1. Classification of breech presentations.

A1
Breech presentation is defined as positioning of a fetus in a longitudinal lie with the buttocks or feet closest to the
cervix.
Classification
a. Frank breech presentations(65%) - Frank breech is when the baby's legs are folded up against his head
and his bottom is closest to the birth canal (in other words, when the hips of the fetus are flexed and the legs
extend straight upward with the knees straight and the feet at the head)
b. Complete breech presentations(10%)- Complete breech is when both of the baby's knees are bent and his
feet and bottom are closest to the birth canal (in other words, baby’s hip and knee joints are flexed)
c. Incomplete breech presentation(25%)
i. footling breech- incomplete footling, It is characterized by one leg presenting through the cervix. One
leg is fully extended and the other fully flexed at hips and knee joints.
ii. kneeling breech- baby’s hip joint is extended and knee joints are flexed on one or both sides

Incomplete Breech (25%)

Frank Breech (65%) Complete Breech (10%)
Footling Breech Kneeling Breech

A K A

J
The baby's hip joints are Hexed and knee The baby's hip and knee jams A extended The baby's hip joints are extended and knee
The baby's hip and knee joints are flexed.
joints are extended on one or both sides . joints are flexed on one or both sides

2. Definition of complete breech presentation.

A2
Complete breech is when both of the baby's knees are bent and his feet and bottom are closest to the birth canal (in
other words, the baby's hips and knee joints are flexed)
i. Circumference of the buttocks- 34-35cm
ii. Circumference of the shoulders- 34-35cm
iii. Circumference of the fetal head- 32cm **Breech presentation is defined as positioning of a fetus in a
longitudinal lie with the buttocks or feet closest to the cervix.
3. Definition of frank breech presentation.
A3

Frank breech is when the baby's legs are folded flat up against his head and his bottom is closest to the birth canal
(in other words, when the hips of the fetus are flexed and the legs extend straight upward with the knees straight
and the feet at the head or face.)

i. Circumference of the buttocks- 32cm

ii. Circumference of the shoulders- 3 9-4 lcm

iii. Circumference of the fetal head- 32cm

**Breech presentation is defined as positioning of a fetus in a longitudinal lie with the buttocks or feet closest to
the cervix.

4. Definition of incomplete footling presentation.

A4

It is a type of breech presentation characterized by one leg presenting through the cervix. One leg is fully extended
and the other fully flexed at hips and knee joints. **Breech presentation is defined as positioning of a fetus in a
longitudinal lie with the buttocks or feet closest to the cervix.

5. Definition of complete footling presentation

A5
It is a type of breech presentation characterized by both legs presenting through the cervix. Both legs are fully
extended at hip and knee joint.
**Breech presentation is defined as positioning of a fetus in a longitudinal lie with the buttocks or feet closest to
the cervix.

6. Classification of fetal malpresentations

A6

Fetal Malpresentations are abnonnal positions of the vertex of the fetal head relative to the maternal pelvis.

Classification
• Breech (Complete, incomplete, frank, footling, kneeling)
• Transverse
• Deflexed presentation ( Sinciput, brow, Face)
• Compound (there is more than one body part presenting)

7. Classification of deflexed presentations.

A7
Deflexed presentations are cephalic presentations of the fetus where the neck is not as flexed as should be.
There are 3 degrees of deflexed presentations (the more the extension of the fetal head, the higher the degree)

• First degree: Sinciput Vertex presentation- The leading part is the large fontanelle. On vaginal exam,
The sagittal suture, large and small fontanels are on the same level and can be palpated. The fetal head
presents with a fronto-occipital diameter-12-12.5cm
• Second degree: Brow presentation- The leading point is the middle of the frontal suture. On vaginal
exam: the frontal suture, the large fontanel, orbital ridges, eyes, and root of the nose are noticed . The nose
and mouth are not palpable- The fetal head presents with a mento-occipital diameter - 13 - 13,5cm

• Third degree: face presentation- The leading point is the chin. On vaginal exam the face line with mouth,
nose, the, orbits and chin are presented. The fetal head presents with a hyobregmaticus distance 9.5cm

Nb: With normal pelvic sizes, vaginal delivery in deflexed presentation is possible only in cases of posterior
variety of the fetus. Except in brow presentation where vaginal delivery is not possible regardless of variety
of fetus.
** Variety is determined by the position of the fetal back to the anterior or posterior wall of the uterus. Hence in
Anterior Variety, the fetal back is facing the anterior wall of the uterus**.

Causes of deflexed presentations are:

• Decreased uterine tone and incoordinate uterine contractions
• Contracted pelvis especially flat
• Decreased tone muscles of the pelvic floor
• An extremely large or small fetus
• Flaccid abdomen ( decreased tone of muscles of the anterior abdominal wall)
• Stiffness of the atlanoccipital joint
• Tumors of the thyroid gland or other tumors of the fetal neck
• Umblical cord shortening ( can be absolute or relative)
8. Definition of sinciput vertex presentation.

A8
It is the first degree deflexed position
It is determined by means of vaginal examination during which is possible to palpate the anterior and posterior
fontanelles, sagittal suture, large and small fontanels are on the same level.

The leading point is the large fontanel, fetal head presents with
a frontooccipital diameter -12-12.5cm
Vaginal Delivery is possible in posterior variety in:
■ Not large fetus
■ Adequate uterine contractions
■ Normal pelvic sizes

**The cardinal movements in labor:

• 1st - moderate head deflexion
• 2nd - internal head rotation
• 3rd - head flexion
• 4th - extension
• 5th - internal rotation of the shoulders, external rotation of the head
 9. Definition of brow presentation.
A9
This the second degree of deflexed position, where the head is extended.
It is determined by vaginal examination by finding- the frontal suture, the large fontanel, orbital ridges, eyes, and
root of the nose . The nose and mouth are not palpable.
The leading point is the middle of the frontal suture.
The fetal head presents with a mento-occipital diameter - 13 - 13,5cm

NB: Vaginal delivery is impossible, only res a rean secti o n is recommended

**The cardinal movements in labor:

• 1st - Head deflexion
• 2nd - internal head rotation
• 3rd- Head flexion
• 4th - Head deflexion
• 5th - Internal rotation of the shoulders, external rotation of the head
lO.Definition of face presentation.
A10
This is the 3rd degree of deflexed presentation, where the head is extended and the face is the presenting part.
On vaginal exam: The face in line with mouth, nose, the, orbits and chin are presented The leading point is chin
The fetal head presents with hyobregmaticus diameter 9,5cm

**The cardinal movements in labor are:

1st- Deflexion
2nd- Internal Rotation
3rd- Extension
4th- internal rotation of fetal body and external rotation of head

11. Classification of multiple pregnancies.

A11
Classified according to;
• Number of fetus: Twins, triplets, quadruplets etc.
• Number of fertilized eggs (dizygotic or monozygotic)
• Number of placenta: Monochorionic or dichorionic
• Number of amniotic cavities: diamniotic or monoamniotic

12. Definition of polyhydramnios. The most probable reasons

A12

Polyhydramnios is the excessive accumulation of amniotic fluid — the fluid that surrounds the baby in the
uterus during pregnancy. Normally, the volume of amntonic fluid increases to about IL -1,5 L more by 36 weeks
but decreases thereafter. Somewhat, more than 2000 mL of amniotic fluid is considered excessive, or
hydramnios

Some of the known causes of polyhydramnios include:

• A birth defect that affects the baby's gastrointestinal tract or central nervous system
• Maternal diabetes
• Twin-twin transfusion — a possible complication of identical twin pregnancies in which one twin
receives too much blood and the other too little
• A lack of red blood cells in the baby (fetal anemia)
• Blood incompatibilities between mother and baby
• Infection during pregnancy
13. Definition of oligohydramnios. The most probable reasons.
A13
Oligohydramnios is the condition of having too little amniotic fluid, less than 500ml
What causes low amniotic fluid?
• Birth defects - Problems with the development of the kidneys or urinary tract which could cause little
urine production, leading to low levels of amniotic fluid.
• Placental problems - If the placenta is not providing enough blood and nutrients to the
baby, then the baby may stop recycling fluid.
• Leaking or rupture of membranes -This may be a gush of fluid or a slow constant trickle of fluid. This is
due to a tear in the membrane. Premature rupture of membranes (PROM) can also result in low
amniotic fluid levels.
• Intrauterine growth retardation
• Post Date Pregnancy- A postdate pregnancy (one that goes over 42 weeks) can have low levels of
amniotic fluid, which could be a result of declining placental function.
• Maternal Complications- Factors such as maternal dehydration, hypertension, preeclampsia, diabetes,
and chronic hypoxia can have an effect on amniotic fluid levels

14. Pelvic classification according to the degree of contraction.

A14
This classifies it according to the size of the true pelvis;
Normal true conjugate is 11cm
Four degrees of pelvic contractions should be distinguished:
• I degree - True conjugate is 11-9 cm. Vaginal delivery is possible.
• II degree - True conjugate is 9-7, 5 cm. Vaginal delivery is possible.
• III degree - True conjugate is 7,5 - 5,5 cm Cesarean section is perfonned.
• IV - degree - True conjugate is less than 5.5 cm. Cesarean section is perfonned.
15. Classification of the pelvis according to the form of contraction.
A15
It is distinguished by two categories:
i. Often occurred
ii. Rare occurred iii.
OFTEN OCCURING:
 i. Generally contracted pelvis- Is characterized by diminution of all true pelvic diameters (anteroposterior,
transverse, and oblique) into 1-2 cm. Subpubic arch is narrow.
ii. Flat pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted flat pelvis
e.g Simple flat pelvis - Is defined as shortening of anteroposterior diameters at all levels of true pelvis, as a result
of this sacrum is inclined anteriorly to pubis.

RARE OCCURING:
i. obliquely contracted pelvis,
ii. obliquely dislocated pelvis,
iii. transverse contracted pelvis,
iv.
osteomalacic pelvis,
v.
funnel-shaped pelvis,
vi.
spondylolisthetic pelvis,
vii.
contracted pelvis as a result of exostosis and bone tumors
Management of labor. Cesarean section should be performed in all types of rare pelvic contraction.

16. Definition of anatomical and functional contracted pelvis

A16
Anatomically contracted pelvis is characterized by shortening of all or one diameters of the true pelvis
(anteroposterior, transverse, and oblique) by 1,5 - 2cm and more.
• Clinically or functional contracted pelvis - pelvis with normal dimensions, but vaginally delivery is
impossible due to “cephalopelvic disproportion”.

17. Clinical signs of the clinical (functional) contracted pelvis •

A17
Arresting of the head in the pelvic inlet
• Uterine contractions abnormality.
• Positive Vasten’ sign: if disproportion between fetal head and pubic symphysis is prominent
• Signs of urinary bladder compression.
• Edema of the cervix, and vaginal walls, productions of fistulas.
• Danger of uterine rupture - over distension of lower uterine segment
• Pushing occurs in location of fetal head in inlet.
18. Definition of the general contracted pelvis.
A18
Is characterized by diminution of all true pelvic diameters (anteroposterior, transverse, and oblique) by 1-2
cm. Subpubic arch is narrow. Average sizes of the pelvis are:
• D. spinarum - 23 cm,
• D. cristarum - 26 cm.
• D. trochanterica - 29 cm
• C. externa - 18 cm
• C. diagonalis - 11 cm
• C. vera - 9 cm.
Management of labor: Caeserean section is method of choice although Vaginal delivery may be possible
Course of labor in general contracted pelvis:
a. prolongation of labor
b. Fetal head flexion which it is elongated in the ocipitofrontal diameter (dolichocephaly)
c. Posterior fontanel is situated into the axis of pelvis
d. Molding of the fetal head. Caput succedaneum is formed in the area of posterior fontanel with increasing
narrowing of the pubic arch, the occiput cannot emerge directly beneath the symphysis as a result perineal
tears occur.
19. Definition of simple flat pelvis.
A19
Is defined as shortening of anteroposterior diameters at all levels of true pelvis, as a result of this sacrum is inclined
anteriorly to pubis. Average sizes of the pelvis are:
• D. spinarum - 26cm
• D. cristarum - 29 cm
• D. trochanterica - 31 cm
• C. externa - 18 cm
• C. diagonalis - 11 cm
• C. vera - 9 cm.

Management of labor. In the case of posterior asynclitism cesarean section should be performed. Vaginal
delivery in a flat rachitic pelvis which is a type of simple flat pelvis

Course of labor in simple flat pelvis

a. prolongation of labor;
b. sagittal suture arresting in the transverse diameter of the plane of inlet;
c. anterior fontanel is the leading point of the fetal head
d. asynclitism should be presented
** posterior asynclistism , the sagittal sure of the baby is inclined towards thesacrum
20. Definition of flat rachitic pelvis
A20
flat rachitic pelvis is a commonly occuring type of flat contracted pelvis whereby
the true conjugate is shortened;
the side walls converge (with the distance spinarum and cristarum become the
same);
an additional promontory may present between the 1st and 2nd vertebrae of the sacrum &
the suprapubic arch is shallow and wide the dimensions of the pelvic outlet may be normal or even
increased because the top of the sacrum is situated posteriorly.
the average pelvic sizes that may present in the flat rachitic pelvis are:
26cm for distancia spinarum and cristarum
3 lcm for distancia trochanterica
17cm for the external conjugate
10cm for the diagonal conjugate
and 8cm for the conjugate vera (true conjugate)

**TRUE CONJUGATE NORMAL AVERAGE SIZE IS 11CM**

21. Classification of uterine contractions abnormalities uterine contractions
A21

are the periods of tightening and shortening of the muscles of the uterus (or
myometrium) that result in the dilation of the cervix and help the fetus descend into the
birth canal, uterine contraction abnormalities may be
classified into 2, where they may be as a result of
1. hypotonic uterine dysfunction - whereby the tone of the uterine muscles are lower than normal, leading to
less or too slow contractions than normal.
- main form - uterine inertia
2. hypertonic uterine dysfunction - whereby the tone of the uterine muscles are increased, leading to more
or too fast contractions than normal. - main form - hypertonic uterine
contractions
**hypotonic uterine dysfunction
- uterine inertia - describes the decrease in strength and duration and increase in intervals of contractions,
which may be caused by
• overstretching of the uterus from multiple births, fetal macrosomia,
polyhydramnios, etc;
• bowel or bladder distention preventing fetal descent • or excessive use of
analgesia or anesthesia it results in a prolonged active phase of labour and exhaustion of the mother. **
**graphical presentation is by friedman 's graph **
** normal contractions are
• about 4-5 per hour,
• at about 10 minutes intervals,
• each lasting for a duration of about 40-50 seconds **
** therapeutic interventions
• stimulation with oxytocin,
• amniotomy - artificial rupture of the amniotic sac)
• nipple stimulation - to release endogenous pitocin
• warm enema **
**hypertonic uterine dysfunction
- hypertonic uterine contractions - are ineffectual, uncoordinated and erratic contractions, that involve
only a portion of the uterus
• usually occur in primigravidas
• contractions are painful and of increasing frequency at decreased intervals, but do not result in
cervical dilation and descent of the fetus into the birth canal, it results in decreased placental
perfusion, which leads to the early occurence of fetal distress**
'-■graphicalpresentation is by friedman's graph **
** therapeutic interventions
• comfort measures - like warm adequate back rub, music
• mild sedation
• bed rest and position changing
• adequate hydration
• tocolytics - e.g. magnesium sulfate **
22. Which fetuses are called as “large" and “giant? large and giant fetuses describe fetal A22

macrosomia. large fetuses: have estimated average weight of above 3,700g-4,000g. and giant babies have
estimated average weight of above 4,000g.

**Normal birth weight - 2700-4000g**

23. Definition of hypotonic uterine dysfunction
A23
hypotonic uterine dysfunction is the condition during labour whereby the tone of the uterine muscles are lower
than normal, leading to less or too slow contractions than normal, the main hypotonic uterine dysfunction is
- uterine inertia - which describes the decrease in strength and duration, and the increase in intervals of
contractions, which may be caused by
• overstretching of the uterus from multiple births, fetal macrosomia, polyhydramnios,
etc;
• bowel or bladder distention preventing fetal descent
• or excessive use of analgesia or anesthesia it results in a prolonged active phase of
labour and exhaustion of the mother.

**GRAPHICAL PRESENTATION IS BY FRIEDMAN'S GRAPH**

** NORMAL CONTRACTIONS ARE
• ABOUT 4-5 PER HOUR,
• AT ABOUT 10 MINUTES INTERVALS,
•
EACH LASTING FOR A DURATION OF ABOUT40-50 SECONDS ** ** THERAPEUTIC
INTERVENTIONS
• STIMULATION WITH OXYTOCIN,
• AMNIOTOMY - ARTIFICIAL RUPTURE OF THE AMNIOTIC SAC)
• NIPPLE STIMULATION - TO RELEASE ENDOGENOUS PITOCIN
• WARM ENEMA**

24. Definition of hypertonic uterine dysfunction

A24
hypertonic uterine dysfunction is the condition during labour whereby the tone of the uterine muscles are
increased, leading to more or too fast contractions than normal the main hypertonic uterine dysfunction is
- hypertonic uterine contractions - which are ineffectual, uncoordinated and erratic
contractions, that involve only a portion of the uterus.
• they usually occur in primigravidas
• contractions are painful and of increasing frequency at decreased intervals, but do not result in cervical dilation
and descent of the fetus into the birth canal.
it results in decreased placental perfusion, which leads to the early occurence of fetal distress.
 **GRAPHICAL PRESENTATION IS BY FRIEDMAN'S GRAPH** **
THERAPEUTIC INTERVENTIONS
• COMFORT MEASURES - LIKE WARM ADEQUATE BACK RUB, MUSIC
• MILD SEDATION
• BED REST AND POSITION CHANGING
• ADEQUATE HYDRATION
• TOCOLYTICS - E.G. MAGNESIUM SULFATE **

25. Etiology of hypotonic uterine dysfunction

A25
hypotonic uterine dysfunction is the condition during labour whereby the tone of the uterine
muscles are lower than normal, leading to less or too slow contractions than normal. the main
hypotonic uterine dysfunction is
- uterine inertia - which describes the decrease in strength and duration, and the increase in
intervals of contractions,

ITS ETIOLOGY INCLUDES

• overstretching of the uterus from its multiple births, fetal macrosomia,
polyhydramnios, etc;
• bowel or bladder distention preventing fetal descent
• or excessive use of analgesia or anesthesia it results in a prolonged active phase of labour and
exhaustion of the mother.

** intrauterine pressure during the contraction (usually less than 25 mmhg)

**GRAPHICAL PRESENTATION IS BY FRIEDMAN'S GRAPH**

** NORMAL CONTRACTIONS ARE
• ABOUT 4-5 PER HOUR,
• AT ABOUT 10 MINUTES INTERVALS,
• EACH LASTING FOR A DURATION OF ABOUT40-50 SECONDS ** ** THERAPEUTIC INTERVENTIONS
• STIMULATION WITH OXYTOCIN,
• AMNIOTOMY - ARTIFICIAL RUPTURE OF THE AMNIOTIC SAC
• NIPPLE STIMULATION - TO RELEASE ENDOGENOUS PITOCIN
• WARM ENEMA **

26. Indications for perineotomy, episiotomy

A26
perineotomy or episiotomy is the surgical incision of the perineum to enlarge the outlet in order
to make room for the fetal head descent during labour.
The indications are:
• resistant perineum causing delay in the fetal head delivery
• fetal macrosomia
• ineffective maternal pushing
• shoulder dystocia
• abnormal fetal heart rate during delivery

**The two most common types are midline perineal incision (perineotomy) and right mediolateral perineal incision
(episiotomy).**

27. Indications for amniotomy

amniotomy is the artificial rupture of the amniotic sac with a tool called an amniohook (which os a long crochet
type of hook with a prick at the end) or an amnicot (which is a glove with a small prick at the end), it induces
contractions similar to those of spontaneous labour.

The indications are

• hypotonic uterine dysfunction (uterine inertia)
• polyhydramnios
• in the need for placement of internal fetal scalp electrodes
• in the need for placement of intrauterine pressure monitoring catheters

28. Indications for c-section

cesarean section is the surgical procedure whereby the delivery of a fetus is done through an incision in the mothers
abdominal wall (laparotomy) and uterine wall (hysterotomy), it is done when spontaneous vaginal delivery endangers
the fetus or mother.

The indications are maternal:

• contracted pelvis
• failure to progress in labour or failed labour induction
• pre-eclampsia and eclampsia
• active genital herpes
• cardiac disease
• obstructive lesions of birth canal (previous cervical surgery, cervical cancer, ovarian tumors,
etc)
• abdominal cerclage (cervix stitch closed to prevent miscarriage)
• previous uterine surgery, rupture or myomectomy fetal:
• cephalopelvic disproportion
• fetal malpresentations
• proven fetal distress
• placenta previa
• vasa previa (fetal umbilical cord vessels close to internal opening of the cervix)
• abruptio placenta
• cord prolapse
• congenital fetal anomalies
• conjoined twins
29. Indications for vacuum extraction of the fetus
A29

vacuum extraction is a type of assisted operative delivery with the use of a suction by a vacuum pump and a set of
cups which are applied to the vertex of the fetal head to aid in descent.

The indications are

• failure to progress in labour (2nd stage)
• ineffective maternal pushing
• progressive intrauterine asphyxia
• proven fetal distress
• maternal cardiac disorders

** complications- caput succedaneum , cephalohematoma

30. Indications for application of surgical forceps

A30

surgical forceps delivery is a type of assisted operative delivery with the use of surgical forceps to aid in the fetal
head descent.

The indications are

• failure to progress in labour (2nd stage)
• ineffective maternal pushing
• progressive intrauterine asphyxia
• proven fetal distress
• maternal cardiac disorders
31. Conditions for obstetric forceps operation
A31

obstetric forceps delivery is a type of assisted operative delivery with the use of surgical forceps to aid in the fetal
head descent.

The conditions in which it may be used are:

• fully dilated cervix
• abscence of membranes
• cephalopelvic proportion
• fetal head station +2 or greater
• presence of indications
- failure to progress in labour (2nd stage)
- ineffective maternal pushing
- progressive intrauterine asphyxia
 - proven fetal distress
- maternal cardiac disorders

32. the conditions for the c-section

A32

cesarean section is the surgical procedure whereby the delivery of a fetus is done through an incision in the
mothers abdominal wall (laparotomy) and uterine wall (hysterotomy).

The conditions in which it may be used are when spontaneous labour and vaginal delivery endangers the fetus or
mother.
- there should be presence of indications maternal:
• contracted pelvis
• failure to progress in labour or failed labour induction
• pre-eclampsia and eclampsia
• active genital herpes
• cardiac disease
• obstructive lesions of birth canal (previous cervical surgery, cervical cancer, ovarian tumors, etc)
• abdominal cerclage (cervix stitch closed to prevent miscarriage)
• previous uterine surgery, rupture or myomectomy
fetal:
• cephalopelvic disproportion
• fetal malpresentations
• proven fetal distress
• placenta previa
• vasa previa (fetal umbilical cord vessels close to internal opening of the cervix)
• abruptio placenta
• cord prolapse
• congenital fetal anomalies
• conjoined twins

33. anesthesia for the c-section

A33
for cesarean section, spinal, epidural or general anesthesia may be used.
Spinal anesthesia
- it is easier to perform, requires less time and is more reliable than epidural
- its primary disadvantage is the risk of developing severe hypotension (have epinephrine on
standby). E.g local anesthesia;Bupivicaine
Epidural anesthesia
- has the advantage of multiple use (hence is ideal in cases where it was already used during labour) - it has a
smoother hemodynamic course E.g local anesthesia;Bupivicaine
General anesthesia
- induces systemic response ; anesthetic drugs that may be used for c-section are propofol, ketamine,
thiopental.

34. Etiology and pathogenesis of perineal and cervical lacerations

A34
perineal and cervical lacerations are tear injuries to the perineum or cervix
respectively, during labour and delivery.

pathogenesis of perineal and cervical lacerations they occur at the expulsion stage of labour which is usually
accompanied by a marked distension in the of the birth canal structures including the cervix and the perineum, in
excessive strain beyond the elastic threshold of these parts, they rupture or lacerate.

Etiology of perineal lacerations

- they usually occur in primigravidas due to inflexible, inelastic perineum.
- fetal macrosomia
- shoulder dystocia
- breech presentation
- operative delivery
- contracted pelvis
- fast and rapid delivery
**SIGNS OF THREATENED PERINEAL LACERATION: PERINEAL PROTRUSION, CYANOSIS, EDEMA AND
PALLIDNESS/ PALLOR**

Etiology of cervical lacerations

- primigravida status
- forced or operative delivery
- fetal macrosomia
- contracted pelvis

35. Classification of cervical lacerations

A35
cervical lacerations are tear injuries to the cervix, during labour and delivery.
Minor side lacerations of the cervix are physiological, and they occur in all women during first childbirth.
It is classified into 3 groups according to severity or degree of the laceration:
- 1st degree - laceration is up to 2cm and not more
- 2nd degree - the laceration exceeds 2cm but the does not reach the fornix (1cm away from it)
- 3rd degree - the laceration reaches the fornix and may extend into the upper part of the vagina
deep lacerations injure the vessels and cause profuse bleeding and sometimes hematoma from accumulation around
parametrial tissues.

**MUST BE REPAIRED BY SUTURING. **

36. Classification of perineal lacerations -

A36
perineal lacerations are tear injuries to the perineum, during labour and delivery.
It is classified into 3 groups according to severity or degree of the laceration:
- 1st degree - the laceration involves the posterior fourchette and only a small area of perineal skin and vaginal
wall; but the perineal muscles remain intact.
- 2nd degree - in addition to the perineal skin and vaginal walls, the laceration involves the perineal muscles
(except the external rectal sphincter).
- 3rd degree:

♦ incomplete 3rd degree laceration - all the mentioned structures including the external sphincter ani are
lacerated.
♦ complete 3rd degree laceration - all the mentioned structures including the external sphincter ani and the
rectal wall are lacerated.
**MUST BE REPAIRED BY SUTURING (CATGUT SUTURES)**

37. Etiology, pathogenesis of uterine rupture -

A37
uterine rupture is the obstetrical injury or disruption to the uterine wall during labour and delivery.
Pathogenesis
uterine rupture results from the overdistention of the uterus beyond its elastic threshold in the induction of the forces
of labor during the expulsive stage , which results in the disruption of the integrity of its wall.
The etiological factors:
- it may be spontaneous, without any extraneous cause
1. As a result of fetal macrosomia and cephalopelvic disproportion
2. previous uterine surgery (c-section, myomectomy, etc)
3. multiparity

- may be as a result of traumatic rupture from

1. improper operative interventions
2. difficult forceps delivery
3. breech extraction
4. hydrocephalus
38. classification of uterine rupture
A38
Uterine rupture is the obstetrical injury or disruption to the uterine wall during labour and delivery.
it may be classified:
according to damage:
complete (most common) - the rupture involves all the uterine wall layers
(endometrium, myometrium and perimetrium)
incomplete - rupture involves only the endometrium and myometrium

according to etiology:
spontaneous - occurs without any extraneous cause.
 traumatic - occurs mostly due to improper operative interventions.
combined
according to localization of rupture:
rupture of fundus
rupture corpus
rupture of lower segment
separation of fundus from the vaginal fomices
according to time of occurence:
rupture during pregnancy
rupture during labour it may be classified
according to clinical picture:
threatened uterine rupture
definite uterine rupture
**MAJOR COMPLICATIONS - IT LEADS TO ACUTE BLOOD LOSS (FROM UTERINE VESSELS AND VESSELS AT THE
PLACENTAL ATTACHMENT SITE) AND TRAUMATIC SHOCK.**

39. Classification of puerperal genital tract infection after Sazanov and Bartels

A39

postpartum infection, or puerperal infection, is any clinical infection of the genital canal that occurs within 28 days after
miscarriage, induced abortion, or childbirth. The first symptom of postpartum infection is usually a fever of 38° C or more
on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth)

CLASSIFICATION’’
According to stages
I. stage: limited form of infection to the area of the birth wound
• Postpartum endometritis
• Postpartum ulcer of perineum, vulva or cervix
II. stage: Infection spreads beyond the uterus but is limited to the pelvic cavity
• Vulvitis, colpitis, paracolpitis, salpingooophoritis
• Metritis, parametritis
• Thrombophlebitis of pelvic or femoral veins
• Adnescitis
• Pelvioperitonitis
IILstage: - The infection has gone beyond the pelvis and has a tendency to generalization: (boundary between
local and general septic process)
• Distributed peritonitis
• Infectious-toxic shock
• Progressive thrombophlebitis
•Anaerobic gas gangrene
IV. stage: Generalized infection: Sepsis (septicemia, pyosepticemia)
40. Pathogenesis of puerperal genital tract infection

A40

Various risk factors associated for puerperal infection such as ( Cesarean birth, Prolonged rupture of membranes,
Chorioamnionitis, Prolonged labor, Multiple vaginal examinations after the rupture of membranes, Episiotomy or
lacerations e.t.c) All leave the uterus susceptible to invasion and colonization by bacteria especially gram
positive streptococcus, staphylococcus , some game -ve bacteria e.g E coli and some anaerobes e.g Clostridia .

The Infection of uterus can also occur due to ascending route from the tubular canals of the genital tract.
Then the pathogen can then invade the bloodstream and lymph system and spread cause sepsis, cellulitis
(inflammation of connective tissue), and pelvic organs inflammation or generalized peritonitis (inflammation
of the abdominal lining).

The pathogenesis of uterine infection following cesarean delivery which is a leading cause of puerperal infection,
is due to an infected surgical incision-Bacteria that colonize the cervix and vagina gain access to amnionic fluid
during labor and invade uterine tissue.

41. Pathophysiology and etiology of placenta previa

A41

This is abnormal location of the placenta over, or in close proximity to, the internal cervical os. Pathophysiology- The

placenta normally migrates away from the cervical opening as the pregnancy progresses but this may not occur

properly due to

• Uterine factor - Pathological processes that lead to degenerative changes of the endometrium preventing
implantation in normal location (endometritis).
This can occur also occur because of prior Cesarean deliveries, prior instrumentation (such as dilation and
curettage procedures for miscarriages or induced abortions)

• Placental factors - When the placenta must grow larger to compensate for decreased function (lowered
ability to deliver oxygen and/or nutrients), there is an increased chance of developing placenta previa since
the surface area of the placenta will be larger, e.g multigestation

• In Vitro Fertilization whereby the artificially implanted trophoblast may be placed too low

• Pathology of gestational sac causes delayed maturation of the trophoblast, the sac attaches in isthmus or
cervix.

