided
Couples
Couple (use mirena) * Hypertensive - > 35 yrs couple )
* H/O of: PID/ Ectopic * Diabetic
* - - implantation * - - ovulation
How
(create unfavorable * Atrophic endometrium

- - Fertilization - - Fertilization - - Fertilization
medium * Thick cx mucous Progesterone
15
ie inflammatory) * Affect tubal motility
* Emergency contraception: OCPs : 4 tab 12hrs 4 tab , LNG : 0.75 mg 12hrs 0.75mg (up to 48hrs) / IUD : (up to 5 days)
Page
* Contraception during lactation: P ONLY ( as ×× Estrogen×× inhibits lactation )
Prolapse RVF
Def : descent of an organ below normal anatomical position ( eg Cx below level of ischial spine ) Def : uterus directed backward
Incidence : 30%
Etiology : ↓↓ support system : Ligaments : Mackenrodt’s / uterosacral / pubocervical Inc : 15% of normal population
Muscles : levator ani
Endopelvic fascia
Etiology :
Through : repeated childbearing / Menopausal atrophy / Cong anomalies
& predisposing factors : cough / constipation / ↑↑ weight / ascites / asthma * congenital : normal
Vaginal Uterine ( mobile RVF )
Anterior Apical Posterior 1 st
2nd 3rd * Fixed RVF: is acquired
Types Whole ut through adhesions /
Enterocele
Cystocele Cx below ischial Cx seen outside (fundus) endometriosis
vault Rectocele outside vulva
Urethrocele spine vulva * Puerperal : after deliveries
Deficient p (procidentia)
Pathology - keratinization of vagina / loss of rugae - Decubitus ulcer Cl.picture :
- pressure on urethra / UB / ureters - Hypertrophic cervicitis
- SUI ( weakness of bladder neck ) - Supravaginal elongation of Cx
* Symptoms : asymptomatic or
symptoms Urinary Sexual Rectal backache
symptoms of etiology ( pain )
Heaviness / mass protruding from vulva
* Signs : PV : Cx looks anterior
Signs on speculum exam
Mass / loss of rugae Mass / ulcers
Inspection
Palpation Reposit to elicit Levator Gurgling in Sounding for supravaginal elongation Ttt:
PV & PR hidden SUI ani tone enterocele * no ttt required
Ttt 1) proper spacing & kegel’s exercise between pregnancies * Hodge smith pessary was
Prevention 2) proper management of 1st stage ( no bear down ) , 2nd stage ( episiotomy when needed ) used Previously ×××
3rd stage ( repair of hidden tears ) ( not used nowadays )
Temporary - pessary till correction of general condition or in very unfit pts / control of PPT * Ttt of symptoms & etiology
Operations Ant As 1st & Post * Classical repair * Prophylactic plication of
colporrhaphy 2nd degree colporrhaphy + shortening of Young Old round ligament in pelvic
(ant. repair ) uterine ( post.repair ) Mackenrodt’s lig * Vaginal
+ * In case of * Sacrospinous hysterectomy operations as myomectomy
supravaginal fixation(vaginal) & perineal
Classical elongation * Sacrocolpopexy repair
repair ‫ ؞‬Manchester (abdominal ) * Lefort
16
colpodeisis
Or Fothergill
(in unfit pts)
Page
NB : All Op are done post menstrual / No intercourse for 2 months / No pregnancy for 1 year
Urinary incontinence (involuntary escape of urine upon …) Rectovaginal fistula
SUI DO GUF total true (no desire) Def : track between rectum &
(urodynamic incontinence) (urge incontinence) Urethrovaginal vagina
Def Involuntary escape of urine Involuntary escape of urine Connection b urinary & genital tracts
upon ↑ IAP upon desire to micturate (Always wet except in urethrovaginal) Cl.pict :
Et * Same as POP ++ D.contractions (idiopathic / * Obstetric (developing countries ) * if small :
* Hypermobile urethra irritation / infection ) * Surgical (developed countries ) incontinence to flatus
Cl.pict Involuntary escape upon May have desire in small high vesicovaginal * If large:
Can’t make it to toilet fistula or in uretrovaginal fistula incontinence to stools
straining
Inv * Cough test * urine analysis
* Bonney’s test (in POP +SUI) * urine C/S * Sim’s speculum & position ET:
* Q – tip test > 30˚ mobility * Cystoscopy * mostly between lower
N urodynamics : ( D.filling pre <15 cmH2O / 1st Desire 150 ml * Methylene Blue ( 3 gauze test ) rectum & vagina , due to
/ Residual < 50ml / full at 400-600 ml) failed episiotomy repair or
* Filling pr > 15cmH2O * IVP ( if KFTs N ) obstetric trauma.
* Normal filling pressure ( due to contraction of detrusor)
* Leak on cough IVP > IUP * No leakage upon cough * Cystoscopy (to visualize fistula ) Ttt: SURGICAL
( as IUP > IVP) Preoperative : fluid diet &
ttt SURGICAL MEDICAL : bladder training CATHETER IF SMALL intestinal antiseptic for 3-5
Start by - Kegel’s * ttt of infection SURGICAL IF LARGE days
- Scheduled voiding * ttt of stones * Dedoublement vag in low fistulae & OP :
* Periurethral plication * Anticholinergic as abd in high fistulae
NB :
* Low1/3 : transform to
( Kelly’s suture ) oxybutynin (destrusitol ) complete perineal tear &
é 60-70% success In uretrovag : desire is present from N
ureter filling & continuous leakage from repair by Lawson Tait
* TOT > TVT vaginal sling op
( if without POP) affected ureter at site of UVF operation
* Retropubic urethropexy –ve MB test / Abd repair * High fistula: Abdominal
In urethrovaginal : splinting urethra repair by dedoublement as
( Burch colposuspention )
Before surgical repair in VVF: VVF
(Gold standard )
* 3-6 months from procedure while putting Post operative :
success > 90%
a urinay catheter to divert urine, decrease
* Periurethral injection of size of fistula & allow max healing
* Low residue diet for 7 days
collagen * Post op: catheter for 10-14 days * Use laxatives to avoid
in hypermobile urethra constipation
17
* No pregnancy for 1 year
* Delivery by CS * Episiotomy should be done
Page
DD: * Retention with overflow ( intermittent self catheterization ) / * Nocturnal enuresis (psychological ttt) in subsequent deliveries

Scheme for oncology
Definition: From where the tumor arise Cl . picture :
Symptoms:
Incidence: How common / rare related to function / symptoms of metastasis
Etiology : Signs:
Predisposing F: * General: for metastasis
Premalignant lesions : cachexia / anemia / jaundice / virchow’s LN…
* Abdominal:
Pathology: * PV & bimanual :
Gross :
* Ulcer with raised everted edges , irregular necrotic floor , Staging:
indurated base * Stage І : confined to the organ
* Cauliflower mass with areas of hemorrhage & necrosis * Stage ІІ : limited local spread
* Firm / hard endophytic or exophytic nodule * Stage ІІІ : more local spread ± LNs
* Stage ІV: distant spread
Microscopy : ( depends on cell of origin ) ІV a : mucosa of bladder & / or rectum
eg : squamous cell carcinoma / ІV b : distant spread ( L B L B)
adenocarcinoma if arising from glands
Inv.
Grading : To confirm diagnosis :
*G І < 5% malignant undiff.cells = best prognosis To detect spread:
*G ІІ 5-50% malignant undiff.cells = intermediate prognosis * eg: chest x-ray / abdominal & pelvic US / bone scan
*G ІІІ > 50% malignant undiff.cells = poor prognosis To assess fitness of pt for surgery: ECG & Lab testing
Spread : Ttt:
* Direct spread to surrounding structures
Stage І , ІІ : Surgery
* Lymphatic to the draining LNs
* Blood : Lung Bone Liver Brain Stage ІІІ , ІV : Radiotherapy / Palliative
18
Page
Endometrial carcinoma
Def: Tumour arising from Endometrial glands Staging: ( FIGO surgical 2018 )
Inc: commonest tumour of ♀ genital tract & having best prognosis Stage І : confined to the organ (uterus)
Etiology : І a < ½ myometrial invasion
Predisposing F: ++ E2 (unopposed) early menarche / PCO І b > ½ myometrial invasion ± endocervical glands
late menopause /Granulosa cell tumor / use ERT / obesity /Tamoxifen Stage ІІ : limited local spread : Cx. stroma
Premalignant lesions : EH simple 1% / complex 3% Stage ІІІ : more local spread ± LNs
simple é atypia 9% / complex é atypia 29% ІІІ a : Ovaries / FT
Pathology: ІІІ b : Vagina / Parametrium
Gross Localized: endometrial polyp ІІІ c : LNs ( parametric LNs / paraaortic LNs )
Diffuse: ++ endometrial thickening > 5mm Stage ІV: distant spread
Microscopy ІV a : mucosa of bladder & / or rectum
Adenocarcinoma ( best prognosis ) & commonest ІV b : distant spread ( L B L B)
Adenoacanthoma ( + benign sq metaplasia ) Inv.
Adenosquamous ( + malignant sq cells ) To confirm diagnosis :
Clear cell ca / papillary cell ca (undiff. so poorest prognosis) * Screening:TVS ( if ET > 5mm in menopausal) / Hysteroscopy
Grading : * Gold standard ( confirmatory ) : FC & endometrial biopsy
GІ < 5% malignant undiff.cells = best prognosis To detect spread:
G ІІ 5-50% malignant undiff.cells = intermediate prognosis * eg: chest x-ray / abdominal & pelvic US / bone scan
G ІІІ > 50% malignant undiff.cells = poor prognosis * MRI for myometrial invasion & for LNs
Spread : Direct: myometrium / Cx / Ovaries / FT / vagina To assess fitness of pt for surgery: ECG & Lab testing
Lymphatic: para aortic / inguinal / paracervical / Ttt: * Early : Surgery * Late : Radiotherapy
parametrial
Blood : L B L B Stage І : TAH & BSO + cytology ± later radiotherapy
Cl . picture : Stage ІІ : ttt as cancer Cx (Wertheim’s operation )
Symptoms: Post menopausal bleeding (commonest) / type of pt Stage ІІІ : radiotherapy External beam = pelvis
Offensive discharge (pyometra)
Extended = pelvis + abdomen
Signs:
*Gen: for metastasis : cachexia/ anemia / jaundice / virchow’s LN… Stage ІV : Palliative : pain relief / rediotherapy
*Abd: enlarged soft uterus ± signs of metastasis : ascites / liver NB : Young pt desiring fertility : high dose of progesterone
19
*PV & bimanual : enlarged soft uterus can be given in stage I till completing her family
Unfit pt for surgery in stage I , II : Radiotherapy
Page
± adnexal masses ( ? ut to ov or ov to ut )
Ut sarcoma : see fibroid , choriocarcinoma : see v. mole (obst)
Cancer Cervix
Def: Tumour arising from ectocx (> 80%), endocx (15%) starting in reserve cells of TZ Inv.
Incidence: 2nd most common after endometrial Ca. / most preventable To confirm diagnosis :
Etiology : 1) Pap smear : screening for all population
Predisposing F: Sexuality: early / multiple / low socioeconomic / multipara / smoking anually in high risk & / 3 yrs in low risk
Viral: HPV ( 16 , 18 ) / HSV2 / HIV - if N √√
Premalignant lesions: CIN 1 ( LSIL ) / CIN 2,3 (HSIL) - if abnormal LSIL / ASCUS in low risk : medical ttt
CIN 1: abnormal cells & stratification involve lower 𝟏⁄𝟑 of ep. without HSIL / ASCUS in high risk Proceed
invasion 2) Colposcopy ± Biopsy to
CIN 2: abnormal cells & stratification involve lower 𝟏⁄𝟐 (or 𝟐⁄𝟑 ) of ep.
of BM Acetic acid : white (lesion)
CIN 3: abnormal cells & stratification involve all layers of ep. Shiller’s iodine: don’t take the brown dye (lesion)
Pathology: Gross: Ulcer , Nodule , Friable mass (ectocx) / Barrel-shaped cx (endocx) 3) Direct biopsy from lesion ( Knife / Cone / LEEP )
Microscopy: Sq cell Ca ( ectocx >80% ) / Adenocarcinoma ( endocx 15%) 4) FC in endocx
Grading : G І < 5% malignant undiff.cells ( best prognosis ) To detect spread: CXR / Abd & Pelvic US / Bone scan
G ІІ 5-50% malignant undiff.cells ( intermediate prognosis ) Ba enema / EUA / IVP / Cystoscopy / …
G ІІІ > 50% malignant undiff.cells ( worst prognosis ) To assess fitness of pt. for surgery : ECG / Lab tests
Spread: Direct: uterus / vagina / parametrium / uterosacral /bladder /rectum. ttt
Lymphatic: 1ry : paracervical / obturator / ext iliac / int iliac 1ry prevention ( HPV vaccine before sexual life )
2ry : common iliac / lat. sacral / para aortic CIN 1 regress spontaneously in 70%
Blood : L B L B medical ttt &repeat pap smear after 3months
Cl . picture : 2 , 3 CO2 laser / Diathermy /Cryocautery
Symptoms CIN: may be asymptomatic LEEP / LLETZ / Conization
Contact bleeding / AUB / Offensive discharge / Back pain TAH in old age (not desiring fertility)
Signs General: Signs of metastasis ( anemia – jaundice – virchow’s LNs…) / Uraemia Cancer Cx: - Early stage : Surgery
Abdominal: N - Late stage : Radiotherapy
PV& bimanual : Nodule / Mass / Ulcer / vagina / normal sized uterus Stage І a : TAH ( extrafascial hysterectomy )
PR: uterosacral & Parametrial involvement Stage І b / ІІ a : Wertheim’s operation
Staging ( Clinical FIGO 2018 ) (radical hysterectomy)
Stage ІІ b / ІІІ / ІV: Radiotherapy / palliative
Stage І ( confined to cx ) : І a < 5mm depth of invasion
І b > 5mm depth of invasion ( ± uterus ) NB :
Stage ІІ ( local spread ) : ІІ a: vagina ( but not lower 𝟑 ) 𝟏⁄ * In recurrent cases give the opposite initial ttt
ІІ b: parametrium ( but not to lat pelvic wall ) ie if it was surgical ‫ ؞‬give irradiation & vice versa
Stage ІІІ (more local ± LNs): ІІІ a : vagina ( + lower 𝟏⁄𝟑 ) * Unfit patient : Radiotherapy in all stages
* Low risk = low sexuality or -ve HPV DNA testing
ІІІ b: parametrium till lat pelvic wall (Uraemia & Death)
20
* High risk = high sexuality or +ve HPV DNA testing
ІІІ c : LNs * Ca. of cx stump difficult surgery (adhesions)
Stage ІV ( distant ): ІV a: mucosa of bladder & rectum
Page
ІV b: distant spread LBLB no room for radiation
Epithelial 70%
Germ cells 20 - 30% Benign ovarian tumours Clinical classification: Cystic / Solid
Pathological classification: Benign / Malignant
Sex cord stromal < 5% ( premalignant ovarian lesions ) Histological classification
Epithelial tumours (differentiated along) Germ cell tumours (diff. along) Sex cord stromal (diff. along)
embryonic
Granulosa
extra undifferentiated
cells
cells
Leydig
Sertoli
(Tubal ep) (Endo Cx ep ) (End) (urinary ep) ( endoderm , embryonic germ cells & Fibrous Theca
meso,ectoderm villi Yolk
sac sex cord tissue cells
Serous Mucinous Dermoid
Sertoli-leydig cell tumor (androblastoma)(malignant)

Yolk Sac ( Endodermal sinus tumor) malignant
Brenner Gonadoblastoma Fibroma Thecoma
cystadenoma ( BCT )
Size Moderate Huge Small Moderate Small Moderate Small
Endometrioid (malignant from start )
Granulosa cell tumour (malignant )

Site bilateral in 50% unilateral bilat in 15% bilat in 15% bilateral in 10% unilat in > 90% unilateral
Gross
Choriocarcinoma (malignant)
Uni/multilocular Uniloc é thick
Solid
Consistency Papillary Multilocular Solid capsule & Solid Solid
é long pedicle
(exo/endophytic) long pedicle
Stratified sq ep Undifferentiated
Cuboidal ep Columnar ep Transitional
Microscopy é sebaceous Germ cells Fibrous Tissue Theca cells
( ciliated / Non ) é Goblet cells ep
glands & Sex cord cells
Psammoma Pseudo- hair/teeth /bone
In dysgenetic Meig’s syndrome
Characteristic
bodies myxoma Coffee bean - mamilla Post
gonads ( + ascites
features peritonii ttt nuclei - chemical menopausal
(calcified cells) Peritonitis
Y ch . as AIS & Rt pl.effusion)
chemotherapy
CA 125 / CEA Struma -ovarii ____ _____
Secretions ± E2 (thyroxine) E2
CA 19-9
Malignant ____ 30% Fibrosarcoma ____
transformation
30% 5% < 1%
Dysgerminoma (extremely rare)
Complications: cl.picture: Inv : US / CA 125 / Laparoscopy
1) Torsion gangrene (rare) symptoms: asymptomatic
2) Hemorrhage acute abdomen pain
3) Rupture nothing ( in serous ) mass ( abdominal ) Ttt: Ovarian cystectomy
chemical peritonitis ( in dermoid ) no bleeding (except functioning) Oophorectomy ( in huge mass )
pseudo-myxoma ( in mucinous ) Panhysterectomy (TAH + BSO)
21
4) Infection in puerperium signs general : Cachexia in Mucinous ( in old age )
5) Incarceration pressure symptoms abd: swelling (insp. / palp. / percussion)
Page
6) Malignant transformation PV & Bimanual : Adnexal mass (whether laparoscopic or laparotomy)
Malignant ovarian tumours
Def : malignant T. arising from surface ep , germ cells & sex cord stroma of the ovary.
Inc : 3rd most common malignancy of ♀ genital tract é worst prognosis , deaths from ovarian tumours > deaths from end. & cx cancer together
Et : Predisposing F : NG / induction of ovulation / genetic ( BRCA 1 & 2 , Lynch II ) , OCPs are protective as they - - ovulation
Premalignant :Epithelial T( serous & mucinous cystadenoma) / Germ cells ( BCT / Gonadoblastoma ) / Sex cord stromal ( fibroma)
Extreme
old age Epithelial ( > 70 % ) Child bearing Germ cell T ( 20 - 30 %) Sex cord stromal T (< 5 %) *Metastatic
Pathology
ages
Serous Mucinous Granulosa Sertoli-Leydig
Endometriod MCT MST Chorio ca
EST
Dysgerminoma cell T (Androblastoma) Fibrosarcoma Krükenberg
cystadenocarcinoma Yolk sac Gynandroblastoma Tumour
Tumor é solid & cystic Bilat. small
Gross
parts é areas of hge & Solid tumors with areas of hge & necrosis solid nodules in
necrosis DP ( from
May be bilateral / fixed / with intact or ruptured capsule pylorus,colon)
characteristics
Microscopic /
Adenocarcinoma undiff Call Exner

Cyto & Shiller Signet ring
Pseudo - embryonic cells Lymphocytic bodies Extremely
Psammoma é endometrial Syncitio Duval Androgenic cells
myxoma infiltration rare cells
bodies peritonii hyperplasia / ca (hair, teeth ,bone) trophoblasts bodies (Rosette shape)
CA 125 / CEA
Sec
____ HCG AFP LDH E2 / Inhibin androgen ____ ____

