obs cases محلول

Faculty of Medicine
University of Khartoum
Batch 89 - Qayasir
OBS Cases
Collected & Solved by 6th Study Group
(Ali seif, Hazim, Ahmed Mudathir, Migdad Haiyder, Abubakr Khalaf & Mohamed
Emad)
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Obs Cases Collected & Solved by 6th Study Group
1. Fatima is a 25 years old lady who is 32 weeks pregnant into her 3rd
pregnancy. Her first pregnancy miscarried at 9 wdeeks and her 2nd
pregnancy was uncomplicated and delivered by caesarean section at term
due to breech presentation. She presented to the labor room with
minimal vaginal bleeding/spotting
a. What are the important points in history would you like to ask
about (Mention 4)?
- Any associated pain with bleeding
- Fetal movements
- Precipitating factors (trauma, sexual intercourse)
- Antenatal care
- Previous ultrasound scans
- Past medical history (of HTN)
- First episode or recurrent
- Previous history of bleeding
b. Mention the important aspects of your clinical examination?

- Check General examination (Pulse, BP, RR, T)
- Check uterus of tenderness
- Check fetal heart
- Speculum examination after ruling placenta previa; (don’t do
PV)
c. Mention the investigations that you would like to arrange?

- CBC with coagulation profile
- Ultrasound scan
- Fetal CTG
- Urine Analysis
d. What’s the differential diagnosis?

- Placenta previa - Placenta abruption
- Preterm labor - Local Causes (Cervical polyp)
- Vasa Previa - Bleeding Tendency
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e. What are your immediate management steps if her condition is
stable?
- Admission for observation
- Give her steroids
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2. A 30 year old lady at 33 weeks gestation presents with severe itching
specially of the palms and soles which gets worse at night. There was no
skin rash apart from scratch marks seen on examination.
a. What’s the most likely cause of her problem
- Obstetric cholestasis (Intrahepatic cholestasis of pregnancy)
b. What the adverse effects of this condition on the fetus mention 3,
and mother mention 2?
- Fetal:
- Fetal distress
- IUFD
- Premature labor
- Maternal:
- Increased risk of C/S
- Increased risk of PPH
c. How can you diagnose this condition?
- History is suggestive
- Liver function test (bilirubin & ALP) weekly
- Coagulation profile (PT)
- LFTs after delivery
d. How can you monitor the pregnancy with such conditions?
- US
- CTG
- LFTs & Coagulation profile (before & after delivery)
e. What treatment can be given to his woman?
- Chelating Agents: Cholestyramine
- Ursodeoxycholic Acid
- Antihistamine
- Calamine lotion
- Vitamin K
f. What’s the role of Vit-K in the treatment of this case?
- Should be given orally 10 mg daily to 1. reduce
risk of PPH & 2. fetal and neonatal bleeding
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3. A 27 year old primigravida at 32 weeks gestation presented with
painless watery vaginal discharge. The general examination
revealed no abnormality. Abdominal examination showed no
tenderness. The fundal level was corresponding to dates with
cephalic presentation. The fetal heart was 146/min. Speculum
examination confirmed ruptured membranes with a closed
cervical Os.
(Preterm-Premature Rupture of Membrane (PPROM)
a. What’s the main objective of the management?
- Expectant management to reach reasonable maturity while
observing mother and fetus for infection
b. How would you monitor the mother clinically?
- General Examination for vitals (Temp, Pulse, BP, RR)
- Abdominal Examination for Uterine tenderness
- Monitor for infection by Offensive Vaginal discharge
c. What are the maternal investigations to rule out infection?

- CBC for TWBCs - Inflammatory markers (CRP)
- Urine Analysis - Vaginal Swab and culture
d. How would you perform fetal surveillance for wellbeing?

- Fetal Kick Count - CTG
- Ultrasound & umbilical artery Doppler
- Biophysical Profile (Movement, RR, Tone, Amniotic Fluid Index)
e. Mention 2 important medications you administer to the mother
- Steroids (Dexamethasone)
- Prophylactic Antibiotics (Erythromycin)
f. When will you decide to deliver the baby
- If evidence of fetal compromise
- If evidence of maternal compromise (Sepsis, infection)
- If reached reasonable maturity (between 34-37 weeks)
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4. A mother seeks advice for her 16 year old daughter who has not
started to menstruate.
a. The following are the likely causes? (Mention 6)
- Constitutional “Most common”
- Chromosomal abnormalities
- Hypothalamic-pituatiry axis:
o Hypogonadotrophic Hypogonadism (Kallman’s Syndrome)
o Hypergonadotrophic Hypogonadism (Ovarian Dysgenesis “Turner
Syndrome”, Ovarian Agenesis)
- Androgen insensitivity
- PCOS
- Genital tract abn. (Imperforate Hymen, Transverse vaginal septum)
b. Areas to examine (Mention 5)