42. Classification of placenta previa

A42

Placenta previa is the abnormal localization of the placenta over, or in close proximity to, the internal cervical os.
Classification
• complete or total - if the entire cervical os is covered by the placenta ;
• partial - if the margin of the placenta extends across part but not all of the internal os of the cervix ;
• marginal, if the edge of the placenta lies adjacent to the internal os of the cervix ;

• low lying - if the placenta is located near but not directly adjacent to the internal os till 6 cm.

***Caesarean delivery is indicated in all except when the placenta is at least 2cm away from the cervical
os.

43. Pathophysiology and etiology of placenta abruption

A43

Placenta abruption is a premature separation of the normally implanted placenta from the uterine wall.

Pathophysiology : This occurs when there is hemorrhage into the decidua basalis, leading to premature placental
separation and further bleeding.The bleeding could be concealed within the uterus between the separated placenta
and the uterine wall forming a hematoma (concealed type) or could be seen externally ( revealed and mixed type).
Decidual Hematoma leads to degeneration and necrosis of decidua basalis and adjacent placental parts

Exact etiology is NOT clear but associated risk factors include

• Maternal hypertension
• Increased Age and parity
• External trauma
• Prior placental abruption
• Preterm prematurely ruptured membranes
• Cigarette smoking
• Cocaine abuse
• Polyhydramnios
• Uterine leiomyoma,

44. Diagnostic evaluation of placental abruption

A44
Clinical Manisfestation ;
• External bleeding may be present in revealed and mixed type
• Uterine tenderness and rigidity
• Back pain
• Signs of Fetal distress
 • Uterine hypertonus or high-frequency contractions
• Increased fundal height may be present on palpation in concealed type
• Dead fetus when placenta is totally sheared.
• Change in maternal hemodynamic status

Lab/ instrument diagnostic evaluation

• Coagulation disorders
• Ultrasonography- to note position of placenta, severity of abruption, survival of fetus

In concealed type of placental abruption, accumulated blood may seep into the uterine myometrium causing
couverlaires uterus ( uteroplacental apoplexy) seen as dark purple sections of ecchymosis with indurations on visual
inspection of uterus on laparoscopy
45. Etiology of postpartum hemorrhage
A45

Postpartum hemorrhage is defined as estimated blood loss >500 mL after vaginal birth or >1000 mL after cesarean
delivery of fetus.

A loss of these amounts within 24 hours of delivery is termed early or primary PPH, whereas such losses are termed
late or secondary PPH if they occur 24 hours after delivery
Etiology
Most common etiology of Postpartum hemorrhage- 4T’s- tone, tissue,trauma,thrombin
1. Tone - uterine atony/ uterine inertia : Diminished uterine tone; reduced contractility of uterus which maybe to
due , over-distention of uterus , infection to uterus , decreased contractility of lower uterine segment seen in
placental previa)
Overdistension of uterus maybe also be due polyhydraminous , multiple gestation,) Uterine atony may also be due to
effect of some obstetric medication e.g anesthetics; Halothane

2. Tissue- presence of retained placental tissue , invasive placenta; where the placenta invades the layers of the
uterus ( e.g placenta accreta; the placenta invades uterine and attaches strongly, Placental Increta; placenta
invades the myometrium (deeply), placental percreta; here the placenta invades beyond the myometrium, to the
serosa and may even evade beyond to adjacent organs).

3. Trauma of genital tract-

•. uterine rupture, uterine inversion
• laceration of cervix, vagina or perineum
• vaginal hematoma
Trauma may be as a result of use of instruments like forceps and vacuum extraction in delivery

4. Thrombin- Due to coagulation disorders whether congenital (von willebrands disease) or acquired ( severe
preeclampsia), anticoagulants use.
46. Principles for monitoring women who are at risk of postpartum hemorrhage

A46
surveillance of uterine tonus through abdominal palpation is recommended in
all women for early identification of postpartum uterine atony. This is to assess need for uterine massage or
uterotonics
• Monitoring status of placental delivery for possible need for Active removal with controlled cord traction
( Brandt-Andrews method (manoeuvre)).

• Monitoring Vital signs; Pulse rate, blood pressure measurement. And also monitoring level of Clotting
factors in the blood

• Ensuring all lacerations are sutured carefully

• Estimation of blood loss (this may be done by counting the number of saturated pads, or by weighing of
packs and sponges used to absorb blood; 1 milliliter of blood weighs approximately one gram)

• Monitoing urine output. Empty the urinary bladder by means of a catheter because an overdistended
bladder predetermines uterine atony due to common innervation
47. Etiology of the third stage of labour bleeding

A47

The third stage of labor refers to the period following the completed delivery of the newborn until the
completed delivery of the placenta. Usually last between 5-15minutes but could go up to 30minutes

The main causes of third-stage bleeding are:

-Bleeding from placental site which could be due to placental abruption, retained placenta. -Uterine atony
and genital tract trauma due to lacerations in the genital tract are also also associated with bleeding in
third stage of labor

-Attempt at Passive delivery of the placenta during the third stage of labor is also associated with more
bleeding in contrast to active method of managing third stage of labor with administration of oxytocin and
controlled cord traction after fetus delivery.
48. Etiology of early postpartum period bleeding
A48
Early post partum hemorrhage also called primary postpartum hemorrhage is defined as blood loss of at least 500 mL
after vaginal or 1000 mL following cesarean delivery within 24 hours postpartum.
This also includes the bleeding in the third stage of labor ( during delivery of placenta)

The main causes of hemorrhage in early puerperal stage also include the 4 T’s of post partum hemorrhage

1 Tone - uterine atony/ uterine inertia : Diminished uterine tone; reduced contractility of uterus which maybe to due ,
over-distention of uterus , infection to uterus , decreased contractility of lower uterine segment seen in placental previa)
Overdistension of uterus maybe also be due polyhydraminous , multiple gestation,) Uterine atony may also be due to
effect of some obstetric medication e.g anesthetics; Halothane

2. Tissue- presence of retained placental tissue , invasive placenta;

where the placenta invades the layers of the uterus ( e.g placenta
accreta; the placenta invades uterine and attaches strongly, Placental
Increta; placenta invades the myometrium (deeply), placental
percreta; here the placenta invades beyond the myometrium, to the
serosa and may even evade beyond to adjacent organs).

3. Trauma of genital tract-

•. uterine rupture, uterine inversion
• laceration of cervix, vagina or perineum
• vaginal hematoma

Trauma may be as a result of use of instruments like forceps and vacuum extraction in delivery

4. Thrombin- Due to coagulation disorders whether congenital (von willebrands disease) or acquired ( severe
preeclampsia), anticoagulants use.

49. Causes of postpartum pathological hemorrhage

A49

Postpartum hemorrhage is defined as estimated blood loss >500 mL after vaginal birth or >1000 mL after cesarean
delivery of fetus.

A loss of these amounts within 24 hours of delivery is termed early or primary PPH, whereas such losses are termed late
or secondary PPH if they occur 24 hours after delivery

Etiology
Most common etiology of Postpartum hemorrhage- 4T’s

1. Tone - uterine atony/ uterine inertia : Diminished uterine tone; reduced contractility of uterus which maybe to due ,
over-distention of uterus , infection to uterus , decreased contractility of lower uterine segment seen in placental
previa)
Overdistension of uterus maybe also be due polyhydraminous , multiple gestation,) Uterine atony may also be due to
effect of some obstetric medication e.g anesthetics; Halothane

2. Tissue- presence of retained placental tissue , invasive placenta; where the placenta invades the layers of the uterus
( e.g placenta accreta; the placenta invades uterine and attaches strongly, Placental Increta; placenta invades the
myometrium (deeply), placental percreta; here the placenta invades beyond the myometrium, to the serosa and may
even evade beyond to adjacent organs).

3. Trauma of genital tract-

•. uterine rupture, uterine inversion
• laceration of cervix, vagina or perineum
• vaginal hematoma

Trauma may be as a result of use of instruments like forceps and vacuum extraction in delivery

4. Thrombin- Due to coagulation disorders whether congenital (von willebrands disease) or acquired ( severe
preeclampsia), anticoagulants use.

50.Main terminal states in obstetrics

A50
• Hemorrhagic shock
• Postpartum purulent Septic disease
• Eclampsia
• HELLP syndrome
• Fetal distress

♦ Hemorrhagic shock - a state of severe hemodynamic and metabolic disorders that result from blood loss and
characterized by the inability of circulatory system to provide adequate perfusion of vital organs.
Depending on severity , Signs - anxiety , rapid heart rate, , blue lips and fingernails, low or no urine output, profuse
(excessive) sweating, shallow/Rapid breathing, dizziness, confusion, chest pain, loss of consciousness, low blood
pressure, weak pulse

♦ Postpartum purulent Septic disease

Systemic inflammatory process due to infection; most commonly strep, anaerobes and staphylococcus
Signs of sepsis - Tachycardia ,Pallor - Clamminess - Peripheral shutdown - Systemic inflammation - Fever or
hypothermia - Tachypnoea - Cold peripheries - Hypotention - Confusion - Oliguria - Altered mental state

Signs of inflammation seen on lab studies: Increased WBC, inflammatory markers ESR, CRP, calcitonin. +ve Bacteria
growth upon blood culture

♦ Eclampsia- Eclampsia, which is considered a complication of severe preeclampsia, is commonly defined as new
onset of grand mal seizure activity and/or unexplained coma during pregnancy or postpartum in a woman with signs
or symptoms of preeclampsia.
The clinical manifestations of maternal preeclampsia are hypertension and proteinuria with or without coexisting systemic
abnormalities involving the kidneys, liver, or blood

♦ HELLP syndrome is a complication of pregnancy characterized by hemolysis, elevated liver enzymes, and a low
platelet count.

Symptoms may include feeling tired, retaining fluid, headache, nausea, upper right abdominal pain, blurry vision,
nosebleeds, and seizures.Complications may include disseminated intravascular coagulation, placental abruption, and
kidney failure.

♦ Fetal distress refers to the compromise of the fetus due to inadequate oxygen or nutrient supply. This can occur due to
maternal, fetal or placental factors. At its most severe it may lead to neonatal brain injury or stillbirth.
51. Stages of hemorrhagic shock

A51

Hemorrhagic shock is a state of severe hemodynamic and metabolic disorders that result from blood loss and
characterized by the inability of circulatory system to provide adequate perfusion of vital organs.

Evaluation of hemorrhagic shock stage severity

Shock Hypovolemia Blood loss, ml % from body weight Hemodynamics data, diuresis
stage stage Circulating
blood volume
deficiency
1 Mild 10%-20% 500 1,0 -1,5 % Ps - 90-100 beats per min;
1000,0 Arterial blood pressure (BP) - >100 mm Hg;
Central Venous pressure (CVP) - 80-100 mm Hg;
Diuresis - N.
II Moderate 20%-30% 1000,0 1,5
Ps - 120 beats per min;
1500,0 2,0 %
BP - <100 mm Hg;
CVP-<60 mmHg;
Diuresis - < 50 ml per hour (oligouria)
III Severe 30%-40% 1500,0 2,0
Ps - 140 beats per min;
2000,0 2,5 %
BP - <70 mm Hg;
CVP-<40 mmHg;
Diuresis - < 30 ml per hour (anuria)
IV Considerable 40% and > 2000,0 and > > Ps - 140 beats per min; BP - <50 mm Hg; CVP-0;
2,5 % Diuresis- anuria
52. High risk factors for postpartum hemorrhage

A52
Postpartum hemorrhage is defined as estimated blood loss >500 mL after vaginal birth or >1000 mL after cesarean
delivery of fetus.

RISK FACTORS INCLUDE

• Placental abruption. The early detachment of the placenta from the uterus.
• Placenta previa. The placenta covers or is near the cervical opening.
• Overdistended uterus. Excessive enlargement of the uterus due to too much amniotic fluid or a large baby
( Polyhydramnos), especially with birthweight over 4,000 grams
(macrosomia).or Multiple pregnancy
• Gestational hypertension or preeclampsia. High blood pressure of pregnancy.
• Coagulopathies e.g Congenital ( Von willebrands disease), acquired (Thrombocytopenia with HELLP syndrome)
• Trauma during birth e.g uterine rupture, vulvovaginal injury, episiotomy
• Prolonged labor
• Infection; chorioamnionitis
• Medications to induce labor
• Medications to stop contractions (for preterm labor)
• Use of forceps or vacuum-assisted delivery
• General anesthesia e.g halothane

Etiology of postpartum coagulation disorders

Post partum coagulation disorders can also lead to post partum hemorrhage due to decreased ability of blood clotting.

Maternal clotting factors induced by pregnancy decline after delivery, raising the hemorrhage risk. Other
pregnancy-related coagulation abnormalities include

• Platelet dysfunction: Thrombocytopenia may be related to preexisting disease, such as idiopathic thrombocytopenic
purpura (ITP) or, less commonly, functional platelet abnormalities. Platelet dysfunction can also be acquired
secondary to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count).
• Inherited coagulopathy: Preexisting abnormalities of the clotting system, Von Willebrands disease Hemophilia A
or B or familial hypofibrinogenemia

• Use of anticoagulants: This is an iatrogenic coagulopathy from the use of heparin, enoxaparin, aspirin, or
postpartum warfarin.

• Disseminated intravascular coagulation (DIC): This can occur from sepsis, placental abruption, amniotic fluid
embolism, HELLP syndrome, or intrauterine fetal demise.
 • Dilutional coagulopathy: Large blood loss, or large volume resuscitation with crystalloid and/ or packed red blood
cells (PRBCs), can cause a dilutional coagulopathy and worsen hemorrhage from other causes.

53. Anatomy of female reproductive organs

A53

The female reproductive anatomy includes both external and internal structures.

The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and
to protect the internal genital organs from infectious organisms.

The main external structures of the female reproductive system lie outside the true pelvis and they include:

• Labia majora(“large lips”): enclose and protect the other external reproductive organs. During puberty, hair
growth occurs on the skin of the labia majora, which also contain sweat and oil-secreting glands.

• The labia minora (“small lips”) They lie just inside the labia majora, and surround the openings to the vagina and
urethra. This skin is very delicate and can become easily irritated and swollen.

• Bartholin’s glands ( greater vestibular glands ) : These glands are located next to the vaginal opening on each
side and produce a fluid (mucus) secretion.

• Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in
males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the
penis.

• Skene glands (paraurethral glands )- for lubrication

The internal reproductive organs are those organs that are within the true pelvis and they include:
• Vagina: The vagina is a canal that joins the cervix to the outside of the body. It also is known as the birth canal.

• Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is
divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the
uterus, called the corpus.

• Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce
eggs and hormones.

• Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as pathways for
the ova (egg cells) to travel from the ovaries to the uterus. Fertilization of
an egg by a sperm normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it
implants to the uterine lining. Parts of the fallopian tube Fimbriae , Infundibulum, Ampulla ( part where
fertilization occurs ) and isthmus
 Topography of the pelvic organs
The lesser pelvis (or "true pelvis") is the space enclosed by the pelvic girdle and below the pelvic brim: between the
pelvic inlet and the pelvic floor.bounded in front and below by the pubic symphysis and the superior rami of the
pubis; above and behind, by the sacrum and coccyx;
The lesser pelvis contains the pelvic colon, rectum, bladder, and some of the sex organs. The rectum is at the back, in
the curve of the sacrum and coc cyxie bladder is in front, behind the pubic symphysis.
Also contains the Internal genitalia: ovaries, uterine tubes, uterus and vagina

The greater pelvis (or "false pelvis") is the space enclosed by the pelvic girdle above and in front of the pelvic brim.
The greater pelvis supports the intestines (specifically, the ileum and sigmoid colon), and transmits part of their
weight to the anterior wall of the abdomen.

54. Female internal genitalia

A54
• Vagina: The vagina extends from the vulva externally to the uterine cervix internally. It is located within the
pelvis, anterior to the rectum and posterior to the urinary bladder.
• Uterus: Muscular Pear shaped organ divided into cervix, body and fundus.
• Cervix: the inferior portion of the uterus, separating the body of the uterus from the vagina. The cervix is
cylindrical in shape, with an endocervical canal located in the midline, allowing passage of semen into the
uterus.
• Uterine tubes (oviducts or fallopian tubes): are uterine tubes located bilaterally at the superior portion of the
uterus. Their primary function is to transport sperm toward the
egg, which is released by the ovary, and then to allow passage of the fertilized egg back to the uterus for
implantation.
• Parts of the fallopian tube Fimbriae , Infundibulum, Ampulla ( part where fertilization occurs) and isthmus

• Ovaries: are paired organs located on either side of the uterus within the mesovarium portion of the broad
ligament below the uterine tubes. The ovaries are responsible for housing and releasing the ova, or eggs,
necessary for reproduction.
55. Blood supply of the female genitalia
A55
• Abdominal aorta - ovarian artery - ovaries and fallopian tubes - ovarian vein (ovarian vein drains into
inferior vena cava on right side and renal vein on left side ). Ovaries also receive blood supply from
ovarian branch of uterine artery .
• Abdominal aorta - common iliac artery - internal iliac artery - uterine artery - uterus - uterine vein
• Abdominal aorta - common iliac artery - internal iliac artery - vaginal artery - vagina - uterine vein
• The external genital female organs are supplied by branches from internal pudendal artery (a.pudenda
internal) and partly from iliac arteries. Internal pudendal artery is the anterior branch of internal iliac
artery.
56. Instrumental methods of examination in gynecology
A56
• Speculum exam: Cusco bivalve speculum, sims speculum
• Pap Smear: speculum, vaginal swab, cytobrush, microscopic slide
• Pelvic organ ultrasound: Transvaginal or abdominal
• CT, MRI, PET scan
• Colposcopy: endoscopy exam of cervix
• Biopsy
• Culdocentesis:Transvaginal aspiration of douglas pouch (cul de sac)
• Culdoscopy: Visualize pelvic organs through incision of douglas pouch
• Hysteroscopy
• Investigative laparoscopy

57. General and special methods of examination in gynecology

A57

general examination:
• measuring the height, weight, BMI
• Body type determination (ectomorph, mesomorph, endomorph)
• vital signs (temperature, blood pressure, pulse rate, respiratory rate),
• general appearance,
• examination of the breasts,
• distribution of hair,
• Skin, Presence of postoperative scars and striae
• examination of the heart and lungs (ECG,, auscultating the lungs),
• examination of the back and extremities (varicosities, edema, pedal pulsation, coetaneous lesion)

Special:
• Speculum exam
• Bimanual exam
• Rectovaginal
• Rectobadominal
• bacterioscopy examination (smear for purity degree), cytologic investigation of vaginal smears, bacteriological
checkup, methods of functional diagnostics, colposcopy, biopsy, uterine sounding,
• fractional diagnostic curettage of cervical canal and uterine cavity with the following histological research,
culdocentesis, pertubation and hydrotubation.
• X-ray examination methods such as hysterosalpingography, pelviography and bicontrast pelviography are also
used.
• Colposcopy, hysteroscopy, laparoscopy and culdoscopy are endoscopic methods in gynecology.
58. Instrumental methods of examination in gynecology
A58
• Speculum exam
• Pap Smear: using speculum, taking of vaginal swab, cytobrush, microscopic slide
• Pelvic organ ultrasound: Transvaginal or abdominal
• CT, MRI, PET scan
• Cytology
• Colposcopy: endoscopy exam of cervix
• Biopsy
• Culdocentesis:Transvaginal aspiration of douglas pouch
• Culdoscopy: Visualise pelvic organs through incision of douglas pouch
• Hysteroscopy
• Investigative laparoscopy

59. Endoscopic methods of investigation in gynecology.

A59

• Colposcopy: it’s a medical diagnostic procedure to visually examine the cervix as well as the vagina and vulva
using a colposcope.

• Culdoscopy: Its a technique for endoscopic visualization and minor operative procedures on the female pelvic
organs in which the instrument called a”culdoscope” is introduced through a puncture in the wall of the pouch of
Douglas can be used to diagnose ectopic pregnancy

• Hysteroscopy: Hysteroscopy is a form of minimally invasive surgery. The surgeon inserts a tiny telescope
(hysteroscope) through the cervix into the uterus. The hysteroscope allows the surgeon to visualize the inside of
the uterine cavity
Methods in Hysteroscopy
- you lie on a couch with your legs held in supports
- an instrument called a speculum may be inserted into the vagina to hold it open
- the vagina and cervix are cleaned with an antiseptic solution
- a hysteroscope (long, thin tube containing a light and camera) is passed into the uterus

• Investigative laparoscopy
60. Regulation of menstrual cycle

A60

The menstrual cycle is regulated by the coordinated functions of the hypothalamus, pituitary, ovaries, and
endometrium

• . The follicular phase begins with an increase in follicle stimulation hormone ( FSH ), which causes increases in
luteinizing hormone ( LH ) and gonadotropin-releasing hormone ( GnRH ). Increase in Estrogen levels cause
increases in progesterone, stimulating proliferation of the endometrium.

• A spike in LH and FSH (“LH surge”) causes ovulation, following a suppression of GnRH.

• Estrogen levels continue to rise following ovulation and the corpus luteum forms, which secretes progesterone in
significant levels and causes decreases in LH and FSH levels.

• Without implantation, estrogen and progesterone levels will fall and the corpus luteum will degrade.

. 61. Definition of menarche

A61

Menarche is The time in a girl's life when menstruation first begins, Usually around 10-16 years , averagely at 13years
Mechanism- Menarche occurs in the setting of a maturing hypothalamic-pituitary-ovarian (HPO) axis which depends on
normal hypothalamic and pituitary function, normal female reproductive anatomy,

**Reasons for early or delayed menarche-

The age at which menarche occurs is affected by genetic and environmental factors. Menarche may be delayed by poor
nutrition, high levels of exercise (athletes or dancers), and several medical conditions, such as diabetes mellitus,
congenital heart disease, and ulcerative colitis.
Early menarche may occur with other conditions, such as hypothyroidism, CNS tumors, and head trauma.

**Anovulatory cycles are usually present within the first 1st l-2yrs after menarche with average cycle between 21-45
days

62. Definition of menopause

A62
The menopause is when a woman stops having periods and is no longer able to get pregnant naturally.
The menopause is a natural part of ageing that usually occurs between 45 and 55 years of age, as a woman's oestrogen
levels decline.

Stages of Menopause
• Perimenopause
- Irregular, short menstrual periods , Palpitations, night sweats, depression, anxiety
- Forgetfulness (in some women)

- Uncomfortable symptoms include hot flashes, insomnia, irritability, and backaches - May last four to five years or
longer
• Menopause:
- 12 months after the last menstrual period
- Production of progesterone and eggs stops
- Normally happens between the ages of 45 and 55
• Postmenopause- Vaginal dryness, vaginal infections, joint aches and pains

63. Definition of Oligomenorrhea

A63

oligomenorrhea — Oligomenorrhea is defined as irregular and inconsistent menstrual blood flow in a woman. In
Oligomenorrhea, menstruation usually occurs with intervals of more than 35 days

Oligomenorrhea is often a sign of underlying disease. Following may be the causes of oligomenorrhea.
• Polycystic ovarian disease
• Androgen secreting tumor of the ovary
• Androgen secreting tumor of the adrenal gland
• Hormonal changes and puberty
• Cushing syndrome
• Hyperthyroidism
• Prolactinomas
• Hypothalamic amenorrhea
• Pelvic inflammatory disease
• Asherman syndrome
• Uncontrolled diabetes mellitus

64. Definition of Polymenorrhea

A64
Polymenorrhea describes when a person’s menstrual periods are normal in terms of volume of blood flow, but
occur at intervals of less than 21 days

It is a term for frequent, short menstrual cycles. This can occur naturally, but in some cases, it is a symptom of an
underlying issue.

Can be caused by
- certain sexually transmitted diseases (STDs) (such as chlamydia or gonorrhea) that cause inflammation in the
uterus.This is called pelvic inflammatory disease.
- Endometriosis
- Peri menopause - Birth control pills
Sometimes, the cause of polymenorrhea is unclear and its generally referred to as abnormal uterine bleeding

65. Definition of Amenorrhea

A65
Amenorrhea — absence of menses.
Primary Amenorrhea - adolescent who has not reached menarche ( first period ) by age 15 years Secondary
amenorrhea- defined as the cessation of regular menses for three months or the cessation of irregular menses for six
months.

**Normal Menstrual Flow Interval- 21-35 days , Duration 3-7 days, Amount usually 30-50ml, greater than 80ml is
abnormal

The main symptom of amenorrhea is the absence of your monthly period.

The main causes of primary amenorrhea include family history, genetics, and lifestyle. Women with the following
factors are more at risk:
• A family history of amenorrhea
• A genetic or chromosomal defect. These can affect your ovary function and menstrual cycle, e.g Turner syndrome
• Severely overweight or underweight.
• Outflow tract obstruction.e.g imperforate hymen, cervical stenosis
• An eating disorder.
• A poor diet.
• Stress.

Main cause of secondary amenorrhea - PREGNANCY, polycystic ovarian syndrome, menopause, pituitary
disorders( e.g pituitary adenoma, Sheehan syndrome(post partumpituitary gland necrosis caused by severe blood loss
during or after delivery ), hyperprolactinemia, or primary ovarian insufficiency.

. 66. Classification of Amenorrhea

A66
• Primary Amenorrhea - condition where an has not reached menarche ( first period ) by age 15 years
• Secondary amenorrhea is the suppression of menstrual function in woman who has menstruated before, cessation of
regular menses for three months or the cessation of irregular menses for six months.
• Physiological amenorrhea is absence of menses before puberty period, during pregnancy and lactation, in menopause
period.

• The pathological amenorrhea can be provoked by many causes, especially by general state changes, most frequently
by endocrine diseases. There are different forms of pathological amenorrhea: hypothalamic, pituitary, ovarian and
uterine ones according to the level of menstrual function regulation disturbance.

• Genuine — absence of cyclic changes in women’s organism, most frequently associated with acute insufficiency of
sexual hormones.

• False amenorrhea (cryptomenorrhea — latent menses) — absence of menstrual blood excretion because of cyclic
 changes presence in organism. False amenorrhea is a clinical sign of genital organs development abnormalities —
atresia of hymen or vagina, when blood, having no exit, is accumulated in vagina, uterus and uterine tubes.

67. Definition of Polycystic Ovary Syndrome

A67
Polycystic ovarian syndrome is a common endocrine dysfunction typified by oligo-ovulation or anovulation, signs of
androgen excess, and multiple small ovarian cysts.

PCOS can cause missed or irregular menstrual periods. Irregular periods can lead to:
• Infertility (inability to get pregnant). PCOS is one of the most common causes of infertility in women.
Other features Include;
• Development of cysts (small fluid-filled sacs) in the ovaries
• Hirsutism- Too much hair on the face, chin, or parts of the body where men usually have hair. This is called
"hirsutism."
• Acne on the face, chest, and upper back
• Thinning hair or hair loss on the scalp; male-pattern baldness
• Weight gain or difficulty losing weight
• Darkening of skin, particularly along neck creases, in the groin, and underneath breasts • Skin tags,
Can be caused by High levels of androgens
 PCOS - Diagnostic criteria

• Menstrual
Irregularity
• Hyperandrogenism
• Exclusion of other
etiologies

NIH (1990) Rotterdam (2003) AES (2006)

• 2 out of 3 required • Menstrual
1. Menstrual irregularity +/- USG
Irregularity - Polycystic ovary
2. Hyperandrogenism • Hyperandrogenism
3. USG - Polycystic • Exclusion of other
ovary etiologies
• Exclusion of other
etiologies
. 68. Definition of Dysfunctional uterine bleeding.
A68

A dysfunctional uterine bleeding (DUB)which now called Abnormal Uterine bleeding, is the bleeding, not
associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism

The main cause of dysfunctional uterine bleeding is an imbalance in the sex hormones.

Classification
According to onset time:
cyclic- bleeding the appears with menses, but differ from normal by amount of lost blood and duration)
Non-cyclic- appear out of menses or continue with interruptions during all the cycle). According to patient’s
age: juvenile, of reproductive age, climacteric, menopausal bleeding.
Causes of Abnormal Uterine Bleeding
Non-preqnant bleeding that is irregular in timing, frequency, or flow

Remember. PALM-COEIN

P olyps
Endometrial
Cervical

Adenomyosis
Painful heavy periods in women 30s-40s

Leiomyoma
Increase in size in pregnancy or with OCPs

M alignancy / hyperplasia
Consider in all peri- and postmenopausal women

Coagulopathy
Undiagnosed coagulopathy in adolescents
Acquired (anticoagulants, cirrhosis)

Ovulatory dysfunction
Adolescents
Perimenopause
PCOS
Hypothyroidism
Anorexia
Athletes

Endometrial causes
Diagnosis of exclusion

STRUCTURAL CAUSES NON-STRUCTURAL CAUSES

Hormonal contraceptive use Hormone

replacement therapy
Post-GYN surgery

Not otherwise classified

PID
Endometritis
Cervical erosions, cervicitis Vaginal trauma
Foreign bodies
69. Definition of Sheehan’s syndrome
A69

Sheehan's syndrome, also known as postpartum pituitary gland necrosis, is hypopituitarism (decreased functioning of
the pituitary gland), caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth.
Sheehan syndrome is a type of hypopituitarism. Hence you have decrease in pituitary hormones . e.g FSH, growth
hormone, LH, prolactin, thyroid stimulating hormone (TSH), adenocorticotrophic hormone (ACTH)

Symptoms of Sheehan syndrome include:

• difficulty breastfeeding or an inability to breastfeed
• irregular menstrual periods (oligomenorrhea) or no periods (amenorrhea)
• weight gain
• intolerance to cold
• slowed mental function
• loss of pubic and underarm hair
• fatigue or weakness

Theres also- decreased insulin tolerance; Hypoglycemia

70. Definition of Premature ovarian failure

A70

Premature ovarian failure (POF) is a condition when a woman's ovaries stop working normally before she is 40.
This is also called premature ovarian insufficiency

Etiology - This may occur due to Follicular Depletion & Follicular Dysfunction

Cause of Premature ovarian failure in Follicular depletion;

• Idiopathic
• X chromosome related (Turner syndrome, X chromosome deletions and translocations) • Galactosemia
• Autoimmunity- autoimmune diseases where the body does not recognise certain tissues and attacks itself; for
example, lupus
• Environmental toxins
• Iatrogenic- side-effects of chemotherapy, radiotherapy and other cancer treatments
• Fragile Mental Retardation 1 (FMR 1) gene mutation

Cause of Premature ovarian failure in Follicular dysfunction- These

may be due to steroidal Enzyme deficiency e.g;
-Aromatase deficiency is a condition characterized by reduced levels
of the female sex hormone estrogen and increased levels of the male
sex hormone testosterone.
-17-alpha-hydroxylase deficiency- that causes decrease production in glucocorticoids and sex steroids with increase in
mineralocorticoids

Symptoms of Premature ovarian failure

The first sign of POI is usually irregular or missed periods. Later symptoms may be similar to those of natural
menopause:
• Hot flashes
• Night sweats
• Irritability
• Poor concentration
• Decreased sex drive
• Pain during sex
• Vaginal dryness
• Difficulty getting pregnant.
• Dry eyes.
• Irritability or difficulty concentrating.