.
CA 19-9
Grading : GI : < 5% malignant undiff. Cells ( best prognosis ) Inv :
GII : 5 - 50 % malignant undiff. Cells ( intermediate prognosis ) To confirm diagnosis
GIII : > 50% malignant undiff. Cells ( worst prognosis ) US: bilateral / solid / papillae /ascites (1 or more )
Spread : Direct: other ovary / uterus / fallopian tubes Doppler for vascularity / Tumour markers (CA 125) / Laparoscopy
Lymphatic: para aortic LNs To detect spread: Ba meal / enema / upper & lower GI /CXR /CT abd & pelvis
Transcoelomic: peritoneal seedling To assess fitness of pt for surgery : ECG / Labs /…
Blood : L B L B RMI = US (1 or 3) × Menopause (1 or 3) × CA 125 IF > 200 ( High risk )
Cl.pict: Symptoms : Asymptomatic / GIT symptoms / mass / cachexia ( 1 if one criterion in US or 3 if more than one criterion in US)
NO bleeding except in functioning T Ttt: Early : surgery / Late : surgery (debulking + chemotherapy)
Signs: G:cachexia /anemia / jaundice / virchow’s LNs / pl effusion Stage Ia : can be unilat salpingo oophorectomy till completing her family
Abd: inspection / palpation / percussion Stage I – IIa : TAH & BSO + omentectomy + peritoneal cytology
( mass / ascites ) peau d’orange + sampling LNs ± chemotherapy
PV & Bimanual : Nodules in DP / Adnexal masses Stage IIb – IV: debulking ( cytoreductive ) ie remove all tumor tissue > 1cm
Staging: + post operative chemotherapy (2nd look laparotomy / laparoscopy
Ia : one ovary , Ib : both ovaries
FIGO surgical
OR spiral CT is done later for FU & assess need for repeat chemotherapy )
staging 2018
- Stage I (confined to ovary) Ic : one or both é + ve peritoneal cytology
22
- Stage II ( local spread) II a :Ut / FT , IIb : UB / colon / rectum NB: Dysgerminoma is radiosensitive ( due to lymphocytic infiltration )
- Stage III (+LNs ) Ovarian ca has poor prognosis due to late presentation & so diagnosis & ttt
Page
- Stage IV (distant spread) IVa :lung & pleural effusion * Metatstatic ovarian tumours are more common than 1ry ovarian tumours
IVb: distant liver parynchyma / brain / bone
Non Neoplastic (Functional) cysts of the ovary
Definition : Ovarian cysts occuring in childbearing peroid that may cause functional disturbances.
Incidence : 25% of all adnexal masses in child bearing peroid !!!
Follicular cyst CL Cyst Theca lutein Endometriotic cyst Inflammatory Inclusion
(commonest) nd
(2 most common) cysts (Endometrioma) cysts cyst
* Fluid accumulated * Hemorrhage in * Induction of * Functioning * PID in the form of * Invagination
in atretic follicles corpus luteum cyst ovulation drugs endometrial tissue TOC or TOA of germinal ep.
Etiology or
* Unruptured * MFG / GTDs in ovaries in ovarian
dominant Follicle (due to +++β- HCG) substance
Unilateral Unilateral Bilateral Unilat or bilateral Bilateral
Unilocular Unilocular Multilocular Unilocular é thick wall Multiloc. é thick cap
Gross microscopic
Small < 7cm Small < 7cm Large in size > 7cm Small to large size Small to large size
Pathology
Filled é clear fluid Filled é Hgic fluid Filled é clear fluid Filled é chocolate material Filled é fluid / pus
Lined by granulosa Lined by luteinized Lined by luteinized Lined by functioning Lined by epithelial Lined by
Mic
cells granulosa cells theca cells end. tissue menstruates cells ep. cells
E2 May cause mild No, except if
secretionsmay be associated é PRG ++ HCG ++ CA 125 changes to ep.ov.
CA125 elevation tumours ‫؞‬CA125
( MH / PCO)
Asymptomatic
Symptoms Menstrual disturbances Of original cause Chronic pelvic pain Fever / malaise _____
Cl. picture
Pain if complicated (torsion / Hge)

___________ __________
G * Fever / tachycardia
___________ __________
Abd *Tenderness/guarding _____
Signs Of original cause Rigid acute abdomen
PV *Tenderness at mid inguinal point(ov.point) * Nodules in DP * Fixed bilat tender
*Fullness in vaginal fornices & DP * Fixed adnexal mass masses(jumping sign)
US is gold standard for diagnosis US (ground glass appearance) CRP / ESR
Inv CA 125 ( prognostic ) TLC / DLC _____
Laparoscopy if in doubt or complications ++ HCG Laparoscopy(gold standard) US ( gold standard )
* Antibiotics
* Regress spontaneously in few weeks * If < 4cm : ( medical )
according to
* If > 7cm , or didn’t regress: OCPs /Gestagens/ GnRha
Treatment ttt of cause CDC regimen ± _____
‫ ؞‬OCPs / Gestagens * If > 4cm : ( surgical )
23
* Drainage of
* If complicated : lap.ovarian cystectomy Lap. ovarian cystectomy
persistent TOA
Page
NB : Parovarian cyst : if large cystectomy ( laparotomy / laparoscopy )
Malignant tumours of vulva
Def: Malignant tumour arising from labia majora / minora / clitoris . Staging: ( FIGO surgical 2009 )
Inc: 4 most common tumour of ♀ genital tract after end , cx & ovaries
th Stage І : (confined to vulva)
Etiology : * Іa: < 2cm width & < 1mm depth of invasion
Predisposing F : young type (smoking / HPV infection ) / old age * Іb: > 2cm width & > 1mm depth of invasion
Premalignant lesions: VIN (1,2,3) : VIN 1 & 2 usually regress Stage ІІ: ( local spread ) : to lower vagina / lower urethra / anus
Lichen sclerosus & Atrophicus ( in old age ) Stage ІІІ: ( local spread + LNs ) : Inguinofemoral LNs
Paget’s disease ( adenoca. in situ )(multifocal) Stage ІV: ( distant spread )
Pathology: * ІVa: UB mucosa / Rectal mucosa
Gross: VIN : may appear N All urethral mucosa / All vaginal mucosa
Invasive: Nodule / Ulcer / Mass * ІVb: L B L B
VIN :
VIN 1: atypical cells & stratifications in lower 1⁄3 of ep without
Mic: Investigations:
VIN 2: atypical cells & stratifications in lower ⁄2 or ⁄3 of ep invasion
1 2
of BM To confirm diagnosis: Direct excisional biopsy

VIN 3: atypical cells & stratifications in all ep.
Invasive: Squamous cell ca.(commonest) If no apparent lesion: use colposcopy or paint é acetic acid
Paget’s Adeno ca. / Melanoma / Basal cell ca ( rare ) & take biopsy from the white lesions
Grading G І : < 5% malignant undiff.cells ( best prognosis ) To detect spread : Colposcopy for cervix & vagina
G ІІ: 5-50% malignant undiff.cells( intermediate prognosis) to detect associated involvement
G ІІІ : > 50% malignant undiff.cells ( worst prognosis ) (as all are predisposed by HPV infection)
Spread : Direct: vagina / urethra / anus / perineum CXR / CT abdomen & pelvis
Lymphatic: inguinal femoral ( LNs of Cloquet ) To assess fitness of pt. for surgery : ECG & Lab tests
Blood : L B L B
Cl . picture : Treatment:
Symptoms In VIN : Asymptomatic or Pruritis vulvae Early stages: Surgery / Late stages: Radiotherapy
In invasive : Pain / Mass / Ulcer / Contact bleeding In VIN : Symptomatic ttt to relieve pruritis for 3-6 months
(in addition to long standing pruritis valvae ) 1& 2 by topical steroids (as usually regress spontaneously)
Signs : In small lesions : excisional biopsy
*General: signs of metastasis In wide lesions (if not responding to topical steroids):
*Abdominal : rare skinning vulvectomy ± skin graft
*Local: In VIN : raised rough skin / thin reddish epithelium In VIN 3 , Stage Ia : excision
white hyperkeratinization ( leukoplakia ) Stage Іb : wide local excision
24
In invasive: ulcerated / pigmented mass ± inguinofemoral LNs sampling from separate incision
labia majora mostly then minora then clitoris Stage II IV : external irradiation
Page
± enlarged inguinal LNs
Malignant tumours of vagina
Definition: Primary tumours arising from vaginal epithelium Investigations:
or more commonly 2ry from primary tumour elsewhere To confirm diagnosis:
Incidence: least common tumour of ♀ genital tract . Pap smear in VaIN
Etiology : Premalignant lesion: VaIN Excisional biopsy from naked eye lesions
Predisposing F : old age / HPV infection Colposcopy + acetic a staining + biopsy from white lesion
Pathology:
Gross: In VaIN : may appear N To detect spread : US uterus / CXR / CT abdomen & pelvis
Invasive ca : Nodule / Ulcer / Mass
Microscopic: To assess fitness of pt. for surgery : ECG & Lab tests
VaIN:
VaIN 1: atypical cells & stratifications in lower 𝟏⁄𝟑 of ep. without
VaIN 2: atypical cells & stratifications in lower 𝟏⁄𝟐 or 𝟐⁄𝟑 of ep. invasion
VaIN 3: atypical cells & stratifications in all ep. of BM
Invasive ca: Squamous cell carcinoma in > 90% Treatment:
Clear cell / Melanoma / Rhabdomyosarcoma In VaIN :
Grading G І : < 5% malignant undiff.cells ( best prognosis ) Laser ablation of lesion ( under colposcopy)
G ІІ : 5- 50% malignant undiff.cells (intermediate prognosis) Wide local excision
G ІІІ : > 50% malignant undiff.cells ( worst prognosis ) Topical chemotherapy : 5-Flurouracil
Spread: Direct: to nearby organs & malignant fistula may develop In invasive ca vagina
with urinary bladder or rectum Early stages: Surgery / Late stages: Radiotherapy
Lymphatic: as cancer Cx stage І ( involving upper vagina ):
Blood : L B L B Wertheim operation ( radical hysterectomy)
Cl . picture : ( most commonly 2 affecting the upper ⁄𝟑 of vagina )
ries 𝟏
stage І ( involving lower vagina ) till stage ІV:
Symptoms Radiotherapy
* In VAIN: Asymptomatic or contact bleeding
* In invasive ca vagina : contact bleeding / mass / offensive discharge
Signs : General: signs of metastasis Sarcoma Botryoides in prepubertal girls Mass & Bleeding
Abdominal : very rare
PV: Mass / Nodule / Ulcer / Contact bleeding
Staging: Stage І : (confined to vagina)
25
Stage ІІ: ( local spread ) : to Cervix , Uterus …
Stage ІІІ: ( local spread + LNs )
Page
Stage ІV: ( distant spread )
Lower Genital Tract Infections (no fever)
LGT infections: Vaginitis Childhood: foreign body / worms
Menopause : -- E2 Atrophic / Alkaline PH
Childbearing: protected by Stratified squamous epithelium
++ E2 ‫ ؞‬++ Glycogen
Cervicitis Lactobacilli / Lactic acid ( acidic PH )
vaginitis cervicitis
Bacterial vaginosis Candidiasis Trichomoniasis
Acute Chronic Erosion
(commonest) ( 2nd common) (3rd common)
Bacteria Fungus Protozoal
organism
Etiology
Polymicrobial *infection (ch.cervicitis)
sp. Neisseria & On top of acute *hormonal(preg /COCPs)
Gardnerella vaginalis Candida albicans Trichomonas
Chlamydia *congenital
vaginalis
Et
++++ anaerobes --- immunity STD *Mucous polyp

*Mucopurulent
discharge
Cl.picture
PH
Alkaline : 4.7-7 Acidic < 4.5 Alkaline : 5-6 *Nabothian

Profuse / yellowish follicles Contact bleeding
discharge
Fishy odour Extremely irritant *Dyspareunia

Mildly irritant
Profuse / non irritant Cottage cheese *Hypertrophic
Strawberry Cx *Backache
greyish scanty cervicitis
In 25% of cases
+KOH
Hyphae / Flagellated
Mic
Inv.
Clue cells We may do C/S from discharge Pap smear
pseudohyphae protozoon
Fluconazole
150 mg once Doxycycline 100 mg bid / 7days * ttt of the cause.
Metronidazole weekly for 2
Treatment
* Residual cases:
Treatment
500 mg bid / 7days weeks Metronidazole 2gm

Or Cauterization
( CI in 1st trimester, ( CI all through single oral dose
Diathermy
give local cream or pregnancy & in + ttt of partner
Azithromycin 1gm single oral dose Cryo
26
supp only) liver troubles,
give local cream or
( in pregnant females ) Laser
Page
supp only)
Acute PID ( presence of fever )
Definition: Salpingitis , oophoritis , peritonitis Inv:
& rarely endometritis due to regular monthly shedding in Blood tests: ++TLC , ++DLC , shift to Lt , ++ESR ,++ CRP
childbearing period. US to exclude DD : ectopic , complicated ovarian ,
appendicular mass , degenerated myoma
Et: organism: N.gonorrhea, Ch.Trachomatis Laparoscopy: if diagnosis is doubtful
(mostly both together& others) NB: Exam of discharge to detect causative organism & do C/S
route: ascending ( mainly) , local or lymphatic , ( not clinically needed )
blood ( rarely) Fitz Hugh Curtis syndrome (filmy adhesions between the
risk F: sexually active , multiple sexual partners liver & under surface of diaphragm may be seen on
IUD , after menses , after sexual intercourse laparoscopy in cases of chlamydia )
é any procedure : D&C , HSG , Hysteroscopy, … Treatment:
NB: OCPs & barrier contraception ↓ risk ( ie are protective ) Mild PID ( é mild symptoms) Outpatient
Chlamydia may cause silent PID Ceftrioxone 250mg single IM dose
Pathology: + doxycycline 100mg /12hrs/14days
Endosalpingitis / interstitial salpingitis / perisalpingitis ± Metronidazole 500mg oral bid / 14days
( acute catarrhal or acute suppurative ) Severe PID (é severe symptoms ) Hospitalization
Oophoritis : é microabscesses on the surface IV fluids /IV analgesics / IV antipyretics
Pelvic peritonitis IV antibiotics :
Clinical picture: Cefotetan 2g IV/12hrs or cefoxitine 2gm IV/6hrs
Symptoms: fever , malaise , headache , + Doxycycline 100 mg orally / 12hrs for 1-2 days
H/O of recent OBGYN procedure till symptoms become milder then continue previous
Acute lower abdominal pain oral regimen of mild cases for 2weeks
Foul smelling purulent vag. discharge NB:
Signs: Fever > 38.3˚ , tachycardia 1) IF IUD present remove
Lower abdominal tenderness & rebound tenderness 2) In case of TOA give clindamycin 900mg IV / 8hrs
Cx Motion tenderness , discharge or Metronidazole 500 mg IV / 8hrs in addition to
Complications : chronic PID ( if inadequately treated) the 2 mentioned above drugs of severe PID
Tubal obstruction & infertility 3) IF TOA doesn’t resolve by medical ttt :
27
(due to fibrosis & adhesions ) ‫ ؞‬drainage through laparoscopy / laparotomy
++ risk of ectopic pregnancy
Page
or colpotomy ( vaginal drainage)
Chronic PID
Sequelae of acute TB ( chronic from the start )
Pathology: TB is a chronic granulomatous disease
Hydrosalpinx : Etiology: Mycobacterium tuberculosis
sequelae of inadequately treated acute catarrhal salpingitis Blood spread from lungs ( most common )
Pyosalpinx : Pathology :
sequelae of inadequately treated acute suppurative salpingitis FT: (affected in 100% of cases of TB of genital tract )
TOC *Endosalpingitis: caseous material inside thick , tortuous ,
TOA tobacco pouch appearance ( open everted fimbrial end )
Chronic Interstitial salpingitis *Interstitial salpingitis : thick , beaded , salpingitis ithmica nodosa
Clinical picture : *Perisalpingitis: é multiple tubercles on the surface
Symptoms : & on surrounding peritoneum
* history of acute PID Endometrium : affection of basal layer IU adhesions
* dull aching lower abdominal pain or Asherman syndrome ( PEB is diagnostic)
* pelvic congestion Menorrhagia / leucorrhea
Oophoritis : with microtubercles
Rarely : vulval ulceration / cervical ulceration ( DD of cancer cx)
Clinical picture :
Dyspareunia Congestive dysmenorrhea Symptoms: Asymptomatic
* backache Low grade fever/ loss of wt / loss of appetite
* infertility from tubal obstruction & peritoneal adhesions 5-10% of infertility cases are due to TB salpingitis
Signs: Amenorrhea / oligomenorrhea
* adnexal tenderness/ fullness / cyst Signs: Mostly normal
Genital serpiginous ulcers é undermined edges
* fixed RVF in case of extensive adhesions
Investigations :
investigations:
X-ray chest (& pelvis for calcified LNs)
US for adnexal masses
HSG ( not in active TB ) : retort shape tube , IU adhesions
HSG for hydrosalpinx
PEB
Laparoscopy is the gold standard Laparoscopy ± biopsies from suspicial lesion ( serosal tubercles to be
Treatment : stained by Ziel –Nielsen to show the acid fast , alcohol fast bacilli)
Symptomatic ttt Tuberculin is a good –ve test
eg : infertility ttt ( TD + IVF ) Ttt: General ttt for anemia , proper nutrition
pain & congestion in old age ( TAH & BSO)
28
Anti TB ( Rifampicin , INH , Pyrazinamide , Ethambutol)
( antibiotics only in acute exacerbations ) Surgical ttt in case of tubal mass or endometrial TB
Page
& post operative anti-TB ttt
STDs
Bacterial Viral
Chlamydia Donovanosis S
G Trachomatis
Chancroid
(GI)
LGV HSV2 HPV HIV
Neisseria Chlamydia
Organism
gonorrhea Trachomatis Hemophilus Klebsiella Chlamydia Treponema

(columnar & (columnar HSV2 HPV 6 / 11 AIDS Pallidum
Ducreyi granulomatis L1,2,3
transitional) epithelium)
PID Vulval lesions Vulval + Systemic manifestations
Mucopurulent Subclinical Painful Painless Destructive Painful Painless warts Asymptomatic 1ry (chancre)
discharge papule papule lesion Vesicles Painless
ry
(condyloma Severe form 2 (condyloma
Cl.picture
Lower Mucopurulent painful ulcer Ulcerate Ulcerate painful ulcer acuminata) latum)
abdominal pain discharge é exudation without Kaposi
××× NO ××× exudation sarcoma (maculopapular
Bartholin PID (silent) LNs +++ ××× LNs××× LNs +++ rash)
Urethritis 3ry(systemic)
Systemic Squelae (tabes dorsalis)
(IP 3-5 days) (IP 3-5 days) (IP 3 weeks) (IP 3weeks) (IP 3weeks) (IP 3months) (IP 3years) Congenital
Gram –ve CF Culture Dark field Mic
Gram –ve Obligatory Coccobacilli Pap smear Western blot (spirochetes)
of serum
diplococci intracellular (koilocytes) Non-specific
Donovan collected
Inv.
Culture: Culture : VDRL / RPR

Bodies from Specific:TPH/TPI
Thayer Martin expensive Cl.picture is Colposcopy Eliza In 1ry S Ag present
vesicles
NAAT NAAT enough In 2ry S Ag & Ab
India/Africa India/Africa Ab In 3ry S Ab present
Ceftrioxone Ceftrioxone Acyclovir Vaccine Antiretroviral Penicillin
250mg IM 250mg IM 400mg 10 days ttt In penicillin
(can be taken
+ all through
Cryo allergy:
Ttt
Doxycycline Doxycycline Doxycycline Doxycycline pregnancy) Diathermy Vaccine ? If pregnant:

100mg / bid / 100mg / bid / 100mg / bid / 100mg / bid / Vesicles at Podophyllin Desensitization
7days 7days 3 weeks 3weeks labor = CS Podofilox If not pregnant:
29
(VD is CI) Doxycycline
Page
Other STDs : Trichomoniasis (protozoon) infecting lower genital tract / Pediculosis pubis & scabies ( Ecto parasites(
Pruritis vulvae
With vaginal discharge (80%) Without vaginal discharge (20%)
- Generalized disease
- Allergy
- Candida albicans - Scabies , seborrhea
- Lichen sclerosus (postmenopausal) ttt: corticosteroid cream
-Trichomonas vaginalis ( need follow up as it may be premalignant )
- Psychogenic
- Urinary or rectal incontinence
Vulval swellings
Cystic swellings Solid swellings
- Bartholin’s duct Cyst ttt: marsupialization
Infected cyst ttt: antibiotics
Abscess ttt: drainage
- Inclusion dermoid ttt: excision & biopsy
- Sebaceous ttt: excision & biopsy - Lipoma
- Hydrocele of canal of Nuck ttt: surgical excision - Fibroma
( as hernia repair ) - Nevus
- Endometrioma medical / surgical depending on size ttt: excision &
- Hematoma incision & drainage
- Caruncle
biopsy
- Varicosities medical ttt: sclerosing material or - Papilloma / warts
ligation of the veins ( if not pregnant ) - Hydradenoma
- Hidradenitis suppurativa (it affects sweat glands in the
axilla & mons pubis & causes very bad odor )
ttt : check for DM & local antibiotic cream
30
- Urethral caruncle ( it causes dysuria & contact bleeding )
Page
ttt :excision & cauterization
Anatomy of female genital organs
Gross Histology Blood supply n. supply Lymphatics Applied anatomy
- Mons veneris - Stratified squamous epithelium (A) - Pudendal n. Superficial inguinal - FGM é 4 types with
( hairy pad of fat over SP ) ( keratinized hairy & non hairy ) - Int pudendal artery ( S2 , 3 , 4 ) LNs → deep early ( bleeding , infection )
- Clitoris: midline erectile organ (one of 2 terminal inguinal LNs & & late ( loss of satisfaction, sexual
- 2 labia majora: lat hairy é fat , - Transitional ep. For Bartholin branches of ant - Sensory: femoral LNs problems & frigidity ) complications.
sweat & sebaceous glands gland division of IIA) Ilioinguinal
- 2 labia minora: med é - Branches from n. ( L1 )
non hairy skin , no sweat or femoral a (Ext iliac a)
Vulva
sebaceous glands - Superficial & deep - Genital