- Height and weight
- Breast development
- Pubic & Axillary hair
- Inguinal area for undescended testis
- External Genitalia & hymen by speculum
c. Important investigations and its objectives? (mention 3)

- Karyotyping for sex chromosome disorders; for Turner’s
Syndrome or Androgen Insensitivity
- LH:FSH ratio; for Ovarian activity, PCOS, Ovarian failure
- US for uterine abnormalities (absent uterus) & obstructive
causes
d. Treatment of obstructive cause?
- Surgical correction
e. Indications of Exogenous estrogen? (mention 2)
- For Breast development
- Prevention of Osteoporosis
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5. Natasha is a 22 year old sexually active unmarried woman. She
presented complaining of lower abdominal pain and offensive
vaginal discharge. On examination her temp. Is 38 and there is
generalized lower abdominal tenderness. Vaginal examination
revealed bilateral adenxial tenderness with positive cervical
excitation. Laboratory investigations showed a negative
pregnancy test with raised CRP and WBCs
a. What’s the diagnosis?
- Pelvic Inflammatory Disease (PID)
b. What are the most common organisms causing this condition
- Chlamydia Trachomatis
- Neisseria Gonorrheae
c. Mention four additional investigations you like to perform to her

- Vaginal swab for culture and sensitivity
- Laparoscopy
- Ultrasounds
- Screen for Hep. B & HIV
d. What are the main lines of management?

- IV Antibiotics: (Ceftriaxone, Azithromycine + Metronidazole)
- Rehydration
- Analgesia & Antipyretics
- Education for the patient
e. Mention three immediate complication if left untreated
- Pelvic Abscess
- Septic Shock
- DIC
f. Mention two long term complications of this condition?
- Subfertility
- Dyspareunia
-
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6. This is a full blood count of Para 8 Women at 37 wks gestation presenting
with shortness of breath and palpitations
TWBC 4.5 x 10 m/l 4 _ 11

RBC's 4.34 million/ml 3.8 _ 5
HB 6.0 g/dl 12 _ 14
HCT 20.5 % 37 _43
MCV 58.8 fl 85 _95
MCH 13.8 pg 28 _ 32
MCHC 23.5 g/dl 32 _ 34
Platelets 161 x 10 m/l 150 _ 400
a. What is your diagnosis?

- Severe anemia with pregnancy
b. If untreated, she is likely to have? (Mention 3).
a. Hypovolemia & Heart failure
b. Sepsis
c. DVT & PE
c. The most logical treatment option is?
- Blood transfusion of Packed cells
d. What precautions you should take during labor for this patient?
- Hydration of patient by NS & Prepare blood. (Minimize chance of bleeding
& avoid episiotomy), Prophylactic antibiotics & analgesia
- Continuous fetal monitoring by CTG
- Shorten the 2nd stage by Instrumental delivery
- Active management of 3rd stage of labor
e. What are the fetal complications of maternal anemia?
- IUGR & LBW
- IUFD
- Premature labor
- Intrapartum & Early neonatal death.
f. What are the complications that may occur during puerperium?
- Peurperial sepsis - DVT & Thromboembolism
- Subinvolution of uterus
- Inability to lactate
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7. Najlaa Ali, 26 years old primigravida in her 30 weeks gestation presented
with left lower limb swelling, redness and calf pain and tenderness. Deep
venous thrombosis was suspected
a. Mention 2 obstetrically related conditions or events that
predisposes to development of this condition
- Antiphospholipid Syndrome
- Hyperemesis Gravidarum
- Anemia
b. What’s the most important management step needed before the
diagnosis of DVT is either established or excluded?
- Admission & rehydration
c. What are the baseline investigations will you request for her?
- CBC - Coagulation profile with thrombophilia screen
- Liver Function Test - Renal Function test
d. Mention 2 objective investigations needed for the diagnosis?
- Duplex US “best initial”
- Contrast Venography with abdominal shield “Gold
standard”
- V/Q mismatch
e. What are the further treatment steps you will do after the diagnosis
of DVT is confirmed?
- After admission and immobilization, TED Stocking &
Analgesia.
- Anticoagulation with SC LMW Heparin Loading 5000 IU &
maintenance 12 hourly bolus dose
f. What are the future advices you will give her in the postnatal visit
after treatment is completed?
- Continue heparin for 6 weeks. And no need for further
prophylaxis in future pregnancies.
- Avoid COCs & use compression stockings for 2 years to
prevent post-thrombotic syndrome
g. What is the investigations you will perform postnatally after
treatment is complete.
- Screen for Thrombophilia
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8. A 30 years old multiparous patient has undergone an instrumental
delivery for failure to progress in the second stage of labor. You were
called to see her 15 minutes following the delivery because of heavy
vaginal bleeding with blood loss about 600 ml. the placenta was
apparently complete
a. What’s your diagnosis?
- Primary post-partum hemorrhage
b. List two most likely causes for this problem