71. Definition of Asherman’s syndrome

A71
Asherman's Syndrome, or intrauterine adhesions/scarring or synechiae, is an acquired uterine condition,
characterized by the formation of adhesions (scar tissue) inside the uterus and/or the cervix.
Etiology -
• Damage to basilar layer of endometrium secondary to vigorous dilation and curettage (D&C) in miscarriages or post
partum retained placenta, intrauterine myomectomy, cesarean
delivery ,hystrescopic procedures , metroplasty , uterine artery embolisation
• Endometritis (infection, genital tuberculosis and schistosomiasis )

The adhesions may cause:

• Amenorrhea (lack of menstrual periods) or hypomenorrhea (light blood flow < 30ml) • Repeated miscarriages
• Infertility

72. Definitions of Premenstrual Syndrome

A72
It’s a combination of physical and emotional symptoms that many women get after ovulation and before the start
of their menstrual period.

Etiology unclear but its believed to be associated with changes estrogen and progesterone after ovulation and also
changes in serotonin ,PMS symptoms go away within a few days after a woman’s period starts as hormone levels begin
rising again.
Symptoms
• Irritability or hostile behavior
• Feeling tired
• Sleep problems (sleeping too much or too little)
• Appetite changes or food cravings
• Trouble with concentration or memory
• Tension or anxiety
• Abdominal pain
• Abdominal bloating
• Acne
• Depression, feelings of sadness, or crying spells

73. Definition of Endometriosis.

A73
Endometriosis is a condition in which cells similar to those in the endometrium, the layer of tissue that normally
covers the inside of the uterus are present In sites other than the uterine mucosa.
Most often this is on the ovaries, fallopian tubes, and tissue around the uterus and ovaries but in rare cases it may also
occur in other parts of the body.

Clinical manifestation may include

Dysmenorrhea - painful, sometimes disabling cramps during the menstrual period; pain may get worse over time
(progressive pain), also lower back pains linked to the pelvis
Chronic pelvic pain - typically accompanied by lower back pain or abdominal pain Dyspareunia - painful sex
Dysuria - urinary urgency, frequency, and sometimes painful voiding
Infertility
Other symptoms- heavy or irregular period, constipation , vomitting , chronic fatigue. Pain on defecation

Causes
Theory of retrograde menstration or transtubal migration theory, where it is believed that endometrial
tissue may attach to ovaries or else where in the uterus in women with back flow of menstrual fluid to pelvic
region instead of out of the vagina.
Genetics: increase In risk when it affects first degree relatives
The hematogenous and lymphogenous spread theory

74. Classification of Endometriosis

A74

The ENZIAN classification morphologically descriptive classification of Deep infiltrative Endometritis (DIE), taking into
account retroperitoneal structures.
In this classification retroperitoneal structures are divided into three compartments:
• Compartment A: vagina, recto-vaginal septum
• Compartment B: uterosacral ligaments to the pelvic wall (BB: bilateral involvement);
• Compartment C: rectum and sigmoid colon.
Disease severity is classified as:
• Grade 1: invasion <1 cm;
• Grade 2: invasion 1-3 cm;
• Grade 3: invasion >3 cm
• Deep endometriosis invasion beyond the lesser pelvis and invasion of organs are recorded separately:
• FA: adenomyosis;
• FB: bladder invasion;
• FU: intrinsic ureteral endometriosis;
• FI: bowel disease cranial to the sigmoid colon; • FO: other locations. Stage I
• Minimal
• Few superficial implants

75. Definitions of Climacteric syndrome

A75
Also called perimenopausal period syndrome or menopause transition syndrome , begins several years before
menopause. It's the time when the ovaries gradually begin to make less estrogen. It usually starts in women's 40s, In
the last 1 to 2 years of perimenopause, this drop in estrogen speeds up. At this stage, many women have menopause
symptoms.
Symptoms
• Hot flashes
• Breast tenderness
• Worse premenstrual syndrome
• Lower sex drive
• Headache
• Dizziness
• Fatigue
• Irregular periods
• Vaginal dryness; discomfort during sex
• Urine leakage when coughing or sneezing
• Urinary urgency (an urgent need to urinate more frequently)
• Mood swings
• Trouble sleeping
Cause- due to progressive decline in ovarian production of estrogen and other sex hormones

. 76. Classification of Benign Breast Diseases.

A76
Benign breast diseases constitute a heterogeneous group of lesions including developmental abnormalities,
inflammatory lesions, epithelial and stromal proliferations, and neoplasms. CLASSIFICATION
Non-proliferative : no increase in risk
• Cysts : micro & macro
• Ductal ectasia
• Mastitis
 • Fibrosis
• Metaplasia :Squamous or apocrine
• Mild hyperplasia
Proliferative without atypia :RR 1.5-2.0 (RR- relative risk)
• Complex fibroadenoma
• Papilloma
• Sclerosing adenosis
• Hyperplasia :moderate or severe
Proliferative with Atypia: RR 4.5- 5.0
• Atypical ductal hyperplasia
• Atypical lobular hyperplasia (RR- relative risk)

77 classification of gestational trophoblastic disease

A77

Gestational trophoblastic Disease refers to a group of rare diseases in which abnormal trophoblast cells grow inside
the uterus after conception. It begins in the layer of cells called the trophoblast that eventually becomes the placenta and
usually forms finger like projections called villi. These diseases may be benign or malignant

1.BENIGN - HYDATIDIFORM MOLE ( Molar pregnancy ) abnormal proliferation of syncytiotrophoblast and

replacement of normal placental trophoblastic tissue by hydropic placental villi( Swollen and fluid like villi) divided
into

■complete Hydatidiform mole- develops when 1 or 2 sperm cells fertilize an egg cell that contains no nucleus or
DNA (an “empty” egg cell). No fetal development or membrane diffuse swelling of villi, Diffuse trophoblastic
hyperplasia. Ultrasonography shows characteristic snowstorm appearance

■partial Hydatidiform mole- develops when 2 sperm fertilize a normal egg. These tumors contain some fetal tissue,
but this is often mixed in with the trophoblastic tissue. Some fetal structures formed but malformed, fetus not
viable. Focal villi swelling and focal trophoblastic hyperplasia

2 GESTATIONAL TROPHOBLASTIC TUMOR

■invasive mole- An invasive mole is a hydatidiform mole that has grown into the muscle l^er of the uterus, most
commonly develops from complete moles.
■persistent mole
■placental site trophoblastic tumour-
■ epithelioid trophoblastic tumour
 ■gestational choriocarcinoma- metastatic gestational trophoblastic tumour may also be classed as
■non-metastatic - localized only in the uterus
■metastatic -poor prognosis metastatic disease - distant metastasis most commonly in, lungs brain and liver

Symptoms of GTD - Abnormal vaginal bleeding during or after pregnancy, enlarged uterus for gestational age,
Severe nausea or vomiting during pregnancy, High BP , Pelvic pain or pressure

78) classification of benign cervical lesions

A78
Benign cervical lesions comprise of non-cancerous tumors or changes to the cervix
Classification-
• True cervical erosion
• false cervical erosion (pseudoerosion, endocervicosis)
• cervical leukoplakia (without atypia, simple one)
• cervical polyps (simple, proliferating, epidermizing polyps); papilloma, condylomas • endometriosis
• posttraumatic changes (ectropion, scars)
• exo- and endocervicites

• True cervical erosion - a pathological process,which is a result of damage and following exfoliation of
original stratified squamous epithelium. Absence of epithelium on cervical vaginal part appears.
• Cervical pseudoerosion is a benign pathological process, which is characterised by presence of original
columnar endocervical tissue on exocervical surface.
• Polyps of mucous membrane of cervical canal which are created from the mucous of the external os,
middle or upper third part of endocervix.
• Cervical endometriosis is characterized by the presence on the cervical surface of rust colored, dark
brown spots those have been described as “mulberry” or “raspberry”.
• Cervical ectropion- the cells lining the cervical canal present on the surface of the cervix
• Cervical Leukoplakias Leukoplakia is a pathological state of epithelium that is characterized by its
thickness and cornification.
79) definition of cervical dysplasia
A79

Cervical dysplasia, also called cervical intraepithelial Neoplasia (CIN) and it is a precancerous condition in
which abnormal cell growth occurs on the surface lining of the cervix or endocervical canal (the opening
between the uterus and the vagina)

The term dysplasia refers to abnormal appearance of cells when viewed on microscope

according to the degree of epithelium changes , cultural atypia and epithelial layer architecture, it is
classified as
-mild (CIN I)- hyperplasia and basal cell atypia occupies 1/3 of epithelium layer -moderate (CIN II)-
changes take occur in more than 1/3 but less than 2/3 of the epithelial layer -severe dysplasia ( CIN III)-
dysplasia affects greater the 2/3 of the epithelial layer

80) classification of uterine leiomyoma

A80

Uterine leiomyomas, also known as uterine fibroids, are benign smooth muscle tumors of the uterus

according to their location

• subserosal
• Interstitial (intramural, intraperietal)
• submucosal
• Intracavitary
• atypical forms of uterine fibroids location (retrocervical, paracervical, intraligamentary myoma)

according to size the

fibromyoma can have
•one fibroid (nodulosus fibromyoma),
•many fibroids (multiple fibromyoma)
•diffuse growth (diffuse fibromyoma).

• subserosal — They grow under the outer serosal layer of the uterus, they may have a wide or thin pedicle.

• interstitial (intramural, intraparietal)—they are the uterine fibroids, that are growing within the
muscular wall of the uterus, their frequency is 40-45%

• submucosal—they are the uterine fibroids that are growing under the uterine mucous into the uterine
cavity, their frequency is 20% of all the patients

• atypical forms of uterine fibroids location: retrocervical myoma - it grows from the posterior surface of
the uterine cervix, it is situated within a retrocervical fat; paracervical myoma - it grows from the lateral
 part of uterine cervix, it is situated in the paracervical fat; intraligamentary myoma grows from the
uterine body or cervix within the broad ligaments

81) prevention of genital tract infection

A81

1) Abstinence
2) Delay sexual activity
3) Use condoms and dental dams consistently and correctly. Use a new latex condom or dental dam for each
sex act, whether oral, vaginal or anal.
4) Decrease number of sexual partners ( one) and get tested
5) Wiping from front to back after bowel movements, Doing so after urinating and after a bowel movement
helps prevent bacteria in the anal region from spreading to the vagina and urethra.
6) Not wearing tight fitting bottoms
7) Avoid potentially irritating feminine products. Using deodorant sprays or other feminine products, such
as douches and powders, in the genital area can irritate the urethra.
8) Empty your bladder soon after intercourse. Also, drink a full glass of water to help flush bacteria
9) in the case of candidiasis vulvovaginitis caused by Candida , avoid long term treatment with antibiotics.
10) Drink plenty of liquids, especially water. Drinking water helps dilute your urine and ensures that you'll
urinate more frequently — allowing bacteria to be flushed from your urinary tract before an infection can
begin.
11) Get vaccinated. Getting vaccinated early, before sexual exposure, is also effective in preventing certain
types of STIs. Vaccines are available to prevent human papillomavirus (HPV vaccine- Gardasil)
82) etiology of vaginal infections
A82
• organisms that cause sexually transmitted disease
e. g trichomonas vaginalis causing trichomoniasis.
•vulvovaginal candidiasis caused by Candida albicans , Other bacterial infections, such as chlamydia and
gonorrhea,
• Some viral vaginal infections include herpes simplex virus type 2 (HS V-2), which causes herpes, and the
human papillomavirus (HPV), which causes genital warts.
• Bacterial vaginosis- normal vagina flora in the case of bacterial vaginosis which is as a result of an
overgrowth of both anaerobic bacteria and aerobic bacteria gardnerella vaginalis
others include; mycoplasma hominis, mobiluncus spp, bacteroides spp, peptostreptococcus, ureaplasma
urealyticum
• Wearing underwear that is tight or non-cotton
• Weakened immune system
 predisposing factors for colonization and inflammation include:
-changes in reproductive hormone levels associated with premenstrual periods, pregnancy and oral
contraceptive use
-prolonged use of antibiotics (this eliminates the protective vaginal bacterial flora) -
diabetes mellitus
-immunosuppressive states, eg hiv infection

83) etiology of pelvic inflammatory disease

A83

Pelvic inflammatory disease (PID) is an infection of one or more of the upper reproductive organs, including the
uterus, fallopian tubes and ovaries.

causes of pelvic inflammatory disease (PID)

Most commonly acute PID is an ascending infection from the lower genital tract

• Most cases due to sexually transmitted organisms causing Sexually transmitted diseases e.g of organisms;
-viral
-bacterial ( chlamydia trachomatis , n.gonorrhea)
-fungi
-parasitic (trachomatis vaginalis ) gonorrhea and
chlamydia are the most common cause
• May also be caused by procedures that break the cervical mucus barrier, so it allows the vaginal
flora the opportunity to colonize the upper genital tract, the procedures are;
-endometrial biopsy
-endometrial curettage
-intra uterine device (iud)insertion
-hysteroscopy

• intrauterine device users in some cases, pid develops from bacteria that has traveled through the vagina
and the cervix by way of an intrauterine device (iud)

• endogenous microorganisms (vaginal flora ) anerobes - group b streptococcus

non hemolytic streptococcus
coagulase - staphylococcus
aerobes - bacteroides species, peptococcus, actinomyces, peptostreptococcus

84. clinical signs of gonorrheal infections

A84

• Lower abdominal pain (most consistent symptom of PID)

• Increased vaginal discharge or mucopurulent urethral discharge (Creamy or slightly green)
• Dysuria (usually without urgency or frequency)
• dyspareunia (painful intercourse)
• Cervical motion tenderness
• Adnexal tenderness (usually bilateral) or adnexal mass
• Intermenstrual bleeding
• Fever, chills, nausea, and vomiting (less common)

• Acute forms has expressed clinical manifestations.

• subacute form is characterized by subfebrile condition, sometimes by expressed clinical symptoms, which
appeared two weeks before.
• Torpid gonorrhea in acute form has mild clinical manifestations or is asymptomatic, but n. gonorrhoeae are
found in the patient.
• latent form - no symptoms, but person is a source of infection, diagnosed when there is no bacteriologic and
bacterioscopic confirment,
• chronic gonorrhea lasts for more than 2 months, or without establishing of the beginning.
85. role of human papilloma virus infection in the development of genital problems
A85
human papillomavirus (hpv) is the most common viral infection of the reproductive tract, most sexually active
women and men will be infected at some point in their lives and some may be repeatedly infected. Causes genital
warts
• Hpv is sexually transmitted, but penetrative sex is not required for transmission, skin-to-skin genital contact is a
common mode of transmission
• Pathogenesis - the virus infects epithelial cells, one of the rapidly dividing cells that form the skin and mucous
membranes, the virus reproduces within the host cell and when the cell dies, as part of natural cell turnover, the
new virus particles (virions) are released and can infect other cells, long term infection with high-risk strains of
hpv can lead to the development of cervical dysplasia and carcinoma
• Strains that have increased risk with developing cervical cancer : hpv 16, 18 31 and 11

• Vaccine-Gardasil (best given at 11-13years)

the hpv viral genome (e6, e7) are responsible for the oncogenic properties of hpv the
e6, e7 proteins block natural control of grow th ofcervi cal cells

86) classification of method of contraception

A86

•hormonal contraception
•intrauterine contraception
•barrier
•surgical
•postcoital methods of contraceptives

• hormonal contraception
-combined (estrogen- progestin) oral contraceptives
-Progestin only contraceptives
-prolonged injective contraceptives depot e.g medroxyprogesterone -implant
contraceptives

• barrier method of contraception

physical barriers male and female condoms vaginal diaphragms cervical caps chemical spermicides - they exist in
different forms - creams, gels , vaginal foam tablets , sponges , films
• intrauterine contraception emissive copper bearing intrauterine device
emissive progestin intrauterine devices e.g Mirena

• rhythm method of contraception based on avoidance of coitus for 3 days

before and 3-4 days after expected ovulation to determine ovulation, you
use basal temperature test and infertility scale

• surgical contraception involves female sterilization by means of tubal

 laparoscopic cautery for male - by ligation of section of vas deferens
disadvantages - irreversible

• postcoital contraception it is used when coitus was not protecte d by other

methods of contraception e.g combined oral contraceptives - 2-4 pills within
72 hours of intercourse,
10-12mg of ethinyl estradiol per 1 dose twice in 12 hours

87) etiology of female infertility

A87
Female infertility means not being able to get pregnant (with constant intercourse) after at least one year of trying
(or 6 months if the woman is over age 35)

ETIOLOGY
• disorders of ovogenesis and absence of ovulations ( endocrine infertility) — 35-40%
• tubal factors 20-30%
• diseases of genitals— 15-25%
• uterine and cervical factors
• immunological causes — 2%

• endocrine infertility most times the causes of female infertility are endocrine diseases that are associated with
ovogenesis and ovulation disorders
patients with
-hyperprolactinaemia
-hyperandrogeny
-polycystic ovarian syndrome
-premature ovarian failure
-post puberty form of adrenogenital syndrome
-dysfunction of hypothalamic-pituitary system ( amenorrhea, hypomenstrual syndrome)
•tubal factors - pelvic inflammatory disease, Obstruction of the uterine tubes by polyps

•uterine and cervical factors infertility can be caused by the state of uterine mucous membrane, when
endometrium undergoes dystrophic changes that interfere with implantation process and cause uterine form of
amenorrhea, this can happen as a result of carried inflammatory processes, repeated curretages of uterine
cavity and action of cauterizing chemical substances.

infertility can also happen as a result of uterine cervix inflammation - endocervicitis, this is due to the cervical
canal epithelial structural changes, viscidity and acidity of cervical mucus, that interferes with penetration of
spermatozoa into uterine cavity.
88) symptoms of acute abdomen
A88
Acute abdomen' is defined as a sudden onset of severe abdominal pain developing over a short time period
Symptoms and signs
• severe abdominal pain,
• muscular guarding and rebound tenderness are the symptoms of peritoneal irritation (blumberg
sign) . anterior abdomen wall takes part in breathing act.
• Nausea and vomitting
• high temperature, fever , chills
• tachycardia
• diminished or absent bowel sounds
• tender adnexa are present at bimanual examination, cervical motion causes pain, posterior fornix is painful.

gynecology causes : ovarian torsion, adnexal torsion, ectopic pregnancy, ruptured ovarian cyst, acute pelvic
inflammatory diseases, endometriosis, tubo-ovarian abscess

Non- gynecological causes-Appendicitis, acute bowel obstruction,Abdominal aortic aneurysm, Pancreatitis

89) classification of ectopic pregnancy

A89
Ectopic pregnancy, also called extrauterine pregnancy, is when a fertilized egg grows outside a woman's uterus.
Most commonly this occurs in the fallopian tube.

CLASSIFICATION
depending on where a fertilized ovum has implanted:

• tubal pregnancy: in majority of cases over 90% the tubal pregnancy occurs ( most commonly in
the ampulla ). interstitial pregnancy happens in interstitial portion of tube, Or other parts of the
fallopian tube ; in isthmus andfijmbraie
• ovarian pregnancy,
• abdominal pregnancy,
• pregnancy in rudimentary uterine horn
• intra-ligamentory (between folds of wide uterine ligament)

• cervical pregnancy

according to clinical duration

• unruptured
• interrupting ectopic pregnancy - interrupting of ectopic pregnancy happens by type of tubal abortion or by
type of uterine tube rupture.
Symptoms
• sharp waves of pain in the abdomen, pelvis, shoulder, or neck
• severe pain that occurs on one side of the abdomen
• light to heavy vaginal spotting or bleeding
• dizziness or fainting

rudimentary horn is a uterine anomaly presenting along side a unicornuale uterus resulting from the
incomplete development of one of the Mullerian ducts and an incomplete fusion with the contralateral side

90) etiology of ectopic pregnancy

A90

Etiological factors
• Anatomic changes in tissues of uterine tube that appear as the result of inflammatory processes are the main
causes of the violation of ovum transport and ectopic pregnancy.
• inflammation of mucous membrane, edema and presence of inflammatory exudates in acute and chronic stage
may cause dysfunction of uterine tubes
• damaging of muscular layer and changes in the innervation of the tube le ad to changes of its peristalsis and
delay of fertilized ovum passing through it
• operative interventions into the organs of true pelvis.
• ectopic pregnancy frequently happens in women with genital infantilism, endometriosis, tumor of the uterus and
uterine adnexa.
• toxic influence of exudate in tube at chronic inflammation can cause speed up trophoblast maturing and
proteolytic enzymes activate and implantation occurs before fertilized ovum enters the uterus
• in case of the slow development of trophoblast an ovum is implanted in lower uterine (placenta praevia)
segments or outside uterine cavity — in its cervix (cervical pregnancy).

risk factors
usage of intrauterine contraceptives increases the risk of ectopic pregnancy pelvic inflammatory disease
polyps
previous ectopic pregnancy (increases risk by 10-20%)
Smoking
previous tubal surgery, e.g Tubal ligation
congenital tubal diverticula
abnormally long tube
ORAL EXAM’ QUESTIONS
FOR V – YEAR STUDYING STUDENTS

I group of questions
1. Classificationofbreachpresentations.
A1

2. Definition of complete breech presentation.

A2

A breech pregnancy or breech presentation called a complete breech presentation

occurs when the hips and the knees of the fetus are flexed.

3. Definition of frank breech presentation.

 A3

A frank breech presentation, in which the hips of the fetus are flexed and the legs extend
straight upward with the knees straight and the feet touching the fetus head

4. Definition of incomplete foot-link presentation.

A4

It is characterized by one leg presenting through the cervix. One leg is fully extended and
the other fully flexed at hips and knee joints.

5. Definition of complete foot-link presentation.

A5

It is characterized by both legs presenting through the cervix. Both legs are fully extended.
(Double footling presentation)

6. Classification of fetal malpresentations.

A6

Malposition’s are abnormal positions of the fetal head relative to the maternal pelvis.
Malpresentations are all presentations of the fetus other than vertex.

Classification
1. Breech (Complete, incomplete or frank, foot, knee)
2. Transverse
3. Cephalic (Face, brow, sinciput)

Compund (there is more than one body part presenting)

7. Classification of deflexed presentations.

A7

1. First degree: Sincipital presentation

2. Second degree: Brow presentation
Third degree- face presentation

8. Definition of sinciput vertex presentation.

A8 presenting part is large fontenalle and parietal bones
 9. Definitionofbrowpresentation.
A9 presenting part is frontal bone

10.Definition of face presentation.

A10
Face is the presenting part
11.Classification of multiple pregnancies.
A11
Number of fetus: Twins, triplets, quadruplets etc.
• Number of fertilized eggs (dizygotic or monozygotic)
• Number of placenta: Monochorionic or dichorionic
• Number of amniotic cavities: diamniotic or monoamniotic

12.Definition of polyhydramnios. The most probable reasons

A12
Polyhydramnios is the excessive accumulation of amniotic fluid — the fluid that surrounds
the baby in the uterus during pregnancy. Normally, the volume of amntonic fluid increases to
about 1L -1,5 L more by 32-34 weeks but decreases thereafter. Somewhat, more than 2000
mL of amniotic fluid is considered excessive, or hydramnios
Some of the known causes of polyhydramnios include:
• A birth defect that affects the baby's gastrointestinal tract or central nervous system
• Maternal diabetes
• Twin-twin transfusion — a possible complication of identical twin pregnancies in which one
twin receives too much blood and the other too little
• A lack of red blood cells in the baby (fetal anemia)
• Blood incompatibilities between mother and baby
• Infection during pregnancy

(Idiopathic most common Maternal

T1DM: abnormalities of transchorionic flow Maternal-fetal
Chorioangiomas
Multiple gestation
Fetal hydrops (increased erythroblastosis)
Fetal
Chromosomal anomaly (up to 2/3 of fetuses have severe polyhydramnios) Respiratory:
cystic adenomatoid malformed lung
CNS: anencephaly, hydrocephalus, meningocele
GI: tracheoesophageal fistula, duodenal atresia, facial clefts (interfere with swallowing)

13.Definition of oligohydramnios. The most probable reasons.

A13
Oligohydramnios is the condition of having too little amniotic fluid, less than 1l
What causes low amniotic fluid?
• Birth defects – Problems with the development of the kidneys or urinary tract which could
cause little urine production, leading to low levels of amniotic fluid.
• Placental problems – If the placenta is not providing enough blood and nutrients to the baby,
then the baby may stop recycling fluid.
• Leaking or rupture of membranes –This may be a gush of fluid or a slow constant trickle of
fluid. This is due to a tear in the membrane. Premature rupture of membranes (PROM) can
also result in low amniotic fluid levels.
• Intrauterine growth retardation
• Post Date Pregnancy– A postdate pregnancy (one that goes over 42 weeks) can have low
levels of amniotic fluid, which could be a result of declining placental function.
• Maternal Complications– Factors such as maternal dehydration, hypertension, preeclampsia,
diabetes, and chronic hypoxia can have an effect on amniotic fluid levels

(Idiopathic most common Maternal

Uteroplacental insufficiency (preeclampsia, nephropathy)
Medications (ACEI) Fetal
Congenital urinary tract anomalies (renal agenesis, obstruction, posterior urethral
valves)
Demise/chronic hypoxemia (blood shunt away from kidneys to perfuse brain) IUGR
Ruptured membranes: prolonged amniotic fluid leak Amniotic fluid normally decreases
after 35 wk GA)

14.Pelvic classification according to the degree of contraction.

A14
15.Classification of the pelvis according to the form of contraction.
A15

16.Definition of anatomical and functional contracted pelvis.

A16
1. Anatomically contracted pelvis is characterized by shortening of all or one
diameters of the true pelvis into 1,5 - 2 cm and more.
2. Clinically or functional contracted pelvis - pelvis with normal dimensions, but
vaginally delivery is impossible due to “cephalopelvic disproportion”.

The main causes:

●fetal macrosomia

●postdate pregnancy

●uterine inertia

●fetal malpresentation, especially fetal head extension – sinciput vertex, brow, face
17.Clinical signs of the clinical (functional) contracted pelvis.
A17

Positive Vasten’ sign: if disproportion between fetal head and pubic symphysis is prominent

18.Definition of the general contracted pelvis.

A18

19.Definition of simple flat pelvis.

A19

20.Definition of flat rachitic pelvis.

A20

21.Classification of uterine contractions abnormalities.

A21

1. False labor.

2. Uterine inertia (hypotonic dysfunction):

1. Primary: absence of progressing dilation of the uterine cervix
2. Secondary: cessation of birth pangs in active phase of labor
3. Inadequate voluntary expulsive forces.

3. Excessive uterine activity (hypertonic dysfunction).

4. Incoordinative uterine activity (hypertonic dysfunction):

1. dyscoordination,
2. hyperactivity of lower uterine segment,
3. circulative dystocia (contractile ring),

Uterine tetania.

22.Which fetuses are called as “large” and “giant?

A22
1. A large fetus (the weight of the fetus estimated 3700 g and more).
2. A giant fetus (the weight of the fetus estimated 4000g and more)

23.Definition of hypotonic uterine dysfunction.

A23
Hypotonic uterine dysfunction: (Uterine inertia) - uterine contractions is less than normal

describes lack of progressive cervical dilatation and/or descent of the fetus and is similar to
the arrest disorders.
It is such condition in which uterine contractions strength, duration and frequency are
inadequate, that’s why cervical effacement, dilation and fetal descending is slowly than in
normal labor

HYPOTONIC UTERINE CONTRACTIONS

UTERINE INERTIA
●Etiology and Pathophysiology:
●Overstretching of the uterus --large baby, multiple babies, polyhydramnios, multiple parity
●Excessive use of analgesia
ASSESSMENT

●Signs and Symptoms of HYPOTONIC UTERINE INERTIA:

●Weak contractions – become mild
●Infrequent (every 10 – 15 minutes +) and brief,
●Can be easily indented with fingertip pressure at peak of contraction.
●Prolonged ACTIVE Phase
●Exhaustion of the mother
●Psychological trauma -

24.Definition of hypertonic uterine dysfunction.

A24
Hypertonic uterine dysfunction - uterine tone elevated.

characterized by high strength of uterine contractions and increasing of their frequency

The main cause of this disorder is
hyperexcitability of nervous system in woman.
Impairment of fetoplacental circulation, placental abruptio, deep cervical and vaginal ruptures
should be presented in uterine hyperactivity.

HYPERTONIC UTERINE CONTRACTIONS

●Most often occur in first-time mothers, Primigravida
●Increase in frequency of contractions, but intensity is decreased, do not bring about dilation
and effacement of the cervix.

Signs and Symptoms

●PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain
●Dilation and effacement of the cervix does not occur.
●Prolonged latent phase. Stay at 2 - 3 cm. don’t dilate as should
●Fetal distress occurs early– uterine resting tone is high, decreasing placental perfusion.
●Anxious and discouraged

25.Etiology of hypotonic uterine dysfunction.