- Hymen : memb 2 cm deep to external pudendal branch of Type 1 Type 2 Type 3 Type 4
vulval opening ( vestibule ) é arteries genito- Removal Removal Removal of Burning or
opening to allow menses femoral n. of clitoris of clitoris clitoris,labia pricking or
& labia minora & piercing
- Bartholin glands on posterolat (V) (L1,2 ) minora labia majora
aspect of labia majora , duct Venous plexuses that
opening in vestibule accompany arteries - Post - Clitoridal cyst : post circumcision
Vestibule cutaneous n. - Cryptomenorrhea:in imperforate
Urethral opening
of the thigh hymen
Vaginal opening , partially
closed by hymen in virgins
- Bartholin cyst : in obstructed duct
- Septum : longitudinal / transverse
- Fibromuscular tube é rugae Non keratinized stratified (A) Pudendal n. Upper third : - Ant. wall prolapse:
inside squamous epithelium forming Vaginal a from IIA ( S2 , 3 , 4 ) as Cx Cystocele , urethrocele
the distensible mucosal lining + middle rectal a - Post wall prolapse:
- 7 – 9 cm anterior wall related ( Rugae) + inferior rectal a Lower third : Enterocele , rectocele ,
to UB & urethra to Inguinal LNs deficient perineum
- Support :
-10 – 11 cm posterior wall (V) Middle third : post ( Uterosacral lig )
related to DP , rectum , Vaginal plexus to IIV II LNs lat ( Mackenrodt’s lig )
perineal body ant ( Pubocervical lig )
Vagina
- Episiotomy : cut post or posterolat

- Lat borders related to : vag wall in addition to perineal ms
1) ureter 1cm & skin
2) cardinal ( Mackenrodt’s ) lig - Post colpotomy or culdocentesis :
3) levator ani for drainage of pelvic abscess in DP
( deep perineal ms ) - US guided oocyte retrieval in IVF
4) bulbocavernous through post fornix
( superficial perineal ms ) - Ureter may be injuried at lat fornix
while clamping the vag angles in
31
TAH
- Pudendal n block :
Page
done at level of ischial spines

Gross Histology Blood supply n. supply Lymphatics Applied anatomy
- Pear shape 1× 2× 3 inches - Endometrium (A) -Inf - Fundus : - Ut prolapse : 1st , 2nd & 3rd degrees
Fundus
( modified mucosa é glands & - Uterine a ( tortuous hypogastric paraaortic LNs - Ut. support : lat , post & ant
Isthmus Cornual end stroma ) course on lat borders) plexus - Cornu : é round - MRKH Syndrome in case of 1ry
Cx Body - Myometrium of body of ut from ant division of IIA PS : S2 , 3, 4 lig to superficial amenorrhea é presence of secondary
- AVF ( 85% ) or RVF ( 15 % ) formed of 3 ms layers : - At Cx , it crosses ½ an inguinal LNs sexual characters
- Ant : UB / Pubocervical lig Outer longitudinal inch lat above ureter S: - Body : II LNs - Cong anomalies :
Uterus
- Post : DP / Uterosacral lig Middle criss-cross (water under the bridge) T5 , T6 - Cx : as septate / bicornuate / didelphys
- Lat: Broad lig & inside it : Iner circular - Branches from ( motor ) 1ry → paracervical with RPL , PTL
Fallopian tubes While Cx is formed of outer & ovarian a anastomosis T10,T11,T12 , L1 parametrial , - Cx is sensitive only to dilatation
Remnants of Wolffian ducts inner layers only at cornu with uterine a (sensory) obturator , II LNs ( Cx dilatation should be done under
Uterine artery - Perimetrium : peritoneal (V) & EILNs anesthesia )
Ureter covering which is adherent to - Pampiniform plexus 2ry → CI LNs ,
& Mackenrodt’s lig the body but loose at Cx in broad lig that follow Lat. sacral &
the arteries. paraaortic LNs
2 Tortuous tubes 10cm in length - Mucosa ( endosalpinx ) cubical (A) S ( T11 , T12 ) Paraaortic LNs - Tubal point
Ampulla 5cm Infundibulum
Isthmus 2cm
2cm
or columnar partially ciliated Branches from uterine through ovarian ( ½ inch above mid inguinal point )
& ovarian arteries & lymphatics in cases of pain , PID , ectopic .
Fallopian tubes
- Musculosa: 2 ms layers - Commonest site for ectopic

( outer long & inner circular ) PS pregnancy ( ampullary part )
Interstitial
part 1cm
Fimbrial end é (V) - Hydrosalpinx & pyosalpinx
fimbria ovarica
- Serosa or peritoneal covering Rt ovarian v . ( ch . PID )
- Runs in upper part of broad lig → IVC - Commonest permanent method of
related to loops of intestine contraception ( tubal ligation )
above é ovaries posterior & Lt ovarian v. - TD in cases of hydrosalpinx
inferior to them → Lt renal v. prior to IVF
- For ovum pick up , transport
& nutrition for ovum & sperm
(A) S ( T10 , T11 ) Paraaortic LNs - In ovariotomy : 6 clamps needed
- Almond shape 1×2×3cm in - Ovarian arteries from 2 on each pedicle (ovarian ,
fossa ovarica on lat. Pelvic 2 abdominal aorta & infundibulopelvic & mesovarium)
wall 1 - Branches from uterine ligaments.
- On ureter & bifurcation of artery that anastomose PS - Streak gonads in absence of sex cord
Ovaries
II vessels 1) Outer cortex é follicles at é ovarian vessels cells covering the germ cells ,
- Not covered by peritoneum different stages of forming Turner syndrome ( 45 XO )
- Corrugated surface due to development covered by (V) - Responsible for
repeated stigma of ovulation single layer of cubiodal ep . - Rt ovarian vein 1) ova production ( ie ovulation )
- Attached to ut by ovarian 2) Inner medulla → IVC 2) hormone formation ( E2 , PRG ) by
ligament , to lat pelvic wall by 3) Hilum ( site of attachment of granulose & theca cells of oocytes
32
infundibulopelvic lig , to the mesovarium , carries blood - Lt ovarian vein
back of the BL by mesovarium vessels , nerves & lymphatics → Lt renal vein
Page
while leaving the ovary )

Ureter Pelvic floor Perineum
Gross : Area of 5 cm between vaginal orifice & anus
25 cm in length , retroperitoneal covered by less hairy skin & less SC tissue
- Enters pelvis in ovarian fossa above the 1
bifurcation of CIA Perineal body :
- Runs downwards in the base of BL 2 - a fibromuscular pyramidal structure
below uterine artery . between posterior vaginal wall ( lower 1⁄3 )
3
- crosses forward related to lateral vaginal & anterior wall of anal canal
wall to enter trigone of the urinary bladder.
1) Peritoneum of DP with extra peritoneal
Histology : fat & cellular tissue
Lined by transitional epithelium
2) Levator ani ms ( deep perineal ms ) ,
Blood supply : ( urogenital diaphragm ) with : Perineal body Anal canal
(A) - ischiococcygeus Perineum 5cm
Branches from IIA , uterine artery , - ileococcygeus
Inf. vesical artery , vaginal artery - pubococcygeus - It is the point of insertion of superficial
( part mostly affected in child birth ) perineal ms & above it passes the levator ani
(V) → pubourethralis (decussation of the ms muscle
Follow the arteries fibers on either side to form a
sphincter around urethra) Applied anatomy :
Lymphatic drainage : → pubovaginalis If defective , ie: deficient perineum that
Iliac LNs (decussation of ms fibers around vagina) causes sexual problem & is treated by
→ Puborectalis posterior colpoperineorrhaphy .
Applied anatomy : (decussation of ms fibers around rectum)
- Injury at
Clamping infundibulopelvic ligament 3) Perineal ms ( superficial )
Clamping Uterine artery 1 cm lateral to Cx ( ischiocavernosus , bulbocavernosus &
Clamping Vaginal angles transverse perineii ms )
- Avascular necrosis in meticulous dissection Fat & skin of vulva
→ uretro vaginal fistula , symptoms
33
manifest few days post – operatively * The midline is pierced by urethra , vagina
& anal canal
Page
Uterine & cervical ligaments
Support ( to prevent prolapse ) Protect important structures
1) Broad ligament:
1) Lateral cervical = Mackenrodt’s ligament ( lateral from uterus to lateral pelvic wall )
= Cardinal ligament ( strongest ) Contents :
Fanning from uterus to lateral pelvic wall - Fallopian tube (FT)
- Uterine vessels
2) Uterosacral ( posterior ) : - Parametrial lymphatics & LNs
- S & PS nerves
From uterus & Cx to periosteum of sacrum
- Ureter
- Remnants of Wolffian duct:
3) Pubocervical ( anterior ) : Hydatid cyst of Morgagni at fimbrial end of FT
From Cx to back of SP Epoophoron
Paroophoron
Gartner duct : lateral to tube & downward to
anterolateral wall of vagina
Paraovarian cyst : in case of cystic dilatation of
remnants of Wolffian duct
2) Round ligament :
Gubernaculum that attaches cornual end of of uterus to
labia majora passing through inguinal canal ,
it protects Sampson artery
3) Ovarian ligament:
Protects ovarian vessels
NB :
Infundibulopelvic ligament is not attached to uterus or Cx , it is
34
between ovary & lateral pelvic wall & protect ovarian vessels
Page
Sexual differentiation
Timing:
At moment of fertilization , whether the ovum is fertilized by X or Y sperm
Y chromosome carries TDF : For Testicular differentiation ( through H-Y Ag )

MDIF : which inhibits Mullerian duct
Absence of Y chromosome NO TDF ‫ ؞‬No testicular growth
NO MDIF ‫ ؞‬MD will grow
♂ Male phenotype development needs :
1) Y chromosome : for testicular differentiation , hormone formation & spermatogenesis
Mullerian duct inhibition
2) Responsive endorgans ( Receptors )
♀ Female phenotype development needs :

Abscence of Y chromosome ( Not the presence of extra X chromosome )
Proof : Turner XO has female phenotype
Normal Female Sexual Differentiation

Internal organs External genitalia
1) Genital ridge ( abdominal origin ): Urogenital sinus (sinovaginal bulb):
give rise to 2 Ovaries gives rise to urethra , lower vagina & vulva
2) Wolffian duct undergoes atrophy - Genital swellings : Labia majora ( eq to scrotum in ♂ )

3) Two Mullerian ducts develop to give rise to: 2 Fallopian tubes
(pelvic origin) 1 Uterus - Genital folds : Labia minora ( eq to penile urethra in ♂ )
1 Cx
1 Upper vagina - Genital Tubercle : Clitoris ( eq to penis in ♂ )
4) Fusion of 2 Mullerian ducts ( paramesonephric ducts ) occur
from below upwards followed by canalization : resulting in
single vagina , single Cx , single uterus but 2 Fallopian tubes
35
NB : Wolffian duct gives rise to male genital organs . so it atrophies in females
Page
Mesonephric duct gives rise to urinary system

Abnormalities in female sexual development
* Ovaries : * Cervix :
ry
Aplasia / streak gonads (as Turner Syndrome ): 1 amenorrhea Atresia ( failure of canalization ): cryptomenorrhea
with abscent 2ry sexual characters (NO ova , NO hormone production) ( hematometra , hematosalpinx , endometriosis ) & sometimes
* Fallopian Tubes : TAH is the only possible ttt .
Aplasia / accessory ostia / diverticulum : Ectopic pregnancy
* Uterus :
Aplasia 1ry amenorrhea é presence * Vagina :
( MRKH Syndrome ) : of 2ry sexual characters - Longitudinal vag septum ( failure of fusion of 2 Mullerian ducts) :
Unicornuate ut Dyspareunia
( only 1 Mullerian duct PTL
developed ) : -Transverse vag septum ( failure of fusion & canalization of
Bicornuate ut urogenital sinus below with Mullerian ducts above ) :
PTL & Cryptomenorrhea ( ttt : excision of septum )
( Failure of fusion of
incompetent isthmus
2 Mullerian ducts ) :
Septate ut - Aplasia as in MRKH Syndrome
Failure of implantation ( failure of development of Mullerian ducts)
( failure of complete
‫ ؞‬infertility , RPL , ‫ ؞‬only lower part of vagina develops : Dyspareunia
canalization of the 2 fused
missed abortion ( ttt Mc Indoe operation & neovagina formation )
Mullerian ducts ) :
Communicating functioning
Ectopic pregnancy
rudimentary horn : * Vulva :
Imperforate Hymen: Cryptomenorrhea
Non-communicating
Hematometra / (ttt : Hymenotomy through cruciate incision )
functioning rudimentary
Endometriosis
horn :
Uterus didelphys
Dyspareunia from
( failure of fusion of the 2 NB:
longitudinal vaginal
Mullerian ducts ): Usually anomalies in Mullerian ducts ( Paramesonephric ducts )
septum /
2 uteri , 2 cervices , are associated with anomalies of mesonephric ducts responsible
PTL from small sized ut
2 vaginae for development of Kidneys , ureters & UB ( ie urinary system ) :
36
Arcuate ut Of no clinical ‫ ؞‬Recommended to do IVP in case of any Mullerian anomalies
Page
( depressed fundus ) : significance

Endoscopy in Gynecology
Laparoscopy Hysteroscopy
Introduction of an optic lens through umbilicus to visualize Introduction of an optic lens through cervix to visualize
Def
peritoneal cavity & pelvic organs the uterine cavity

* Diagnostic : Unexplained infertility * Diagnostic: Infertility
Ch. Pelvic pain / Endometriosis RPL / Ut septum
Indications
Cong anomalies of uterus AUB / Polyp

* Operative : Ovarian ( cystectomy / oophorectomy ) * Operative : Polypectomy
Tubal ( ectopic / ligation / disconnection ) Septum resection
Uterus ( myomectomy / hysterectomy ) Myomectomy ( submucous )
Endometriosis : ablation of foci Division of of IU synechia
Adhesiolysis Tubal occlusion
- GA - NO anesthesia ( in office procedure ) ,
- Trendlenberg position ( head down ) Local or GA in operative procedures
Technique
- Veress needle at umbilicus & inflate 3-5 liters CO2 - Dorsal lithotomy position
é pressure 15 mmHg - Dilatation of Cx in operative procedures
- Introduce lens , light source , camera & manipulator - Uterine distension by CO2 , glycine ( is a must in op procedures)
- MB dye may be injected through Cx to visualize patency of FT - Lens , light source ,camera are introduced
- Irrigation , evacuation at the end of procedure - Removal of instruments at the end of procedure
- Anesthesia complications / Cutaneous surgical emphysema
- Fluid overload ( commonest complication )
Comp.
- Electrosurgical complications to bowel , uterus , nerves

- Electrolyte imbalance
- Injury to vessel , intestine , bladder / Infection
- Anesthesia complications ( if used )
- Neurological injury in poor patient positioning
- Less hospital stay , early return to work
- Minimal adhesions - Can be done without anesthesia as an office procedure
Adv.
37
- Early recovery , less GIT complications ( ileus , gastric dilatation ) ( no dilatation for diagnosis)
- Better cosmetic - Proper visualization of uterine cavity
Page
- Rare wound complications ( dehisence & infection )

Operative Gynecology
Sounding Dilatation Curettage
NO ANESTHESIA ANESTHESIA NEEDED
Uterine sound
* Diagnostic :
1) Measure length of uterine cavity * Dilatation alone in :
- PEB to detect ovulation
in IUD insertion , before D&C - Spasmodic dysmenorrhea
- In AUB & DUB to detect endometrial
2) Diagnose direction of Ut (AVF or RVF) - Cx stenosis
pattern & type
3) Diagnose supravaginal elongation - Drainage of pyometra or hematometra
- Diagnose malignancy of Ut & Cx
Uses
of the Cx in prolapse
- Diagnose diseases of Endometrium
4) Diagnose ut hypoplasia
as TB endometritis
Cx : body , N 1 : 2 * Dilatation preliminary to another
* Theraputic :
5) Diagnose Cx stenosis operation:
- Postabortive
6) ttt of pyometra - Op on Cx as Fothergill
- Endometrial , Cx polypi
( as mere sounding drainage ) - Op on Ut as curettage , polypectomy
- DUB
- Anesthesia complications
- Perforation
- Ut perforation - Anesthesia complications
Comp.
- Infection
- Cx laceration incompetent isthmus - Dilatation complications
- Bleeding
- Infection - Asherman Syndrome
- Abortion in case of pregnancy
- Shock in case of inadequate anesthesia
NB: In case of uterine perforation :
- Stop procedure
- Give antibiotics
38
- Observe vital signs If normal : Discharge the patient
Page
If deteriorates or intestinal contents appear through Cx : Exploratory laparotomy and proceed.