- Uterine Atonia
- Trauma to vagina
c. List two clinical signs you would look for on general examination?
- Pulse Rate Increased
- Blood Pressure
d. How would you manage this patient? List 2 important actions
- Call for help & Resuscitate
- Uterine massage to stimulate contractions & bimanual
compressions
e. Mention 4 medications you use in such cases
- IV infusion of oxytocin, 10 IU loading; and maintenance 40 IU
in 500 ml NS over 4 hrs.
- IM Ergometrine 0.25 – 0.5 mg once; after excluding HTN &
cardiac causes,
- Rectal Misoprostol 4 – 5 tabs (800 – 1000 ug)
- IM or intramyometrial Carboprost up to 8 doses
f. List 2 complications of this condition
- Hypovolemic schock
- Acute renal failure
- DIC
- Sheehan’s Syndrome
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9. A 26 years old primigravida presents to the A&E department at 10 weeks
gestation with history of vaginal bleeding and passage of grape like
vesicles
a. Name the likely diagnosis?
- Molar pregnancy
b. List other two possible symptoms you would ask about?
- Hyperemesis Gravidarum (Excessive vomiting)
- Symptoms of early Pre-eclampsia (epigastric pain, headache)
- Symptoms of hyperthyroidism
c. List two clinical features you would look for on examination?
- Large for Date uterus
- Doughie uterus
d. What would you request for confirming the diagnosis?
- US
- Serial B-hCG increasing not proportionate to GA
- Histopathology
e. Mention two possible complications of this disorder?
- Invasive Mole
- Choriocarcinoma
f. How would you manage such a case?
- Admission & resuscitate if vomiting or severe bleeding
- Suction & Evacuation under anaesthesia
- IV oxytocin following evacuation & follow up by serial b-hCG
levels
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10.A 30 year old woman presented with an irregular and painful cycle with
low grade fever and lower abdominal pain. A diagnosis of PID was made.
a. What are the organs that are involved in PID?
- Uterus - Fallopian tubes
- Ovaries - Cervix - Peritoneum
b. What are the symptoms of acute PID apart from above mentioned
ones – Mention 3?
- Passage of foulsmelling offensive vaginal discharge
- Deep dyspareunia
- Sweating & palpitations
c. What are the long term complications of PID?

- Subfertility
- Ectopic Pregnancy
- Chronic pelvic pain
- Perihepatitis Fitz-Hugh-Curtis Syndrome
d. What are the commonest organisms that cause PID – mention 2?

- Chlamydia trachamoatis
- Neisseria Gonorrhea
e. What is gold-standard tool for diagnosis of PID?
- Laparoscopy
f. Mention 3 differential diagnosis of PID?
- Endometriosis
- Pelvic Abscess
- Ovarian cyst
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11.A 28 years old insulin dependent diabetic. She had one previous delivery 3
years ago by difficult forceps delivery. The baby’s weight was 4.1 kgs. She
is currently pregnant and booked in the antenatal clinic at 12 weeks
a. Mention 5 important components in her antenatal care
- US scan to confirm date
- Urinalysis for Glucose
- HbA1C % & Random Blood Glucose
- CBC for Hb & tWBCs
- Monitor Long term complications of DM by Fundal Examination &
RFTs.
b. Her Intrapartum care should include
- 1st stage: Insulin sliding scale; Continuous CTG monitoring &
Epidural analgesia
- 2nd stage: anticipate Shoulder Dystocia and prepare for
instrumental delivery or C/S
- 3rd stage: Active Management.
Or Just Answer (1- Insulin sliding scale. 2- Continuous CTG monitoring 3-

Epidural analgesia)
c. The immediate neonatal care of her baby should include ??**
- APGAR Score & guard against neonatal hypoglycemia
- Vit K
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12.A 30 year old lady at 33 weeks gestation presents with severe itching
specially of the palms and soles which gets worse at night. There was no
skin rash apart from scratch marks seen on examination
a. What’s the most likely cause of her problem?