A25

HYPOTONIC UTERINE CONTRACTIONS

UTERINE INERTIA
●Etiology and Pathophysiology:
●Overstretching of the uterus --large baby, multiple babies, polyhydramnios, multiple parity
●Excessive use of analgesia

• Excess maternal nervous sickness and emotions (maternal exhaustion);

• impairment of nervous mechanisms of labor regulation as a result of previous acute and
chronic infectious diseases, nervous system disorders:
• Pathological changes of uterine cervix and uterus;
• “Cephalopelvic disproportion”
• hydramnion, multiple pregnancy, oligohydramnion;
• postdate pregnancy;
• administration of excess anesthesia;
• inadequate usage of uterotonic drugs
26.Indications for perineotomy, episiotomy,
A26
Episiotomy is incision of the perineum towards the ischial tuberosity
Indications;
• Threatened rupture of the perineum
• High perineum (more than 4cm)
• Premature Labor
• Breech presentation
• Reducing the second stage of labor according to induction concerning the fetus
• Application of obstetrical forceps
• Perineotomy is incision of the perineum towards the anus. It is conducted when perineal
rupture has already started.
27.Indications for amniotomy.
A27
Amniotomy is intentional rupture of the amniotic sac

Indications
• Polyhydramnios
• Oligohydramnios (flat fetal bladder)
• Partial placental previa
• Multifetation (after the birth of the first fetus)
• Dilation of uterine orifice by more than 7cm
• Administration of uterotonics in uterine inertia
• Late gestosis
• Extragenital pathology (hypertension, kidney disease, cardiovascular pathology)

28.Indications for c-section

A28

29.Indications for vacuum extraction of the fetus.

A29
Maternal indications include heart disease, pulmonary injury or compromise,
intrapartum infection, certain neurological conditions, exhaustion, or prolonged second-
stage labor.
Fetal indications for operative vaginal delivery with vacuum include prolapse of the umbilical
cord, premature separation of the placenta, and a nonreassuring fetal heart rate pattern.
Although “fetal distress” or “fetal jeopardy”

30.Indications for application of obstetrics forceps.

A30
termination of labor by forceps, provided it can be accomplished safely, is indicated in any
condition threatening the mother or fetus that is likely to be relieved by delivery. Maternal
indications include heart disease, pulmonary injury or compromise, intrapartum
infection, certain neurological conditions, exhaustion, or prolonged second-stage labor.
Fetal indications for operative vaginal delivery with either forceps or vacuum include
prolapse of the umbilical cord, premature separation of the placenta, and a nonreassuring fetal
heart rate pattern. Although “fetal distress” or “fetal jeopardy” are terms commonly used to
define an indication for termination of labor, both terms are nonspecific and somewhat vague
31.Conditions for obstetrics forceps operation.
A31
1. The head must be engaged.
2. The fetus must present as a vertex or by the face with the chin anterior.
3. The position of the fetal head must be precisely known so that cephalic placement of the
forceps can be performed.
4. The cervix must be completely dilated before application of forceps. If prompt delivery
becomes imperative before complete dilatation of the cervix, cesarean section is indicated.
5. Before forceps application, the membranes must be ruptured to permit a firm grasp of the
fetal head by the forceps blades.
6. There should be no disproportion between the size of the head and that of the pelvic inlet or
the midpelvis.

 Live fetus
 Full dilation of the cervix
 Absence of membranes
 Cephalopelvic proportion
 Location of fetal head in the pelvic cavity (+2) or in the plane of pelvic outlet (+3)

32.The conditions for the c-section

A32
 Intact amniotic fluid
 Normal temperature
 Alive fetus

33.Anesthesia for the c-section .

A33
 Spinal anesthesia: Spinal anesthesia has the advantages of being easy to perform,
requiring less time, and being more reliable than epidural analgesia. The primary
disadvantage is the potential for severe hypotension – consider prehydration with 20
cc/kg, proper positioning, and keeping phenylephrine AND epinephrine on hand
 Epidural anesthesia: Epidurals offer the advantage of multiple use (which is ideal if
an epidural was already placed for labor analgesia), a smoother hemodynamic course
 General anesthesia
Drugs: Thiopental, Propofol, Ketamine

34.Etiology and pathogenesis of perineal and cervical lacerations.

A34
Perineal lacerations usually occurs in inflexible, inelastic perineum in women who give birth
for the first time. Scar changed perineum after the first labour
1. Etiology: fast and rapid delivery, deflexion fitting of the head, breech presentation,
large fetus, improper methods of protection of the perineum hampered disengagement
of the shoulder girdle.

Cervical lacerations may be voluntary and violent in case of forced or operative

delivery.Minor side lacerations of the cervix are called physiological. They occur in all
women during childbirth at first.

35.Classification of cervical lacerations.

A35

36.Classification of perineal lacerations

A36
37.Etiology, pathogenesis of uterine rupture.
A37

Pathogenesis: Uterine rupture results from overdistention of the lower segment

associated with mechanical obstruction to birth of fetus

38.Classification of uterine rupture.

A38

39.Classification of puerperal genital tract infection after Sazonov and Bartels.

A39

According to stages

I stage: limited form of septic infection that has not spread outside the uterus
1. Postpartum endometritis
2. Postpartum ulcer of perineum, vulva or cervix

II stage: Infection spreads beyond the uterus but is limited to the pelvic cavity
1. Vulvitis, colpitis, paracolpitis, salpingooophoritis
2. Metritis, parametritis
3. Thrombophlebitis of pelvic or femoral veins
4. Adnescitis
 5. Pelvioperitonitis

III stage: Distributed infection (boundary between local and general septic process
1. Distributed peritonitis
2. Infectious-toxic shock
3. Progressive thrombophlebitis
4. Anaerobic gas gangrene

IV stage: Generalized infection: Sepsis (septicemia, pyosepticemia)

40.Pathogenesis of puerperal genital tract infection.

A40
 Systemic Inflammatory response syndrome (SIRS) of the organism to a
destructive infectious process in the reproductive organs. Occurrence of postnatal
infection is promoted by changes in vaginal biogenesis, development of immune
deficiency before end of pregnancy, pregnancy complications.
 Infection spread mostly hematogenously, less frequently lymphogenous routes,
or tubular routes along cervical canal and tubes.

41.Pathophysiology and Etiology of placenta previa.

A41
abnormal location of the placenta over, or in close proximity to, the internal cervical os.
1. Pathological process that lead to degenerative changes of the endometrium
preventing implantation of gestational sacs in a typical site (endometritis, hypoplasia
of uterus).
2. Pathology of gestational sac causes delayed maturation of the trophoblast, the sac
attaches in isthmus or cervix.

In Vitro Fertilization whereby the artificially inseminated trophoblast may be placed too
low.

42.Classification of placenta previa

A42
1. complete or total - if the entire cervical os is covered;
2. partial - if the margin of the placenta extends across part but not all of the internal
os;
3. marginal , if the edge of the placenta lies adjacent to the internal os;
4. low lying - if the placenta is located near but not directly adjacent to the internal os
till 6 cm.
43.Pathophysiology and Etiology of placental abruption
A43
44.Diagnostic evaluation of placental abruption
A44

45.Etiology of Postpartum hemorrhage

A45
Postpartum hemorrhage is defined as blood loss in excess of physiologic blood loss at the
time of vaginal delivery – 0,5% from body weight.
Postpartum hemorrhage before delivery of the placenta is called third-stage hemorrhage.
Postpartum hemorrhage after delivery of placenta during the first two hours is called as
hemorrhage in early puerperal stage.

Uterine atony:
1. Overdistended uterus – multiple fetuses, Hydramnios, distention with clots.
2. Anesthesia or analgesia – halogenated agents, conducted analgesia with hypertension.
3. Exhausted myometrium – rapid labor, prolonged labor, oxytocin or prostaglandin
stimulation.
4. Chrionamnionitis.
5. Previous uterine atony.
Genital tract trauma:
1. Complicated vaginal delivery.
2. Cesarean section or hysterectomy, forceps or vacuum.
3. Uterine rupture; risk increased by: previously scarred uterus, high parity,
hyperstimulation, obstructed labor, intrauterine manipulation.
4. Large episiotomy, including extensions.
5. Lacerations of the perineum, vagina or cervix.
Bleeding form placental implantation cite:
1. Retained placental tissue – avulsed cotyledon, succentuariate lobe
2.Abnormally adherent – accreta, increta, percreta.
Coagulation defects – intensifies other causes:
1. Placental abruption.
2. Prolonged retention of dead fetus.
3. Amnionic fluid embolism.
4. Saline-induced abortion.
5. Sepsis with endotoxemia.
6. Severe intravescular hemolysis.
7. Massive transfusions.
8. Severe preeclampsia or eclampsia.
9. Congenital coagulopathies.

46.Principles for monitoring women who are at risk of postpartum haemorrhage.

A46
1. Empty the urinary bladder by means of a catheter because an overdistended
bladder predetermines uterine atony due to common innervation
2. Active management of placental removing
3. After detachment of placenta, check its integrity, if it is not complete, manual
revision of uterus.
4. Uterotonics such as oxytocin or carbetocin are given for uterine atony

Suture all lacerations carefully

47.Etiology of the third stage of labour bleeding.

A47

The main causes of third-stage bleeding are genital tract trauma and bleeding from
placental site.

Genital tract trauma:

1. Complicated vaginal delivery.

2. Cesarean section or hysterectomy, forceps or vacuum.

3. Uterine rupture; risk increased by: previously scarred uterus, high parity,

hyperstimulation, obstructed labor, intrauterine manipulation.

4. Large episiotomy, including extensions.

5. Lacerations of the perineum, vagina or cervix.

Bleeding form placental implantation cite:

1. Retained placental tissue – avulsed cotyledon, succentuariate lobe

2.Abnormally adherent – accreta, increta, percreta.

48.Etiology of the early postpartum period bleeding.

A48

Uterine atony:
1. Overdistended uterus – multiple fetuses, Hydramnios, distention with clots.
2. Anesthesia or analgesia – halogenated agents, conducted analgesia with hypertension.
3. Exhausted myometrium – rapid labor, prolonged labor, oxytocin or prostaglandin
stimulation.
4. Chrionamnionitis.
5. Previous uterine atony.
Genital tract trauma:
1. Complicated vaginal delivery.
2. Cesarean section or hysterectomy, forceps or vacuum.
3. Uterine rupture; risk increased by: previously scarred uterus, high parity,
hyperstimulation, obstructed labor, intrauterine manipulation.
4. Large episiotomy, including extensions.
5. Lacerations of the perineum, vagina or cervix.
Bleeding form placental implantation cite:
1. Retained placental tissue – avulsed cotyledon, succentuariate lobe
2.Abnormally adherent – accreta, increta, percreta.
Coagulation defects – intensifies other causes:
1. Placental abruption.
2. Prolonged retention of dead fetus. 3. Amnionic fluid embolism.
4. Saline-induced abortion.
5. Sepsis with endotoxemia.
6. Severe intravescular hemolysis.
7. Massive transfusions.
8. Severe preeclampsia or eclampsia.
9. Congenital coagulopathies

49.Causes of postpartum pathological haemorrhage.

A49
Causes of Postpartum Hemorrhage
●uterine atony
●genital tract trauma
●bleeding from the placental site (retained placental tissue, low placental implantation,
placental adherence, uterine inversion)
●coagulation disorders
Predisposing factors for Coagulation defects
1. Placental abruption.
2. Prolonged retention of dead fetus.
3. Amnionic fluid embolism.
4. Saline-induced abortion.
5. Sepsis with endotoxemia.
6. Severe intravascular hemolysis.
7. Massive transfusions.
8. Severe preeclampsia or eclampsia.
9. Congenital coagulopathies

50.Main terminal states in obstetrics

A50
 Hemorrhagic shock
 Postpartum purulent Septic disease
 Eclampsia
 HELLP syndrome
 Fetal distress

51.Stages of Hemorrhagic shock.

A51
52.High risk factors for postpartum hemorrhage.
A52
• Placental abruption. The early detachment of the placenta from the uterus.
• Placenta previa. The placenta covers or is near the cervical opening.
• Overdistended uterus. Excessive enlargement of the uterus due to too much amniotic fluid
or a large baby, especially with birthweight over 4,000 grams (8.8 pounds).
• Multiple pregnancy. More than one placenta and overdistention of the uterus.
• Gestational hypertension or preeclampsia. High blood pressure of pregnancy.
• Having many previous births
• Prolonged labor
• Infection
• Obesity
• Medications to induce labor
• Medications to stop contractions (for preterm labor)
• Use of forceps or vacuum-assisted delivery
• General anesthesia

53.Anatomy of Female Reproductive Organs.

A53
Ovaries
• consistofcortexwithovaandmedullawithbloodsupply
• supported by infundibulopelvic ligament (suspensory ligament of ovary)
• mesovarium: peritoneal fold that attaches ovary to broad ligament
•bloodsupply:ovarianarteries(branchesoffofaorta),leftovarianvein(drainsintoleftrenalvein),righ
t ovarian vein (drains into inferior vena cava)

FallopianTubes
•8-14cm muscular tube extending laterally from the uterus to the ovary
•interstitial,isthmic,ampullary,andinfundibularsegments;terminatesatfimbriae
•mesosalpinx:peritonealfoldthatattachesfallopiantubetobroadligament
• bloodsupply: uterine and ovarian arteries

54.Female Internal Genitalia.

A54
Vagina
•muscular canal extending from cervix to vulva, anterior to rectum,and posterior to bladder
• lined by rugated,stratified squamous epithelium
• upper vagina separated by cervix into anterior, posterior,and lateral fornices
• blood supply: vaginal branch of internal pudendal artery with anastomoses from
uterine ,inferior vesical, and middle rectal arteries
Uterus
•thick walled, muscular organ between bladder and rectum,consisting of two major parts:
■ uterine corpus
◆ blood supply: uterine artery (branch of the internal iliac artery, anterior division)
■ cervix
◆ blood supply: cervical branch of uterine artery
•supported by the pelvic diaphragm,the pelvic organs, and 4 paired sets of ligaments
■ round ligaments: travel from anterior surface of uterus, through broad ligaments, and
inguinal canals then terminate in the labia majora
◆ function: anteversion
◆ blood supply: Sampson’s artery (branch of uterine artery running through round ligament)
■ uterosacral ligaments: arise from sacral fascia and insert into posterior inferior uterus
◆ function: mechanical support for uterus, prevent prolapse, and contain autonomic nerve
fibres
■ cardinal ligaments: extend from lateral pelvic walls and insert into lateral cervix and vagina
◆ function: mechanical support, prevent prolapse
■ broad ligaments: pass from lateral pelvic wall to sides of uterus; contain fallopian tube,
round
ligament, ovarian ligament, nerves, vessels, and lymphatics

55.Blood supply of the female genitalia.

A55
External Genitalia
Anterior labial commissure
Clitoris
External urinary meatus
Vestibule Vaginal orifice
Posterior fourchette (frenulum of labia)
• blood supply:internal pudendal artery
• sensory innervation:pudendal nerve
• lymphatic drainage: inguinal nodes

Vagina
blood supply: vaginal branch of internal pudendal artery with anastomoses from
uterine ,inferior vesical, and middle rectal arteries
Uterus
blood supply: uterine artery (branch of the internal iliac artery, anterior division)
■ cervix
◆ blood supply: cervical branch of uterine artery

56.Instrumental methods of examination in gynecology.

A56
 Speculum exam: Cusco bivalve speculum, sims speculum
 Pap Smear: speculum, vaginal swab, cytobrush, microscopic slide
 Pelvic organ ultrasound: Transvaginal or abdominal
 CT, MRI, PET scan
 Cytology
 Colposcopy: endoscopy exam of cervix
 Biopsy
 Culdocentesis:Transvaginal aspiration of douglas pouch
 Culdoscopy: Visualise pelvic organs through incision of douglas pouch
 Hysteroscopy
  Investigative laparoscopy

57.General and special methods of investigation in gynecology.

A57
General:
 Passport Data, Patient’s complains (character of complains e.g. pain), gynecological
history(anamnesis morbi), life history (anamnesis vitae), Gynecological history
includes data about menstrual, sexual, generative and Woman’s secretory functions.
 general examination (external genital organs examination, speculum examination,
bimanual (vaginal-abdominal and rectal-abdominal) examination)
Special:
 bacterioscopy examination (smear for purity degree), cytologic investigation of
vaginal smears, bacteriological checkup, methods of functional diagnostics,
colposcopy, biopsy, uterine sounding,
 fractional diagnostic curettage of cervical canal and uterine cavity with the following
histological research, culdocentesis, pertubation and hydrotubation.
 X-ray examination methods such as hysterosalpingography, pelviography and
bicontrast pelviography are also used.
 Colposcopy, hysteroscopy, laparoscopy and culdoscopy are endoscopic methods in
gynecology.

58.Instrumental methods of examination in gynecology.

A58
 Speculum exam: Cusco bivalve speculum, sims speculum
 Pap Smear: speculum, vaginal swab, cytobrush, microscopic slide
 Pelvic organ ultrasound: Transvaginal or abdominal
 CT, MRI, PET scan
 Cytology
 Colposcopy: endoscopy exam of cervix
 Biopsy
 Culdocentesis:Transvaginal aspiration of douglas pouch
 Culdoscopy: Visualise pelvic organs through incision of douglas pouch
 Hysteroscopy
Investigative laparoscopy

59.Endoscopic methods of investigation in gynecology.

A59
 Colposcopy: endoscopy exam of cervix
 Culdoscopy: Visualise pelvic organs through incision of douglas pouch
 Hysteroscopy
 Investigative laparoscopy
60.Regulation of menstrual cycle.
A60
61.Definition of menarche.
A61
The first menstrual cycle or first menstrual bleeding in females

62.Definition of menopause.
A62
When a woman experiences her last menstrual cycle resulting in the end of her ability to
reproduce. The cessation of menstruation. Occurs from age 49-52

Confirmatory diagnosis is increased FSH level

63.Definition of Oligomenorrhea.
A63
when you often don't get your period for 35 days or more and as a result have only four to
nine periods each year
64.Definition of Polymenorrhea.
A64
menstrual cycle that is shorter than 21 daymenorrhea
65.Definition of Amenorrhea.
A65
Amenorrhea — absence of menses. Women who have missed at least three menstrual periods
in a row have amenorrhea, as do girls who haven't begun menstruation by age 15
66.Classification of Amenorrhea.
A66
  Primary amenorrhea is the absence of menstrual function from puberty age.
 Secondary amenorrhea is the suppression of menstrual function in woman who
has menstruated before.
 Physiological amenorrhea is absence of menses before puberty period, during
pregnancy and lactation, in menopause period.
 The pathological amenorrhea can be provoked by many causes, especially by
general state changes, most frequently by endocrine diseases. There are different
forms of pathological amenorrhea: hypothalamic, pituitary, ovarian and uterine ones
according to the level of menstrual function regulation disturbance.
 Genuine — absence of cyclic changes in women’s organism, most frequently
associated with acute insufficiency of sexual hormones.
 False amenorrhea (cryptomenorrhea — latent menses) — absence of menstrual
blood excretion because of cyclic changes presence in organism. False amenorrhea is
a clinical sign of genital organs development abnormalities — atresia of hymen
or vagina, when blood, having no exit, is accumulated in vagina, uterus and
uterine tubes.

67.Definition of Polycystic Ovary Syndrome.

A67 Polycystic Ovarian Syndrome – HAIR-AN Hirsutism, HyperAndrogenism,
Infertility, Insulin Resistance, Acanthosis Nigricans
ovaries may develop numerous small collections of fluid (follicles) and fail to regularly
release eggs.

PCOS is a “syndrome,” or group of symptoms that affects the ovaries and ovulation. Its three
main features are:

 cysts in the ovaries

 high levels of male hormones

 irregular or skipped periods

In PCOS, many small, fluid-filled sacs grow inside the ovaries. The word “polycystic” means
“many cysts.”

These sacs are actually follicles, each one containing an immature egg. The eggs never
mature enough to trigger ovulation.

68.Definition of Dysfunctional uterine bleeding.

A68
DUB is a condition that causes vaginal bleeding to occur outside of the regular menstrual
cycle.

The main cause of dysfunctional uterine bleeding is an imbalance in the sex hormones

Terms frequently used to describe abnormal uterine bleeding:

Menorrhagia - Prolonged (>7 d) or excessive (>80 mL daily) uterine bleeding occurring at
regular interval

Metrorrhagia - Uterine bleeding occurring at irregular and more frequent than normal
intervals

Menometrorrhagia - Prolonged or excessive uterine bleeding occurring at irregular and more

frequent than normal intervals

Intermenstrual bleeding - Uterine bleeding of variable amounts occurring between regular

menstrual periods

Midcycle spotting - Spotting occurring just before ovulation, typically from declining
estrogen levels

Postmenopausal bleeding - Recurrence of bleeding in a menopausal woman at least 6 months

to 1 year after cessation of cycles

Amenorrhea - No uterine bleeding for 6 months or longer

69.Definition of Sheehan’s syndrome

A69
Sheehan's syndrome, also known as postpartum pituitary gland necrosis, is hypopituitarism
(decreased functioning of the pituitary gland), caused by ischemic necrosis due to blood loss
and hypovolemic shock during and after childbirth.

70.Definition of Premature ovarian failure

A70
Premature ovarian failure (POF) is when a woman's ovaries stop working before she is
40. POF is different from premature menopause. With premature menopause, your periods
stop before age 40. You can no longer get pregnant.

Women with primary ovarian insufficiency can have irregular or occasional periods for years
and might even get pregnant. But women with premature menopause stop having periods and
can't become pregnant.

Causes:

 Genetic disorders such as Fragile X syndrome and Turner syndrome

 A low number of follicles
 Autoimmune diseases, including thyroiditis and Addison disease
  Chemotherapy or radiation therapy
 Metabolic disorders
 Toxins, such as cigarette smoke, chemicals, and pesticides

71.Definition of Asherman’s syndrome

A71
Asherman's Syndrome, or intrauterine adhesions/scarring or synechiae, is an acquired
uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus
and/or the cervix.

The causes of Asherman’s syndrome can include:

 Operative hysteroscopy
 Dilation and curettage (D&C)
 Cesarean section (c-section)
 Infections: . Some infections that could lead to Asherman’s syndrome
include cervicitis and pelvic inflammatory disease (PID).
 Radiation treatment

72.Definitions of Premenstrual Syndrome

A72
73.Definition of Endometriosis.
A73
Endometriosis is when the tissue that makes up the uterine lining (the lining of the
womb) is present on other organs inside your body.

Sometimes the sheded endometrium come out of fallopian tube and deposit in other Place this
is known as a retrograde menstruation
But normally this endometrium is absorbed or degraded by macrophages
But in some woman who is immunity is weak the macrophages can’t able to digest this
sheded Endometrium

Most common sites are ovary and pouch of Douglas.

74.Classification of Endometriosis.
A74

ARSM ENDOMETRIOSIS STAGES:

Endometriosis Stage Manifestation of the Condition
Stage I (1-5 points) Minimal ,Few superficial implants
Stage II (6-15 points) Mild, More and deeper implants
Stage III (16-40 points) Moderate,Many deep implants, Small.
cysts on one or both ovaries
Presence of filmy adhesions
Stage IV (>40 points) Severe
Many deep implants
Large cysts on one or both ovaries
Many dense adhesions

ENDOFOUND ENDOMETRIOSIS CLASSIFICATION

Category I: Peritoneal endometriosis

The most minimal form of endometriosis in which the peritoneum, the membrane that lines
the abdomen, is infiltrated with endometriosis tissue.

Category II: Ovarian Endometriomas (Chocolate Cysts)

Endometriosis that is already established within the ovaries. These forms of ovarian cysts are
of particular concern due to their risk of breaking and spreading endometriosis within the
pelvic cavity.

Category III: Deep Infiltrating Endometriosis I (DIE I)

The first form of deep infiltrating endometriosis involves organs within the pelvic cavity. This
can include the ovaries, rectum, uterus, and can significantly distort the anatomy of the pelvic
organs.

Category IV: Deep Infiltrating Endometriosis II (DIE II)

The other more extreme form of DIE involves organs both within and outside the pelvic
cavity. This can include the bowels, appendix, diaphragm, heart and lungs among others.

75.Definitions of Climacteric syndrome.

A75
The climacteric syndrome is a set of symptoms caused by the decline of ovarian hormone
levels, which alters brain neurotransmission and provokes musculoskeletal pains, mood
disorders, poor sleep quality and hot flushes.
76.Classification of Benign Breast Diseases.
A76
Benign breast diseases constitute a heterogeneous group of lesions including developmental
abnormalities, inflammatory lesions, epithelial and stromal proliferations, and neoplasms.

Causes
Changes in breast tissue (fibrocystic breast changes).
Breast infection (mastitis)
Scar tissue from a breast injury.
Hormone fluctuations, especially during menstruation, pregnancy or menopause.
Medication use, such as hormonal contraceptives (birth control pills) and hormone
replacement therapy.
77.Classification of Gestational trophoblastic disease.
A77
Gestational trophoblastic disease (GTD) is a group of rare diseases in which abnormal
trophoblast cells grow inside the uterus after conception.
According to types
 hydatidiform mole
 invasive hydatidiform mole,
 chorioncarcinoma,
 trophoblastoma of the placental site.
According to staging
 Stage I – Confined to the uterus
 Stage II – Limited to the genital structures
 Stage III – Lung metastases
 Stage IV – Other metastases

78.Classification of Benign cervical lesions.

A78
  True cervical erosion - a pathological process,which is a result of damage and
following exfoliation of original stratified squamous epithelium. Absence of
epithelium on cervical vaginal part appears.
 Cervical pseudoerosion is a benign pathological process, which is characterised by
presence of original columnar endocervical tissue on exocervical surface.
 Polyps of mucous membrane of cervical canal are created from the mucous of the
external os, middle or upper third part of endocervix.
 Cervical endometriosis is characterized by the presence on the cervical surface of
rust colored, dark brown spots those have been described as “mulberry” or
“raspberry”.
 Cervical ectropion is an inversion of cervical mucous as a result of badly renewed
cervix after labour trauma
 Cervical Leukoplakias without atypia belong to hyperkeratoses. Leukoplakia is a
pathological state of epithelium that is characterized by its thickness and
cornification.

79. Definition of Cervical Dysplasia

A79
Cervical dysplasia is a precancerous condition in which abnormal cell growth occurs on the
surface lining of the cervix or endocervical canal
80. Classification of uterine leiomyoma.
A80
Leiomyomas of the uterus (or uterine fibroids) are benign tumors that arise from the
overgrowth of smooth muscle and connective tissue in the uterus.

 subserosal — subperitoneal uterine fibroids, which are growing under the outer
serosal layer of the uterus, may have a wide or thin pedicle. It has been estimated that
10-16% of all myomas are subserosal ones
 Intramural — uterine fibroids, which are growing within the muscular wall of the
uterus, their frequency is 40-45%
 submucosal — uterine fibroids which are growing under the uterine mucous into the
uterine cavity, their frequency is 20% of all the patients
According to size
 The fibromyoma can have one fibroid (nodulosus fibromyoma),
 many fibroids (multiple fibromyoma)
 Diffuse growth (diffuse fibromyoma).

81. Prevention of genital tract infection

A81

82. Etiology of vaginal infections

 A82 Bacterial vaginosis: Gardnerella vaginalis (a gram-variable coccobacillus),
Mobiluncus species, Mycoplasma hominis, and Peptostreptococcus species
 Use of antibiotics
 Diabetes or pregnancy
 Hormonal changes such as ovulation, menopause, or pregnancy
 Wearing underwear that is tight or non-cotton
 Weakened immune system
 Use of douches, perfumed feminine hygiene sprays
83. Etiology of pelvic inflammatory disease
A83

84. Clinical signs of gonorrheal infection

A84
85. Role of human papillomavirus infection in development of genital problem
A85
86. Classification of method of contraception
A86

87. Etiology of female infertility

A87
88. Symptoms of “Acute abdomen”
A88
89. Classification of ectopic pregnancy
A89
90. Etiology of ectopic pregnancy
A90
Etiology
• 50%due to damage of fallopian tube cilia following PID
• intrinsic abnormality of the fertilized ovum
• conception late in cycle
• transmigration of fertilized ovum to contralateral tube
 In case of the slow development of trophoblast an ovum is implanted in lower uterine
(placenta praevia) segments or outside uterine cavity — in its cervix (cervical
pregnancy).

Part 2
 II group of questions
2.1 Diagnosis of complete breech presentation

B1
Complete breech is when both of the baby's knees are bent and his feet and bottom are closest
to the birth canal

History:-
-Previous breech presentation.

Abdominal examination:

Fundal grip:-hard, round ballottable head.

Lateral grip:- fetal back on one side palpable as smooth curve structure whereas limbs on
other side felt small irreqular structure.

Pelvic grip: broader, softer and irregular mass with ill define outline.

- Fetal heart sounds: above the umbilicus before engagement , below the umbilicus after
engagement.

P/V examination:- Presentating part

-During pregnancy:- soft and irregular part are felt.

-During labour:- palpation of ischial tuberocities, sacrum and its spine, sole of foot,
genitalias and anus.

Investigations:
- USG:- confirmatory.

2.2. Diagnosis of frank breech presentation

B2
Frank breech is when the baby's legs are folded flat up against his head and his bottom is
closest to the birth canal

■ BOX - 1 Complete Breech frank Breech 1

P»r .ibdom
Fundal grip I e Head—suggested by
herd end globular |
Lateral grip • Fetal back is to one
Pelvic grip 1 ■ Breech—suggested by I e Small hard and a
soft, broad and J
FHS e Usually located at a
Per
During e Soft and irregular
During • Palpation of ischial
labor tuberosities sacrum
and the feet by the
e Head
• Irregular small pans
■ irregular parts are
e Located at a lower
conical mass is Mt | e
a Hard feel of the
■ Palpation of ischial
tuberosities. anal
opening and sacrum

2.3. Diagnosis of incomplete foot-link presentation

B3
Incomplete breech is when one of the baby's knees is bent and his foot and bottom are closest
to the birth canal.

• Leopold's maneuver: Ballotable head felt at fundus.