OBSTETRICS
39
Page
Pain , BLEEDING Abortion Inc : 15% RPL
≥ 3 successive spontaneous
Def
Def : Termination of pregnancy before viability ( < 24 wks ) whether fetus is living or dead
abortions
‫منذر‬ ‫مركون‬ ‫غير مكتمل‬ ‫مكتمل‬ ‫حتمي‬ * APL (Antiphospholipid S)
Types Septic
Threatened Missed Incomplete Complete Inevitable * LPD (Luteal phase defect)
* anatomical uterine defects
Dead or Living / Dead
Etiology
(ut septum)
Fetus Living (blighted ovum) Remnants ____ or Dead (fundal submucous myoma)
=
(anembryonic sac) (ROM < 24wks) * ch.anomalies / endocrinal
Brownish ____ * thrombophilia
Bleeding + ++ +++++ ± foul discharge * Cx incompetence (2nd )
S discharge
_____ ____ * infections / Trauma
Pain + ++ +++ Dull pain
Fever , * Labs :
____ ____
General DIC if > 4 wks ± shock ± SHOCK
Septicemia LA, Endocrinal ,TFTs ,
Investigations
S = period of Slightly enlarged anticardiolipin, PRG level
Abd < amenorrhea < amenorrhea = amenorrhea Tender uterus * US : eg: Cx length < 2.5cm
amenorrhea uterus
Cx Closed Closed Open Closed Open Closed / Open in Cx incompetence
* HSG : eg: funneling
+
US To show GS / CRL / ± Pulsations / Uterine contents in Cx incompetence
TLC,CRP,ESR
Inv
Return –ve * Hysteroscopy

HCG N ↓↓ ↓ ± ↓↓ Ttt of the cause: eg
after 1 wk
*LD Aspirin
*ttt of DIC if *Ttt of shock *Antibiotics LMWH (clexane) SC
present *Termination: *Ergometrine in APL
*Termination: ONLY surgical: (methergine) *PRG in 1st trimester in LPD
Medical: PGs ( no time for *Termination: *septum resection
*Rest
>12wks medical ) Medical: PGs in septate uterus
( physical / *myomectomy(hysteroscopic)
ttt
mental) SE ___
ttt Surgical: SE Surgical:(Risky) in fundal submucous myoma
*cerclage operation for
SE < 12wks SE
*PRG incompetent Cx
< 12wks < 12wks (at 12-13wks)
Hysterotomy Hysterotomy
Vaginal Abdominal
40
Hysterotomy (12-24wks) (12-24wks)
common less common
> 12wks
Mc Donald /
Page
Anti D is given to all Rh –ve ladies Shirodkar

Bleeding , PAIN Ectopic pregnancy Inc: 1.5%
Def: Pregnancy outside the normal endometrial cavity ,eg tubes , ovaries , Cx , CS scar ,rudimentary horn , abdomen …
( Tubal ectopic in > 95 % of cases ) Ttt: Correction of shock ( if present )
Et (risk factors): abnormality in tubes
Medical : MTX 1mg/kg body weight IM if
- Inflammation ( PID)
Undisturbed /vitally stable / mass < 3.5 cm / no fetal pulsations /
- Adhesions ( surgery , prev. ectopic or endometriosis )
β-HCG <6000Miu & follow up by repeating β-HCG to confirm
- Affection of tubal motility by P only contraception
successful ttt
( POP / IUD / both = Mirena )
Surgical : if
Pathology:
β-HCG > 6000 / GS > 3.5 cm / Pulsating fetus / Failed MTX
Tubes: decidual reaction, distension , rupture ± IPHge or tubal
- Laparoscopy ( Salpingostomy or Salpingectomy in ruptured tube )
abortion & tubal mole formation
- Laparotomy in vitally unstable pt
Uterus: decidual reaction without villi (Arias Stella reaction)
(Salpingostomy or Salpingectomy)
Clinical picture:
Depends on whether pregnancy is disturbed ( rupturd é IPHge) or not.
NB:
Symptoms:
- Ovarian ectopic ( spiegelber criteria )
PAIN (stabbing ,dull aching , acute abdomen, fainting &syncope)
- Cervical ectopic ( severe bleeding )
Bleeding : mild from decidual separation upon disturbance
- Pregnancy on CS scar ( increase in incidence nowadays )
Signs:
- Rudimentary horn (excision of horn : metroplasty ( upper segment
General : BP / pulse ± signs of SHOCK
incision ) & subsequent scheduled LSCS)
Abd: ± surgical abdomen in case of IPHge (Cullen’s sign )
- Pregnancy of unknown location (PUL)
PV: fullness on one side / tenderness & rebound / Jumping sign
Complications : Leading cause of maternal mortality in 1st In all of them medical ttt ( MTX) IM whenever possible ,
DD : other causes of acute abdomen sp in ( ovarian , Cx , CS scar ) to preserve ovaries & uterus
(appendicitis / severe UTI / ovarian torsion / hge / rupture of a cyst) Otherwise Oophorectomy or Hysterectomy may be needed
Inv:
β-HCG : Rising but NOT doubling ie ( ↑ by < 75% in 48hrs ) - Abdominal ectopic (extremely rare )
US: Empty uterus above discrimination zone TVS : 1500 mIU • may reach 3 trimester
rd
Adnexal mass ± fetal pulsations TAS : 6500 mIU • ttt: Laparotomy ( NOT CS) & removal of fetus ,
± fluid in DP if disturbed If placenta is attached to important structure: cut cord short
Fullness at adnexa ( ± GS / ± Fetal pulsations ) & leave placenta to undergo autolysis
Fluid in DP ( undercovered by MTX & broad spectrum antibiotics )
41
Laparoscopy: is Gold standard for diagnosis
Page
Anti D is given to all Rh –ve non sensitized ladies

Inc: 0.15% GTDs ( Abnormal proliferation of villi )
Differentiated (With villi) Undifferentiated (NO villi) ( metastatic)
GTN
V.Mole Invasive Mole Chorio Ca. Placental site tumour Epithelioid
The tumour marker is The tumour marker is
( benign) ( non-metastastic) ( HCG ) ( HPL ) tumour
Et : Abnormal fertilization Low risk High risk
Risk factors: extreme Age , Race (Asia) , ↓vit A , H/O of v.mole * Age < 40 / * < 4 months from preg. * Age > 40 / * > 4 months from preg.
Types: Complete mole ( more common ): paternal origin : * β-HCG < 100.000 * β-HCG > 100.000
anucleated ovum fertilized by 1 or 2 sperms * No H/O of chemotherapy * H/O of chemotherapy
46XX or 46XY * No liver or brain metastasis * Liver or brain metastasis
Partial mole : normal ovum (é nucleus ‫ ؞‬23X) ttt: Single agent chemotherapy ttt: Combined chemotherapy
fertilized by 2 sperms 69XXX or 69XXY or 69XYY ( MTX ) ( EMA – CO )
Pathology: Pathology : Gross: intrauterine friable mass é areas of hge & necrosis
Uterus complete : just villi é no sac or fetal parts ‫ ؞‬softer & larger Mic: undiff. Cyto & Syncytiotrophoblasts except in
partial : villi & abnormal fetus are present simultaneously Pl.site & Epitheliod (undiff. intermediate villi )
Ovaries: Theca lutein cysts in 60% of cases ( sp in complete mole ) Grading : G1: < 5% malignant undiff.cells
Clinical picture: G2: 5-50% malignant undiff.cells
Symptoms: bleeding / prune juice discharge / vesicles / pain G3: > 50% malignant undiff.cells
symp of ↑ β-HCG (hyperemesis/PIH /thyrotoxicosis) Spread: Direct : vagina / ovaries
Signs: Gen :anemia / ↑BP / dehydration / thyrotoxicosis / shock Lymphatic : very rare
Abd : Ut > period of amenorrhea / soft & Doughy Blood : Lung B L B
PV& bimanual : soft doughy ut / vesicles / full adnexa Cl.pict S:H/O of v.mole/abortion /FT pregnancy/ bleeding/ S of mets
Complications: S Gen :of metastasis ( anemia , jaundice , hemoptysis… )
bleeding / shock / PIH Abdominal : enlarged soft uterus
may turn to : Invasive mole 20% / Chorioca. 5% ( ‫ ؞‬need FU ) PV & bimanual : soft ut / passage of tissues
(If : Age > 40 year / Theca lutein > 6 cm / Pre ttt β-HCG >100.000) FIGO staging Stage І : Uterus
Inv: β- HCG : very high Stage ІІ : (Uterus) + Ovaries ± Vagina
US: snow storm appearance / Theca lutein cysts Stage ІІІ : (Uterus + Ovaries ± Vagina) + Lungs
Inv. to detect metastasis ( CXR / MRI / CT brain / US abdomen) Stage ІV : + distant metastasis : Liver / Brain
Inv: To confirm diagnosis : HCG / HPL ( in pl.site tumor ) / US
Ttt: Suction Evacuation under PGs & antibiotics
To detect spread :Chest X-ray / MRI / US abdomen / CT brain
TAH ( in old age , not desiring fertility)
To assess fitness of pt for surgery
NB: FU by β HCG weekly till –ve then monthly for 1 year
Use OCPs to prevent pregnancy during FU period Ttt: Chemotherapy: single agent chemotherapy ( in low risk)
42
MTX only if β-HCG is plateau or rising combined chemotherapy ( in high risk)
Anti D is given to Rh –ve non sensitized mothers in case of partial mole Hysterectomy if: old age ( no desire for fertility)
Page
( no need to be given in complete mole as there is no fetus ) chemoresistant ( placental site & Epithelioid)
Female bony Pelvis Anatomy of Fetal skull Terminologies
1) Pelvic Inlet Engaging diameters Engagement: passage of widest
Sacrum ala
transverse diameter of the presenting part
Transverse 13 cm 1) P.Inlet A /P engaging diameters: (eg :BPD) through plane of pelvic inlet.
A/P 2) P.Cavity Lie: ( longitudinal / transverse )
MV 13.5cm
11 cm SP SP
Attitude: fetal parts (flexed / extended)
outlet (wedge )
*Diagonal conjugate: Presentation: 1st felt on PV
3) P.Ischial
Obstetric
12.5 cm on PV exam. spine
Cephalic 96%
*Oblique: Rt > Lt 12cm 4) P.Outlet Vertex 95% occiput
( sigmoid colon ) OF 11.5cm SMV
Face 0.5% chin (mentum)
2) Pelvic Cavity Plane of Greatest Brow 0.1% no engagement
pelvic dimensions SOF 10cm
Breech 3.5% sacrum
12.5 cm SOB 9.5cm SMB
Shoulder 0.5% scapula
Denominator :
Full flexion Full extension Bony landmark of the presenting part
3) Obstetric Outlet = Plane of Least Asynclitism (tilt) :
pelvic dimensions ( Bispinous 10.5cm ) ( in Vertex ( in Face
presentation) presentation) (eg : ant asynclitism = post parietal bone
4) Anatomical Outlet presentation , when sagittal suture is
toward ant.)
A/P cephalic presentation Position:
13 cm Rt & Lt: in relation to mother
Ant &Post:in relation to denominator
Transverse engaging diameters: Station: 0 when occiput is at the level of
Transverse 11 cm ( Bituberous )
(ant sagittal : 6-7 cm / post sagittal : 7-10 cm) ischial spines in vertex presentation
Plane of Ischial spine : • BPD ( largest ) = 9.5 cm Leopold manoeuver:
( F.level / F.grip / UG / 1st & 2nd PG )
1) levator ani • BTD = 8 cm Naegle’s formula :
2) external os of Cx ( prolapse )
• BMD = 7.5 cm LMP + 7days + 9months EDD
3) station 0 (when vault at it )
• Supra parietal / Sub parietal = 9 cm Obstetric code:
43
4) pudendal n. block
5) change of obstetric axis F P A L
( in asynclitism )
Page
> 36 wks 24-36 < 24 wks now
6) forceps application at or below this level
Mechanism of Normal Labor
Def : Spontaneous delivery of a single , full term , living fetus , presenting by the vertex , through birth canal in a period > 4 hrs & < 12-18 hrs
for active 1st stage of labor , without interference & without complications to the mother or the new born.
( theories )
↑ PGs / ↑ fetal cortisol / ↑uterine distension Uterine contractions & Retractions é Cervical changes = True labor pains
↓ PRG / ↓ pl.oxytocinase
1st stage 2nd stage 3rd stage
(cervical effacement & dilatation) 40-60 mmHg (fetal delivery) 80mmHg (Placental delivery)
• PG : 12-18 hrs • PG : 2 hrs • < 30 mins
LOA
• MG : 6-8 hrs • MG : 1 hr
❖ Descent Signs of separation:
Cx dilatation (cm)
Latent phase
Active phase
( till 4 cm ) ❖ Engagement 1) gush of blood
( may happen in late pregnancy /
1st stage / or in 2nd stage of labor ) 2) elongation of cord
❖ ↑ Flexion 3) suprapubic bulge
10 ( When head reaches pelvic floor )
Deceleration ❖ Internal rotation Schultze Duncan
8
Friedmann ( As head now is a ball )
HEAD
6 Max slope (80%) (20%)
curve ( SOB 9.5 cm × BPD 9.5cm )
4 Acceleration ❖ Extension (1st step to be seen)
2 ( Forward movement of head
as result of 2 forces of uterine
2 4 6 8 10 12 14 hrs contractions & pelvic floor ms )
True labor pains False labor pains ❖ Restitution
(Braxton – Hicks) ( In opposite direction of internal
DD: * Regular / Rhythmic * Irregular rotation)
false labor pains *↑ frequency * Stationary or ❖ External rotation
*↑ strength decreasing in ( In same direction of internal
(Braxton – Hicks *↑ duration frequency / strength
rotation )
44
contractions) * Not relieved by & duration
analgesics or sleeping * Relieved by ❖ Expulsion
Page
analgesics or sleeping ( Of whole fetal body )
Management of Normal Labor
1st stage 2nd stage 3rd stage
( Cervical effacement & dilatation ) (Fetal delivery) (Placental delivery)
Aim : to get efficient uterine contractions ie 3 contractions / 10mins , each
Aim : to support the head Aim : active management
lasting 1 min é intensity of 40-60 mmHg
by Ritgen maneuver by ecbolics to prevent
OR Cx dilatation : 1 cm / hr in PG , 1.5cm /hr in MG 1min ( ± episiotomy if needed) PPHge
( ± CTG for high risk patients ) 10 min
* Transfer to delivery room. Active management:
Admission in active phase ie > 4 cm , unless otherwise indicated ( to ↓↓ PPHge)
* Lithotomy.
Upon admission In the ward ie : give ecbolics
* Drapping. (methergine /oxytocin…)
H/O obst F P A L 1) Partogram * Evacuate UB. & wait for signs of
GPL (see next page ) * Ask patient to bear down separation of placenta:
during contractions * gush of blood
LMP / EDD Maternal Fetal (FHS)
( Naegele’s F ) * elongation of cord
Medical / Surgical N 140-160 b/min
& relax inbetween * suprapubic bulge
Examination: * contractions 1) DO Brandt - Andrews
if efficient observe 1) Ritgen Manoeuver ( Push fundus upward &
Gen : BP / T / pulse if not efficient augmentation ( support perineum ) , controlled cord traction )
ROM Then Explore:
Abd : Leopold M. Upon crowning = Placenta & memb.
( FL / FG / UG / Oxytocin allow gradual extension to make sure they are
1st Pelvic grip / * PV of fetal head complete.
Presentation / position
Or 2nd Pelvic grip )
Cx dilatation / effacement
‫ ؞‬SOF : 10 cm Genital tract for tears
If head is allowed to extend 2) ± Manual separation of
PV: Station / ROM the placenta if it didn’t
Presentation / position ×before crowning×: deliver by Brandt -
* BP ‫ ؞‬distending diameter Andrews maneuver
Cx dilatation / effacement * Nutrition ( fluids ) OF : 11.5cm 4th stage
Station / ROM * Analgesics ‫ ؞‬Perineal tears
Inv Fetal : FHS * Enema 1st 2 hrs after delivery ,
which are more liable to
45
Maternal: Rh / CBC 2) ± Episiotomy
2) ± CTG (only if indicated) PPHge.
Page
Maternal & fetal : US (only in high risk cases)
Partogram ( for following up progress of labor )
Rule of 5 for the presenting part

(felt abdominally) :
station
5⁄ = -3
5
* Patient line to the left of the
4⁄ = -2
5 Alert line = normal progress
Abdomen 3⁄
5 = -1 * Patient line inbetween Alert
line & Action line
2⁄ = 0
Pelvis 5 = slow progress
1⁄ = + 1 / +2 * Patient line on the Action
5
0⁄
5 = +3 line = arrest of progress
Low Intermediate Normal

intensity intensity intensity
Contractions
46
Page
Cephalic presentation ( OA + )
Occipito - posterior Face Brow
Definition Longitudinal lie in which head is fully flexed Longitudinal lie in which head is fully
Head is midway between
& occiput posterior (occiput is denominator) extended
flexion & extension
{ It’s a malposition & not a malpresentation } (mentum is denominator)
Incidence 20% at time of labor 1/500 1/2000
Position LMA : most common as it results from
ROP : most common occupying wider ROD
extension of ROP
Etiology Gen: CPD / Fetal anomalies / MFG /… Gen : CPD / Pendulous abdomen / … General causes
Specific : Android / Anthropoid pelvis Specific : Anencephaly
Mechanism • 90% : long ant rotation DOA • MA : ant rotation DMA • Transient brow :
& delivery by extension & delivery by flexion delivery as OP or MA
• 6% : short post rotation DOP • MP : 𝟐⁄𝟑 long ant rotation to MA &
( face to pubis ) & delivery by flexion delivery by flexion • Persistent brow
• 4% : NO rotation ( deep transverse arrest 𝟏⁄ no rotation or post rotation
𝟑 ( MV = 13.5 cm ) :
or persistent oblique OP ) obstructed to DMP : obstructed obstructed
Complications Maternal : Prolonged labor / PROM / PPHge / Puerperal sepsis
Fetal : Distress / Asphyxia / Birth injuries / Instrumental delivery / Complications of associated anomalies
Management
Pregnancy: Leopold : as OA : FL ( same ) / FG ( buttocks ) / UG ( back Rt )
1st Pelvic Grip ( done : delayed engagement ) / 2nd Pelvic Grip ( not done )
Auscultation : FHS below umbilicus / US
Labor: PV : occiput / chin ( Tumefaction ) / or no landmark
1st stage : watchful expectancy for factors that favor long anterior rotation:
( Roomy pelvis ( no CPD ) / Good pelvic floor muscles / Strong uterine contractions / Adequate liquor )
• 90% : delivery as LOA • MA & 𝟐⁄𝟑 MP: episiotomy as • Transient brow :
• 6% : Face to pubis ( distending diameter distending diameter is SMV 11.5 cm manage accordingly
OF 11.5 cm ) ‫ ؞‬do episiotomy • 𝟐⁄𝟑 MP : forceps delivery
• 4% : instrumental for rotation & extraction NEVER ventouse • Persistent brow : CS
47
(eg Kielland forceps or ventouse) OR safer CS
Page
OR safer CS
Breech presentation
Def :It is a longitudinal lie in which buttocks with feet (complete) / buttocks only ( frank) / feet (footling) / knee are the presenting part.
Incidence: 3.5% at full term / 25% at 28 wks Position: LSA
Etiology: General : contracted pelvis / ut septum / fibroid / pl.previa / MFG
Specific: Hydrocephalus ( in full term ) , Prematurity
Mechanism :
for Buttocks ( Descent / Eng (BTD 9.5cm) / Int rotation / ant buttock hinge below SP, post buttock deliver 1 st by Lat Flexion of spine )
Shoulders ( Descent / Eng (BAD 12 cm ) / Int rotation / post shoulder deliver 1st by Lat Flexion of spine )
After coming head (Descent /Eng (BPD 9.5) / Int rotation(opposite direction as it enters pelvis in opposite axis)/ delivery by Flexion)
Complications:
Maternal : 4 Ps ( Prolonged labor / PROM / PPHge / Puerperal sepsis )
Fetal Retained after coming head
Post. rotation of the head do Prague manoeuvre
Extension of arm do Lövset manoeuvre
Fetal birth injuries
( nerves: Erb’s palsy / bones : hip dislocation / viscera: rupture spleen,rupture liver, rupture anal sphincter& hymen defloration)
Fetal distress / Sudden compression & decompression
Diagnosis : During pregnancy Leopold maneuver ( FL:same as amenorrhea period / FG: head / UG / PG: buttocks )
FHS ( above umbilicus )
US
During labor + PV ( tip of sacrum + ischial tuberosities at same plane ) 1) ROM / cord prolapse
Management: 2) Pl. separation
During pregnancy: ECV (60% success ) , at 36 wks if not CI , Side effects: 3) Loops of cord around fetal neck
During labor : 4) Fetal distress
5) ++ labor
CS in 80% ( due to unpredictable hazards) in Primigravida
Indications of CS: 1) Extended neck / 2) Twins 1st breech ( locked twins) / 3) Preterm
4) weight < 2 kg , > 3.5 kg / 5) Breech presentation other than complete or frank / 6) Other indications for CS
VD: *Assisted breech delivery : spontaneous delivery of buttocks & shoulders , BUT Assisted delivery of head
Burns-Marshall Mauriceau-Smellie-Veit ± Kristiller’s manoeuver Piper’s forceps
48
( Leave baby hanging by its weight) (Jaw flexion shoulder traction) ( supra pubic pressure on head by assistant )
Page
*Breech extraction ONLY done in : fetal distress é fully dilated Cx / 2nd twin if breech
Shoulder presentation
Def : Transverse Lie é scapula as denominator ( ant or post )
Incidence: 0.5%
Etiology: General : CPD / Septate ut / Pl. previa Position: LSA
Specific Pendulous abdomen in multipara RSA
Mechanism : NO mechanism (Obstructed labor)
Complications: Maternal 4 Ps
Fetal + neglected shoulder
Diagnosis : During pregnancy Leopold manoeuver ( FL less than period of amenorrhea / FG empty
st
UG head on one side & buttocks on the other side / 1 PG empty )
FHS at level of umbilicus at the head side
US
During labor: + PV Gridiron (ribs)
Management: During pregnancy: ECV till 1st stage of labor
During labor : CS
NB : IPV and breech extraction is ONLY done for 2nd twin ( if transverse )
NB : neglected shoulder : Arm prolapse with ROM for long time & IUFD , delivery by CS ( mostly upper segment )
for maternal safety to prevent rupture uterus
é intact memb. Cord presentation & Cord prolapse é ROM Obstetric
Def : cord is below presenting part either é intact membranes ( presentation ) or é rupture membranes ( prolapse ) emergency
Et : general : Maternal
Fetal ( specific ) : malpresentations as shoulder / incomplete breech / footling / …
Diagnosis : PV : mind PULSATING or NOT
Management : IF PULSATING : reposit the cord & urgent CS / IF fully dilated Cx : forceps in cephalic engaged
IF NON PULSATING : allow VD ( not an emergency ) breech extraction in breech presentation
Complex presentation
nd
Def : Arm beside head or buttocks in 2 stage
Management : reposit the arm & proceed é VD
Unstable Lie
49
Def : Fetus continuously changes its position & / or presentation after 34 weeks GA
Page
Management : stabilized induction ie induction of labor while it is in a cephalic presentation after 36 wks
Multi fetal gestation (Twins in 97% of cases , Triplets in 1-2% )
Definition: Simultaneous presence of 2 or more fetuses in the uterus
Inc: DZT 1-2% ( due to ↑↑ use of induction of ovulation ) > MZT 1⁄250 ( cleavage after fertilization of one ovum by one sperm)
If < 3 days Dichorionic Diamniotic 30%
cleavage in MZT If 4-8 days ( chorion formed) Monochorionic Diamniotic 65%
If 8-12 days ( ch & amnion formed) Monoch. Monoam. 5% MOST SERIOUS
If > 12 days ( parts formed) Conjoined ( rare )
Mechanism : Depends on the presentation of 1st & 2nd fetuses
Diagnosis : During pregnancy : FL : > period of amenorrhea
Leopold manoeuver FG / 1st PG : fetal poles are small in relation to size of abdomen
UG : many poles are felt in addition to many limbs
FHS : 2 sounds of max. intensity are felt at different sites ( Galloping sign )
During labor : + PV
Complications:
Maternal : 4 Ps + ↑↑ rate of medical disorders ( hyperemesis / HTN / anemia / GD /…)
Fetal 1) vanishing twins ( in 1st trimester)
2) MZT MC , MA & tttt : discordant twins ( shared placenta ) One fetus LGA / polyhydraminos / polycythemia
Conjoined twins (due to delayed cleavage) Other fetus SGA / oligohydraminos / anemic
st
3) locked twins , if we allow VD when 1 fetus is breech ( which should not be done )
4) death of one fetus : 1st trimester ( early ) : Little risk
3rd trimester ( late ) : ++ DIC
5) PTL ( COMMONEST complication ) & prematurity complications
Management : During pregnancy : more frequent ANC visits due to more ++ of medical disorders during pregnancy
During labor : CS : if 1) other indications of CS 2) > 2 fetuses
3) monoamniotic twins or conjoined twins 4) 1st fetus is non cephalic
st
VD : if 1 fetus is cephalic & no other indications of CS
Delivery of 2nd twin
If cephalic if breech if transverse
50
ROM & ROM & ROM &
Allow VD spontaneous Do breech extraction Do IPV & breech extraction
Page
Guard against Atonic postpartum hge by prophylactic ecbolics
Prerequisites for normal labor: Abnormal labor Specific Types
Shoulder dystocia
Passages ( maternal ) : NO CPD / NO soft tissue obstruction
Passenger ( fetus ): NO macrosomia / NO cong anomalies or malpresentations that interfere é VD Def: Head delivered,but ant shoulder
didn’t (impacted at SP) ( Turtle sign )
Power ( efficient uterine contractions in active stage ) Et : Fetal macrosomia /
PPT labor Maternal DM
Def : < 4 hrs Complications:
Complications: Maternal : lacerations / infection / atonic PPHge Ttt:
Prophylactic epidural Maternal : exhaustion /laceration
Fetal : Erb’s palsy
Fetal : birth injuries Exploration ± suture tears + antibiotics
Ttt :
Fetus examination for ICH * Mc Robert’s ( Hyper flexion &
Prolonged labor ( prolonged 1st stage / 2nd stage ) abduction of maternal thigh )
N progress 1cm / hour in PG , 1.5 cm / hour in MG OR presence of efficient ut contractions ± suprapubic pressure
Causes : Power problem 40-60 * Wood Cork Screw
Passages : ie CPD mmHg * Manual delivery of post. Arm
* Zavinelli Maneuver
Passenger ie malpresentations / macrosomia / anomalies 1min
Ttt of cause : In hypotonic : augment by AROM / Oxytocin 3 / 10 min
Cx dystocia
In hypertonic : IV fluids / analgesics / epidural * Rigid or spastic cx causing arrest
of dilatation
In CPD: CS * May result in annular detachment
In arrest of labor: No progress at all ( whether in dilatation OR in effacement OR in descent ) of Cx
for 1hr in MG , 2 hrs in PG : ‫ ؞‬CS * Ttt : Anti spasmodic ,
NB : Instrumental delivery in 2nd stage ONLY on fully dilated Cx , and presence of uterine contractions. If no response, then CS
Obstructed labor CPD
nd
Def : Arrest of 2 stage due to mechanical obstruction (ie passages / passenger ) Def: one or more of diameters is
in presence of efficient ut contractions decreased
Pathology : Pathological retraction ring ( Bandl’s ring ) Et: bony affection
Pathological retraction ring ( Bandl’s ring ) Constriction / contraction ring ( spine / pelvic bones / femur )
* Between UUS & LUS * Spasm of circular smooth ms fibers Clinical pelvimetry: PV to estimate
* Moves upward * Any site sacral concavity & promontory,
* Seen abdominal & felt vag * Felt vag only sacrosciatic notch width, pelvic
* + Fetal distress / severe maternal exhaustion * No maternal or fetal distress side walls , ischial spines , and
* Relieved by CS * Ms relaxation / anasthesia subpubic angle width
Cl.picture : Maternal General: dehydration / Exhaustion CPD tests : Pinard ( no PV)
Muller-Kerr ( é PV)
Abd: Bandl’s ring
Ttt:
PV: fully dilated / edematous / caput / high station * No CPD : Allow VD
51
Fetal distress * Moderate CPD (1st degree) :
Complications : Rupture uterus / Necrotic VVF / Lacerations / Infection / Atony ‫ ؞‬Trial of labor
Page
Ttt: CS * Severe CPD ( 2nd degree ) : ‫ ؞‬CS
APHge NB: Placental migration : < 24 weeks
Definition : Bleeding after fetal viability (24 wks) till delivery Lower edge of placenta may be seen near
Etiology : Maternal Obstetrics : Abruptio-placentae ( accidental hge ) / Placenta pervia (PL PRV) int os , but é formation of LUS , placenta
Gynecology : Vaginal lesion / Cervical lesion migrates upward to its normal position,
Systemic : Drugs ( anticoagulants ) / Systemic disorders away from internal os & the condition
resolves in > 90% of cases
Fetal : vasa previa ( minimal bleeding severe fetal distress)
Accidental Hge Placenta previa
( commonest ) ( 2nd most common ) Management of APHge:
Normally implanted
Definition placenta Placenta implanted on LUS Termination if :
* Reached maturity
PG (PIH) Multipara / old age OR * Labor pains
Risk Factors External trauma Prev CS / prev PL PRV OR * Maternal or fetal complication
Sudden ROM in polyhydramnios Malpresentations / Smoking
* In PIH: Blood inbetween Otherwise Conservative until one of 3 factors
myometrial fibers tender hard above are reached
ut Couvelaire ut (concealed Shearing mechanism between LUS that
Mechanism
( Pathology )
accidental Hge) Atonic PPHge forms & placenta Unavoidable bleeding Termination
* In trauma : soft ut & normal
myometrium VD LSCS
( revealed accidental Hge) In Accidental hge In PL PRV
Complete centralis / incomplete centralis ( unless CI ) ( unless Lateralis )
Types Mixed / Revealed / Concealed Marginalis < 2 cm from os /
Lateralis > 2 cm from os * In case of abnormal adhesions of
Symptoms ±Vag bleeding / Always vag bleeding placenta ( Placenta Accreta / Increta /
Clinical picture
usually abdominal pain Painless causeless recurrent bleeding Percreta) ttt : Cesarean hysterectomy
General PIH ? Type of patient ( = USCS followed by hysterectomy)
± Shock (BP may not be ↓) ± Shock as any attempt to separate the placenta
Signs Tender ut (in concealed) / No ut tenderness / FL = amenorrhea /
Abd increta / percreta will result in severe
FL > amenorrhea malpresentations bleeding
PV & Contraindicated till exclusion of PL PRV
speculum
52
Complications HELLP / DIC / Atony Placenta Accreta / Increta / Percreta NB: Rescussitation in shock ( if present )
Maternal : US /CBC / LFTs / KFTs / Inv for DIC / HELLP
Page
Investigations
Fetal : Assessment of fetal wellbeing ( DFMC / NST / BPP / Doppler )
Obstetric Trauma
Rupture ut Cx laceration Vag / perineal tears
Risk F: Management :
Rupture uterus : Prophylactic to guard against obstetric trauma by proper
* Scarred uterus UUS ( 2 - 9% ) > LUS ( 0.2 - 0.9 % ) management of 1st ( ecbolics ) , 2nd ( instrumental /
* Grand Multipara episiotomy ) & 3rd ( explore genital tract ) stages
* Maluse of PGs / oxytocin
* Over distended uterus Rescussitation ± blood transfusion
* Instrumental delivery
Cx, vag, perineal Lacerations : Repair of tear
* Scarred Cx / vagina / perineum * Rupture ut :
* Instrumental delivery exploratory laparotomy ut repair
* Precipitate labor ± subtotal hysterectomy ( if unrepairable )
* Large sized fetus * Cx , vag , perineal lacerations :
* Cx: manual dilatation of Cx vaginal exploration under GA & repair
( delivery through incompletely dilated Cx )
OR omitting episiotomy when indicated
Cl.picture:
Rupture ut :
* sudden relieve of abdominal pain
* fetal head receed upward
* vaginal bleeding / ± shock / fetal distress
Cx , vag , perineal lacerations :
H/O & examination
53
Page
Complications of 3rd stage
PPHge (1ry / 2ry ) retained placenta uterine inversion
Shock ± DIC
PPHge Retained Placenta
Def : loss > 500 cc in VD or > 1000 cc in CS Def : failure of delivery of placenta within 30 minutes of fetus delivery
* Within 24 hrs ‫ ؞‬1ry PPHge Inc: 0.5 %
( atonic / traumatic / retained parts / inversion / systemic cause ) Et :
* from 24hrs till end puerpurium ‫ ؞‬2ry PPHge * Retained separated due to Atony ( commonest )
( infection / retained parts / trauma / chronic ut inversion / polyp / chorio ca) Contractoin ring ( need halothane )
Et : risk f for : Rupture ut ( ttt as before )
* Atony (commonest): prolonged labor , use of ecbolics , over distension of ut, * Retained non separated due to placenta accreta spectrum
anemia ,….. ( accreta / increta / percreta )
* Trauma ( 2nd common ) ( ut , Cx , vag, perineum ) Cl.picture : PV & Bimanual exam to detect cause
* Retained parts (3rd common & leading cause of 2ry PPHge) : ( ± accreta ) Management :
* Inversion ( pull on placenta / fundal fibroid ) 1) Ecbolics + Brandt - Andrews ( controlled cord traction )
* Systemic blood disorder ( DIC, ITP, coagulation disorders… ) If failed:
Cl. picture : 2) Manual separation of placenta
*S
* S General: ± shock NB :
Abd: ut lax (atony) / ut contracted (traumatic) / * If retained fragments :surgical evacuation by ovum forceps
ut subinvoluted (retained parts) * If placenta accreta : attempt of separation
PV: dark clots ( atony ) / fresh blood ( trauma ) / tears / retained parts * If undiagnosed placenta increta / percreta : hysterectomy with ovarian
* Complications: Shock ± death preservation
( leading cause of maternal mortality in Egypt )
DIC / Sheehan syndrome / Hysterectomy
Ttt: PREVENTION : proper ANC ( anemia ttt ) Specific
& labor management ( 1st , 2nd & 3rd ) stages
ACTUAL Inversion : ttt: reposition under GA
1) Rescussitation ± blood transfusion Shock : ( Hgic ) : ABC & replacement whole blood / packed RBCs
together
( Septic ) : broad spectrum antibiotics + as before

All
1) Ecbolics + massage
1) Explore genital tract ( for tears / retained parts ) DIC : replacement cryoppt / ttt underlying cause / Never heparin ××
+ bimanul compression Vaginal
2) Bakry intrauterine balloon ( inserted vaginally )
54
3) Bilateral ut a. ligation
Abdominal
4) Bilateral IIA ligation / B-Lynch suture
Page
exploration
4) Subtotal hysterectomy

Assessment of fetal wellbeing
Antepartum Intrapartum
( from viability till labor ) ( in 1st & 2nd stages of labor )
1) DFMC : N 10 movements / 12 hrs 1) Passage of Meconium ( in cephalic presentation ) :
2) NST : fetal heart acceleration in relation to its movements indicates fetal distress
( for 20 min )
2) CTG : relation of FHR to uterine contractions
N 15 b/min acceleration for 15 sec ( = reactive NST )
- N FHR = 110 – 160 b / min
15 b/ min 15 b / min
15 15 • If < 100 bradycardia CTG ONLY FOR
= fetal distress
sec sec • If > 160 tachycardia HIGH RISK
20 min -Loss of beat to beat variability = fetal acidosis

• If non reassuring NST Repeat for another 20 min
-Early deceleration = head compression N
• If non reactive NST ‫ ؞‬Do BPP
3) BPP : US to detect ( movement / tone / breathing / AFI / NST ) -Variable deceleration = cord compression ( exclude cord prolapse )
-Late deceleration = fetal distress ( sp if persistent late deceleration)
Each item 0 if not present
3) fetal scalp PH N PH = 7.25 – 7.35
2 if present
• If 7.2 – 7.35 ‫ ؞‬mild acidosis
‫ ؞‬Total score = 10
• If < 7.2 ‫ ؞‬severe acidosis
• If < 8 / 10 ‫ ؞‬do doppler
Management of Intrapartum distress ( asphyxia )
( NB: Modified BPP = NST + AFI )
* Stop oxytocin / give IV fluids
4) Doppler study: for umbilical artery , MCA
* mask O2 / put pt in Lt lateral position
• If + + resistence ( low flow ) ‫ ؞‬placental insufficiency
• If NO flow ‫ ؞‬Alert sign Persistent distress Returns back to N
• If reversed flow ‫ ؞‬Action should be taken
Immediate Termination continue labor é close observation
NB : If high risk cases ‫ ؞‬assessment of fetal wellbeing
DFMC done daily
Not fully fully
NST / BPP done biweekly
55
dilated dilated
Doppler done weekly Forceps in cephalic pr.
Page
CS VD
Breech extraction in breech pr.
Fetal growth disorders
SGA LGA
90th LGA ( Macrosomia )
( < 10th percentile for their GA ) AGA ( > 90th percentile for their GA )
10th
Types SGA Types
Constitutionally small IUGR Constitutionally large in DM sp uncontrolled

As in small mothers big mothers / multipara Past date
‫ ؞‬N fetus Symmetrical Asymmetrical ‫ ؞‬N fetus
20% 80%
( fetal intrinsic cause) ( maternal placental Cl.picture: Symptoms : of the cause / oversized abdomen
insufficiency cause) Signs: General : of cause
NO brain sparing Abdominal : ++ FL / ++ SFH
‫ ؞‬Bad prognosis √√ brain sparing
‫ ؞‬Good prognosis Inv : Of cause , eg: DM
US
Cl.picture : Symptoms : small sized abdomen ttt: Of cause as control DM
( < period of amenorrhea ) Consider CS if > 4.5 kg
Signs: General : of cause ×× Instrumental deliveries
Abdominal : ↓↓ FL / ↓↓ SFH ( 24 - 32 wks )
Inv : US + Doppler : ( to detect cause & to assess fetal wellbeing ) IUFD
ttt: If constitutionally small : leave
If ch.anomalies : terminate at any GA Definition: Death in utero after fetal viability
If IUGR Etiology: Idiopathic in 50%
Maternal as in placental insufficiency
Preterm Term Fetal anomalies / infections
Cl.picture: ↓ or NO fetal movements
Assess fetal wellbeing Terminate ↓↓ FL < period of amenorrhea
& Terminate if : ( VD or CS ) Complications : DIC if retained for weeks
Reaches maturity ttt: Wait for spontaneous labor pains
Or signs of distress upon assessment of fetal wellbeing
56
If anxious or start complication :
Or maternal condition necessitate termination Terminate VD OR CS according to obstetric condition
Page
PROM
Definition : ROM after fetal viability& before onset of labor
Incidence : 10%
Etiology: Idiopathic
Infection ( commonest ) : GTI , UTI
Cx incompetence
Polyhydramnios
Local membrane defect / smoking
Complications : Preterm labor ( commonest ) within 24-48 hrs
Chorioamnionitis ( most serious )
Placental abruption
If ch.oligohydramnios : lung hypoplasia , limb deformity , amniotic band
Clinical picture : Symptoms : gush of fluid
Signs : General : fever ( in case of infection )
Abdominal : FL < period of amenorrhea / tender uterus in chorioamnionitis
PV( under STRICT aseptic conditions ) : speculum for fluid pooling in posterior fornix
Investigations : Confirm diagnosis : Speculum / Nitrazine paper / +ve fern / Amniosure
Detect complications ( infection ) : CRP / TLC / DLC / ESR
US for AFI : If < 5 ‫ ؞‬oligohydramnios
Management :
IF < 36 wks Conservative : Antibiotics

NO maternal or fetal complications + NO
NO Ut contractions Follow up maternal & fetal conditions TOCOLYSIS
IF > 36 wks Antibiotics