•
• Lateral grip: fetal back one side and irregular on other side.
•
• Pelvic grip: small hard, long mass. Auscultation heard above umbilicus
•
• Vaginal exam: one foot and 5 toes are palpable, the foot can readily be identified as right
or left on the basis of the relation to the great toe
•
• Ultrasound or CT scan
2.4. Diagnosis of complete foot-link presentation
B4

Complete breech is when both of the baby's knees are bent and his feet and bottom are closest
to the birth canal.

• Leopold's maneuver: Ballotable head felt at fundus.

Lateral grip: fetal back one side and irregular on other side.

Pelvic grip: small hard, long mass.

Auscultation heard above umbilicus

• Vaginal exam: Both feet and 10 toes are palpable.

•
• Ultrasound or CT scan

2.5. Complications of delivery in breech presentations

B5
Maternal

Genital Tract Injuries

C. Section

Extension of scarlaterally or need of inverted T incision

Vaginal Delivery

Cervical, Vaginal lacerations

Uterine Rupture

Perineal tears

Extension of episiotomy
Infections

Post partum Hemorrhage

Cord prolapse

Fetal
Fracture of Humerus, Clavicle, Femur (More with vaginal)

Brachial Plexus Injury

Spinal cord injury

Vertebral fracture

Sternocleidomastoid hematoma (Rt. › Lt.) (Pseudotumor of SCM) (Fibromatosis Colli)

Fetal genital tract injuries

Inherent to breech (CS or Vaginal) : Hip Dysplasia

2.6.Diagnosis of transverse lie

B6The external inspection shows than the abdomen is unusually wide from side to side,
whereas the fundus of the uterus extends scarcely above the umbilicus.

On palpation, with the first maneuver no fetal pole is detected in the fundus.

On the second maneuver, a ballottable head is found in one side of uterus and the breech in
other.

The third and fourth maneuvers are negative unless labor is well advanced and the shoulder
has become impacted in the pelvis.

When the fetal head is situated in the left side of the uterus the first position of the fetus is
identified.
When the fetal head is situated in the right side of the uterus the second position is
recognized.

Vaginal exam: no presenting part. Unless there is prolapse of arm then arm may be palpable
Ultrasound or CT scan

2.7. Diagnosis of oblique lie

B7
When the position of the fetus forms an acute angle to mothers spine. So the body is diagonal

On palpation, with the first maneuver no fetal pole is detected in the fundus.

On the second maneuver, a ballottable head is found in one side of uterus and the breech in
other.

The third and fourth maneuvers are negative unless labor is well advanced and the shoulder
has become impacted in the pelvis.

When the fetal head is situated in the left side of the uterus the first position of the fetus is
identified.
When the fetal head is situated in the right side of the uterus the second position is
recognized.

Vaginal exam: no presenting part. Unless there is prolapse of arm then arm may be palpable

Ultrasound or CT scan

2.8. Diagnosis of sinciput vertex presentation

B8
DEFINITION:
- Also known as "military position", occurs when the head is neither flexed nor extended. The
anterior fontanel is felt as the presenting part.

POSITION:
- The anterior fontanel (bregma) is the point of designation and can present in any position
relative to the maternal pelvis.

DIAMETER:
- presenting diameter is occipito-frontal (12,5 cm)

DIAGNOSIS:
-The diagnosis of a sinciput presentation is rare made with abdominal palpation by Leopold
maneuvers
- Vaginal examination in labour:
After the cervix has a 4-5 cm dilation at the sagittal suture's extremities, both fontanelles
(anterior and posterior) can be palpated; In the cranial presentation only the little fontanelle is
palpated.

- Ultrasound evaluation reveals the cephalic extremity in the intermediate attitude

2.9. Diagnosis of brow presentation

B9
DEFINITION:
- In a brow presentation, the fetal head is midway between full flexion (vertex) and
hyperextension (face) along a longitudinal axis. The presenting portion of the fetal head is
between the orbital ridge and the anterior fontanel.
The face and chin are not included.

- The frontal bones are the point of designation and can present (as with the occiput during a
vertex delivery) in any position relative to the maternal
pelvis.

When the sagittal suture is transverse to the pelvic axis and the anterior fontanel is on the
right maternal side, the fetus would be in the right fronto-transverse position (RFT).

- Most frequent positions are: right fronto-posterior position and left fronto-anterior position

DIAGNOSIS:
Diagnosis of a brow presentation can occasionally be made with abdominal palpation by
Leopold manuuvers:

a prominent occipital prominence is encountered along the fetal back, and the fetal chin is
also palpable;
however, the diagnosis of a brow presentation is usually confirmed by examination of a
dilated cervix

The fetal head presents with mento-occipital diameter, aleader point

is middle of frontal suture.
- Vaginal examination in labour:
Orbital ridge, eyes, nose, forehead, and anterior fontanel are palpated

Mouth and chin are not palpable, thus excluding facepresentation

- Fetal ultrasound evaluation again notes a hyperextended neck

2.10. Diagnosis of face presentation

B10

DEFINITION:
- In a face presentation, the fetal head and neck are hyperextended, causing the occiput to
come in contact with the upper back of the fetus while lying in a longitudinal axis.

The presenting portion of the fetus is the fetal face between the orbital ridges and the chin

POSITION:
- The fetal chin (mentum) is the point designated for reference during an internal examination
through the cervix. The occiput of a vertex is usually hard and has a smooth contour, while
the face and brow tend to be more irregular and soft.

Like the occiput, the mentum can present in any position relative to the maternal pelvis. For
example, if the mentum presents in the left anterior quadrant of the maternal pelvis, it is
designated as left mentum anterior(LMA).

DIAMETER:
- presenting diameter is submento-bregmatic (9.5 cm)

DIAGNOSIS:
- Face presentation is diagnosed late in the first or second stage of labor by examination of a
dilated cervix
- On digital examination, the distinctive facial features of the nose,mouth, and chin, the malar
bones, and particularly the orbital ridges can be palpated.

This presentation can be confused with a breech presentation because the mouth may be
confused with the anus and the malar bones or orbital ridges may be confused with the ischial
tuberosities

The facial presentation has a triangular configuration of the mouth to the orbital ridges
compared to the breech presentation of the anus and fetal genitalia
2.11. Diagnosis of polyhydramnios
B11
Symptoms:
- dyspnea.
- edema.
- abdominal distention
- preterm labour.

Fetal abnormalities associated with polyhydramnios include neonatal macrosomia, fetal or

neonatal hydrops with anasarca, ascites, pleural
or pericardial effusions, and gastrointestinal tract obstruction (eg,
duodenal atresia, tracheoesophageal fistula).

- Abdominal examination:
- Increase uterus than expected.
- difficult to palpate fetal parts.
- difficult to hear fetal heart sound.
- ballotable fetus.

Ultrasound:
- excessive amniotic fluid.
- fetal abnormalities.

Ultrasound: An alternative way of measuring amniotic fluid is measuring the largest pocket in
four specific parts of your uterus. The sum of these measurements is the amniotic fluid index
(AF)). Polyhydramnios is usually defined as an (AFI) of more than 24 cm or a single pocket
of fluid at least 8 cm in depth that results in an amniotic fluid volume of more than 2000 ml

2.12. Diagnosis of oligohydramnios

B12
Diminished amniotic fluid volume (AFV)

Amniotic fluid volume of less than 500 mL at 32-36 weeks' gestation

- Amniotic fluid volume depends on the gestational age; therefore, the best definition may be
AFl less than the fifth percentile.
Single deepest pocket (SDP) of less than 2 cm

Amniotic fluid index (AFI) of less than 5 cm or less than the fifth percentile

Diagnosis:
1- The fundal level is lower than the period of amenorrhea.
2- Breech presentation is common.
3- The fetal parts are easily felt and the fetus is almost immobile.
4- The FHS are clearly heard.

1- Ultrasound : Values :
* Confirm diagnosis : DVP ≤2 cm or AFI ≤5cm.
• Detect a cause : - Fetal growth restriction. - Congenital anomalies.
• Malpresentation.

Diagnosis
Abdominal examination
On inspection – the uterus is larger than expected for the period of gestation and is globular in
shape the skins appears stretched and shiny with marked strike gravidarum and obvious
superficial blood vessels.
On palpation- the uterus feels tense and it is difficult to feel the fetal parts but the fetus may
be balloted between the two hands.A fluid thrill may be elicited.

Ascultation auscultation of the fetal heart is difficult because the quantity of fluid allows the
fetus to move away from the fethoscope.

2.13 Diagnosis of multiple pregnancy

B13
CLINICAL DIAGNOSIS OF TWIN PREGNANCY

Uterine height > POG Period of gestation

Multiple fetal parts felt on Leopold maneuver

2 fetalheads felt on Leopold maneuver

• HCG -* Hyperemesis

Maternal serum chorionic gonadotrophin, Alpha fetoprotein and Unconjugated oestriol

Increase Fluid volume in body - Cardiac output - Increases chances of Cardiacfailure

Anemia more likely in twins as compared to Singleton pregnancy

The diagnosis is made by obstetric ultrasonography.

2.14 Vasten's sign evaluation

B14

Henckel-Wasten’s sign

Positive (а) – the head surface is above the surface of the symphysis

At level (б) – front surface of the fetal head is at level of the symphysis

Negative (в) – front surface of the head is placed below the plane of the symphysis

Diagnosis

The symptoms of the threatening uterine rupture are noticed in case of severe disproportion
between the pelvis and the fetal head. That is over distention and painful low segment of the
uterus, high location of the contraction ring, the symptoms of cervix pressure, its edema, that
spread of the external genitalia.

Diagnosis of the big fetus

History (the height and the weight of the husband, the weight of the pregnant at birth, the
weight of the babies at previous deliveries, diabetes mellitus of the pregnant or
other endocrinologicaldiseases.
Objective examination: the circumference of the abdomen more than 100 cm, the height of
the uterus more than 40cm, the size of the fetal head by palpation, the measurement of the
fetal head by the ultrasound, ultrasound measurement of the pelvis

2.15 Diagnosis of the general contracted pelvis

B15
All diameters reduced, but the anteroposterior diameters are shortened greater then the others
• Usually connected with rickets of the childhood

Is characterized by combination of the signs of generally contracted

and flat pelvis.
Average sizes of the pelvis are:
D. spinarum - 24cm
D. cristarum - 25 cm
D. trochanterica - 28 cm
C. externa - 16 cm
C. diagonalis - 9 cm
C. vera - 7 cm.

Course of labor depends from predominance of kind of pelvis contraction.

Management of labor. Cesarean section is the method of choice

2.16 Diagnosis of simple flat pelvis

B16Flat Pelvis
• reduced anteroposterior diameters with normal transverse and oblique diameters

a) Simple flat (or platypellic) pelvis

Is defined as shortening of anteroposterior diameters at all levels of true pelvis, as a result of
this sacrum is inclined anteriorly to pubis.

Average sizes of the pelvis are:

D. spinarum- 26cm. D. means distance
D. cristarum - 29 cm
D. trochanterica- 31 cm
C. externa - 18 cm
C. diagonalis- 11 cm
C. vera - 9 cm.

Course of labor in flat pelvis

prolongation of labor;
sagittal suture arresting in the transverse diameter of the plane of inlet;

anterior fontanel is the leading point of the fetal head

asynclitism should be presented

Management of labor. In the case of posterior asynclitism cesarean section should be

performed. Vaginal delivery in a flatrachitic pelvis

2.17 Diagnosis of flat rachitic pelvis

B17
True conjugate is shortened.

Sidewalls tend to converge, as result of this D. spinarum and D. cristarum are the same.

Additional promontorium may be presented between 1 and 2 vertebrae of sacrum

Subpubic arch is shallow and wide

Top of the sacrum is situated posteriorly that's whydimensions of the pelvic outlet are normal
or even increased

Average sizes of the pelvis are:

D. spinarum - 26cm
D. cristarum - 26 cm
D. trochanterica - 31 cm
C. externa - 17 cm
C. diagonalis - 10 cm
C. vera - 8 cm.
Course of labor in flat pelvis
prolongation of labor;
sagittal suture arresting in the transverse diameter of the plane of inlet;

anterior fontanel is the leading point of the fetal head

asynclitism should be presented

Management of labor. In the case of posterior asynclitism cesarean section should be

performed. Vaginal delivery in a flatrachitic pelvis

2.18 Perculiarities of delivery in case of macrosomia

B18

• Labor problems. Fetal macrosomia can cause a baby to become wedged in the birth
canal, sustain birth injuries, or require the use of forceps or a vacuum device during
delivery (operative vaginal delivery). Fetopelvic disproportion. Sometimes a C-section is
needed.

• Genital tract lacerations. During childbirth, fetal macrosomia can cause a baby to injure
the birth canal - such as by tearing vaginal tissues and the muscles between the vagina
and the anus (perineal muscles).

• Bleeding after delivery.

2.19 Signs of multifetal pregnancy

B19
Abdominal examination
Inspection:- the size of the uterus may be larger than expected for the period of gestation
after the 20th week. Palpation:- The fundal height may be greater than expected for the period
of gestation.
- The presence of two fetal poles (head or breech) multiple fetal limbs.
- Lateral palpation may reveal two fetal backs or limbs on both sides.
- Pelvic palpation one fetus may lie behind the other and make palpation difficult.

Auscultation:-Hearing two fetal hearts is not diagnostic. Comparison of the heart rates
should reveals difference of at least 10 beats per minutes.
Effect of Twins on Pregnancy
- Exacerbation of minor disorder
- Nausea, Morning Sickness and heart burn may be more persist.
- Anaemia

Ultrasound: -it will demonstrate two heads at 15 weeks when the outline of the head will be
noted

X -ray- may be used after the 12 th week of gestation.

2.20 Peculiarities of pregnancy duration in multiple gestation

B20
• The average gestational age at delivery of twins is approximately 36 weeks

• Similarly, the mean gestational age at delivery in triplet pregnancies was 32 to 33 weeks

• with 31 weeks in 37 quadruplet pregnancies

2.21 Peculiarities of pregnancy duration in polyhydramnios, oligohydramnios

B21
• Polyhydramnios: Can lead to premature rupture of membranes.

• Spontaneous labor fetal abnormalities associated with polyhydramnios include neonatal

macrosomia, fetal or neonatal hydrops with anasarca, ascites, pleural or pericardial
effusions, and gastrointestinal tract obstruction (eg, duodenal atresia, tracheoesophageal
fistula).

• 0ligohydramnios: Can lead to fetal distress which could lead to preterm delivery.

• When the oligohydramnios is associated with renal agenesis or dysgenesis,

symptoms/signs include a marked deformation of the fetus due to intrauterine constraint
(Potter syndrome).

• Obstructive uropathies cause similar deformations, including external compression with

a flattened facies and epicanthal folds, hypertelorism, low-set ears, a mongoloid slant of
the palpebral fissure, a crease below the lower lip, and micrognathia. Thoracic
compression may also occur.
 • Oligohydramnios adversely affects fetal lung development, resulting in pulmonary
hypoplasia that typically leads to death from severe respiratory insufficiency.

2.22 Peculiarities of labor duration in polyhydramnios, oligohydramnios

B22
• Consider hospitalizing and thoroughly evaluating the mother in cases diagnosed after 26-
33 weeks' gestation.

• If the fetus does not have an anomaly, delivery should be performed if the biophysical
profile is nonreassuring.

• The instillation of isotonic sodium chloride solution in the second trimester may be of
benefit in some patients. Use transabdominal amnioinfusion to instill 400-600 mL, which
may improve visualization for ultrasonography and increase the amniotic fluid volume.

• In cases associated with postmaturity, review the pregnancy dating. If the gestation is
truly longer than term, deliver the fetus by means of either induction or cesarean
delivery.

• If meconium is present during labor, administer amnioinfusion therapy to reduce the

potential for fetal distress and prenatal aspiration.

2.23 Clinical signs of hypotonic uterine dysfunction

B23

Hypotonic uterine dysfunction: (Uterine inertia) - uterine contractions is less than

normal.

Etiology and Pathophysiology:

Overstretching of the uterus -large baby, multiple babies, polyhydramnios, multiple parity

Bowel or bladder distention preventing descent

Excessive use of analgesia

Cephalopelvic disproportion and malpositions are common causes

Signs and Symptoms of HYPOTONIC UTERINE INERTIA:

Weak contractions become mild

Infrequent (every 10 - 15 minutes +) and brief

Can be easily indented with fingertip pressure at peak of contraction.

Prolonged ACTIVE Phase

Exhaustion of the mother

Psychological trauma - frustrated

2.24 Clinical signs of hypertonic uterine dysfunction

B24

Hypertonic uterine dysfunction - uterine tone elevated.

Most often occur in first-time mothers, Primigravidas

Contractions are ineffectual, erratic, uncoordinated, and of poor quality that involve only a
portion of the uterus

Increase in frequency of contractions, but intensity is decreased, do not bring about dilation
and effacement of the cervix.

Signs and Symptoms

PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain

Dilation and effacement of the cervix does not occur.

Prolonged latent phase. Stay at 2 - 3 cm. don't dilate as should

Fetal distress occurs early- uterine resting tone is high, decreasing placental perfusion.

Anxious and discouraged

2.25 Clinical signs of ineffective maternal pushing efforts

B25
• -Incorrect pushing technique and position

• -Fear of injury due to pain and tearing sensation when pushing

 • -Decreased or absent urge

• -Maternal exhaustion

• -Analgesia or anesthesia effects

• -Psychological unreadiness to "let go" of her baby

2.26 The complications caused by application of obstetrics forceps

B26

In the infant:
Bruising: Severe bruising will cause marked jaundice which may be prolonged

Cerebral irritability - A traumatic forceps delivery may cause cerebral edema or hemorrhage.

Cephal haematoma - is a swelling on the neonate's skull, an effusion of blood under the
periosteum covering it, due to friction between the skull and pelvis.

Tentorial tear- results from compression of the fetal head by the forceps. The compression
causes elongation of the head and consequent tearing of the tentorial membrane.

Facial palsy-occasionally the facial nerve may be damaged since it is situated near the
mastoid process where it has little protection.

In the mother:
Bruising and trauma to the urethra
This may cause dysuria and occasionally haematuria or a period of urinary retention or
incontinence.

Vaginal and Perineal trauma

The vaginal wall may be torn during forceps delivery and the vagina must be inspected
carefully prior to perineal repair. The episiotomy may extend or be accompanied by a further
perinea tear and these must be repaired with care. As with any damaged perineum there may
be bruising, oedema or occasionally haematoma formation.

2.27 The complication caused by c-section

B27
The immediate complications are
Hemorrhage from the placental site, or the wound;
gut distention and ileus; infection;
pulmonary collapse
Thrombo embolism.

Intra-operative
Blood loss >1 litre -Blood transfusion
Bladder/bowel laceration (also, ureters)
Hypo- or atonic condition of uterus
Possible damage of venous plexus r uterine artery at transverse
incision

- The late complications are

Abdominal hernia,
Intestinal obstruction due to adhesions,
vague abdominal pain

2.28 Clinic manifestation of endometritis

B28
• It usually begins as a localized infection at the placental site but can spread to
involve the entire endometrium. Incidence is higher after cesarean birth.
• Assessment for signs of endometritis may reveal a fever (usually greater than 38°
C); increased pulse; chills; anorexia; nausea; fatigue and lethargy; pelvic pain;
uterine tenderness and enlargement; or foulsmelling, profuse lochia

• There can be Lochimetra: If evacuation from the uterus is disturbed because of

spasm of internal uterine orifice or cervical canal obstruction with blood clots.

• Leukocytosis and a markedly increased red blood cell sedimentation rate are typical
laboratory findings of postpartum infections. Anemia may also be present.

• Blood cultures or intracervical or intrauterine bacterial cultures (aerobic and

anaerobic) should reveal the offending pathogens within 36 to 48 hours.

2.29 Clinic manifestation of peritonitis

B29
• High temperature, severe lower abdominal pain, fever or chills, tachycardia are common.

There can be nausea and some- times vomiting. Muscular defense and rebound tenderness
 are the symptoms of peritoneal irritation. Anterior abdomen wall takes part in breathing act.

Tender adnexa are present at bimanual examination. Cervical motion causes pain. Posterior
fornix is painful.

• Laboratory tests reveal increasing of white blood cell count and erythrocyte
sedimentation rate. C-reactive protein levels may appear.

• General blood test should be done 4-5 times per day to diagnose transformation of
pelvioperitonitis to peritonitis.

2.30 Clinic manifestation of progressive thrombophlebit IS

B30

Superficial thrombophlebitis
• Dilation of subcutaneous veins.
• 1 -2 week after labor.
st nd

• Local pain along the vein obstructed by thrombus.

• Cyanotic or dark purple color, increased volume of limb by 1-2cm Deep vein
thrombophlebitis

• Metrothrombophlebitis of veins of uterus: during first 6-13 days. Sub febrile body
temperature, rapid pulse, and sub involution of uterus, prolonged bleeding from uterus.
Bimanual exam reveals faceted external surface of uterus and convoluted bands under
serous

• Thrombophlebitis of pelvic veins: on 10- 12th day. Bimanual exam reveals enlarged
uterus which does not correspond to postpartum term. Veins and palpable convoluted
band is palpable near base of broad ligament in lateral pelvic walls.

• Deep vein thrombophlebitis of lower extremities: pain in limbs, swollen, cold and
tingling feet. Fever and chills

2.31Clinic manifestation of general septic process

B31
• Tachycardia, tachypnea
• Hyperthermia or hypothermia
• Leukocytosis or leukopenia
• Lactic acidosis, oliguria, acute disorders of consciousness
• Arterial hypotension
• Syndrome of multi-organ failure
o Symptoms of respiratory distress: reduced partial oxygen to
 70 mmHg
o Symptoms of DIC:thrombocytopenia, increased fibrinogen, increased
prothrombin index, increased level of fibrinogen degradation
o Kidney dysfunction syndrome: oliguria, increased creatinine.
Reduced sodium in urine
o Hepatic dysfunction syndrome: hyperbilirubinemia, increased
ALT, AST and alkaline phosphatase
o Encephalopathy

2.32 Diagnosis of different types of uterine rupture by the location and degree
B32
• Depending on whether the laceration communicates directly with the peritoneal
cavity or is separated from it by the visceral peritoneum over the uterus or that of
the broad ligament complete and incomplete rupture of the uterus have been
distinguished. An incomplete rupture
may, of course, become complete at any moment.

• By the time of occurring: during pregnancy; during labor.

• By localization: in the uterus fundus; in the uterine body; in the lower uterine segment;
colporrhexis.

• Diagnosis is made my laparotomy or rarely ultrasound

2.33 Clinical manifestation of placental previa

B33
Sign and symptom of placenta pracvia
- Painless bleeding from vagina occurs at night

Bright red vaginal bleeding without pain during the second half ofpregnancy is the main sign
of placenta previa.

- The uterus is not tender or tense on palpation

- The fetal head remains unengaged
- There is malpresentation
- The lie is oblique or transverse
- The lie is unstable, usually in a multigravida

Type 1 placenta praevia

- The majority of the placenta is in the upper uterine segment
- Vaginal delivery is possible
- Blood loss is usually mild
- The mother and the fetus remains in good condition

Type 2 placenta praevia

- The placenta is partially located in the lower uterine segment near the internal
- cervical os (marginal placenta pravia).
- Vaginal delivery is possible particularly if the placenta is
implanted anteriorly
- Blood loss is usually moderate
- Fetal hypoxia is more likely to be present

Type 3 placenta pracvia

The placenta is located centrally over the internal cervical

Bleeding is likely to be sever particularly when thelower segment stretches and

the cervix begins to efface and dilate in late pregnancy

Vaginal delivery is in appropriate.

Type 4 placenta praevia

The placenta is located centrally over the internal cervical os and sever haemorrhage is very
likely

Vaginal delivery should not be considered

Caesarean section is essential in order to save the life of the mother and fetus.

2.34 Diagnosis evaluation of placenta previa

B34
Diagnosis
- Using Abdominal and transvaginal ultrasound scanning will confirm the existence of
placenta praevia and establish its degree.

- The colour of the blood is bright red, denoting fresh bleeding.

Assesement
If the haemorrhage is slight the mothers blood pressue, respiratory rate and pulse rate may be
normal
In severe hemorrhage;
- The blood pressure will be low and the pulse rate raised
- Respirations is also rapid
- The mother’s skin colour will be pale and her skin will be cold and moist
- Vaginal examination should not be attempted

Assessing the fetal condition

The mother should be asked whether fetal activity has been normal.Excessive or cessation
fetal movement is another indication of sever fetal hypoxia.

2.35 Pathophysiology and etiology of uterine rupture

B35

1. Weak Caesarian Section Scar

Cause: -
- Wound healed by secondary or more of stage
- If another pregnancy occurs with in six months
- Over distension as in subsequent twin or ployhydraminos
Occurrence- During 1st stage of labour or the last four weeks of pregnancy.

2. Due to obstructed labour

Cause- When labour is obstructed it causes excessive thinning of the lower uterine segment
during labour.It is more common during 2nd stage of labor

3. Due to trauma
Cause:

- Operative procedure
e.g internal version, craniotomy

- Extraction of the after coming head of the hydrocephalus baby:

e.g Cervical tear

4. Due to unwise use of oxytocic drugs

Cause - Using intravenously or intramuscularly to induce labour
2.36 Clinical manifestation of uterine rupture
B36
1. Weak Caesarian Section Scar
Sign and symptoms
- Constant abdominal pain accompanied by vomiting even
when the pulse below 100.
- Vaginal bleeding
- Shock

2. Due to obstructed labour

1. Rising pulse rate and temperature
2. Tonic contraction and Bandl’s ring
3. Tenderness of the lower uterine segment
4. Vaginal bleeding

Other manifestations

sudden pain between contractions

contractions that become slower or less intense
abnormal abdominal pain or soreness
recession of the baby's head into the birth canal
bulging under the pubic bone
sudden pain at the site of a previous uterine scar
loss of uterine muscle tone
rapid heart rate, low blood pressure, and shock in the mother

2.37 Diagnostic evaluation of uterine rupturE

B37
• Laparotomy

• Monitor electrolytes and hemodynamics

2.38 Clinical manifestation of placental abruption

B38
Premature separation of the normally implanted placenta from the uterine wall.
Etiology: when there is hemorrhage into the decidua basalis, leading to premature placental
separation and further bleeding.

Patients at risk:
Maternal hypertension
Multiply pregnancy
Polyhidramnios
External trauma
Preterm prematurely ruptured membranes
Cigarette smoking
Cocaine abuse
Uterine leiomyoma,

Clinical findings and Diagnosis

External bleeding can be profuse or there may be no external bleeding (concealed
hemorrhage)
Uterine tenderness
Back pain
Fetal distress
Uterine hypertonus or high- frequently contractions
Dead fetus when placenta is totally shared.
Coagulation disorders
Ultrasonography can help in diagnosis

OR

Class 1 characteristics include the following:

No vaginal bleeding to mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and heart rate
No coagulopathy
No fetal distress

Class 2 characteristics include the following:

No vaginal bleeding to moderate vaginal bleeding
Moderate to severe uterine tenderness with possible tetanic
contractions
Maternal tachycardia with orthostatic changes in BP and heart rate
Fetal distress
Hypofibrinogenemia (ie, 50-250 mg/dL)

Class 3 characteristics include the following:

No vaginal bleeding to heavy vaginal bleeding
Very painful tetanic uterus
Maternal shock
Hypofibrinogenemia (ie, < 150 mg/dL)
Coagulopathy
Fetal death
2.39 Diagnostic evaluation of placental abruption
B39
Ultrasound, Non stress test, Biophysical profile

Laboratory testing is not useful in making the diagnosis but can include:

Kleihauer-Betke test: sensitivity 17%. Findings help to detect fetal redblood cells in the
maternal circulation.

CA-125: elevated

D-dimer: sensitivity 67, specificity 93%

Thrombomodulin: sensitivity 88, specificity 77%.

Hypofibrinogenemia < 200 mg/dL.

Thrombocytopenia < 100,000/microL.

Assessment of the mother’s condition

There may be history of pregnancy induced hypertension, external cephalic version.If there is
placental separation after the birth of a first twin or loss of copious amounts of amniotic fluid
during rupture of aminiotic memberane.

If the blood loss is revealed;

More severe degrees are associated with abdominal pain
The uterus has a hard consistency and there is a guarding on palpation of the abdomen.Fetal
parts may not be palpable the fetal heart is unlikely to be heard with a fetal stethoscope

2.40 Postpartum hemorrhage due to uterine atony clinic and diagnosis

B40
Definition:- Post partum hemorrhage is bleeding from the genital tract during the 3rd stage of
labour, or with in 24 hours after delivery of the placenta to the amount of 500ml or any
amount that will change the patient’s condition
Atonic Postpartum Hemorrhage (80% of PPH)
This is bleeding from the placental site when the uterus is not well contracted. This is a failure
of a myometrium at the placental site to contract and retract and to compress torn blood
vessels and control blood loss by a living ligature action.

Signs

The main symptom of atony of the uterus is a uterus that remainsrelaxed and without tension
after giving birth

excessive and uncontrolled bleeding following the birth of the baby

decreased blood pressure

an increased heart rate

pain , backache

Atony of the uterus is usually diagnosed when the uterus is soft and relaxed and there's
excessive bleeding after giving birth

2.41 Diagnosis of placenta insitu

B41
Clinical findings, Diagnosis, Management
1. Absence of the signs of placental separation during 30 minutes.