OR Presence of maternal or fetal complications +
57
OR Presence of Ut contractions Termination ( whether VD or CS depending on obstetric condition )
Page
Amniotic fluid disorders
Oligohydramnios Polyhydramnios ( hydramnios)
↓ liquor < 500cc ↑ liquor > 2liters
Definition
AFI < 5 or deepest pocket < 4cm AFI > 20 ordeepest pocket > 8cm
Incidence 5% 0.5%
( ↓ production by fetus or placenta) ( ↓ swallowing by fetus or ↑ production )
* H/O of ROM * Idiopathic
Etiology * Renal agenesis * DM ( uncontrolled )
* Pl.insufficiency * Anencephaly / oesophageal or duodenal atresia
* Indomethacin * Placenta tumours
* Small size abdomen < amenorrhea * Oversize abdomen > amenorrhea
Cl.picture * Picture of the cause ( eg : PE ) * Pressure symptoms ( as resp. embarrassment )
* Picture of the cause ( eg : DM )
Investigations US for volume / AFI / Deepest pocket
* Of cause ( placental insufficiency ) * Of cause ( uncontrolled DM )
* Limb deformity / lung hypoplasia / * Pressure symptoms
amniotic band syndrome * Sudden ROM , Placental abruption ,
Complications
* Cord compression / fetal distress Cord prolapse
* Malpresentations , Dysfunctional labor ,
Atonic PPHge
* ttt of cause
Treatment * Termination if : reach 36 weeks / occurance of complications / start of labor pains
* Amnio-infusion ( rarely done ) * Amniocentesis (to relieve pressure symptoms)
NB : * Amniotic fluid functions : protect from infection / regulate temperature / lung expansion / limb movements / nutrition
58
* Amniotic fluid composition : 99% water, clear, alkaline / mainly FETAL contribution
Page
Preterm labor Post term pregnancy
Definition: start of labor pains after fetal viability & < 36 wks Definition: pregnancy continue after 42 weeks
Incidence: 5-10% Incidence: 5-10%
Etiology: Idiopathic / miscalculation . Etiology: Miscalculation.
Cx incompetence / septate or bicornuate uterus Idiopathic.
Over distended ut ( polyhydramnios / MFG / fibroid ut ) Anomalies as Anencephaly.
Medical / obstetric indication for termination.
Placental cause
PROM / GTI / UTI / smoking / excessive physical activity
Clinical picture:
Iatrogenic ( induced PTL in complicated uncontrolled
pregnancies)
Symptoms : of cause / may be oversized abdomen ( 80%)
Clinical picture: Signs : may be normal or oversized abdomen ( 80%)
Symptoms : true labor pains < 36 wks Complications:
Signs: General : of cause or risk factor 80% LGA (in normally functioning placenta)
Abd : true ut contractions / cause 20% IUGR with its sequelae (in placental aging)
PV: start cx changes (dilatation / effacement) ↓ liquor / meconium stained liquor
Complications ( ALL FETAL ) : & meconium aspiration during delivery
RDS / Retinopathy of prematurity / Cerebral hge Investigations:
Neonatal sepsis / Necrotising enterocolitis US : for AFI / placental grading
Investigations : Growth curves
CTG to confirm PTL Management:
US : short cervical canal < 2.5 cm * IF date is confirmed by CRL or by accurate LMP
FFN (Fetal fibronectin): from 24-32 wks
‫ ؞‬Termination
N absent , if present ( by vag swab ) ‫ ؞‬50% PTL within 2 wks
Management: Induction of labor CS if indicated
* Prophylactic against RDS: steroids 24mg IM
& delivery 24hrs after last dose :
ROM PG Oxytocin
Betamethasone ( long acting) 12mg 24 h 12mg
Dexamethasone ( short acting) 6mg 12h 6mg 12h 6mg 12h 6mg
If Cx dilated with low Bishop score < 5 if Bishop score > 5
* IF still in latent phase (Cx < 4cm dilatation & < 50% effacement) (unripe Cx) (ripe Cx)
can use Tocolysis to delay labor till Steroids work / NICU transfer:
1) Ca channel Blocker ( Nifedipine) * IF date not confirmed
2) β2 agonist ( Ritodrine) ‫ ؞‬Assessment of fetal wellbeing ( DFMC / NST / BPP / Doppler )
3) PGs synthetase inhibitor ( Indomethacin ) < 32wks Till 42 wks
59
4) oxytocin inhibitor ( Atosiban ) occurrence of labor pains
5) MgSO4 if < 28wks to prevent CP
Page
occurrence of complications
6) Natural Progesterone IM weekly
PE Hypertensive disorders with pregnancy
Definition: HTN ≥ 140/90 ( mild ) or ≥ 160/100 ( severe ) * Preeclampsia : HTN + Ptnuria > 20 wks GA
+ proteinuria > 0.3 gm/24hrs after 20 wks GA ( mild ) or > 5gm/24hrs ( severe ) * Gestational HTN : HTN > 20 wks GA
Incidence: 4-7 % of pregnancies/ leading cause of maternal mortality in developed countries * Chronic HTN :HTN < 20 wks GA
Et: genetic / vascular / immunological … Theories Risk F: PG / ++ HCG / kidney troubles / SLE * Superimposed PE : chronic HTN + PE
Pathology : * ECLAMPSIA : PE + Seizures
N Trophoblastic invasion of spiral arterioles of myometrium
Inv : Maternal : laboratory / fundus exam /
Wider vessels & + + uteroplacental perfusion
neurological exam
In PE Failure of Trophoblastic invasion in spiral arterioles Fetal : DFMC / NST / BPP /Doppler
( assessment of fetal wellbeing )
Narrower vessels with ++ vascular resistance Treatment:
* Mild PE é NO fetal or maternal compromise:
( Vascular endothelial cell damage) in placenta FU ( NO medical or obstetric intervention
Release of mediators ↓ uteroplacental perfusion needed)
* Severe PE é fetal or maternal compromise
Kidneys Liver BVs Brain Retina IUGR & Oligohydramnios ( not responding to medical ttt):
* Affection *Affection * Edema * Edema Termination whether VD or CS After
of kidney of liver * ± convulsions * Hge Stabilisation by MgSO4
functions functions *Oedema * Visual IV drugs hydralazine
‫ ؞‬ptnuria & *Subcapsular *DIC affection Steroids for lung maturity
oliguria Hge *HELLP * Severe PE é NO fetal or maternal
Clinical picture: disease of signs (& symptoms appear when complications occur ) compromise:
Signs : BP ≥ 140/90 ( mild ) ≥ 160/100 ( severe ) Medical ttt & FU till maturity or occurance of
A/C in urine > 0.3 ( albumin / creatinine ratio ) complications ( whichever happens first )
or ptn > 0.3 gm/24hrs urine collection ( mild ) > 5gm /24hrs ( severe ) - Labetalol : drug of choice
± Oedema - α methyl dopa : may cause PP depression
* Headache - Ca channel blocker: as Nifedipine
Symptoms: brain affection NB:
* Vomiting
* Blurring of vision ( retinal affection ) * ACE inhibitors are CI as they are teratogenic
* Epigastric pain * LDA ( Aspirin ) is given prophylactically in
* Rt. Hypochondrial
high risk patients
pain ( liver affection )
* ↓ DFMC ( in IUGR ) * Diuretics are CI as pt has hemoconcentration
60
* In ECLAMPSIA: give Diazepam ( in addition
* Vaginal bleeding ?? * Oliguria ( in kidney affection ) to MgSO4 ) to control convulsions then ttt as
Page
( Accidental hge) ( APHge) * LL oedema severe uncontrolled cases

Rh isoimmunization
Definition: hemolysis of fetal RBCs by maternal Ab
Etiology : sensitization of the mother by Rh –ve Mother received Rh+ve blood transfusion
Rh –ve Mother × Rh+ve Father Rh+ve fetus
Pathogenesis : dd × DD ( Dd )
Dd Dd & dd
st
- 1 baby may be affected if previous maternal blood transfusion with Rh+ve blood
- Fetus may be spared if : 1st baby
2nd baby but 1st one was Rh-ve ( heterozygous father )
With ABO incompatibility
Small amount of exposure
Effect: depends upon Immune system of the mother
Associated ABO incompatibility
She may marry Rh –ve or heterozygous Rh+ve man
Complications: ( FETAL ONLY ) Hemolytic anemia ( mild form )
Neonatal jaundice : Icterus gravis neonatorum ( commonest & moderate form )
± kernicterus if bilirubin > 20 mg % cross BBB
Hydrops fetalis ( severe form ) generalized edema ( Budda attitude )
Investigations: Rh blood group of mother & father
Indirect coomb’s test
Amniocentesis ( if indirect coomb’s > 1⁄16 )
US for fetal anomalies ( HSM / Ascites )
Treatment: Prevention: Anti D (only for non sensitized Rh –ve mothers )within 72hrs of delivery of Rh+ve fetus & at
28wks GA & immediately after any procedure done during pregnancy ( Abortion , Ectopic , Amniocentesis , … )
If indirect coomb’s < 1⁄16 follow up
> ⁄16
1 amniocentesis
If ↑ bilirubin & ↓ Hb ( ‫ ؞‬hemolysis ) Hb N 18gm% , bilirubin N < 2 mg / dl
< 34wks > 34wks Follow up with titre
Intrauterine transfusion Terminate
61
After delivery: exchange transfusion for the baby with O –ve blood
Page
Definitive ttt is plasmapheresis for maternal blood to remove antibodies (very costly, available in limited centers, doubtful prognosis )
GIT disorders with pregnancy
1) Emesis Gravidarum (NVP) 5) AFLP ( acute & may be fatal )
Reassurance / small frequent meals / ↓↓ fat & ↑↑ carbohydrate intake Definition: fat deposition within liver cells in 3rd trimester
2) Hyperemesis Gravidarum (HEG) ‫ ؞‬affection of function +++AST & ALT
Def: Excessive vomiting in 1st trimester that affects general condition Incidence : extremely rare
Etiology ( theories ) : ++ HCG / - - Vit B1 ( Thiamine ) / Psychogenic Etiology : unknown ?! error of metabolism ( enzymatic )
Pathogenesis : Dehydration / hemoconcentration Cl.picture : nausea , vomiting , abdominal pain , jaundice
& Electrolyte disturbance hypoglycemia , HTN (PE)
Complications Starvation ketosis coagulopathy , DIC
↓ liver glycogen & ++ AST , ALT Inv: ++PT , PC , INR , Bilirubin , AST , ALT , hypoglycemia
Mallory Weiss Syndrome
ttt: prompt delivery ( serious condition )
Wernicke’s encephalopathy
+ + & ICU admission to support general condition
Inv : Na / K / LFTs / Hct / chloride in urine
Treatment: Hospitalization / NPO
IV fluids & correct electrolytes
IV Antiemetics
Rarely termination ( in severe cases of encephalopathy)
3) GERD 6) HBV 7) HCV
Definition: epigastric discomfort after meals virus DNA virus RNA virus
ttt: Reassurance & symptomatic ttt: * Rare during pregnancy * < 5% risk
Small frequent meals & avoid recumbency after meals Mostly in 3rd trimester
Antacids 1hr after meal Vertical
* during labor from * during labor if
H2 receptor antagonist ( Cimetidine , Ranitidine = Zantac) transmission infected maternal instrumental delivery
Proton pump inhibitor ( Omeprazole = Controloc ) secretion é abrasions of baby
4) Intrahepatic cholestasis
* Duing pregnancy: * ttt is CI during
Def : cholestasis & pruritis > 20 wks GA
Antiviral ttt in 3rd pregnancy
Inc : 1-4 % , Etiology : unknown ?! genetic
Diagnosis : Cl.picture : Itching éout rash , sp. palms & soles
* VD is safe (teratogenic )
Jaundice ( rare ) * Neonate immediately * Breast feeding is
Inv: ++ bile acids receives: allowed
Treatment
Mild + AST, ALT , Bilirubin HBIG ( passive ) ( except in cracked ,
Ttt: Symptomatic : cold baths , antihistaminics HB vaccine bleeding nipples)
62
Ursodeoxycholic acid tab (active immunization)
Termination if : reach 36 weeks / occurance of labor pains / * Breast feeding is
Page
maternal or fetal complications allowed
UTI é pregnancy Venous thromboembolism
1) Asymptomatic bacteruria Effect of pregnancy on blood:
Def : > 100.000 CFU + + clotting factors & - - fibrinolysis
Inc: 6% of pregnant females + + platelets activation
( ↑↑ in 2nd trimester due to stasis & compression ) Venous stasis due to pressure by gravid ut.
Diagnosis : urine analysis ‫ ؞‬+ + thromboembolic events in pregnancy & puerpurium
urine culture & sensitivity Risk F: > 35 yrs , multipara , obese , VV, H/O of DVT ,
Ttt is a must as 30 – 45 % pyelonephritis : out pt antibiotics thrombophilia , APS , CS, sepsis sp . pelvic
2) Acute cystitis ( lower UTI ) Cl.pict of DVT: red , hot , tender , swollen calf ms
Inv: Doppler US
As asymptomatic bacteruria + frequency , dysuria
Venography ( CI during pregnancy )
NO systemic manifestations ( ie : no fever )
Ttt:
3) Acute pyelonephritis ( upper UTI ) Prophylactic :
Def : upper UTI with systemic manifestations * Hydration
Cl.picture: fever/ loin pain * LDA
Complications: * Elastic stocking
Maternal: pulmonary dysfunction from sepsis & anemia * LMWH (clexane) single SC injection :
Fetal : PROM , PTL , Morbidity & Mortality in high risk multifactorial , till end of puerpurium
Inv : Urine analysis Actual ttt :
Urine culture & sensitivity Therapeutic dose of IV heparin or LMWH
Assessment of fetal wellbeing NB: Warfarin is CI in 1st trimester ( teratogenic )
Ttt: Hospitalization + IV fluids , antipyretics , analgesics & in 3rd trimester ( fetal ICHge)
Start IV antibiotics then modify according to C/S When to stop anticoagulants before delivery?
- Aspirin 1 week before delivery
- Clexane 24hrs before delivery
Seizures (convulsions , Epilepsy) é pregnancy Pulmonary Embolism
75% remain same , 25% worsen due to metabolism of anticonvulsants. Cl.pict: Breathlessness / Hypoxia / Tachycardia /
Effect of anticonvulsants on fetus : FCA , CP/MR ,- - VitK (é phenytoin) Pleuritic chest pain
Management : Inv: ECG changes
Maternal : Ventilation / perfusion scan
63
* Extra folic since before pregnancy 800μg daily Pulmonary angiography
* Monotherapy is better é least possible dose to control seizures Ttt: ICU support , O2 Therapy ,
Page
Fetal : anomaly scan IV Anticoagulant ( high therapeutic dose)
DM with pregnancy
Definition : Diagnosis :
hyperglycemia / glucosuria / microangiopathy Maternal :
Screening for all pregnant ladies (24-28wks):
Types: 50gm OGTT If ≥ 140 mg /dl
GDM : Only during pregnancy 100gm OGTT > 165 mg /dl
Overt DM : Type І : insulin dependent Diagnostic :
Type ІІ : non insulin dependent FBS > 95mg % & 100gm 1 hour OGTT > 200mg/dl
Risk F : HbA1c: to assess glycemic control over past 3 months
old age , multipara , H/O of IUFD , H/O of congenital anomalies ( best indicator for occurrence of fetal congenital anomalies)
Fetal US 1st trimesteric for NTD , Anencephaly
2nd trimesteric for FCA
Effect of pregnancy on DM :
3rd trimesteric for Macrosomia , Polyhydramnios
pregnancy is diabetogenic due to placental anti insulin hormones
Assessment of fetal wellbeing
( PRG , Cortisol , HPL ) & insulinase enzyme
Treatment:
( ↑ insulin requirements ) Diet + exercise : if blood sugar < 200mg/dl
Continue metformin ( if was given since before pregnancy )
Effect of DM on pregnancy : Insulin : if blood sugar > 200 mg /dl
Maternal: ↑ infection ( vulvovaginitis ) 2⁄ dose at morning & 1⁄3 dose at night
3
Abortion / PTL / PROM / Puerpural sepsis
50 : 50 ( regular : NPH )
Instrumental deliveries
××× Oral hypoglycemic ×××
++ DKA / PE Delivery : depends on glycemic control
Fetal : Macrosomia / polyhydramnios * if good control ‫ ؞‬wait for spontaneous labor pains
FCA :VSD ( most common ) , * if uncontrolled ‫ ؞‬terminate after giving steroids for
NTD ( most specific ) lung maturity.
Sudden IUFD
Fetal birth injuries & shoulder dystocia WHITE classification for DM :
Neonatal : Hypoglycemia A : GDM A 1: no need for insulin
( give IV glucose to the new born upon delivery ) A 2: with need for insulin
B : overt DM started > 20yrs age for duration of < 10yrs
Hypocalcemia
C : overt DM started 10- 20yrs age for duration of 10-20yrs
Polycythemia D : overt DM started < 10 yrs age for duration of > 20yrs
Hyperbilirubinemia
64
E : overt DM with calcified pelvic vessels
RDS F : overt DM with nephropathy
Page
R : overt DM with retinopathy
Thyroid disorders
Anemia é pregnancy Cardiac diseases é pregnancy
é pregnancy
Def: ↓ Hb less than 11gm% Types: RHDs (developing ) , CHDs (developed)
1) physiological Goiter Effect of pregnancy on heart :
or less than 10.5gm% in 2nd trimester
Due to ++ blood supply ± BP = ↑↑CO × ↓↓↓TPR
Inc: commonest medical disorder during pregnancy
- - iodine ↑SV × ↑HR (hyperdynamic circulation)
Effect of pregnancy on blood :
++ total T3 & T4 Waterhummer pulse: (++ S / D) difference
* Physiological ( dilutional anemia ) due to ↑ TBG
( ++ plasma > + RBCs ) Apex :shifted to 4th intercostal space outside MCL
( free T3 & T4 unchanged) Split S1 / appearance of S3 / Systolic murmur
* Tachycardia & Hyperdynamic circulation
* Max effect at 20 wks 2) Hyperthyroidism NYHA classification:
Etiology : * Graves’ disease (commonest І : Dyspnea on > ordinary effort
* Nutritional (Fe deficiency anemia) COMMONEST during pregnancy): ІІ : Dyspnea at ordinary effort
* Megaloblastic (folic A. & Vit B12 deficiency) Autoimmune ІІІ : Dyspnea on < ordinary effort
* Hemorrhagic * Thyroid storm : VІ : Dyspnea at rest
Hypermetabolic Effect (complications):
(bleeding in early, late pregnancy & PPHge)
* Complications: Maternal : Worsen NYHA classification by 1grade
* Hemolytic (congenital or acquired)
Abortion , PTL , IUGR Fetal : LBW / IUGR / Fetal anemia
* Hereditary (thalassemia , sickle cell anemia) Management:
* Aplastic * Inv: - -TSH , + + freeT4 ,
+ +TSH receptor Ab * In pregnancy
Effect (complications): More frequent ANC
Maternal: easy fatigability , PTL , PPH , * Ttt:
Propylthiouracil ± βB / Guard against anemia / infection / HTN
Puerpural sepsis / Hyperthyroidism
Steroids
Fetal:IUGR, LBW, PTL, neonatal sepsis , anemia Digitalis to be continued or started whenever needed
× × NO radioactive iodine × ×
Inv: * In Labor:
M ( for iron deficiency anemia): 3) Hypothyroidism Semisitting / O2 mask / Analgesics / Antibiotics
CBC / serum ferritin / TIBC Rare in pregnancy as it causes Avoid fluid overload
F : Assessment of fetal wellbeing infertility & anovulation Care é oxytocin ( has ADH like action )
Ttt: Commonest cause: Shorten 2nd stage by forceps / ↓ bearing down
Mild (10-11gm/dl) : oral iron Autoimmune Smooth VD or CS ( whenever indicated )
Moderate ( 7-10gm/dl) :parentral iron (Hashimoto thyroiditis) In 3rd stage : * Lasix to ↓ VR & heart load
Severe ( 4-7gm/dl) / Decompensated Inv : + + TSH , - - freeT4 * NO Ergometrine
( < 4gm/dl ): blood or packed RBCs Ttt : Eltroxine * In puerpurium :
65
Breast feeding CI in HF
Guard against PPH / P.sepsis NB: Proper selection of contraception
Page
Continue iron in puerpurium requirements ↑↑ in pregnancy
Fetal asphyxia Neonatal asphyxia
( In utero ) ( Post natal )
Def: ↓O2 & ↓ elimination of CO2 ‫ ↑ ؞‬CO2 acidosis ( PH < 7.2 ) Def: ↓O2 & ↓ elimination of CO2 ‫ ↑ ؞‬CO2 acidosis in neonate
Etiology: persistent fetal asphyxia
Etiology: 1) Maternal : uncontrolled medical disorders morphine given to the mother 2 – 4 hrs before delivery
2) Placenta : separation / insufficiency meconium aspiration
3) cord: prolapsed / loops around the neck cong anomalies of respiratory , circulatory systems
prematurity
4) fetus: anomalies / instrumental deliveries birth injuries
Cl. Picture: APGAR score at 1min for need of rescussitation
Cl. Picture: ( FETAL ) 5min for prognosis
1) Abnormal CTG in assessment of fetal wellbeing: 0 1 2
- Loss of beat to beat variability Appearance Trunk pink
- Sinusoidal rhythm ( color ) Blue Extremities blue Pink
- Late deceleration (sp.persistent) ___
Pulse < 100 b/min > 100b/min
- Brady < 100 OR Tachy >160 b/min
Grimace ___
Active cough
2) Meconium stained liquor in cephalic presentation ( reflexes ) Grimace
3) Fetal scalp PH < 7.25 & sneeze
Management: Activity Active
( movement ) Limp Some flexion
* First aid measures: movement
1) Stop oxytocin + IV fluid rehydration Respiration ___
Slow , irregular Active cry
2) Turn mother to Lt lateral position + O2 mask
Ttt:
3) Atropine to the mother Prevention proper ANC & control of maternal diseases
* If distress proper intranatal care * Proper use of Instrumental delivery
Relieved : continue VD é continous CTG monitoring
* Episiotomy whenever needed
Not relieved : immediate delivery * Proper use of morphine
* Care during delivery of
ttt : A ( Airway & suction )
after coming head
If engaged presenting part If not fully dilated B ( Breathing & O2 mask )
& fully dilated Cx C ( Circulation CPR & warmth )
D ( Drugs ): Naloxone : morphine antidote
66
Forceps or CS NaHCO3 : to combat acidosis
Breech extraction Adrenaline : to combat bradycardia
Page
Antibiotics : in case of sepsis
Fetal birth injuries
Definition: Injuries of fetus at birth (iatrogenic)
Etiology: (Instrumental / prematurity / CPD …..)
Types:
1) Bone injuries:
- Skull : ± ICHge*
Subperiosteal Hge Caput succedaneum ( scalp edema )
( cephalhematoma ) ( chignon )
Wrong application of forceps / Normal ventouse application
Causes
* Depressed fracture or fissure fracture Prolonged / obstructed labor
When After few hours At birth
Overlie a certain bone Any area of the scalp
Shape Never crosses suture line May cross the suture line
Skin over it is normal Skin over it is echymotic
May be infected Subside spontaneously
Calcification in 1-2 days
Fate Hyperbilirubinemia
ttt: Expectant ttt (Antibiotics & follow up)
Measures to ↓ ICT ( in cases of ICHge )
- Other bones : humerus / clavicle / spine injuries / shoulder dislocation