2. External bleeding – in the case of partial adherence, absence of the bleeding – in the case of
total placenta accreta.
In the case of placental adherence bleeding stop, but in the case of placenta accreta, increta
and percrata increase.
That’s why in these cases manual removal of the placenta should be stopped immediately

2.42 Diagnosis of DIC syndrome

B42
pathological syndrome, which is based on the activation of vascular-platelet or coagulation
hemostasis (external or internal), resulting initially blood clotting in the microvasculature,
blocking itswith fibrin and cellular units,

2.43 Diagnosis of fetal distress

B44
Diagnosis of acute fetal distress:- Fetal heart rate abnormality, Dearly stage
tacchycardia>160bpm: during severe hypoxia <120 bpm OCST (out ofcenter sleeping testing)
shows late deceleration, variable deceleration 0fetal heart rate <100 bpm, with frequent late

decelrations indicating severe fetal hypoxia, may die intrauterine any moment

Meconium stained amniotic fluid: green color, dirty, thick and little volume
I degree: light green.
II degree: yellowish green, dirty.
III degree:brownish yellow, thick Diagnosis of chronic fetal distress:-

• Reduced or absent fetal movement . Abnormal fetal monitoring

• Low fetal biophysical profile scoring
• Fetal retardation
• Reduced placental function
• Meconium stained amniotic fluid Abnormal fetal pulse oxymetry

2.44 Diagnosis of 1 stage of hemorrhagic shock

B44
Compensated
• Blood loss: 10 %-20%
• Amount lost: 500 -10 0 0,0 ml
• % of body weight: 1,0 -1,5 %
• Pulse - 90-10 0 beats per min;
• Arterial blood pressure (BP) - >100 mm Hg;
• Central Venous pressure (CVP)-80-100 mmHg;
• Diuresis-Normal
• Mental Status: Normal or slightly anxious

2.45 Diagnosis of 2 stage of hemorrhagic shock Moderate

B45
• Blood loss: 20%-30%
• Amount lost: 1000,0-1500,0ml
• % of body weight: 1,5 -2,0 %
• Pulse -120 beats per min;
• BP - <10 0 mmHg;
• CVP-<60 mmHg;
 • Diuresis -< 50 ml per hour (oligouria)
• Mental Status: Mildly anxious or agitated

2.46 Diagnosis of 3 stage of hemorrhagic shock Severe

B46
• Blood loss: 30%-40%
• Amount lost: 1500,0-2000,0ml
• % of body weight: 2,0 -2,5 %
• Pulse -140 beats per min;
• BP - <70 mmHg;
• CVP-<40 mmHg;
• Diuresis-< 30 ml per hour (anuria)
• Mental Status: Confused, agitated

2.47 Diagnosis of 4 stage of hemorrhagic shock Considerable

B47
• Blood loss: 40%
• Amount lost: 2000, 0
• % of body weight: > 2,5 %
• Ps -140 beats per min;
• BP-<50 mm Hg;
• CVP-0;
• Diuresis-anuria
• Mental Status:
• Obtunded, lethargic

2.48 Complications of placenta previa

B48
2.49 Differential diagnosis of amenorrhea
B49
2.50 Symptoms of dysfunctional uterine bleeding
B50
ABNORMAL uterine bleeding with no demonstrable organic cause, genital or extragenital. It
is a Diagnosis of EXCLUSIO N. Can be ovulatory or anovulatory
. heavy menstrual bleeding
. bleeding that contains many clots or large clots
. bleeding that lasts more than seven days
. bleeding that occurs less than 21 days from the last cycle
• spotting
. bleeding between periods
Other common symptoms that can occur with DUB are:
. breast tenderness
. bloating
• pelvic pain or pressure

2.51 Differential diagnosis of dysfunctional uterine bleeding

B51
• Endocrine disturbances
• Polycystic ovary disease
• Stress
• Extreme weight changes
• Long-term drug use
 • Anatomic abnormalities

2.52 Diagnosing of juvenile bleeding

B52
• In many girls with juvenile uterine bleedings the fibrous-cystic mastopathy is found,
that's why the examination of breasts in such patients is obligatory.

• In patients with hypoestrogenic type of bleeding mucous membrane is pale-pink, uterine

cervix is conic in shape, "pupil" and "fern" symptoms are positive, bloody excretions are
not significant and without mucus. During the rectal-abdominal examination uterine size
corresponds to the age, an angle between the body and cervix is not expressed, ovaries
are not palpated.

• In patients with hyperestrogeny type of bleeding mucous membrane of vagina is pink

coloured, the vaginal folds are well expressed, uterine cervix is cylindrical in shape,
"pupil" and "fern" symptom +++ or ++++. There are plenty of bloody excretions with
mucus admixtures. At rectal-abdominal examination uterus is slightly enlarged, an angle
between its body and cervix is clearly expressed, ovaries may be enlarged comparing to
the age norm.

• On sonogram the uterus exceeds an age norm, ovaries are considerably greater, than in
healthy girls, and there are small cysts compartments in them.

• Estrogens secretion by urine is decreased, concentration of Progesterone in serum is also

 decreased.

• Hysteroscopy shows hyperplasia and polyps of endometrium, rough uterine contours.

2.53 symptoms of premenstrual syndrome

B53
• Behavioral: Mood lability, Food cravings, Increased appetite, Oversensitivity, Anger,
Crying easily, Feeling isolated

• Psychological: Irritability, Fatigue, Anxiety/tension, Depression, Forgetfulness, Poor

concentration

• Physical: Fatigue, Bloating, Breast tenderness, Acne, Swelling, Headache, GI

symptoms, Hot flashes, Heart palpitations, Dizziness

Signs and symptoms

* Emotional changes
— Depression
— Anxiety
- Anger
— Suicide
* Behavioural changes
— Withdrawn
- Physical & verbal aggression
* Breast tenderness
* Gastrointestinal
- Bloated
— Fluid retention
— Constipation/diarrhoea
— Nausea

2.54 Diagnosing of premenstrual syndrome

B54
Diagnosis is done Based on the somatic and affective symptoms.
If there’s;
• >1 somatic and affective symptom 5 days prior to menses x 3 cycles o Somatic:
Depression, anger, irritability, confusion, social withdrawal, fatigue o Affective: breast
 tenderness, bloating, headache, swelling
• Resolve within 4 days onset of menses and symptom free until day 12 of cycle
• Not due to medications, drugs or ETOH use
• Causes Dysfunction: Marital, parenting, work/school attendance/performance,
isolation, legal difficulties, suicidal ideation
2.55 Differential diagnosis of premenstrual syndrome
B55
psychiatric disorder
Medical condition:
• Dysmenorrhea
• hyper- or hypo- thyroidism
• Peri-menopause
• Migraine
• Chronic fatigue syndrome
• Irritable bowel syndrome

• Drug abuse
2.56 Symptoms of climacteric syndrome
B56
Climacteric is the period of life starting from the decline in ovarian activity until
after the end of ovarian function. According to the definition, the period includes
peri-menopause, menopause and postmenopause

Symptoms are;
• Amenorrhea for atleast 12month

• Menstrual irregularity, vasomotor instability, hot flushes, irritability, increased

weight, painful breasts, dyspareunia, increased/decreased libido, atrophy of
urogenital epithelium and skin. Urinary incontinence, Night sweats.

• Weight gain,
• Psychological symptoms include anxiety, poor memory, inability to concentrate,
depressive
mood, irritability, mood swings, less interest in sexual activity.

•
2.57 Differential diagnosis of climacteric syndrome

B57
• Adjustment Disorders
• Anemia
• Depression
• Dysthymic Disorder
• Hypothyroidism
• Dementia
• Depression secondary to a general medical condition
• Endocrine disorders (eg, hypothyroid)
• Substance abuse
• Use of medications, such as beta-blockers

Differential Diagnosis of Menopausal Symptoms-1

Hot flushes, vasomotor sy m ptom s Vaginal dryness, dyspareunia

1. Hyperthyroidism 1. Bacterial vaginosis

2. Pheochromocytoma 2. Yeast infection
3. Febrile illness 3. Pelvic pathology
A. Anxiety and A. Poor vaginal lubrication
psychological symptoms 5. Marital discord

2.58 Clinic of endometriosis

B58
• .Painful periods (dysmenorrhea). Pelvic pain and cramping may begin before
your period and extend several days into your period. You may also have lower
back and abdominal pain.
• Pain with intercourse. Pain during or after sex is common with endometriosis.
• Pain with bowel movements or urination. You're most likely to experience
these symptoms during your period.
• Excessive bleeding. You may experience occasional heavy periods
(menorrhagia) or bleeding between periods (menometrorrhagia).
• Infertility. Endometriosis is first diagnosed in some women who are seeking
treatment for infertility.
• Other symptoms. You may also experience fatigue, diarrhea, constipation,
bloating or nausea, especially during menstrual periods.

2.59 Diagnosis of endometriosis

B59
• Abdomen: Diffuse or focal tenderness, rarely tender masses (e.g. in post CS
scar)
• Uterus: Retroverted, fixed/with decreased mobility, tender
• Adnexae: Enlarged, fixed/with decreased mobility, tender
• Other findings: Nodularity or focal tenderness in the cul-de-sac, recto-vaginal
septum, or over utero-sacral ligaments
• Laparoscopy is generally used to confirm diagnosis - hallmarks of the
disease are peritoneal or retroperitoneal implants, adhesions and
endometriomas
• Increased concentrations of CA-125 and placental protein 14 (PP14) have
been related specifically to the presence of endometriotic cysts and deep
endometriosis.

2.60 Differntial diagnosis of endometriosis

B60

Table 4. Differential Diagnosis of Symptoms Commonly Associated with

Endometriosis
Symptom Selected alternative
Adnexal diagnoses
Benign and malignant ovarian
masses cysts, hydrosalpinges
Chronic lower Irritable bowel syndrome,
abdominal pain adhesions, pelvic vascular
Chronic lower Musculoskeletal strain
Dyschezia (i.e., Constipation, anal fissures
difficulty with
Dysmenorrhea Adenomyosis, physiologic
Dyspareunia Psychosexual problems,
Dysuria Urinary
vaginaltract infection,
atrophy, infectious
Infertility Anovulation, luteal phase
deficiency, cervical or tubal
Adapted with permission from Farquhar C. Endometriosis. BMJ.
2007;334(7587):249.

2.61Diaqnosis of benign breast disease

B61
• Fibrocystic breast changes: Your breasts will feel lumpy and Inside your
breasts, the lumps are made up of a fibrous, rubber-like, thick tissue, or a fluid-
filled cyst.
• Fibroadenomas: This will feel like a small, round, moving marble in your breast.
• Cysts: These are fluid-filled lumps in your breasts that may be tender when you
touch them. You may notice that they appear and disappear each time you have
your period.
• Mastitis: You may feel a lump in your breast. The lump may appear red and
warm. People diagnosed with mastitis typically have a fever.
• Fat necrosis: This is a lump that may feel round and hard. It happens when fatty
tissue turns
hard. It’s common in women who are extremely overweight. Sometimes, these
lumps are the result of an injury to your breast. It may be filled with fat.
• Nipple discharge: The fluid coming from your nipple may be different colors. A
clear or milky color represents a problem with your hormones. If the discharge is
green-black, it may represent a blocked milk duct. If the discharge is bloody, it
could be related to an injury, infection, or benign tumor. It also can be associated
with breast cancer.
• Calcification: You may or may not feel these tiny, hard spots in your breast.
They are due to leftover, hardened calcium deposits in your breast. Eating or
drinking too much calcium does not cause it. Most are benign. However, some
calcification can be a sign of cancer.
• Hyperplasia, adenosis, intraductal papilloma, and lipoma: You will likely feel
breast pain and lumps with these less common, benign breast conditions

2.62 Clinical features of of uterine leiomyoma

B62
Many women who have fibroids don't have any symptoms. Symptoms can be
influenced by the location, size and number of fibroids, symptoms of uterine
fibroids include:
• Heavy menstrual bleeding
• Menstrual periods lasting more than a week
• They may cause excessive or prolonged heavy periods, leading to iron-deficiency
anaemia and therefore lethargy and pallor. Larger fibroids, no matter their
position, appear to be more likely to cause menorrhagia, possibly due to a
variety of growth factors promoting angiogenesis.
• Pedunculated submucosal fibroids may cause persistent intermenstrual
bleeding.
• Pelvic pressure or pain
• Frequent urination
• Difficulty emptying the bladder
• Constipation
• Backache or leg pains Examination:
• Palpable abdominal mass arising from the pelvis.
• Enlarged, often irregular, firm, non-tender uterus palpable on bimanual
pelvic examination.
• Signs of anaemia due to menorrhagia.
2.63 Differential diagnosis of uterine leiomyoma
B63
• Dysfunctional uterine bleeding.
• Endometrial polyps, endometrial cancer.
• Endometriosis.
• Chronic pelvic inflammatory disease.
• Tubo-ovarian abscess.
• Uterine sarcoma.- Abnormal uterine bleeding, pelvic pain/pressure, and a pelvic
mass are the primary presenting symptoms and signs for both leiomyomas and
sarcoma, • Ovarian tumour.
• Pelvic masses (other causes of a pelvic mass include tumour of the large bowel,
appendix abscess, and diverticular abscess).
• Pregnancy
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 Pain before Heavy or
and during prolonged
periods periods with
Fatigue Fatigue due to
anemia

Painful Frequent
urination urination
during periods
Painful sexual
Painful sexual
intercourse
intercourse
depending on
location of
Painful bowel Constipation
movement and bloating
during penoos
2.64 Diagnosis of benign cervical lesions
B64
Algorithm for investigation for all cervical lesions
• Speculum exam
• Pap smear, bacterioscopy
• Visual inspection after application acetic solution
• Colposcopy
• Biopsy
• Pelvic examination

**Benign cervical Lesions(BCL): Are non cancerous cervical

tumors that don’t metastasize or invade the surrounding
tissues & not a life threatening conditions.
The following are examples of the BCL: Cervical polyps, Cervical
ectropion. Cervical fibroids, Cervical stenosis & Nabothian
follicles.

2.65 Diagnosis of dysplasia

B65
If a biopsy shows dysplasia, it’s then classified as cervical
intraepithelial neoplasia (CIN). Now Based on biopsy
• CIN 1 refers to the presence of dysplasia confined to the basal 1/3
of the cervical lining, or epithelium (formerly called mild
dysplasia). This is considered to be a low-grade lesion.
• CIN 2 is considered to be a high-grade lesion. It refers to
dysplastic cellular changes confined to the basal 2/3 of the lining
tissue (formerly called moderate dysplasia).
• CIN 3 is also a high grade lesion. It refers to precancerous
changes in the cells encompassing greater than two-thirds of the
cervical lining thickness, including full-thickness lesions that were
formerly referred to as severe dysplasia and carcinoma in situ
A colposcopy is an in-office procedure that allows the doctor to get
a very close view of your cervix. A vinegar solution is applied to the
cervix and a special light is used. This makes any abnormal cells
stand out.
Pap test results will indicate a squamous intraepithelial lesion (SIL).
This means cellular tissue damage or dysplasia.
There are different categories of SIL, including:
• low-grade SIL (LSIL)
• high-grade SIL (HSIL)
• possibility of cancer
• atypical glandular cells (AGUS)

2.66 Diagnosis of the ovary tumors

B66
• Speculum investigation
• Bimanual examination / Pelvic exams
• Uterine sounding.
• a blood test (for CA-125 and sometimes other markers)
• Imaging tests.- such as
1. Ultrasonography( transvaginal ultrasound, 2. Laparoscopy may
help determine the size, shape and structure of your ovaries.

• The diagnosis must be confirmed with surgery to inspect the

abdominal cavity, take biopsies (tissue samples for microscopic
analysis), and look for cancer cells in the abdominal fluid. This helps
to determine if an ovarian mass is benign or malignant.

2.67 Differential diagnosis of the ovary tumors

B67
• Hydrosalpinx/pyosalpinx
• Low-lying cecum
• Metastatic gastrointestinal carcinoma
• Ovarian torsion
• Pelvic abscess
• Pelvic kidney
• Peritoneal cyst
• Retroperitoneal mass
• Urachal cyst
• Uterine anomalies
• Uterine fibroids

2.68 Clinical features of gestational trophoblastic disease

B68
• Metastasis to the lower genital tract presents as purple to blue-
black papules or nodules, which are extremely vascular and
 may bleed profusely if biopsied
• Abdominal tenderness, if liver or gastrointestinal metastases
have occurred
• Abdominal guarding and rebound tenderness, if a
hemoperitoneum has occurred due to bleeding from an
abdominal metastasis
• Bleeding from a metastasis could also result in signs and
symptoms of hemorrhagic shock
• Neurologic deficits, from lethargy to coma, if brain metastasis
has occurred
• Jaundice, if liver metastasis causes biliary obstruction

2.69 Diagnosis of gestational trophoblastic disease

B69
Laboratory studies used in the diagnosis of GTN are as follows:
• Serum quantitative hCG - To assess response to therapy and
disease status
• CBC - May help detect anemia secondary to bleeding
• Liver enzymes - May become elevated in patients with
metastasis to the liver
• Imaging studies
Instrumental Images
• Pelvic ultrasonography - May show persistent molar tissue in
the uterus
• Chest radiograph - Recommended because the lung is the most
frequent site of metastasid
• CT scan of the chest (optional)
• CT scan of the abdomen and pelvis with contrast
• MRI of the head (preferable to CT)
2.70 Symptoms of cervical cancer
B70
• Blood spots or light bleeding between or following periods
• Menstrual bleeding that is longer and heavier than usual
• Bleeding after intercourse, douching, or a pelvic examination
• Increased vaginal discharge
• Pain during sexual intercourse
• Bleeding after menopause
• Unexplained, persistent pelvic and/or back pain

2.71 Symptoms of ovarian cancer

B71
• bleeding from the vagina that isn't normal (such as heavy or
irregular bleeding, bleeding between periods), especially after
menopause
• frequent discharge from the vagina that is clear, white or
coloured with blood
• a lump that can be felt in the pelvis or abdomen
• bladder problems such as the need to urinate often and the
urgent need to urinate
• constipation
• changes to digestion such as difficulty eating, feeling full after
a small meal, heartburn, gas, indigestion or nausea
• frequent feeling of pressure in the pelvis or abdomen
• fatigue
• pain in the legs, lower back, pelvis or abdomen
• pain when having sex
• swelling of the abdomen
 • weight loss
• buildup of fluid in the abdomen (ascites), around the lungs
(pleural effusion) or in the legs (lymphedema)
difficulty breathing

2.72 Symptoms of endometrial cancer

B72
• Vaginal bleeding after menopause
• Bleeding between periods
• An abnormal, watery or blood-tinged discharge from your
vagina
• Pelvic pain

2.73 Differential diagnosis of benign and malignant ovarian tumors

B73
• Adnexal Tumors
• Ascites
• Borderline Ovarian Cancer
• Colon Cancer
• Colonic Obstruction
• Ectopic Pregnancy
• Endometriosis
• Gastric Cancer
• Ovarian Cysts
• Pancreatic Cancer
• Pelvic Inflammatory Disease
• Peritoneal Cancer
 • Urinary Tract Obstruction
• Uterine Cancer
• Uterine Leiomyoma (Fibroid)

2.74 Symptoms of special forms of ovarian tumors

B74
• Androblastoma: breast, uterine and female external genitalia
atrophy, amenorrhea, masculinizing features.
is a masculinizing tumor
• Thecoma: menopausal bleeding, enlarged uterus and breasts,
increased libido, impaired menstrual function .infertility, pregnancy
loss.
• Folliculoma: Symptoms depend on the level of
hyperestrogenemia and on the women age. The girls have the signs
of precocious puberty. In reproductive age group women
amenorrhea, acyclic bleeding, and later menopausal uterine bleeding
may be present.
• Dermoid cysts: No symptoms are common for small sizes
tumors.Pain in case of large cysts. Small cysts are asymptomatic.
• The Brenner tumor: postmenopausal bleeding.

Diagnosis : Bimanual examination, ultrasonography and laparoscopy

Treatment
: surgical
2.75 Differential diagnosis of endometrial cancer

B75
In early disease, uterine cancer must be differentiated from other
diseases causing endometrial thickening:
 • Benign endometrial proliferation
• Endometrial hyperplasia

• Endometrial polyp

• Submucosal uterine leiomyoma

In advanced disease, uterine cancer must be differentiated from other diseases:

• Uterine sarcoma

• Endometrial stromal sarcoma (ESS)

• Leiomyosarcoma of the uterus

• Malignant mixed Mullerian tumour (MMMT) of the uterus

2.76 Interprtation of Pap smear

B76
The main purpose of a Pap smear test is to identify cellular changes in the cervix, which
could be caused by HPV. By detecting cervical cancer cells early with a Pap smear,
treatment can start before it spreads and becomes a bigger concern. It's also possible to
test for HPV from the Pap smear specimen, too.
 PAP SMEAR
It’s
Importance

• Pap smear test is important because it

detects cervical cancer which is treatable if
detected early
• Having regular smear is important
because cervical cancer rarely has
symptoms before it spreads to other parts in
the body
• Pap smear can also spot cells that have the
potential to turn cancerous over time and stop the disease before it even has a

chance to develop
• Pap tests should be performed every three years for patients between the ages of 21 and
29
• After age 30, the Pap test should be combined with the test that looks for HPV, which
can cause cervical cancer
• Consult your doctor to determine the screening program that works best for you
PAP smear: It is used as a screening procedure of cervical pathology.

PROCEDURE: The patient is put into lithotomy position. The cervix is exposed with
speculums. The cytological material from the cervix by Ayre’s spatula or cervix brush is
collected from the squamo-columnar junction, and put on the glass slide. Then the material is
fixed and sent to the cytological laboratory. The results according to the Papanicolau
classification are:
I. - normal,
II. a- inflammatory process
II. b - mild dysplasia
III. a - moderate dysplasia
III b - severe dysplasia
IV - carcinoma in situ V-
cancer.
VI - smear is not informative
USES
Is a procedure to test for cervical cancer in women.
2.77 Diagnostic criteria of acute bartholinitis
B77
• Redness around the exit site of the excretory duct of the gland - while the patient's state
of health does not change.
• The palpation of the enlargement of the excretory duct of the gland - while pressing from
it a small amount of pus is released
• Strong pain in the area of that large labia, where the abscess developed - it is so
pronounced that the patient experiences real pain when walking, sitting and stepping off a
chair.
Dyspareunia.
• Raise body temperature to 39 degrees.
• Weakness, chills, weakness
Laboratory
• smear on bioflora - is done just to identify the bacteria
• a common blood test - left shift leukocytosis
• general urine analysis - to identify the risk of infection in the urinary system;

2.78Diagnostic criteria of endometritis

B78
• Fever
• Lower abdominal pain
• Foul-smelling lochia in the obstetric population
• Abnormal vaginal bleeding
• Abnormal vaginal discharge
• Dyspareunia (may be present in patients with pelvic inflammatory disease [PID])
• Dysuria (may be present in patients with PID)
• Malaise
Additional
• smear on bioflora - is done just to identify the "inmates" of pathology;
• a common blood test - left shift leukocytosis, increased ESR
• general urine analysis - to identify the risk of infection in the urinary system;
• Acute endometritis is characterized by the presence of neutrophils within the
endometrial glands.
• Chronic endometritis is characterized by the presence of plasma cells and
lymphocytes within the endometrial stroma.
2.79 Diagnostic criteria of pelvic inflammatory disease
B79
• Abdominal pain (usually bilateral and in the lower quadrants), Onset of pain in
association with menses,
• Menometrorrhagia: is a condition in which prolonged or excessive uterine bleeding
occurs irregularly and more frequently than normal
• Vaginal discharge (purulent),
• Dyspareunia,
• Dysuria,
• Fever, and/or chills, • Nausea or vomiting.
• Painful palpation of the uterus and appendages during bimanual examination
Additional
• a common blood test - left shift leukocytosis, increased ESR
• Culdocentesis generally is productive of “reaction fluid” (cloudy peritoneal fluid) which,
when stained, reveals leukocytes with or without gonococci or other organisms.
• Ultrasound: incomplete septation of the tubal wall (“cogwheel sign”) is a marker for
acute disease, and a thin wall (“beaded string”) indicates chronic disease.

2.80 Diagnostic criteria of Parametritis

B80
• Moderate tenderness in lower parts of abdomen, in back, high body temperature (38-
39°C), tachycardia are found.
• Signs of peritoneal irritation are diminished or absent bowel sounds, especially
associated with ileus, indicate more serious infection, including the possibility of
abscess formation.
• Bimanually before or behind on left or right side of the uterus infiltration may be
palpated. It is firm and immovable. Infiltration is classified into anterior, posterior
and lateral.
• It is obligatory to perform a rectal-vaginal examination, in which it is necessary to reveal
the prolapse of the infiltrate or abscess in the direction of the rectum and
determine the condition of the mucosa above it (mobile, limited mobile,
immovable), which reflects the fact and extent of involvement in the inflammatory
process of the anterior or lateral walls of the rectum.

2.81 Diagnostic criteria of unruptured ectopic pregnancy

B81
• Abdominal pain- reported in abdomen, back, shoulder
• Amenorrhea-
• Vaginal bleeding- withdrawal bleeding secondary to separation of placenta from its
implantation site w/ declining hormonal support of endometrium or tubal rupture
• Abdominal tenderness- • Adnexal fullness or mass
• Transvaginal and transabdominal ultrasound: Diagnosis of ectopic only if gestational sac
can be identified and localized outside the uterus

Ectopic pregnancy- is when a fertilised egg implants itself outside of the womb, usually in
one of the fallopian tubes.
General symptoms of Ectopic pregnancy
• Pain
• Abnormal menses (amenorrhoea)
• Irregular bleeding
 • • Pregnancy symptoms
Signs -afebrile ,abdominal tenderness, rebound tenderness palbable mass
access
Signs and Symptoms of
Un ruptured Ectopic Pregnancy

• Symptoms of early pregnancy

- Irregular spotting or bleeding
-Nausea
- Swelling of breasts
Bluish discoloration of vagina and cervix
- Softening of cervix
Slight uterine enlargement
Increased urinary frequency
• Abdominal and pelvic pain

Unruptured ectopic pregnancy Ruptured ectopic pregnancy

• Symptoms o* early prcgpancy
(irregular spotting or Needing
nausea, ot breasts, bluish
dtscolorabon of vagina and cervn.
softer eg of cervix, < ght utenne
enlargement. increased urinary
frequency)
• Abdominal and peMc pain
• Corapse and weakness
• fast weak pulse <110 per minute or
morel
• Hypctensron
• Hypovolaemia
• Acute abdominal and peMc pain
• Aoco’niral dtstensron1
• Rebound tenderness

Vaginal Bleeding in Early 2

Pregnancy

Symptoms and Mftns of ruptured and unruptured ectoprc pregnancy

• Pallor
2.82 Diagnostic criteria of ruptured ectopic pregnancy
B82
• Lower Abdominal pain of varying severity
• Period of Amenorrhea usually 6-10weeks • Recurrent Vaginal bleeding
• Abdomen:
Distension
Rigidity
Tenderness, rebound tenderness, Involuntary guarding
• Evidence of hypovolemic shock (eg, orthostatic blood pressure changes, tachycardia)
• Aspiration of nonclotting blood with hematocrit greater than 15% signifies ruptured
ectopic pregnancy through culdocentesis

• Laparoscopy: when signs are equivocal laparoscopy confirmation may be necessary as free
blood will be seen in the pouch of douglas
• Abdominal ultrasound scan shows: empty bulky uterus with a pseudo-sac or endometrial
sac
blood clot in peritoneal cavity
free fluid in the pouch of douglas and abdominal recesses

2.83 Diagnostic criteria of ovarian apoplexy

B83
Ovarian Apoplexy is the rupture of the ovary, which often occurs in the middle or in the
second phase of the menstrual cycle.
Signs and symptoms :
• Sudden, aching pains, mostly one-sided, often with radiation into the epigastric region.
• Positive frenicus-symptom.
• Weak tension of the abdominal wall of the lower abdomen.
• Weakness, cold sweat, nausea, vomiting.
• Signs of increasing anemia (tachycardia, acrocyanosis, pallor).
• progressing of hemorrhagic shock.
On examination: there is marked soreness of the affected ovary, and positive symptoms of
irritation of the peritoneum.
Pelvic ultrasound reveals in the affected ovary a large corpus luteum cyst with signs of
hemorrhage in it and/or free fluid (blood) in the abdominal cavity.
decrease in hemoglobin levels in CBC

2.84 Diagnostic criteria ofOVARIAN TORSION

B84
Definitive
diagnosis is by laparoscopy:
• The abdomen is very tender, and localized rebound tenderness can be noted in the lower
quadrants.
• The most important sign is the presence of a large pelvic mass on physical examination
• Mild temperature elevation and leukocytosis may accompany the infarction. The diagnosis
must be suspected in any woman with acute pain and unilateral adnexal mass.
• ultrasound findings include an enlarged ovary, ovarian mass, free fluid, follicles at the

periphery of an enlarged ovary, thickening of a cyst wall, and a twisted pedicle

• An enlarged ovary with or without an underlying mass and a twisted pedicle and findings
of torsion on ultrasound, are also seen on CT or MRI.
2.85 Diagnostic criteria of rupture of ovarian cyst
B85
Hypovolemia is present only when there is a hemoperitoneum.
• The most important sign is the presence of significant abdominal tenderness, often
associated with rebound tenderness because of peritoneal irritation.
• The abdomen can be moderately distended with decreased bowel sounds.
• On pelvic examination, a mass is often present if the cyst is leaking and not completely
ruptured.

2.86 Diagnostic criteria of vaginitis caused by Tr.Vaginalis

B86
• At acute and subacute forms women complain of foamy yellowish vaginal discharge with

foul odor, vulvar itching, dysuria. Objective data: erythema, maceration, vulva, perineum
scratching, cervical erosion, erythema and edema of vaginal mucosa, foamy purulent
discharge. At torpid forms clinical manifestations are mild or absent.
• Chronic trichomoniasis is characterized by vaginal discharge, itching, but there are no
inflammatory manifestations, there can be frequent relapsing.
• Presence of Tr. Vaginalis in vaginal smear

2.87 Diagnostic criteria of bacterial vaginosis

B87
In clinical practice BV can be diagnosed using the Amsel criteria:
• Thin, white, yellow, homogeneous discharge
• Clue cells on microscopy
• pH of vaginal fluid >4.5
• Release of a fishy odor on adding alkali—10% potassium hydroxide (KOH) solution.
• At least three of the four criteria should be present for a confirmed diagnosis

2.88 Indications for culdocentesis

B88
• To diagnose suspected leaking or ruptured ectopic pregnancy in the following clinical
situations: o Hemodynamically unstable patients when ultrasonography is not immediately
available o When ultrasonography or laparoscopy is not available
• In place of diagnostic peritoneal lavage to detect hemoperitoneum following blunt
abdominal trauma, particularly in patients with previous abdominal surgery.
• To diagnose ruptured ovarian cysts in patients with sudden onset of pelvic pain, sometimes
following intercourse or a pelvic examination, or occurring mid-cycle.
• To obtain fluid for culture to aid in the diagnosis and treatment of pelvic inflammatory
disease (PID).
• For diagnosis and treatment of ascites

2.89 Uterine atony: clinical signs

B89

Uterine atony occurs when the myometrium cannot contract and it’s the most common
cause of postpartum hemorrhage.
Clinical signs:
Uterus will be difficult to feel and if found, will feel soft and boggy
Fundal height may be high
Lochia is increased and may contain blood clot
excessive hemorrhage
Decrease blood pressure
Tachycardia
Abdominal pain
Backache

2.90. Couvelaire Uterus: clinical signs

B90
Couvelaire uterus also known as uteroplacental apoplexy is associated with the severe form of
concealed placenta abruption where there is a massive extravasation of blood into the uterine
myometrium up to the serous coat or peritoneal cavity and it can only be diagnosed on
laparotomy Clinical signs:
• uterine hypertonus,
• fetal distress, • fetal death,
• and rarely, hypovolemic shock (shock secondary to severe blood loss).
• The uterus may adopt a bluish/purplish, mottled appearance due to extravasation of blood
into uterine muscle.
• pain secondary to uterine contractions,
uterine tetany or localized uterine tenderness.
III group of questions
1. The manual aid by Tsovyanov I on the labor in the frank breech presentation.
C1
2. The classic manual aid in labor in breech presentation.
C2
 3. The manual aid by Tsovyanov II in labor in the footling breech presentation.
C3

4. Management of pregnancy in breech presentations.

C4
5. Management of pregnancy with oblique lie.
C5
6. Management of pregnancy with transverse lie.
C6
7. Management of labor in sinciput vertex presentation.
C7
 8. Management of labor in brow presentation.
C8

9. Management of labor in face presentation.

C9
CHIN-ANTERIOR POSITION
 If the cervix is fully dilated:
- Allow to proceed with normal childbirth;
- If there is slow progress and no sign of obstruction augment labour with
oxytocin;
 - If descent is unsatisfactory, deliver by forceps.
 If the cervix is not fully dilated and there are no signs of obstruction, augment labour
with oxytocin. Review progress as with vertex presentation.
CHIN-POSTERIOR POSITION
 If the cervix is fully dilated, deliver by caesarean section.
 If the cervix is not fully dilated, monitor descent, rotation and progress. If there are
signs of obstruction, deliver by caesarean section.
 If the fetus is dead:
- Deliver by craniotomy;
- If the operator is not proficient in craniotomy, deliver by caesarean section.

10. Management of pregnancy and labor with polyhydramnios.

C10
Determine underlying cause
Screen for maternal disease/infection Complete fetal U/S evaluation
Depends on severity
Mild to moderate cases require no treatment
If severe, hospitalize and consider therapeutic amniocentesis
 Drainage of excess amniotic fluid: Amniocentesis
 Oral medication indomethacin (Indocin) to help reduce fetal urine production and
amniotic fluid volume. Indomethacin isn't recommended beyond 31 weeks of
pregnancy
 Early amniotomy (artificial rupture of membranes) is recommended to prevent
uterine contractions abnormalities. In the third stage of labor contractile drugs for
prevention of early postpartum hemorrhage are used.

11. Management of pregnancy and labor with oligohydramnios.

C11
Always warrants admission and investigation
Rule out ROM (rupture of membranes)
Fetal monitoring (NST non-stress test, BPP biophysical profile)
U/S Doppler studies (umbilical cord and uterine artery)
Maternal hydration with oral or IV fluids to help increase amniotic fluid
Injection of fluid via amniocentesis will improve condition for ~1 wk – may be most
helpful for visualizing any associated fetal anomalies
Consider delivery if term
Amnio-infusion may be considered during labour via intrauterine catheter

12. Management of pregnancy and labor with multiple-pregnancy

C12
 Diet: additional 300 K cal per day, increased proteins, 60 to 100 mg of iron and 1 mg
of folic acid extra
 Increased rest
 Fetal surveillance by USG – every 4 weeks
 Hospitalization not as routine
 Corticosteroids -only in threatened preterm labor , same dose
 Fetal surveillance, including fetal heart rate monitoring, biophysical profiles, and
umbilical cord Doppler measurements, is available when indicated.
 Cesarean delivery is recommended for twins unless the presenting twin is in
vertex presentation.

. Management
• U/S determination of chorionicity must be done within T1(ideally8-12wkGA)
• increased antenatal surveillance
■ serial U/S q3-4 wk from 22 wk GA to assess growth (uncomplicated diamniotic
dichorionic)
■ increased frequency of U/S in monochorionic diamniotic and monochorionic
monoamniotic twins
■ Doppler flow studies weekly if discordant fetal growth (>30%)
■ BPP as needed
• may attempt vaginal delivery if twinA presents as vertex, otherwise CD (40-50% of all
twin deliveries, 10% of cases have twin A delivered vaginally and twin B delivered by
CD)
• mode of delivery depends on fetal weights, GA, and presentation

13. Management of pregnancy with clinical(functional)contracted pelvis.

C13
 14. Principles of pregnancy management in contracted pelvis.
C14
Management based on true conjugate levels
Four degrees of pelvic contractions should be distinguished:
 I degree – True conjugate is 11-9 cm. Vaginal delivery is possible.
 II degree – True conjugate is 9-7,5 cm. Vaginal delivery is possible.
 III degree – True conjugate is 7,5 – 5,5 cm Cesarean section is performed.
 IV – degree – True conjugate is 5.5 cm. Cesarean section is performed.

15. Principles of labor management in contracted pelvis

C15
 Mild to moderate contraction: Vaginal delivery. Severe contraction: c-section
 Management in the case of clinically contracted pelvis – only cesarean section
 Flat pelvis: In the case of posterior asynclitism cesarean section should be performed.
Vaginal delivery in a flatrachitic pelvis
 Generally contracted flat pelvis: C-section
.
16. Peculiarities of labor duration in multiple gestation.
C16
 Prelabour rupture of the membranes
 Cord prolapse
 In coordinate uterine contractions
 Increased operative interference
 Placental abruption after delivery of 1st baby
 Postpartum haemorrhage

17. Management of labor in multiple gestation

C17
. Management
• U/S determination of chorionicity must be done within T1(ideally8-12wkGA)
• increased antenatal surveillance
■ serial U/S q3-4 wk from 22 wk GA to assess growth (uncomplicated diamniotic
dichorionic)
■ increased frequency of U/S in monochorionic diamniotic and monochorionic
monoamniotic twins
■ Doppler flow studies weekly if discordant fetal growth (>30%)
■ BPP as needed
• may attempt vaginal delivery if twinA presents as vertex, otherwise CD (40-50% of all
twin deliveries, 10% of cases have twin A delivered vaginally and twin B delivered by
CD)
• mode of delivery depends on fetal weights, GA, and presentation
 FIRST STAGE: blood to be cross matched and ready. Confined to bed, oral fluids or
npo. intrapartum fetal monitoring
 SECOND STAGE –
o Delivery of first baby: start an IV line. Secure cord clamping at 2 places
before cutting. ensure labeling of 1st baby
o Delivery of second twin: wait for uterine contractions. conduct delivery
o Delivery of second twin – problems & interventions
 -Inadequate contraction- augmentation – ARM, oxytocin
 -Transverse lie – ECV, IPV
 -Fetal distress, abruption, cord prolapse- expedite delivery – forceps,
breech extraction
 THIRD STAGE – AMTSL
o continue oxytocin drip
o carboprost 250µgm IM
o monitor for 2 hours
18. Principles of hypotonic uterine dysfunction’ management.
C18
19. Principles of hypertonic uterine dysfunction management
C19

administration of analgesics such as morphine, meperidine (Demerol), or nalbuphine

(Nubain) to inhibit uterine contractions

Tocolytic Agents (Kaplan )

•Parenteral agents may prolong pregnancy but for no more than 72 h. This does provide a
window of time for
(1) administration of maternal IM betamethasone to enhance fetal pulmonary surfactant
and
(2) transportation of mother and fetus in utero to a facility with neonatal intensive care.
Oral tocolytic agents are no more effective than placebo.
•Magnesium sulfate is a competitive inhibitor of calcium. Clinical monitoring is based
on decreasing but maintaining detectable deep tendon reflexes.
–Side effects include muscle weakness, respiratory depression, and pulmonary edema.
Magnesium overdose is treated with IV calcium gluconate.
–Contraindications include renal insufficiency and myasthenia gravis.
•β-Adrenergic agonists include terbutaline. Tocolytic effect depends on the β2-
adrenergic receptor myometrial activity.
–Cardiovascular side effects (hypertension, tachycardia) are from β1 receptor cardio-
vascular activity. Other side effects are hyperglycemia, hypokalemia, and pulmo- nary
edema.
–Contraindications include cardiac disease, diabetes mellitus, uncontrolled
hyperthyroidism.
•Calcium-channel blockers decrease intracellular calcium (e.g., nifedipine).
–Side effects include tachycardia, hypotension, and myocardial depression.
–Contraindications include hypotension.
•Prostaglandin synthetase inhibitors decrease smooth muscle contractility by
decreas- ing prostaglandin production (e.g., indomethacin).
–Side effects include oligohydramnios, in utero ductus arteriosus closure, and neonatal
necrotizing enterocolitis.

20. Principles of ineffective maternal pushing efforts management

C20
.
21. Principles of postpartum septic complication treatment
C21

 Immediate hospitalization in ICU

 Rational correction of hemodynamics
 Infusion-transfusion therapy, balanced by volume: blood and blood components
 Maintenance of adequate ventilation and gas exchange
 Protection and restoration of vascular endothelium
 Surgical sanation of the focus of infection
 Normalization of intestinal function, early enteral nutrition
 Timely antibiotic therapy (broad spectrum)
 Timely correction of metabolic disorders
 Antimediator therapy and methods of efferent therapy: pentoxphyline,
 22. Complications caused by c-section.
C22

Intra‐operative –
 Blood loss >1 litre –Blood transfusion –
 Bladder/bowel laceration (also, ureters) –
 Hypo- or atonic condition of uterus
 Possible damage of venous plexus r uterine artery at transverse incision
Post‐operative –
 hemorrhage
 Thromboembolic
 Purulent-septic: (metroendometritis, leakage of uterine sutures, peritonitis, sepsis

23. Prevention and treatment of cervical lacerations.

C23
 Deep cervical tears should be repaired immediately. Treatment varies with the extent
of the lesion. When the laceration is limited to the cervix – or even when it extends
somewhat into vaginal fornix – satisfactory results are obtained by suturing the
cervix after bringing it into vie at the vulva.
 Visualization is best accomplished when an assistant applies firm downward pressure
on the uterus while the operator exerts traction on the lips of the cervix with
fenestrated ovum or sponge forceps.
 It is advisable to apply the first suture above 1-2 cm of the angle of the wound and
suture outward. Associated vaginal lacerations are repaired after the cervical tears.
Tamponade with gauze packs will retard hemorrhage from these lesions while
cervical lacerations are repaired. Chromic catgut sutures should be employed, since
they do not have to be removed.
 Prevention: use antispasmodics and analgesia during labor

24. Prevention and treatment of perineal lacerations

C24
 The technique of repairing a first-degree laceration start from the upper angle of the
wound. The mucous of the vagina is closed by interrupted catgut suture. A few
interrupted sutures are placed through the skin.
 At second-degree laceration repair begins from the interrupting suturing of the
muscles, after – the same technique as in the first-degree lacerations.
 At three-degree laceration the rectal mucous has been repaired with interrupted,
fine chromic catgut sutures. The torn ends of the sphincter ani are next
approximated with two or three interrupted chromic catgut sutures. The wound
is then repaired, as in a second degree laceration.
 Prevention: Perineotomy or episiotomy

25. Treatment of different types of uterine rupture by the location and degree.
C25

 Hysterectomy is usually required, but in highly selected cases suture of the wound
may be performed. The tear may be repaired if the patient strongly want to retain
fertility, if her condition is not jeopardized by continued hemorrhage, and if
competent repair is technically possible. The wound edges are approximated.
Suturing techniques are similar to those used for cesarean section. Vikryl suture
 In cases of lateral rupture involving lower uterine segment and uterine artery where
haemorrhage and haematoma obscure the operative field, ligation of the ipsilateral
hypogastric artery to stop bleeding may be needed

26. Management of marginal placenta previa.

C26
27. Management of total placenta Previa.
C27
28. Management placental abruption.
C28

Management
• maternal stabilization: large bore IV with hydration, O2 for hypotensive patients
• maternalmonitoring:vitals,urineoutput,bloodloss,bloodwork(hematocrit,CBC,PTT/PT,
fibrinogen, FDP, type and crossmatch)
• EFM
• bloodproductsonhand(redcells,platelets,cryoprecipitate)becauseofDICrisk
• Rhogam®ifRhnegative
■ Kleihauer-Betke test may confirm abruption
• abruption without fetal/maternalcompromise(mildabruption)
■ <37 wk GA: use serial hematocrit to assess concealed bleeding, deliver when fetus is
mature or when hemorrhage dictates
■ ≥37 wk GA: stabilize and deliver
• abruptionwithfetal/maternalcompromise(moderatetosevereabruption)
■ hydrate and restore blood loss and correct coagulation defect if present
■ vaginal delivery if no contraindication and no evidence of fetal or maternal distress
■ CD if live fetus and fetal or maternal distress develops with fluid/blood replacement,
labour fails to
progress, or if vaginal delivery otherwise contraindicated

29. Management of Uterine rupture.

C29
 Two large-bore intravenous infusion catheters are established, and crystalloid
solution, either lactated Ringer’s or saline, is infused vigorously;
 Type-specific whole blood is obtained in large quantities, and rapid infusion is begun
as soon as possible;
 If the uterine rupture does not extend to the lateral wall of uterus, suture the
rupture. If it extends then Ligation of vessels and hysterectomy is indicated.
30. Complications of Uterine rupture.
C30
 Postoperative infection.
 Damage to ureter.
 Amniotic fluid embolus.
 Massive maternal haemorrhage and disseminated intravascular coagulation (DIC).
 Pituitary failure.

31. principles of management of the third stage of labour bleeding.

C31
 (1) Uterotonic medication administered within one minute after delivery of baby after
ruling out presence of another fetus (10 U oxytocin i/m);
 ●(2) controlled umbilical cord traction and counter-traction to support the uterus until
separation and delivery of the placenta;
 ●(3) uterine massage after delivery of the placenta
32. principles of management of the early postpartumperiod bleeding
C32

 Primary survey of the mother (vital signs

  Uterine massage will stimulate uterine contractions and frequently stops uterine
hemorrhage.
 If lacerations or hematomas are found, direct pressure may help control bleeding.
 Actively bleeding perineal, vaginal, and cervical lacerations should be repaired.

 If uterine inversion occurs, gently push the uterus back into position.

33. Uterine contractile drugs

C33

. Oxytocin analogue: Carbetocin 1ml-100mcg

34. Treatment of postpartum haemorrhage dueto uterine atony

C34
This is done step by step from less invasive to more
 External uterine massage: every 15 minutes during the first 2 hours
 Mannual exploration of uterus
 Bimanual exploration of uterus
 Balloon tamponade for 24 hours
 Compressive sutures (B-linch)
 Ligation of vessels UterineOvarianinternal iliac artery
Carbetocin 1ml-100mcg

35. Management of I degree ofHaemorrhage shock

C35
 Install at least 2 i/v large diameter catheters (16-18 G)
 Collection of 10 ml of blood for laboratory tests (to determine blood group and Rh,
cross-compatibility, hemoglobin and hematocrit, perform Lee-White test before the
start of infusion solutions).
 Catheterization of bladder.
 Stop the bleeding by conservative or surgical methods depending on the cause of
bleeding
 Turn pregnant on the left side to prevent the development of aorto-caval syndrome,
reducing the risk of aspiration when vomiting and providing free airway.
 Start restoration of blood volume: Rapid infusion of crystalloid 1-2 liter and
modified gelatin to 1-1.5 liters . Max infusion of 2l. Shock 1-2 degrees - speed
100-200 ml / min.
 Warm woman, but does not overheat, because with improved peripheral
microcirculation, this may cause a decrease in blood flow to vital organs (B). Give
the large volume of solutions heated up to 36° C.
 Conduct inhalation of 100% oxygen at a speed of 6-8 l/min through a naso-facial
mask or nasal cannula. Hemorrhage stopping

36. Management of2 Iidegree of Hemorrhagic shock

C36
 Install at least 2 i/v large diameter catheters (16-18 G)
 Collection of 10 ml of blood for laboratory tests (to determine blood group and Rh,
cross-compatibility, hemoglobin and hematocrit, perform Lee-White test before the
start of infusion solutions).
 Catheterization of bladder.
 Stop the bleeding by conservative or surgical methods depending on the cause of
bleeding
 Turn pregnant on the left side to prevent the development of aorto-caval syndrome,
reducing the risk of aspiration when vomiting and providing free airway.
 Start restoration of blood volume: Rapid infusion of crystalloid 2 liter and
modified gelatin to 2-2.5 liters . Fresh frozen plasma 250ml, red cell mass 250ml.
Max fluids 3litres. Shock 1-2 degrees - speed 100-200 ml / min. Only then, if
necessary - fresh frozen plasma and red cell mass according to the current protocol
 Warm woman, but does not overheat, because with improved peripheral
microcirculation, this may cause a decrease in blood flow to vital organs (B). Give
the large volume of solutions heated up to 36° C.
 Conduct inhalation of 100% oxygen at a speed of 6-8 l/min through a naso-facial
mask or nasal cannula. Hemorrhage stopping

37. Management of III degree of Hemorrhagic shock

C37
 Install at least shock 3 venous catheterization, 1 of them must be central.
 Collection of 10 ml of blood for laboratory tests (to determine blood group and Rh,
cross-compatibility, hemoglobin and hematocrit, perform Lee-White test before the
start of infusion solutions).
 Catheterization of bladder.
 Stop the bleeding by conservative or surgical methods depending on the cause of
bleeding
 Turn pregnant on the left side to prevent the development of aorto-caval syndrome,
reducing the risk of aspiration when vomiting and providing free airway.
 Start restoration of blood volume: Rapid infusion of crystalloid 2 liter and
modified gelatin to 2-2.5 liters . infuse fresh frozen plasma 750ml, and red cell
mass 750ml. Max infusion of 4l. Shock 3-4 degrees - speed 200-300 ml / min.
 Warm woman, but does not overheat, because with improved peripheral
microcirculation, this may cause a decrease in blood flow to vital organs (B). Give
the large volume of solutions heated up to 36° C.
 Conduct inhalation of 100% oxygen at a speed of 6-8 l/min through a naso-facial
mask or nasal cannula. Hemorrhage stopping

38. Treatment of cervical lacerations.

C38
 When the laceration is limited to the cervix – or even when it extends somewhat into
vaginal fornix – satisfactory results are obtained by suturing the cervix after bringing
 it into vie at the vulva.. Visualization is best accomplished when an assistant applies
firm downward pressure on the uterus while the operator exerts traction on the lips of
the cervix with fenestrated ovum or sponge forceps.
 It is advisable to apply the first suture above 1-2 cm of the angle of the wound and
suture outward. Associated vaginal lacerations are repaired after the cervical tears.
 Tamponade with gauze packs will retard hemorrhage from these lesions while
cervical lacerations are repaired. Chromic catgut sutures should be employed, since
they do not have to be removed.

39. Treatmentofperineallacerations.
C39
 First-degree laceration start from the upper angle of the wound. The mucous of the
vagina is closed by interrupted catgut suture. A few interrupted sutures are placed
through the skin.
 At second-degree laceration repair begins from the interrupting suturing of the
muscles, after – the same technique as in the first-degree lacerations.
 At three-degree laceration the rectal mucous has been repaired with interrupted, fine
chromic catgut sutures. The torn ends of the sphincter ani are next approximated with
two or three interrupted chromic catgut sutures. The wound is then repaired, as in a
second degree laceration.

40. Treatment of ofPolycystic Ovary Syndrome .

C40
 conservative therapy: steroids biosynthesis and mechanism of ovulation, that must
induce restoring of the reproductive function. Glutamine acid 1 tab twice a day,
calcium pantothenic 1 tab 2 times a day. Vitamin E
 If menstrual cycle is not normalized, a therapy by 2-component progestin-estrogen
preparations with minimum amount of sexual hormones: preparations prescribe in
dose of 1 tabl. Per day during 21 days (cure starts to on 5th day of menstrual cycle)
 should be applied, after a 7-day break the course should be repeated, therapy lasts 3-4
months.
 They use Clostylbegit (Clomipheni citras, Clomid, Tamoxyphene (according to the
scheme) during 3 months. At the end of each cycle after reception of the last dose of
the medicine 500-1500 IU of Choriogonin (ChG) for 3-5 days is prescribed
 For hirsutism treatment they use Cytotheroni acetate 100-200 mg per day from the
5th till the 14th day of menstrual cycle.
 Depending on influence on ovaries there are following types of operative treatment:
laparotomy with a wedge-shaped ovaries resection, demedullation, decapsulation,
decortication

41. Management-of Abnormal uterine bleeding n menopause

C41
Treatment
• resuscitate patient if hemodynamically unstable
• treat underlying disorders
■ if anatomic lesions and systemic disease have been ruled out, consider AUB
• medical
■ mild AUB
◆ NSAIDs
◆ combined hormonal contraceptive
◆ progestins (Provera®) on first 10-14 d of each month or every 3 mo if AUB-O ◆
Mirena® IUD
◆ correct anemia - iron
■ acute, severe AUB
– replace fluid losses, consider admission
a) estrogen (Premarin®) 25 mg IV q4 h x 24 h with Gravol® 50 mg IV/PO q4 h or anti-
fibrinolytic (e.g. Cyklokapron®) 10 mg/kg IV q8 h (rarely used)
b) tapering OCP regimen, 35 μg pill TID x 7 d then taper to 1 pill/d for 3 wk with
Gravol® 50 μg IV/ POq4h
◆ after (a) or (b), maintain patient on monophasic OCP for next several months or
consider
alternative medical treatment
– medical (can also consider):
• high dose progestins
• danazol (Danocrine®)
• GnRH agonists(e.g.Lupron®)with add-back if take for >6mo
• ulipristal acetate
• surgical
■ endometrial ablation
◆ if finished childbearing
◆ repeat procedure may be required if symptoms recur, especially if <40 yr
■ hysterectomy: definitive treatment
 42. Management of Abnorma uterine bleeding in reproductive period
C42
Treatment
• resuscitate patient if hemodynamically unstable
• treat underlying disorders
■ if anatomic lesions and systemic disease have been ruled out, consider AUB
• medical
■ mild AUB
◆ NSAIDs
◆ anti-fibrinolytic (e.g. Cyklokapron®) at time of menses
◆ combined hormonal contraceptive
◆ progestins (Provera®) on first 10-14 d of each month or every 3 mo if AUB-O ◆
Mirena® IUD
◆ correct anemia - iron
■ acute, severe AUB
– replace fluid losses, consider admission
a) estrogen (Premarin®) 25 mg IV q4 h x 24 h with Gravol® 50 mg IV/PO q4 h or anti-
fibrinolytic (e.g. Cyklokapron®) 10 mg/kg IV q8 h (rarely used)
b) tapering OCP regimen, 35 μg pill TID x 7 d then taper to 1 pill/d for 3 wk with
Gravol® 50 μg IV/ POq4h
◆ after (a) or (b), maintain patient on monophasic OCP for next several months or
consider
alternative medical treatment
– medical (can also consider):
• high dose progestins
• danazol (Danocrine®)
• GnRH agonists(e.g.Lupron®)with add-back if take for >6mo
• ulipristal acetate
• surgical
■ endometrial ablation
◆ if finished childbearing
◆ repeat procedure may be required if symptoms recur, especially if <40 yr
■ hysterectomy: definitive treatment

43. Treatment of dysfunctional luterine bleeding in climacteriem

C43

 Dilation and Curettage: quickest way to stop bleeding in patients who are
hypovolemic. Appropriate in older women (>35)to exclude malignancy but is inferior
to hysteroscopy
  follow with medroxyprogesterone acetate, OCP’s, or NSAID’s to prevent
recurrence
 Other Surgical interventions: Laser ablation, Loop electrode resection,
Roller electrode ablation, Hysterectomy
Acute bleeding:
 Estrogen therapy 10mg a day in four divided doses treat for 21 to 25 days.
 Medroxyprogesterone acetate, 10 mg per day for the last 7 days of the treatment
 High dose estrogen-progestin therapy: use combination OCP’s containing 35
micrograms or less of ethinylestradiol four tablets per day. Treat for one week after
bleeding stops
 Recurrent bleeding episodes: Progesterone releasing IUD avoids side effects: Must be
reinserted annually.
 Immature hypothalamic-pituitary axis: progestin therapy by itself for 10 days every
month or every other month until full maturity of the axis provides effective therapy.
44. Treatment of juvenile bleeding
C44

 General treatment starts from creation of favorable rest regimen, creation of

physical and psychic calmness, correct feeding, and rich in vitamins. There is
prescribed Sodium bromide and Caffeine, small doses of tranquilizers. Among
physiotherapy the most procedures effective are endonasal Calcium electrophoresis,
Novocaine electrophoresis, vibrate massage of the paravertebral zones. They use
reflexotherapy and laser accupuncture.
  Management of anaemia includes prescribing of ferrum preparations, vitamins
of B group, Ascorutin, Folic acid.
 Haemostatic effect is reached by using of 10% Calcium chloride solution
intravenously, Tranexamic acid
 Hormonal therapy is prescribed on condition that the symptomatic therapy is not
effective. Estrogens or combined estrogen-progestone remedies are indicated.
 Hemostasis by synthetic Progestin’s: monophasic estrogen-gestagen remedies
(Bisecurin, Non-Ovlon, Ovulen) are taken in dose of 2-3 tabl. Per day till the bleeding
stops, then the dose to 1 tabl. Daily is reduced. The medicine is used for 15-20 days
more (1 tabl. per day). In 3-4 days after cancellation menstrual-like bleeding comes.
 Surgical treatment — uterine curettage is indicated in case of disease duration
with frequent relapses for more than 2 years. It is a medically diagnostic procedure
allowing to achieve hemostasis and to examine the endometrium (in general majority
of patients its hyperplasia is found).

45. Treatment of Sheehan’s syndrome

C45
Lifelong hormone replacement therapy which may include
 corticosteroids to replace your adrenal hormones,
 estrogen to replace ovarian hormones
 Levothyroxine to boost your thyroid hormone levels.
 Some studies also suggest the replacement of growth hormone can help some patients
with the correct the body’s muscle to fat ratio, lower cholesterol levels and maintain
bone mass.

46. Treatment of Premature Ovarian failure

C46
Premature ovarian failure — also known as primary ovarian insufficiency — is a loss of
normal function of your ovaries before age 40.
 Estrogen therapy. Estrogen therapy can help prevent osteoporosis and relieve hot
flashes and other symptoms of estrogen deficiency
 If you still have your uterus. Adding progesterone protects the lining of your uterus
(endometrium) from precancerous changes caused by taking estrogen alone.
 Calcium and vitamin D supplements. Both are important for preventing osteoporosis
47. Treatment of Asherman’s syndrome
C47 Asherman syndrome is the formation of scar tissue in the uterine cavity. The problem
most often develops after uterine surgery.
 Operative hysteroscopy. Small surgical instruments are attached to the end of the
hysteroscope and used to remove adhesions. The procedure is always carried out
under general anesthetic. Hyaluronic Acid gel is placed in the uterus to promote
healing and help maintain a physical barrier between the front and back walls of the
uterus.
 Hormonal treatments (estrogen) may be paired with a small intrauterine
catheter left inside your uterus for a few days after the hysteroscopy. This will
reduce the risk of recurring scar tissue formation after the procedure. In fact, estrogen
promotes healing of your endometrium (inner lining of the cavity) and the catheter
provides a physical barrier between your anterior and posterior
  After the procedure, you’ll be given antibiotics to prevent infection and estrogen
tablets to improve the quality of the uterine lining.
 A repeat hysteroscopy will then be performed at a later date to check that the
operation was successful and your uterus is free from adhesions.

48. Treatment of f Climacteric syndrome.

C48
 Hormone therapy. Estrogen therapy is the most effective treatment option for relieving
menopausal hot flashes.

 Vaginal estrogen. To relieve vaginal dryness

 Low-dose antidepressants. Certain antidepressants related to the class of drugs called

selective serotonin reuptake inhibitors (SSRIs) may decrease menopausal hot flashes.

 Gabapentin (Gralise, Horizant, Neurontin). Gabapentin is approved to treat seizures,

but it has also been shown to help reduce hot flashes

 Clonidine (Catapres, Kapvay). Clonidine, a pill or patch typically used to treat high
blood pressure, might provide some relief from hot flashes.

 Medications to prevent or treat osteoporosis.Vitamin D and Calcium supplements

49. TreatmentofPremenstrualSyndrome
C49

50. TreatmentofEndometriosis
C50
medical
■ NSAIDs (e.g. naproxen sodium – Anaprox®) ■ 1st line
◆ cyclic/continuous estrogen-progestin (OCP)
◆ progestin (IM medroxyprogesterone (Depo-Provera®) or oral dienogest (Visanne®)) ◆
Mirena® IUS
■ 2nd line
◆ GnRH agonist (e.g. leuprolide (Lupron®)): suppresses pituitary
– side effects: hot flashes, vaginal dryness, reduced libido
– use >6 mo: include add-back progestin or estrogen to prevent decreased BMD, reduce
vasomotor side-effects
◆ danazol (Danocrine®): weak androgen
• surgical – side effects: weight gain, fluid retention, acne, hirsutism, voice change
■ conservative laparoscopy using laser, electrocautery ± laparotomy
◆ ablation/resection of implants, lysis of adhesions, ovarian cystectomy of endometriomas
■ definitive: bilateral salpingo-oophorectomy ± hysterectomy
■ best time to become pregnant is immediately after conservative surgery
■ if patient is not planning to become pregnant postoperatively, suppress ovulation medically
to
prevent recurrence
51. Conservative treatment of uterine leiomyoma
C51
  Gonadotropin-releasing hormone (Gn-RH) agonists. Medications called Gn-RH
agonists (Lupron, Synarel, others) treat fibroids by blocking the production of
estrogen and progesterone, putting you into a temporary postmenopausal state
 Progestin-releasing intrauterine device (IUD). A progestin-releasing IUD can
relieve heavy bleeding caused by fibroids.
 Tranexamic acid (Lysteda). This nonhormonal medication is taken to ease heavy
menstrual periods. It's taken only on heavy bleeding days.
 Oral contraceptives or progestin’s can help control menstrual bleeding, but they
don't reduce fibroid size.
 Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal
medications, may be effective in relieving pain related to fibroids

52. Indications for surgical treatment of uterine leiomyoma

C52
 myomatous uterus larger than 12-week of pregnancy,
 acceleration of tumor growing,
 presence of such symptoms as pain, bleeding, secondary anemia; myoma’s
complications;
 Suspicion on malignant degeneration and combining with endometriosis and
endometrial hyperplasia.
 Fast growing myoma
.