ttt: Splint / slab ( for long bones injury )
2) Muscle : as sternomastoid ttt: Passive traction
3) Nerves : Brachial plexus
- C5,6 : Erb’s palsy ( Policeman tip position )
Klumpke’s
- C8,T1: Klumpke’s palsy ( failure of grasp reflex) ( Ape hand ) ttt: Physiotherapy palsy
Facial nerve injury : ( flat nasolabial fold ) (will resolve if edema)
due to forceps pressure at stylomastoid foramen
67
4) Organs : liver / spleen / anus / hymen ( as in breech delivery )
Page
Erb’s palsy
NB: proper management of the 2nd stage of labor will prevent most of these iatrogenic birth injuries
Analgesia & Anesthesia Spinal is anesthesia of choice for CS : in
subarachnoid space
( hypotension & headache, ‫ ؞‬IV preload is needed )
Epidural :
( hypotension , ‫ ؞‬IV preload is needed )
General : IV anesthetics as thiopental Na
(ketalar) , in addition to inhalation gas drugs as
І ) Pharmacological N2O & O2 ( affect fetus & mother )
General Local
1) Narcotics: 1) Epidural : used all through labor,
*Pethidine ie: intrapartum & postpartum
× 10
*Morphine Side effects :
*Butorphanol ×5 * block motor too ( not just sensory )
Side effect: Neonatal RDS if given < 2hrs * loss of urge of straining
before delivery * accidental puncture of dura : headache
Antidote : naloxone ( Narcan )
2) Local infiltration anesthesia ( é lidocane )
2) Non- Narcotics : Most commonly used ( for episiotomy or tears )
* Benzodiazepines: diazepam ( valium )
* Phenothiazine derivatives 3) Pudendal nerve block
At level of ischial spine , injected through the vagina
3) Inhalation :
* N2O + O2 50:50 ( laughing gas ) 4) Paracervical block
* Trilene (obsolete due to its toxic metabolites) * Injected on either side of the cervix through the
lateral fornices
* Side effect : fetal bradycardia ( ‫ ؞‬rarely used )
ІІ ) Non-Pharmacological
1) ANC classes ( how to relax / breathing excercises / abdominal & pelvic floor ms excercises )
2) TENS ( Gate theory of pain )
68
3) Acupuncture ( Gate theory of pain )
4) Water birth
Page
Induction of labor Induction of abortion
* 1st Do Bishop score:
0 1 2 3
1st Trimester 2nd Trimester
Dilatation closed 1-2 cm 3-4 cm >5 cm ( no bones ) ( presence of fetal bones )
Effacement < 30% 30-50% 50-80% >80%
A) Surgical is preferred A) Medical is preferred:
Position posterior mid anterior
Consistency firm mid soft (D&C or SE): by Misoprostol PGE1 ,
Station -3 -2 -1 / 0 +1 / +2 complications : If Oxytocin is used, it’s
* If Bishop score < 5 ‫ ؞‬Ripening of Cx is needed by PGs * Cervical lacerations needed in very high doses as
* If Bishop score > 5 ‫ ؞‬Oxytocin or ROM is used for induction oxytocin receptors are
* Uterine perforation
PGs Amniotomy Oxytocin formed in late 2nd trimester
* Infection
For induction or
For augmentation of * Anesthesia complications
For Cx ripening augmentation of
Use
labor or induction if
( IOL ) labor by release of * Remote :incompetent
Bishop score > 5
endogenous PGs
Stipping followed isthmus
Route
PGE1 25μg
by ROM by IV drip ( titrated)
vaginal tab
amniohook
* Dysfunctional B) Medical: B) Surgical (Hysterotomy):
* GIT upset * Cord prolapse
labor ( PGE1 oral or vaginal tab if medical induction failed or
Complications
* Fetal distress is CI
(vomiting ,diarrhea) * Placental
* Rupture Ut sp in
Misoprostol / 4-6hrs for
* Cardiac symptoms separation Delivery of fetus before
multipara & 24hrs )
( palpitations ) * Introduction of viability through an
scarred Ut
* Rupture Ut or Cx infection Complications :
sp in mutlipara * Failed induction
* Rarely fluid abdominal & uterine
overload * failed induction incisions
(ADH like action) (specially in missed abortion)
* Grand multipara * Closed cervix * More than 2 NB : if after viability
* Scarred Ut * Placenta previa previous CS * Incomplete evacuation ‫ ؞‬name is CS
CI
* For augmentation ( as CS will be
69
* GIT complications
of labor done )
* Cardiac complications
Page
If CS is already indicated for termination of this pregnancy

Puerpurium
Definition : period of 6 wks following delivery during which all PPC Program : 1week after labor , then 4-5 weeks later
changes that occurred during pregnancy , will return to check :
back to normal.
* vital signs returned back to normal
Changes:
* breast feeding & no milk engorgement
Uterus: Lochia(endometrium) : rubra serosa alba
Myolysis * uterus back to normal & lochia
Size at umbilicus on day of delivery * abdominal & pelvic floor excercises
then SP ( 2wks later ) * wounds : CS or episiotomy wound
then prepregnancy size ( 4wks later ) * care for bladder & bowel by normal evacuation
After pains: contractions that occur – specially é
breast feeding – to help uterine involution * contraceptive counselling
Cx & lig back to normal (4wks later )
Vagina / Vulva : Reformation of rugae Puerpural pyrexia
Gapping of vulva disappears
Breast : PRL for milk formation Definition: ++ T˚ ≥ 38˚ after 1st 24hrs of delivery , persisting
Oxytocin for milk expression for 24hrs or recurring within 24hrs till end of puerpurium.
Colostrum ( ++Ptns , ++ Ig , -- CHO , -- Fat ) Etiology :
first 3 days , then milk expressed 1) Mastitis / Breast engorgement ( most common )
lactational amenorrhea in 50% of females
pigmentation of areola remains 2) P. sepsis ( most serious )
vital signs : BP back to normal 3) UTI
++ T˚ , but < 38 in 1st 24hrs after labor 4) Wound infection
Transient ++ pulse
5) Respiratory tract infections as COVID – 19 infection
Diuresis ( retention only with painful episiotomy )
Constipation ( due to lax muscles) 6) DVT , Thrombophlebitis
Emotional liability 7) other causes of fever as typhoid , malaria
Post partum blues are very common ( needs
“ Any case of puepural pyrexia should be considered
70
support & reassurance) but rarely depression
( needs ttt) & psychosis (needs hospitalization ) p.sepsis until proved otherwise ”
Page
Puerpural sepsis ( 3rd cause of maternal mortality in Egypt )
Definition : wound infection of genital tract after labor Investigations :
till end of puepurium * To exclude other DD :
Etiology : - Breast exam ( for engorgement & mastitis )
Predisposing F : General : ↓ immunity/ anemia / DM - Chest X-Ray ( for chest infections ) - Urine analysis ( for UTI )
Local : tears / septic conditions / - C/S ( for wound infection ) - Doppler US ( for DVT )
instrumental delivery * To confirm diagnosis :
Prolonged labor & prolonged PROM - Culture & sensitivity from discharge
Retained parts of placenta or membranes - Blood test ( ++CRP , ++ESR , ++TLC ,++DLC (shift to the left) ,
Organism : Polymicrobial ( Gram –ve / +ve / anaerobes ) ++ staff / segmented ratio )
Route of infection : Ascending from vagina - Pelvic US
Autogenous from elsewhere in body Treatment :
Exogenous from attendees * Prevention :
- by proper ANC ( control anemia , DM )
Pathology :
- 1st stage of labor : Avoid prolonged labor
1ry site ( symptoms immediately after delivery )
Give antibiotics in PROM
* Uterus , Cx , Vagina , Perineal lacerations nd
- 2 stage: Avoid instrumental deliveries
2ry site ( late symptoms after 7-10 days ) Proper aseptic techniques while doing episiotomy
* Parametritis , salpingo oophoritis , peritonitis , rd
- 3 stage: Explore placenta & memb. for any missing parts
pelvic thrombophlebitis ( after 14 days ) Repair of any laceration under aseptic technique
* Active ttt :
Cl.picture: - Hospitalization
Symptoms: - IV fluids / IV analgesics / IV antipyretics
* Fever/ foul smelling discharge / lower abdominal pain / - IV antibiotics Cephalosporins for Gram +ve
± oedematous white swollen limbs ( phlegmasia alba dollens ) Gentamycin for Gram –ve
Signs: ( Max for 3 days as they are nephrotoxic )
* General :Fever / tachycardia / toxic facies / dehydration Metronidazole for anaerobes
* Abdominal : tenderness / guarding / rebound tenderness * Special situations : ( in addition to above mentioned ttt )
* PV: jumping sign / horse-shoe induration around Cx - Abscess : drainage
* ± LL affection : swollen white painful limbs - In retained parts : Ergometrine ± D&C
* Septicemia in severe untreated cases - Infected wound : remove suture& drainage
71
- Septic thrombophebitis : anticoagulants& immobilization
Page
- Pelvic abscess: Fowler position , drainage by colpotomy

Instrumental delivery Episiotomy
Forceps Ventouse Definition : an incision in post vaginal wall , perineum & skin
By Chamberlen family done during vaginal delivery to widen the vulval introitus for
Start
( 1st to use forceps on living By Malmstrom in 1954 the fetus

fetus ) in year 1560-1730
* In modern obstetric , only * For rotation & extraction Indications:
low ( outlet ) forceps is used in OA or OP positions
for extraction only * Less enchroachment on maternal
Maternal : rigid perineum
* Kieland long forceps is pelvic space instrumental delivery
rarely used for rotation & * Time consuming
extraction in OP ( need 20minutes to induce –ve Fetal : macrosomia
Indications
* in fetal distress to shorten pressure) malpresentations or malposition

2nd stage ‫ ؞‬not used in fetal distress
* In Face presentation & PTL * CI in face or preterm prematurity ( to avoid sudden compression &
* Aftercoming head of Breech (only used in vertex presentation) decompression of fetal head )
( Piper’s forceps ) * Only used on living fetus as –ve
* Dead fetus suction & scalp edema formation Timing : Just before crowning
ie chignon (which is the mechanism
of action of ventouse) needs living
Types :
fetus to be formed Median Mediolateral
Prerequisites
Fully dilated Cx / Engaged head

Benefit More anatomical
NO CPD / Membranes ruptured
Presence of uterine contractions More cosmetic No extention to anal
Empty bladder & rectum sphincter & rectum so
Antiseptic techniques / Anesthesia Less dyspareunia
avoid damage of anal
Maternal ( mainly ) : Fetal ( mainly ) : Less pain sphincter
- lacerations & tears - cephalhematoma
( perineal / vaginal / cervical & - scalp lacerations
Less blood loss ( ONLY advantage over
even rupture uterus ) - ICHge if excessive –ve Easier repair median episiotomy)
Complications
- PPHge ( traumatic or atonic ) pressure in preterm fetus with

Fetal : fragile BVs Better healing
- if wrong application : Maternal : Complications :
head compression , skull fracture - If wrong application
& ICHge ( includes cervical tissue in the - extension to anal sphincter in median type
72
- cephalhematoma ventouse cup ) lacerations - hematoma Infection
( bone fracture or fissure )
Page
- facial nerve injury - later dyspareunia
Cesarean Section
Def : Delivery of a viable ( ie > 24wks gestation ) fetus through an abdominal ( usually Pfannensteil skin incision )
& uterine (usually transverse lower segment) incision , irrespective the fetus was living or dead .
NB: if this delivery is before viability ( ie before 24wks ) this is called “ Hysterotomy ”
Types of CS : LSCS : Transverse ( more common ) or vertical incision performed in the lower segment of the uterus.
USCS ( Classical CS ) : vertical incision in US of the uterus performed in certain situations as placenta accreta.
Indications:
Maternal : CPD / Medical disorders with failed IOL or if CI / HPV warts in vulva
Fetal : Distress ( while Cx is not fully dilated ) / Macrosomia / Multiple gestations or twins with 1st non – cephalic
Obstetric : Previous more than 1 CS ( ie ≥ 2CS )
Placenta previa / Malpresentations that CI vaginal delivery ( ie MP, brow , transverse lie , persistent oblique OP or DTA)
Techniques:
LSCS USCS
Uses More commonly used Used in certain situations
Inc of rupture 0.2 – 0.9 % ×10 times ( 2-9 % )
Formed of 2 ms layers Formed of 3 ms layers
Scar ‫ ؞‬less Hge / better coaptation / less hematoma ‫ ؞‬more Hge / less coaptation / more hematoma
‫ ؞‬better healing ( strong scar ) ‫ ؞‬worse in healing ( weaker scar )
Peritoneum & Presence of visceral peritoneum
Visceral peritoneum is attached ( not separate )
subsequent ‫ ؞‬suturing it covers the scar ; less ileus , less infection due
‫ ؞‬more adhesions later
adhesions to peritonization & less adhesion formation
Complications of CS :
Intraoperative : Anesthesia complications NB : VBAC ( Vaginal Birth After CS ) or
TOLAC ( Trial Of Labor After CS )
Injury to bladder/ intestine / BVs Prerequisites :
Early post operative: Reactionary Hge ( when BP increases - Only one LSCS with no post operative
& returns back to normal due to slipped ligature ) complications as infection
Ureteric injury symptoms - Proper spacing
Late post operative : Wound infection - No current indication for CS
Paralytic ileus , acute gastric dilatation Complications of VBAC : rupture uterus
Thromboembolic complications
“ Previous normal VD followed by CS
73
Adhesions & subsequent tubal & peritoneal factors of infertility
Placenta accreta if implanted on the scar site improves the chance of a safe and
successful VBAC ”
Page
Prenatal diagnosis of congenital anomalies
Definition : In utero identification of congenital or chromosomal anomalies in the fetus for early management
( ie early induction of abortion if needed , counselling of the parents to be prepared )
Indications: High risk cases needing screening
1) Maternal age > 35 yrs ( more risky for Down syndrome )
2) Early exposure to teratogens ( drugs , radiation , infection )
3) Previous H/O of anomalies in babies or family H/O of genetic disorders
NB : If screening test is positive ‫ ؞‬confirmatory test is needed
Screening Tests Diagnostic (confirmatory ) Tests
( cheap / non invasive / low false –ve ) ( accurate / invasive / low false positive )
1) Maternal serum biochemical markers : 1) Advanced US ( level 2 )
- DMT : β HCG + PAPPA ( 11 – 13 wks ) - anencephaly , cystic hygroma , skeletal anomalies( 11-13 wks)
- TMT : β HCG + MSAFP + uE3 ( 14-16 wks ) - major anomalies : NTDs , skeletal , cardiac , renal & GIT
NB : in Down syndrome all markers ↓↓↓ EXCEPT β HCG ↑↑↑ anomalies , diaphragmatic & ventral hernias ( 18-22 wks )
2) US : 2) CVS : ( trophoblastic tissue biopsy )
- NT , presence of nasal bone ( 11-13 wks ) - vaginal ( at 11wks ) / abdominal ( at 14 wks )
( NT > 3mm , hypoplastic nasal bone in Down ) - both TAS guided / abortion risk 2 %
- Other soft markers : as cardiac echogenic focus , pelvicalyceal 3) Amniocentesis: ( Amniotic fluid & cells shedded obtained
dilatation , short femur , Tricuspid regurge ( as in Down ) by needle US guided)
( 18-22wks ) - abdominal at 14-16 wks
3) Cell free Fetal DNA : ( 10 wks ) - risk of abortion 1% , infection , ROM , Pl.separation
- used as screening & confirmatory 4) Cordocentesis : ( Fetal blood sample , US guided)
- non invasive but expensive & not available in all centers - diagnostic & therapeutic in exchange transfusion
- diagnostic only for 5 -12 chromosomes in Rh isosensitization
( including ch. 21, 13 , 18 ) , but not the whole 23pairs of ch. - abdominal at 20wks
as other diagnostic tests as CVS & amniocentesis 5) Cell free Fetal DNA: ( as before )
NB : PGD ( Pre implantation genetic diagnosis ): Prenatal diagnosis of Down syndrome
Done in association with IVF procedure Screening Confirmatory
Single cell at 8 cell stage or dozen cells in blastocyst stage : 10wks: Cell Free Fetal DNA 10wks: Cell Free Fetal DNA
stage can be taken with no damage to fetus , to provide DNA 11 – 13 wks: DMT : ↑ β HCG + ↓ PAPPA 11wks: Vaginal CVS
for PCR analysis for inherited genetic disorders. US: * NT > 3mm , 14-16 wks: Amniocentesis
74
* hypoplastic nasal bone
“ for diagnosis of anomalies before doing the embryo transfer & in
14-16 wks: TMT: ↑ β HCG + ↓MSAFP +↓ uE3
Page
preimplantation sex selection ( in cases of sex linked anomalies)” 18-22wks: US: Other soft markers

Fertilization , Implantation & Placenta formation
Oogenesis Spermatogenesis
Decidua Decidua basalis
In utero( haploid nb ) Sperm motility Hartmann capsularis +
Sign can Trophoblast
Arrest at prophase of Capacitation occur before ( chorion frondosum)
1st meiotic division till they fuse Decidua
Ovulation Acrosomal reaction together parietalis
( = vera ) Placenta
Fertilization ( see next page )
Zona binding
Zona penetration
Oolema formation Blastocyst
Division of zygote 2 inner cell outer cell a a

4 mass = embryo mass = memb. v
6
8 1) Apposition Umbilical cord
Morula (16 cell stage = solid) 2) Adhesion 2 arteries , 1 vein
3) Invasion ( see next page )
Imbibe water 4) Decidua formation
75
Blastocyst
Page
Diagnosis of pregnancy
1) Symptoms : missed period / nausea & vomiting
2) Signs : amenorrhea / ( Naegle’s formula ) EDD : LMP + 9months + 7days
Sequence of
3) Investigations : Quantitative blood test βHCG ( on day of missed period )
diagnosis
Qualitative blood pregnancy test (+ve / -ve) ( 2-3 days after missed period )
Urinary pregnancy test βHCG ( 3-5 days after missed period )
US ( TVS ) at 5wks GS GS + yolk sac CRL 6wks ( fetus ) with pulsations
Placenta Maternal surface (dull greyish)