53. Surgical treatment of uterine leiomyoma

C53
Uterine artery embolization. Small particles (embolic agents) are injected into the arteries
supplying the uterus, cutting off blood flow to fibroids, causing them to shrink and die.

Radiofrequency ablation. In this procedure, radiofrequency energy destroys uterine fibroids

and shrinks the blood vessels that feed them.

Laparoscopic or robotic myomectomy. In a myomectomy, your surgeon removes the

fibroids, leaving the uterus in place.

Hysteroscopic myomectomy. This procedure may be an option if the fibroids are contained

inside the uterus (submucosal). Your surgeon accesses and removes fibroids using
instruments inserted through your vagina and cervix into your uterus

Endometrial ablation. uses heat, microwave energy, hot water or electric current to destroy
the lining of your uterus, either ending menstruation or reducing your menstrual flow.
Typically, endometrial ablation is effective in stopping abnormal bleeding. 

Abdominal myomectomy. open abdominal surgical procedure to remove the fibroids.

Hysterectomy

54. Management of cervical ectopia

C54
 stimulation of regenerative process of stratified squamous epithelium by
application tampons, moistened with cod-liver oil, dog-rose and sea-buckthorn
oil to the cervix after elimination of inflammatory process in vagina, and laser
therapy by Helium-Neon or semiconductor lasers — ANP-2, Lika-3 should be used.
Treatment course takes 6-8 days
 Medical destruction of pathological substratum by the following remedies such as
Solcovagyn (Solcogyn), Vagotyle, or electrocoagulation, cryodestruction of erosive
surface should be performed if after concervative therapy erosion doesn't heel over.
The biopsy is recommended before electrocoagulation or cryodestruction
 radical surgical intervention is recommended (cone-biopsy or cervical amputation)

55. Treatment of the cervical polyp

C55
Methods to destroy the base of the polyp include the use of:

 liquid nitrogen

 electrocautery ablation, which involves using an electrically heated needle

 laser surgery

 screwing it off with the following coagulation of its pedicle, if its base is visible
 endocervical curettage with the following histological examination is performed
 cryodestruction of polyp’s base .
56. Treatment of Cervical Intraepithelial Dysplasia of I degree
C56
Loop electrosurgical excision procedure (LEEP) uses a small, electrically charged wire
loop to remove tissue. LEEP can also remove tissue samples for further analysis. About 1% to
2% of people may experience complications following the procedure, such as delayed
bleeding or narrowing of their cervix (stenosis).
Cold knife cone biopsy (conization) involves your healthcare provider removing a cone-
shaped piece of tissue containing the abnormal cells. It was once the preferred method of
treating cervical dysplasia, but now it’s reserved for more severe cases. Conization can
provide a sample of tissue for further testing. It has a somewhat higher risk of complications,
including cervical stenosis and postoperative bleeding.
Hysterectomy involves removing your uterus. A hysterectomy may be an option in cases
where cervical dysplasia persists or doesn’t improve after other procedures.

57. Treatment of Cervical Intraepithelial Dysplasia of I degree

C57
Loop electrosurgical excision procedure (LEEP) uses a small, electrically charged wire
loop to remove tissue. LEEP can also remove tissue samples for further analysis. About 1% to
2% of people may experience complications following the procedure, such as delayed
bleeding or narrowing of their cervix (stenosis).
Cold knife cone biopsy (conization) involves your healthcare provider removing a cone-
shaped piece of tissue containing the abnormal cells. It was once the preferred method of
treating cervical dysplasia, but now it’s reserved for more severe cases. Conization can
provide a sample of tissue for further testing. It has a somewhat higher risk of complications,
including cervical stenosis and postoperative bleeding.
Hysterectomy involves removing your uterus. A hysterectomy may be an option in cases
where cervical dysplasia persists or doesn’t improve after other procedures.

58. Treatment of Cervical Intraepithelial Dysplasia of II degree

C58
Treatment for cervical intraepithelial neoplasia grade 2/3 may include
1) cryotherapy,
2) laser therapy,
3) loop electrosurgical procedure (LEEP),
4) cone biopsy to remove or destroy the abnormal tissue.

59. Treatment of Cervical Intraepithelial Dysplasia of II degree

C59

Treatment for cervical intraepithelial neoplasia grade 2/3 may include

1) cryotherapy,
2) laser therapy,
3) loop electrosurgical procedure (LEEP),
 4) cone biopsy to remove or destroy the abnormal tissue.

60. Management of benign breast diseases

C60
 Fibrocystic breast changes: birth control pills to reduce the fluid buildup of this type
of benign breast condition.
 Fibroadenomas: Since this is often related to the use of birth control pills, your
doctor may recommend an alternative birth control method. If it’s painful, your
doctor may surgically remove it.
 Cysts: Your doctor may use a fine needle aspiration to draw out some of the fluid that
is making it painful. If it is a chronic problem, your doctor may surgically remove the
cyst.
 Mastitis: Since this is an infection, your doctor will prescribe antibiotics, recommend
an over-the-counter pain reliever for fever, such as acetaminophen, and suggest you
apply a warm cloth to the lump to soothe the tenderness in your breast.
 Fat necrosis: Usually, fat necrosis does not require further treatment. If it contains
fluid (called an oil cyst), your doctor will likely drain the fluid from the cyst with a
fine needle aspiration.
 Nipple discharge: Treatment will depend on the underlying cause of your nipple
discharge (lump, infection, or cancer).
 Calcification: Your doctor may look at these tiny, white spots on your mammogram.
If it looks like cancer, your doctor may do (or recommend) a surgical or fine needle
biopsy.
 Hyperplasia, adenosis, intraductal papilloma, and lipoma: Based on your pain and
discomfort, your doctor may recommend surgically removing it
.
61. Treatment of molar pregnancy
C61
 Chemotherapy: Methotrexate, Dactinomycin, Etoposide, Cyclophosphamide,
Vincristine (Oncovin, Vincasar), Cisplatin
 Dilation and curettage (D&C). remove the molar tissue from your uterus
 Hysterectomy. Rarely, if there is increased risk of gestational trophoblastic neoplasia
(GTN) and there's no desire for future pregnancies, the uterus may be removed
(hysterectomy).
 HCG monitoring. After the molar tissue is removed, your doctor will repeat
measurements of your HCG level until it returns to normal. If you continue to have
HCG in your blood, you may need additional treatment.

62. Treatment of choriocarcinoma

C62
 A low-risk (cumulative score less than 7, see staging section below) and stage I to III
choriocarcinoma can be treated with a single agent, either methotrexate or actinomycin D
chemotherapy.

High-risk (a cumulative score greater than 7, see staging section below) and stage II to
IV disease are treated with multi-agent chemotherapy, adjuvant radiation, and surgery.

Stage I: Disease confined to the uterus

Stage II: Disease extending beyond the uterus, but confined to genital structures
Stage III: Disease extending to the lungs
Stage IV: Disease invading other metastatic sites

63. Treatment of bartolin duct cyst

C63
Sitz baths: Sit in a bathtub with 3 to 4 inches of warm water a few times a day for several
days. This can provide comfort and promote healing. It could also help the infected cyst to
burst and drain on its own.

Surgical draining: If your cyst is large and infected, surgery may be done to drain the fluid.
A small tube called a catheter will be inserted into the cyst.

Marsupialization: The cyst is surgically opened and drained. Then, the surgeon will stitch
the edges of the cyst wall to form a permanent open pocket or “pouch” for continuous
drainage. This is often helpful for recurrent Bartholin cysts.

Removal of the Bartholin’s gland: In extremely rare cases where treatment is not working

pain medications: Take as directed for pain relief and discomfort.

Antibiotics: If your cyst becomes infected or tests show you have a sexually transmitted
infection (STI), your healthcare provider may prescribe antibiotics.
64. Treatment of bartholinitis
C64
 Conservative treatment is prescribed (bed regimen, antibiotics or sulfonamides, an
ice pack, painkillers).
 Drainage of Bartholin gland in case of abscess

Surgical
 Removal of the Bartholin’s gland
 Marsupialization: The cyst is surgically opened and drained. Then, the surgeon will
stitch the edges of the cyst wall to form a permanent open pocket or “pouch” for
continuous drainage. This is often helpful for recurrent Bartholin cysts.
65. Management of follicular cyst
C65
Symptomatic or suspicious masses warrant surgical exploration Otherwise if <6 cm, wait 6
wk then re-examine as cyst usually regresses with next cycle
OCP oral contraceptives pills (ovarian suppression): will prevent development of new cysts
Treatment usually laparoscopic (cystectomy vs. oophorectomy, based on fertility choice)

66. Management of ovarian cystoma

C66
67. Treatment of vulvitis
C67

Avoiding substances that can irritate the vulva

Keeping the vulva clean and dry
Sitz bath containing soothing substances (to help control the itching)
Applying hydrocortisone or estrogen cream to the vulva

Medications for this condition may include:

oral antibiotics
antibiotic creams (applied directly to the skin)
antibacterial creams (applied directly to the skin)
antifungal creams (applied directly to the skin)
oral antifungal pills
oral antihistamines, if an allergic reaction is a possible cause
estrogen creams

68. Treatment of vaginitis

C68
 Bacterial vaginosis. metronidazole tablets (Flagyl) that you take by mouth or
metronidazole gel (MetroGel) that you apply to the affected area.

 Yeast infections. antifungal cream or suppository, such as miconazole,

clotrimazole .
oral antifungal medication, such as fluconazole (Diflucan).
  Trichomoniasis. metronidazole (Flagyl) or tinidazole (Tindamax) tablets.

 Genitourinary syndrome of menopause (vaginal atrophy). Estrogen — in the

form of vaginal creams, tablets or rings — can treat this condition.

 Noninfectious vaginitis. you need to pinpoint the source of the irritation and avoid it.
Possible sources include new soap, laundry detergent, sanitary napkins or tampons.

69. Treatment of endometritis

C69
 Antibiotics: These medications fight the bacteria causing inflammation of the uterine
lining
 Treating sexual partners: If the endometritis is due to an STI, the person’s sexual
partner or partners may also require antibiotic treatment.

 Surgery to remove tissue: A surgeon may need to remove any tissue left inside the
uterus following childbirth or pregnancy loss.
 Treating any abscesses: needle aspiration to remove infected fluid or pus from the
abscess.
 Further tests: A person may require cervical cultures or an endometrial biopsy to
ensure that the infection is completely gone after finishing the course of antibiotics.

70. Treatment of Pelvic inflammatory disease (PID)

C70
Antibiotics.
Treatment for your partner. To prevent reinfection with an STI, your sexual partner or
partners should be examined and treated.
Avoid sexual intercourse until treatment is completed and symptoms have resolved.

For outpatient treatment, the CDC lists 2 currently accepted treatment regimens, labeled as
A and B
 Regimen A consists of the following:
o Ceftriaxone 250 mg intramuscularly (IM) once as a single dose plus
o Doxycycline 100 mg orally twice daily for 14 days
o Metronidazole 500 mg orally twice daily for 14 days
 Regimen B consists of the following:
o Cefoxitin 2 g IM once as a single dose concurrently with probenecid 1 g
orally in a single dose
o Doxycycline 100 mg orally twice daily for 14 days
o Metronidazole 500 mg orally twice daily for 14 days

For inpatient treatment of PID, the CDC also lists 2 currently accepted treatment regimens,
again labeled as A and B.
  Regimen A consists of the following:
o Cefoxitin 2 g IV every 6 hours or cefotetan 2 g IV every 12 hours plus
o Doxycycline 100 mg orally or IV every 12 hours

 Regimen B consists of the following:

o Clindamycin 900 mg IV every 8 hours plus
o Gentamicin IV in a loading dose of 2 mg/kg, followed by a maintenance
dosage of 1.5 mg/kg q8h

71. Treatment of parametritis

C71
 Treatment begins from using antibiotic of broad coverage against a variety of
common microorganisms and is usually prescribed without cultures.
 Cephalosporins such as cefotetan and cefoxitin are commonly used.
 A combination of ampicillin and aminoglycoside and also the combination of
clindamycin and gentamycin.
 A bottle with ice on the lower part of abdomen is used in case of infiltrative stage
of disease. Biostimulators should be prescribed.
 Persistent pelvic abscess includes drainage by colpotomy, or laparotomy. Intra-
abdominal rupture of pelvic abscess is a surgical emergency

72. Treatment of infection caused by N.gonorrhea

C72
Recommended Regimen
 Ceftriaxone/cefixime 250 mg IM in a single dose
 PLUS Azithromycin 1g orally in a single dos
 a twice-daily dose of doxycycline for 7 days
Additional methods of treatment
 Gonovaccine is used after ineffective antibiotic treatment and relapse in the latent
fresh torpid and chronic form of the disease (200-300 mln. of microbe bodies, in 2-3
days intramuscularly).
 For toilet of external genital organs 0,002% solution of chlorhexidine are prescribed.

73. Treatment of infection caused by C.trachomatis

C73
According to CDC
 Azithromycin 1 g orally in a single dose OR
 Doxycycline 100 mg orally twice a day for 7 days
Alternative Regimens
 Erythromycin base 500 mg orally four times a day for 7 days
 Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
  Levofloxacin 500 mg orally once daily for 7 days
 Ofloxacin 300 mg orally twice a day for 7 days

74. Treatment of bacterial vaginosis

C74
Recommended Regimens for Bacterial Vaginosis
 Metronidazole 500 mg orally 2 times/day for 7 days

 Metronidazole gel 0.75% one full applicator (5 g) intravaginally, once a day for 5
days

 Clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days

Alternative Regimens
 Clindamycin 300 mg orally 2 times/day for 7 days
 Clindamycin ovules 100 mg* intravaginally once at bedtime for 3 days
 Secnidazole 2 g oral granules in a single dose†
 Tinidazole 2 g orally once daily for 2 days
 Tinidazole 1 g orally once daily for 5 days

75. Treatment of unruptured ectopic pregnancy

C75
 Early diagnosis : serum beta-hCG levels increasing or maintained over 24 and 48-
hour intervals, rapid growth, and higher probability of tubal rupture.
Treatment with methotrexate (which stops cell growth and dissolves existing cells)
or surgery.
 Late diagnosis : beta-hCG levels decreasing over 24 and 48-hour intervals
lower chance of tubal rupture.
Treatment with expectant management.(ectopic pregnancy to resolve naturally without
any intervention
76. Treatment of ruptured ectopic pregnancy
C76
Laparoscopic Surgery
 Salpingostomy : Salpingostomy is the creation of an opening into the fallopian tube
and remove ectopic tissue, but the tube itself is not removed in this procedure
 Salpingectomy (Total / Partial) : Salpingectomy refers to the surgical removal of a
Fallopian tube.
 Segmental Resection

77. Treatment of ovarian apoplexy

C77
Ovarian apoplexy is a sudden rupture in the ovary, commonly at the site of a cyst,
accompanied by hemorrhage in the ovarian tissue and/or intraperitoneal bleeding.
Conservative treatment (cold on the bottom of the abdomen, bed rest, observation,
examination).
Birth control (BC) pills may be ordered to stop ovulation. Stopping ovulation may prevent
new cysts from forming.

Cystectomy: The cyst is removed without removing the ovary.

Oophorectomy: The complete ovary, including the cyst, is removed.
78. Indications for conservative management of ectopic pregnancy
C78
 Unruptured
 Size <4cm
 No fetal cardiac activity
 HCG <5,000 mIU
 Hemodynamic stability
 No severe or persisting abdominal pain

TREATMENT
methotrexate (which stops cell growth and dissolves existing cells)
expectant management.(ectopic pregnancy to resolve naturally without any intervention

79. Indications for surgical management of ectopic pregnancy

C79
 The patient is not a suitable candidate for medical therapy.
 Hemodynamically unstable
 ss-hCG is >10,000 mIU/mL
 ectopic pregnancy is > or =4 cm in diameter
 if there is a medical contraindication to methotrexate
 Medical therapy has failed.

Treatment
Salpingostomy : Salpingostomy is the creation of an opening into the fallopian tube and
remove ectopic tissue, but the tube itself is not removed in this procedure
Salpingectomy (Total / Partial) : Salpingectomy refers to the surgical removal of a Fallopian
tube.

80. Differential diagnosis between ovarian cyst and cystoma

C80
Cystoma- they are often result of Infection,clogged sebaceous glands or piercing or
sometimes genetic conditions

Ovarian cyst- primarily caused by hormonal imbalances,endometriosis,or the natural

occurrence of a corpus luteum cyst ,and pregnancy and also sometimes pelvic infections

81. Management of chocolate cyst

C81
Birth control pill: Inhibit ovulation. This can help control pain and slow the growth of cysts,
but it can’t cure them.

Surgery to remove the cysts, called an ovarian cystectomy, is often recommended for women
who have:

- painful symptoms

- cysts larger than 4 cm

- cysts that may be cancerous (but a 2006 review estimates less than 1 percent of cysts are
cancerous)
- infertility

Cystectomy: The cyst is removed without removing the ovary.

Oophorectomy: The complete ovary, including the cyst, is removed.

82. Management of cervical endometriosis

C82
Treatments include hormone therapy, such as the birth control pill, pain relievers, such as
nonsteroidal anti-inflammatory drugs, and surgery.

Surgery to remove the endometriosis tissue on the cervix:

Superficial electrocauterization. A doctor uses electricity or heat to remove the endometrial

growths.

Large loop excision. This involves a tool with a wire loop that carries an electrical current.
The doctor removes endometriosis growths by passing the loop through the tissue of the
cervix.

83. Management of endometrial hyperplasia in reproductive period

C83
Progestin is given orally, in a shot, in an intrauterine device (IUD), or as a vaginal cream.

In case of Atypical endometrial hyperplasia : if hormonal therapy will not work , we have to
do hysterectomy

84. Management of local placenta accreta

C84
85. Management of ovarian cystoma pedicle torsion
C85
Laparoscopy: Once the ovary is accessible, your doctor will use a blunt probe or other tool to
untwist it.

Laparotomy: doctor will make a larger incision in your lower abdomen to allow them to reach
in and untwist the ovary manually.

If too much time has passed — and the prolonged loss of blood flow has caused the
surrounding tissue to die — your doctor will remove it:

Oophorectomy: If your ovarian tissue is no longer viable, your doctor will use this
laparoscopic procedure to remove the ovary.
Salpingo-Oophorectomy: If both the ovarian and fallopian tissue are no longer viable, your
doctor will use this laparoscopic procedure to remove them both.

86. Management of pregnant woman in 32 week of gestation and rupture of amniotic

membranes
C86
Management
A. Initial
• transfertoappropriatefacilityifstable
■ tocolysis and first dose of antenatal steroids prior to transfer
• hydration (normal saline at 150 mL/h)
• bed rest in left lateral decubitus position to reduce aorto caval compression and improve
cardiac output
• sedation(morphine)
• avoid repeated pelvic exams(increasedinfectionrisk)
• U/S examination of fetus (GA, BPP, position, placenta location, estimated fetal weight)
• prophylactic antibiotics (for GBS); important to consider if PPROM (e.g. erythromycin
controversial,
but may help to delay delivery)
B. Tocolysis (Suppression of Labour)
• does not inhibit PTL completely,but may delay delivery(usedfor<48h) to allow for
betamethasone valerate (Celestone®) and/or transfer to appropriate centre for care of the
premature infant
• requirements(allmustbesatisfied) ■ PTL
■ live, immature fetus, intact membranes, cervical dilatation of <4 cm
■ absence of maternal or fetal contraindications
• contraindications
■ maternal: bleeding (placenta previa or abruption), maternal disease (HTN, DM, heart
disease), preeclampsia or eclampsia, chorioamnionitis
■ fetal: erythroblastosis fetalis, severe congenital anomalies, fetal distress/demise, IUGR,
multiple gestation (relative)
• agents
■ calcium channel blockers: nifedipine
◆ 20 mg PO loading dose followed by 20 mg PO 90 min later
◆ 20mgcan be continued q3-8h for 72 h or to a maximum of 180mg
◆ 10mgPOq20minx4doses
◆ relative contraindications: nifedipine allergy, hypotension, hepatic dysfunction, concurrent
β-mimetics or magnesium sulfate use, transdermal nitrates, or other antihypertensive
medications
◆ absolute contraindications: maternal CHF, aortic stenosis
■ prostaglandin synthesis inhibitors: indomethacin
◆ first-line for early PTL (<30 wk GA) or polyhydramnios
◆ 50-100 mg PR loading dose followed by 25-50 mg q6 h x 8 doses for 48 hours
C. Antenatal Corticosteroids
• betamethasone valerate(Celestone®)12mgI Mq 24hx2doses or dexamethasone 6mgIMq
12hx4 doses
■ given between 24 to 33+6 wk GA if expected to deliver in the next 7 d
■ women between 22+0 and 23+6 wk GA at high-risk of preterm birth within the next 7 d
should
be provided with multidisciplinary consultation regarding high likelihood for severe perinatal
morbidity and mortality and associated maternal morbidity – consider antenatal corticosteroid
therapy if early intensive care is requested and planned
■ specific maternal contraindications: active TB
• enhance fetal lung maturity ,reduce perinatal death,reduce incidence of severe RDS ,IVH,
necrotizing enterocolitis, neonatal sepsis
D. Neuroprotection
• MgSO4 4 g bolus followed by 1 g/h infusion for at least 4 h if imminent delivery expected
and <33+6 wk GA

87. Management of pregnant woman in 30 week of gestation with signs of danger of preterm
labor
C87
Management
A. Initial
• transfertoappropriatefacilityifstable
■ tocolysis and first dose of antenatal steroids prior to transfer
• hydration (normal saline at 150 mL/h)
• bed rest in left lateral decubitus position to reduce aorto caval compression and improve
cardiac output
• sedation(morphine)
• avoid repeated pelvic exams(increasedinfectionrisk)
• U/S examination of fetus (GA, BPP, position, placenta location, estimated fetal weight)
• prophylactic antibiotics (for GBS); important to consider if PPROM (e.g. erythromycin
controversial,
but may help to delay delivery)
B. Tocolysis (Suppression of Labour)
• does not inhibit PTL completely,but may delay delivery(usedfor<48h) to allow for
betamethasone valerate (Celestone®) and/or transfer to appropriate centre for care of the
premature infant
• requirements(allmustbesatisfied) ■ PTL
■ live, immature fetus, intact membranes, cervical dilatation of <4 cm
■ absence of maternal or fetal contraindications
• contraindications
■ maternal: bleeding (placenta previa or abruption), maternal disease (HTN, DM, heart
disease), preeclampsia or eclampsia, chorioamnionitis
■ fetal: erythroblastosis fetalis, severe congenital anomalies, fetal distress/demise, IUGR,
multiple gestation (relative)
• agents
■ calcium channel blockers: nifedipine
◆ 20 mg PO loading dose followed by 20 mg PO 90 min later
◆ 20mgcan be continued q3-8h for 72 h or to a maximum of 180mg
◆ 10mgPOq20minx4doses
◆ relative contraindications: nifedipine allergy, hypotension, hepatic dysfunction, concurrent
β-mimetics or magnesium sulfate use, transdermal nitrates, or other antihypertensive
medications
◆ absolute contraindications: maternal CHF, aortic stenosis
■ prostaglandin synthesis inhibitors: indomethacin
◆ first-line for early PTL (<30 wk GA) or polyhydramnios
◆ 50-100 mg PR loading dose followed by 25-50 mg q6 h x 8 doses for 48 hours
C. Antenatal Corticosteroids
• betamethasone valerate(Celestone®)12mgI Mq 24hx2doses or dexamethasone 6mgIMq
12hx4 doses
■ given between 24 to 33+6 wk GA if expected to deliver in the next 7 d
■ women between 22+0 and 23+6 wk GA at high-risk of preterm birth within the next 7 d
should
be provided with multidisciplinary consultation regarding high likelihood for severe perinatal
morbidity and mortality and associated maternal morbidity – consider antenatal corticosteroid
therapy if early intensive care is requested and planned
■ specific maternal contraindications: active TB
• enhance fetal lung maturity ,reduce perinatal death,reduce incidence of severe RDS ,IVH,
necrotizing enterocolitis, neonatal sepsis
D. Neuroprotection
• MgSO4 4 g bolus followed by 1 g/h infusion for at least 4 h if imminent delivery expected
and <33+6 wk GA

88. Management of pregnant woman in 28 week of gestation with initial preterm labor.
C88
Management
A. Initial
• transfertoappropriatefacilityifstable
■ tocolysis and first dose of antenatal steroids prior to transfer
• hydration (normal saline at 150 mL/h)
• bed rest in left lateral decubitus position to reduce aorto caval compression and improve
cardiac output
• sedation(morphine)
• avoid repeated pelvic exams(increasedinfectionrisk)
• U/S examination of fetus (GA, BPP, position, placenta location, estimated fetal weight)
• prophylactic antibiotics (for GBS); important to consider if PPROM (e.g. erythromycin
controversial,
but may help to delay delivery)
B. Tocolysis (Suppression of Labour)
• does not inhibit PTL completely,but may delay delivery(usedfor<48h) to allow for
betamethasone valerate (Celestone®) and/or transfer to appropriate centre for care of the
premature infant
• requirements(allmustbesatisfied) ■ PTL
■ live, immature fetus, intact membranes, cervical dilatation of <4 cm
■ absence of maternal or fetal contraindications
• contraindications
■ maternal: bleeding (placenta previa or abruption), maternal disease (HTN, DM, heart
disease), preeclampsia or eclampsia, chorioamnionitis
■ fetal: erythroblastosis fetalis, severe congenital anomalies, fetal distress/demise, IUGR,
multiple gestation (relative)
• agents
■ calcium channel blockers: nifedipine
◆ 20 mg PO loading dose followed by 20 mg PO 90 min later
◆ 20mgcan be continued q3-8h for 72 h or to a maximum of 180mg
◆ 10mgPOq20minx4doses
◆ relative contraindications: nifedipine allergy, hypotension, hepatic dysfunction, concurrent
β-mimetics or magnesium sulfate use, transdermal nitrates, or other antihypertensive
medications
◆ absolute contraindications: maternal CHF, aortic stenosis
■ prostaglandin synthesis inhibitors: indomethacin
◆ first-line for early PTL (<30 wk GA) or polyhydramnios
◆ 50-100 mg PR loading dose followed by 25-50 mg q6 h x 8 doses for 48 hours
C. Antenatal Corticosteroids
• betamethasone valerate(Celestone®)12mgI Mq 24hx2doses or dexamethasone 6mgIMq
12hx4 doses
■ given between 24 to 33+6 wk GA if expected to deliver in the next 7 d
■ women between 22+0 and 23+6 wk GA at high-risk of preterm birth within the next 7 d
should
be provided with multidisciplinary consultation regarding high likelihood for severe perinatal
morbidity and mortality and associated maternal morbidity – consider antenatal corticosteroid
therapy if early intensive care is requested and planned
■ specific maternal contraindications: active TB
• enhance fetal lung maturity ,reduce perinatal death,reduce incidence of severe RDS ,IVH,
necrotizing enterocolitis, neonatal sepsis
D. Neuroprotection
• MgSO4 4 g bolus followed by 1 g/h infusion for at least 4 h if imminent delivery expected
and <33+6 wk GA

89. Management of fetal distress in first stage of labor

C89
Specific Interventions If Immediate Delivery Is Indicated
•In stage 1 of labor, the only option is emergency cesarean section
Some means of intrauterine resuscitation include:

- Changing the mother’s position

- Ensuring the mother is well-hydrated

- Ensuring the mother has adequate oxygen

- Amnioinfusion (beneficial in suspected umbilical cord compression (particularly when there

is oligohydramnios)

- Tocolysis (a therapy used to delay preterm labor by temporarily stopping contractions)

- Intravenous hypertonic dextrose

- urgency of a caesarean section

Class 1: immediate threat to the life of the woman or fetus. Perform this as soon as possible
after decision. 30 minutes is an appropriate audit standard.

Class 2: maternal or fetal compromise which is not immediately life-threatening. In most

situations, within 75 minutes of making the decision

90. Management of fetal distress in second stage of labor

C90
In stage 2 of labor, an operative vaginal delivery (e.g., vacuum extractor assisted or
obstetrical forceps) may be appropriate, or an emergency cesarean section must be performed

INTRAUTERINE RESUSCITATION
•Decrease uterine contractions: Turn off any IV oxytocin infusion or administer terbutaline
•mg subcutaneously to enhance intervillous placental blood flow.
•
•Augment IV fluid volume: Infuse the parturient with a 500 mL bolus of intravenous normal
saline rapidly to enhance uteroplacental infusion.
•
•Administer high-flow oxygen: Give the parturient 8–10 L of oxygen by facemask to increase
delivery of maternal oxygen to the placenta.
•
•Amniofusion is useful for eliminating or reducing the severity of variable decelerations.
•Change position: Removing the parturient from the supine position decreases inferior vena
cava compression and enhances cardiac return, thus cardiac output to the placenta. Turning
the parturient from one lateral position to the other may relieve any umbilical cord compres-
sion that may be present.
•
•Vaginal examination: Perform a digital vaginal examination to rule out possible prolapsed
umbilical cord.
•Scalp stimulation: Perform a digital scalp stimulation observing for accelerations, which
would be reassuring of fetal condition.