Cotyledon= unit of placenta
Definition : interface between mother & fetus 1 inch 0.5 inch
Formation : Chorion frondosum + decidua basalis 20cm Fetal surface (glistening)
Gross: 20 cm diameter ( discoid ) , 500gm weight , formed of 10-38 cotyledons ( unit of the placenta )
Functions: Abnormalities :
1) Transfer : Simple diffusion : é conc gradiant as H2O , O2 , CO2 1) In shape : Membranacea ( diffuse / large ) placenta ( Circumvellate )
Facilitated diffusion : é carrier as glucose , ketones , FA Bilobate : 2 lobes é tissue inbetween
++
Active transport : against conc. gradient as aa , Ca , Fe Bipartite : 2 parts é membranes inbetween
Pinocytosis : for large molecules as LATS , Ig Succenturiate : one large part & another small
st
2) Endocrine : HCG : glycoptn to maintain CL of pregnancy in 1 accessory lobe ( may be missed & retained in delivery )
HPL : ptn , main metabolic hormone , provide 2) In size & weight : ++ in S , hydrops fetalis , DM
glucose , aa , FA to fetus ( > 600gm & > 5cm thickness )
Estrogen : steroid for hyperplasia of ut ms , breast duct 3) In adhesions : accreta / increta / percreta
↑PRL , ++ Oxytocin receptors 4) In implantation : on LUS = pl.previa
PRG : steroid for hypertrophy of myometrium , decidua, 5) Pl.infarcts: White : fibrin deposition / calcium deposition
Breast alveoli , oedema , immunological Red: hge as in HTN
5) Immunological : for fetal acceptance 6) Calcification: with advanced aging of placenta Membranes
Umbilical cord
Definition : develops from the ventral ( connecting ) stalk ,measures 50cm , 1-2 cm diameter Bipartite
Abnormalities : Placental tissue
1) Insertion : Marginal ( battledore )
Velamentous ( in membranes ) Bleeding from the vessels
if crossing the internal os
2) Knots : False: accumulated Wharton’s jelly ( no complications )
True : fetal asphyxia
76
3) Length : Too long ( > 60 cm ) cord prolapsed & true knots , loops around neck
Too short ( < 35 cm ) prolonged 2nd stage of labor Vasa Previa
Page
4) Vasa previa : Vessels crossing Cx . connecting placenta to another lobe as in velamentous insertion ( If bleeding severe fetal distress ± death )
Physiological changes during pregnancy
1) Genital : 5) Cardiac :
- Uterus : height 7.5 35 cm / weight 50gm 1kg - Apex changed from 5th intercostal space MCL ,
- Cx : LUS is formed from isthmus starting from to 4th intercostal space , outside MCL
2nd trimester & reach 10 cm at full term - ± BP = ↑CO ( ↑SV× HR↑) × ↓TPR
Congested ( Goodell sign ) - Appearance of functional systolic murmurs, but diastolic
Bluish ( Chadwick sign ) murmurs are always due to organic valve lesions.
Mucus plug 6) Urinay:
- Vulva , vagina , ovaries:( ↑ vascularity ) - Dilated ureter (sp. Rt side ) due to dextrorotation of uterus
- Frequency sp 1st & 3rd trimester ( due to pelvic ut in 1st ,
2) Breast : engaged presenting part in 3rd )
++ Size / vascularity / pigmentation of nipple & areola 7) GIT:
Secondary areola appearance - Emesis gravidarum ( morning sickness )
Montgomery tubercles ( dilated sebaceous glands on areola ) - Ptyalism ( ++ Salivation )
Colostrum secretion at 4th month - Reflux esophagitis (Heart burn due to
relaxation of stomach cardiac sphincter) ( relaxin
- Constipation ( reduced GIT motility ) & PRG effects )
3) Skin :
- Pigmentation ( ++MSH ) 8) Blood :
++ Volume sp at 32th wk ( plasma > RBCs ‫ ؞‬dilutional anemia)
Linea Nigra
Hyperdynamic circulation ( ‫ ؞‬functional systolic murmur )
Chloasma gravidarum ( Butterfly pigmentation on face)
++ Fibrinogen & WBCs
- Striae gravidarum ( stretch marks )
9) Respiratory :
Hyperventilation ( ++PRG )
4) Metabolic:
10) Skeletal :
Anabolic (ptn)
- Lumbar lordosis - Backache ( relaxin
Diabetogenic (CHO)
- Relaxation of ligaments & PRG effects )
++FFA
11) Endocrinal :
++ Requirements for Ca / Fe / minerals
Pituitary
Salt & water retention ( PRG effect ) ++ Size / Vascularity / Activity
Thyroid
77
++ weight 12-14 kg ( mostly in 3rd trimester) ++ Total forms of hormones due to ++ binding
Parathyroid ( but active free form is unchanged )
Page
Adrenal ( E2 effect )

ANC Program
Definition : program of preventive obstetrics to ensure safe mother & fetus.
Schedule : 1st visit ( booking visit ) , then return visits monthly till 7th month , then biweekly in 7th & 8th moths , then weekly in 9 th month.
What to do ??
A) Booking visit B) Return visits
1) H/O : LMP / EDD , GA calculation ( Naegles’ formula ) 1) H/O of any complain ± reassurance :
Medical , surgical, family H/O emesis , heart burn , constipation , mild headache ( give paracetamol ) ,
Previous obstetric H/O breast tenderness , Braxton Hicks in late pregnancy ,
2) General Exam : vital signs / weight leg cramps ( give Ca / Mg ) , Backache ( more rest ) ,
3) Inv : Labs: blood group Rh / CBC / RBS / LFTs / KFTs / vaginal discharge ( leucorrhea is normal ) , heat sensation ( PRG effect )
PT , PC , INR / HBsAg / TSH / urine analysis 2) Ask about warning symptoms :
US: gestational sac ( ± intrauterine /± living / ± single ) 1st trimester: ( hyperemesis / bleeding ) 1) Headache
4) Instructions: 2nd trimester ( quickening perception ) 2) Blurring of vision
rd 3) Vomiting
- Diet : Small frequent meals / supplementations : Folic acid 3 trimester
400microgram 1st trimester / Ca , Fe & multivitamins 2nd & 3rd trimester 4) Epigastric pain
- Excercise : mild to moderate with rest whenever fatigued. 5) Rt. Hypochondrial pain 6) ↓ Perception of
- Sleep : 8 hrs night & 2 hrs nap. fetal movement
3) Exam :
- Stop active or passive smoking to avoid SIDS. 8) Vaginal bleeding
General Vital signs 9) ROM 7) LL edema
- Teeth : care & avoid caries. Weight
- Bowel : +++ vegetables to avoid constipation. Obstetric: Leopold maneuvers in 3rd trimester
- Breast : use creams in last trimester to avoid nipple cracks. ( FL / FG / UG / 1st PG / ± 2nd PG )
- Intercourse: allowed except in bleeding or severe pain Doppler stethoscope for FHS
( PGs in semen ++ uterine contractions ) 4) US : one in 2nd trimester ( anomaly scan)
- Travelling : in comfortable way , long flights : aspirin is needed one in 3rd trimester ( fetal growth /liquor amount / pl.location )
( as pregnancy is hypercoagulable state) 5) Routine labs :
-Vaccination : Live attenuated are CI , only dead vaccines ( as tetanus / * In each visit :
polio / rabies / Influenza / cholera / typhoid / Covid19 ) CBC ( to detect & ttt anemia )
or Ig as hepatitis B & A can be given Urine analysis ( for asymptomatic bacteruria)
- Drugs :safe drugs as per FDA category / classification : * 50gm OGTT at 24-28 wks
A ) safe : as L- thyroxine √ ( screening for gestational DM for all pregnant females)
B ) Risky in animals , no data in humans: as penecillin √ 6) At 36wks : PV for primi ( if unengaged head ) to assess pelvimetry
C ) Risk in human is not ruled out : as NSAIDs , Steroids √ & do CPD tests
78
D ) Risky in human , but benefit > risk : as Tetracycline ± 7) Identify high risk pregnancies to be managed accordingly.
X ) Teratogenic , CI in pregnancy as risk > benefit : × × × 8) Prophylactic Anti-D dose for Rh-ve (non-sensitized) ladies at
Page
as chemotherapy , warfarin in 1st trimester 28/32 weeks .
High risk pregnancies
* Definition : pregnancy that endangers health of mother / fetus or newborn
* Examples :
1) Elderly primi ( > 35yrs ) , pregnancy > 40 yrs old , grand multipara ( ≥ 5 deliveries )
2) Maternal medical condition : uncontrolled DM , HTN , cardiac , SLE, …
3) Obstetric problems: H/O of RPL, current APHge , ROM , PTL ,Placenta accreta, …
4) Fetal problems : anomalies , IUGR , Multiple pregnancies , …
* Management :
- More frequent ANC visits
- Delivery in specialized equiped place
- Management in pregnancy & labor accordingly
Maternal mortality in Egypt

* Incidence : 52 /100.000 deliveries as per year 2013 ( number of maternal deaths due to Obstetric causes )
* Common causes:
1) obstetric hemorrhage : as PPHge 30% , as in Egypt
2) PE & Eclampsia : 15% , as in developed countries
3) puerpural sepsis : 3.5% , as in developing or very underdeveloped countries
79
4) others as pulmonary embolism , DIC , Cardiac problems ,…
Page
Clinical History Taking
80
Page
General sheet
Personal H/O : Name / Age / Marital status / Parity / Occupation / Residency / Special habits
C/O : in patient’s own words ( + duration )
Present H/O :
Gynecological sheet Obstetric sheet WARNING SYMPTOMS
1) Analysis of complaint 1) LMP EDD ± GA
( onset / course / duration ) 2) Analysis of 1st trimesteric symptoms
1) Headache
2) Analysis of Pain / Bleeding / Mass Vomiting
2) Blurring of vision
3) Ask about etiological F , symptoms & Bleeding 3) Vomiting
complications of your DD to reach Frequency of micturition
3) Analysis of 2nd trimesteric symptoms 4) Epigastric pain
a provisional diagnosis Quickening 5) Rt. Hypochondrial
4) Investigations & ttt done for this patient st
Relieve of 1 trimesteric symptoms pain
6) ↓ Perception of
5) Review of other systems involvement 4) Analysis of 3rd trimesteric symptoms: fetal movement
( warning symptoms )
5) Analysis of C /O ( if present )
6) Investigations & ttt done 8) Vaginal bleeding
9) ROM 7) LL edema
7) Review of other systems
Past H/O: Medical : medical disorders prior to C/O
Surgical : operations done prior to C/O
Family H/O : of similar condition / consanguinity
Menstrual H/O : menarche / menstrual index eg : 3⁄28 / dysmenorrhea / intermenstrual bleeding
Obstetric H/O : F P A L / GPL / history of contraceptions
> 36 wks 24-36 < 24 now
eg:
Year of GA at termination Outcome Mode of delivery place Pregnancy Postpartum lactation
pregnancy / delivery / termination complications complications
1999 ± 8 wks abortion SE KA NO IUD
Failure of
2003 ± FT L♀ VD home
lactation
OCPs
Private
2007 ± 28wks SB ♂ CS Wound sepsis
clinic
81
Provisional diagnosis : patient’s name ‫ ثالثي‬/ Age / GPL / complaint in medical terms ( + duration ) / provisional diagnosis /
Page
relevant medical problems / relevant surgical operations

Examples of certain sheets:
I. Bleeding sheet
Personal history : as general sheet
Complaint: Excessive or Irregular or Excessive irregular vaginal bleeding for how long
Present history:
• Analysis of the complaint:(menorrhagia, metrorrhagia, menometrorrhagia)
➢ onset, course ,duration , amount of bleeding (number of pads, clots)
• Analysis of other related gynecological complaints :
➢ pain (type,site,radiation,severity,…..)
➢ mass (onset, course, duration,site,..)
➢ discharge (amount, colour, odour ,itching)
• Analysis of the causes :
➢ preceding event e.g. period of amenorrhea, I.U.D. insertion, injectables
➢ contact bleeding
➢ bleeding from other body orifices, ecchymosis
➢ thyroid disorders
➢ heart disease (dyspnea ,palpitation ,L.L.O. ,….)
➢ hypertension
• Analysis of the Consequences: anemia ( dyspnea, easy fatigability, blurring of vision)
• Analysis of investigations and treatment : U/S, D&C, CBC, coagulation profile
• Review of other systems.
Menstrual, Obstetric, Past, Family history, Diagnosis: as general sheet
Modifications in a case of postmenopausl bleeding

Personal History: if widow or divorced should be stated
Complaint: vaginal bleeding after ……. years of cessation of menstruation.
Present history:
• Duration of menopause
• Symptoms suggestive of distant metastasis:
82
➢ Lung (cough , hemoptysis,..) Liver ( rt hypochondrial pain , jaundice )
➢ Bone ( aches and pathological fractures ) Brain ( projectile vomiting , headache,…)
Page
➢ G.I.T. symptoms ( vomiting , constipation , bleeding per rectum)
II.Genital prolapse sheet
Personal history: as general sheet

Complaint: mass protruding from the vulva , sense of heaviness + duration
Present history:
• Analysis of the complaint:
➢ Onset , course , duration,
➢ effect of straining and lying down, (mention if the onset was following delivery)
• Analysis of other gynecological symptoms:
➢ bleeding( menorrhagia)
➢ pain ( congestive dysmenorrhea)
➢ discharge (leucorrhea)
N.B. these are the triad of pelvic congestion due to prolapse.
• Analysis of the consequences :
➢ urinary symptoms: frequency, nocturia, dysuria, sense of incomplete evacuation, urine retention, loin pain, pyelonephritis,
stress incontinence, inability to complete micturition except after digital reduction of the mass.
➢ rectal symptoms: inability to complete defecation except after digital reduction of the mass , constipation , incontinence to
flatus or stools ( if associated with complete perineal tear)
➢ sexual troubles: dyspareunia
➢ backache (traction on uterosacral ligaments in uterine prolapsed)
• Analysis of the Causes:
➢ precipitating factors: chronic cough , chronic constipation, obesity
➢ predisposing factors: symptoms suggestive of weak mesenchyme e.g. hernia, flat foot, varicose v.
• Analysis of investigations and treatment: previous repair , use of pessary
• Review of Other systems:
In Obstetric history: It is important to ask whether her deliveries were difficult and prolonged ended with use of forceps or ventouse,
83
delivery of macrosomic baby
Page
Menstrual, Past, Family history, Diagnosis: the same as general sheet
III. Infertility sheet
Personal history As general sheet plus
• ask about previous marriage

• children from previous marriage
• the age of the youngest child
• husband personal history: age/ occupation/ smoking/ another marriage and the age of the youngest child from the other marriage.
Complaint:Failure of conception for …….. years despite of regular marital life
Present history:
• Duration of her current marriage:

• Analysis of the causes:
➢ Male factor of infertility:
o semen analysis ( results, time) - treatment (nature, duration, result)
o previous operations (hernia, varicocele) - medical disorders and drugs.
➢ Ovarian factor:
o symptoms suggestive of ovulation (regular cycles ,spasmodic dysmenorrhea, premenstrual mastalgia, intermenstrual bleeding ,pain and
discharge)
o hirsuitism , oligomenorrhea ,hypomenorrhea (P.C.O.)
o symptoms suggestive of ovarian failure (hot flushes , nervousness , bony aches)
➢ Tubal factor:
o symptoms suggestive of salpingitis ( bilateral lower abdominal pain associated with offensive vaginal discharge, fever and chills)
o previous abdominal operations that may lead to adhesions
➢ Uterine factor :
o previous dilatation and curettage followed by decrease in the amount of menstrual flow ( suggestive Asherman syndrome)
➢ Cervical factor: vaginal discharge + backache, erosion, cautery, cervical amputation
➢ Sexual factor: Fequency per week, Dyspareunia ( superficial or deep ), vaginismus, effluvium seminis
• Analysis of investigations and treatment :
➢ Investigations as: hormonal profile, hystrosalpingography , sonohystrography, premenstrual endometrial biopsy, folliculometry, laparoscopy
( mention the results )
➢ Induction of ovulation : tablets, injections, how long,
➢ History of Tuboplasty
➢ Previous ART (IUI, ICSI)
• Review of other systems: General or Endocrine as thyroid dysfunction, DM, TB, Hyperprolactenemia
84
Menstrual, Obstetric, Past, Family histories and Diagnosis: as General Sheet.
Page
IV. Primary Amenorrhea sheet
Personal history: As general sheet
Complaint: Non occurrence of menstruation Or Absence of menstruation
Present history:
• Analysis of the complaint a case of primary amenorrhea till age of ….
• Development of secondary sexual characters : breast development, pubic hair, axillary hair
• Analysis of the cause:
➢ Hypothalamic cause: psychological disorders, stress, anosmia, head trauma, drugs
➢ Pituitary causes: galactorrhea , symptoms suggestive of increased intra cranial tension, visual field changes
➢ Ovarian causes: hirsuitism, deepening of voice , pelvi-abdominal mass
➢ Uterine causes: History suggestive of T.B.( night fever ,night sweat, loss of weight, loss of appetite)
➢ Out flow obstruction (cryptomenorrhea): cyclic lower abdominal pain , progressive abdominal swelling, if +ve ask about urine
retention .
➢ General causes: thyroid dysfunction, DM, severe debilitating disease
• Analysis of investigations and treatment:
➢ Hormonal profile, ultrasound, IVP, MRI
➢ Progesterone withdrawal
➢ E .+P. withdrawal
• Review of other systems
No menstrual or obstetric history
85
Family history: ask about similar condition in the family (her sisters)
Page
Past history and Diagnosis: as general Sheet

Modifications in case of 2ry amenorrhea
Personal history: as above

Complaint: cessation of menstruation for …..(how long)
Present history:
• Exclusion of pregnancy:
➢ pregnancy symptoms (nausea, vomiting, abdominal enlargement)
➢ pregnancy test
• Analysis of the last pregnancy event:

➢ post partum hemorrhage ( amount , cause, blood transfusion )
➢ puerperal sepsis ( fever , offensive lochia)
➢ in case of abortion ask about ( fever , D&C, offensive discharge )
• Hormonal treatment: e.g. injectable contraception
• Hypothalamic cause: psychological troubles
• Pituitary cause:
➢ galactorrhea
➢ symptoms suggestive of pituitary adenoma ( increased I.C.T. , visual field changes)
• Ovarian cause :
➢ hirsuitism , deepening of voice , pelvi-abdominal mass
➢ hot flushes , nervousness, bony aches
• Uterine cause:
➢ Symptoms suggestive of T.B.
➢ history of D&C (over curettage suggestive of Asherman syndrome)
• General cause:
86
➢ As 1ry amenorrhea
Page
Menstrual history taken about menstrual condition before amenorrhea
‫ﺭﻗﻢ ﺍﻹﻳﺪﺍﻉ ‪ :‬‬
‫ ‪I.S.B.N :‬‬
‫ﺟﻤﻴﻊ ﺣﻘﻮﻕ ﺍﻟﻤﻠﻜﻴﺔ ﺍﻟﻔﻜﺮﻳﺔ ﻭﺍﻟﻨﺸﺮ ﻣﺤﻔﻮﻇﺔ‬
‫ﻫﺬﻩ ﺍﻟﻨﺴﺨﺔ ﻟﻠﺘﺪﺍﻭﻝ ﺍﻹﻟﻜﺘﺮﻭﻧﻲ ﻓﻘﻂ‬

Nadin OBS

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nadin OBS

Uploaded by

Copyright:

Available Formats

‫ﻫﺪﻳﺔ‬

Gynecology & Obstetrics ‫ﻣﺠﺎﻧﻴﺔ‬

Notes on the Board of

Notes of Dr. Nadine Alaa Sherif Written by:

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Pituitary : FSH / LH * Other catalysts as

proliferative secretory Superficial

+ve spinbarkeit +ve Fern -ve spinbarkeit -ve Fern

Vagina: Cells E2 PRG

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

* Smoking Kallmann * PID * Polyp / septum

* Infections / tumor Spasmodic dysmenorrhea * Discharge Abnormal

( Azo /oligo / terato /

Antioxidants * CC ( oral tabs ) adhesiolysis Septum resection IUI IVF / ICSI

Child bearing period

Complications of Then do US Complications of

* No systemic * No systemic SE * No hormonal CI * High efficacy 4 PRG ONLY

* Low efficacy * Infection / Pain * Amenorrhea in P - nausea * Post ligation

(create unfavorable * Atrophic endometrium

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Sertoli-leydig cell tumor (androblastoma)(malignant)

Endometrioid (malignant from start )

Granulosa cell tumour (malignant )

Adenocarcinoma undiff Call Exner

____ HCG AFP LDH E2 / Inhibin androgen ____ ____

- Stage I (confined to ovary) Ic : one or both é + ve peritoneal cytology

Pain if complicated (torsion / Hge)

of BM To confirm diagnosis: Direct excisional biopsy

++++ anaerobes --- immunity STD *Mucous polyp

Alkaline : 4.7-7 Acidic < 4.5 Alkaline : 5-6 *Nabothian

Fishy odour Extremely irritant *Dyspareunia

500 mg bid / 7days weeks Metronidazole 2gm

gonorrhea Trachomatis Hemophilus Klebsiella Chlamydia Treponema

Culture: Culture : VDRL / RPR

Doxycycline Doxycycline Doxycycline Doxycycline pregnancy) Diathermy Vaccine ? If pregnant:

sebaceous glands - Superficial & deep - Genital

- Episiotomy : cut post or posterolat

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

- Musculosa: 2 ms layers - Commonest site for ectopic

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Y chromosome carries TDF : For Testicular differentiation ( through H-Y Ag )

♀ Female phenotype development needs :

Normal Female Sexual Differentiation

2) Wolffian duct undergoes atrophy - Genital swellings : Labia majora ( eq to scrotum in ♂ )

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

peritoneal cavity & pelvic organs the uterine cavity

Cong anomalies of uterus AUB / Polyp

- Electrosurgical complications to bowel , uterus , nerves

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Return –ve * Hysteroscopy

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

Rule of 5 for the presenting part

Low Intermediate Normal

( Septic ) : broad spectrum antibiotics + as before

Notes of Dr. Nadine’s lectures by Reem Abdelhakim www.nadine-alaa-sherif.weebly.com

20 min -Loss of beat to beat variability = fetal acidosis

Constitutionally small IUGR Constitutionally large in DM sp uncontrolled

IF < 36 wks Conservative : Antibiotics

IF > 36 wks Antibiotics

HCG AFP LDH E2 / Inhibin androgen