- Obstetric cholestasis (Intrahepatic cholestasis of pregnancy)
b. What are the adverse effects of this condition on fetus and mother
- Fetal: spontaneous or iatrogenic Premature labor, IUFD
- Fetal distress, meconium stained liquor, stillbirth
- Maternal: Increased risk of C/S & Increased risk of PPH
c. How can you diagnose this condition

- By typical history and examination & exclusion of other causes
of pruritus
- LFTs: elevated ALP & Transaminases
- Coagulation Profile
- US
d. How can you monitor the pregnancy condition
- Weekly Maternal LFTs and coagulation profile & LFTs after
pregnancy
- Monitor fetus by US, CTG, Biophysical profile & Umbilical
artery Doppler & kick count.
e. What treatment can be given to this women
- Symptomatic treatment by Cholestyramine &
Ursodeoxycholic Acid
- Antihistamine
- Calamine lotion
- Vitamin K
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13.A 20 year old lady who had a normal vaginal delivery 3 weeks ago
presented with difficulty with breast feeding associated with pain,
swelling and redness of the left breast. She had been also suffering from
high grade fever and rigors

- Acute Puerpural mastitis
b. What’s the most likely cause?

- Staphylococcus Aureus
c. How does this condition develop, what’s the source?

- Continuous lactation leading to cracking in nipple & areola
which leads to introduction of bacteria through skin
d. How can you manage this patient?

- Stop breast feeding from the affected breast
- Expression of milk from affected breast
- Symptomatic management by Analgesia & Antipyretics
- Antibiotic for Staph (Flucloxacillin)
e. When is surgical intervention indicated?

- In case of development of Abscess
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14.Fatima is a 31 years old primigravida presented at 42 weeks +1 day to the
outpatient department because she passed her dates. Her antenatal
follow up was uneventful. Her dates were confirmed by an early
ultrasound scan at 10 weeks gestation.
a. What’s her main obstetric problem?
- Prolonged Pregnancy (Post-term)
b. Mention 3 maternal complication of this condition

- Maternal Anxiety & Psychological morbidity
- Increased intervention “Induction of labor”
- Operative delivery with increased risk of genital tract trauma
c. Mention 3 fetal complications
- Perinatal Mortality & Intrapartum Fetal Death
- Meconium Aspiration & assisted ventilation
- Macrosomia / Shoulder Dystocia / Fetal injury
- Neonatal: Hypothermia, Hypoglycemia, Polycythemia
d. Mention two tests you will perform for this lady

- USS assessment of growth & amniotic fluid index
- CTG
e. What are the management options for this lady
- Immediate induction of labour
- Expectant Management
f. What are the underlying causes for the fetal complications

- Placental Insuffienicy (calcifications & protein insuffienicy)
- ?
g. Mention 2 drugs used in the management of this condition
- Oxytocin
- Misoprostol
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15. A 26 years old primigravida referred to the hospital with sympheaseal
fundal level more than dates at 32 weeks gestation. Ultrasound scan
confirmed Polyhydramnios and normal fetal measurements
a. Name two fetal organs you want to check by US scan?

- Esophagus (atresia with or without TEF)
- Head & Back for NTDs (Anencephaly)
b. Name one blood test you want to perform on the mother

- Random Blood Glucose
-
c. Name one drug you want to give?
- IM Dexamethasone
d. While she is inpatient, she complained of sudden gush of fluid

vaginally. Which examination would you like to perform?
- Sterile Speculum Examination
e. Why? Mention 4 Causes

- Site of this fluid
- Take swab for Culture & Sensitivity
- Take sample from fluid and test by Nitrazine dye test &
Ferning test to confirm amniotic origin
- Inspect for cervix os
f. What are the main risks associated with this condition?

- Preterm Labour
- Chorioamniotis
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16.A 52 year old obese and menopause lady presented with episodes of
vaginal bleeding.
a. What’s the aim of your investigations in this lady?

- To exclude endometrial cancer
b. What investigations are required to reach the diagnosis?

- USS
- Hysteroscopy & Biopsy
c. What are the possible causes of such bleeding?

- Endometrial Cancer
- Exogenous estrogens
- Endometrial Polyp
- Atrophic Vaginalis
- Endometrial Hyperplasia
d. Mention the treatment for 2 possible causes?

- Atrophic vaginitis: Topical estrogen cream & pessaries
- Endometrial Cancer: Total abdominal hysterectomy + BSO +
washings ± adjuvant therapy
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17.A mother seeks advice for her 15 year old daughter who has not started
to menstruate despite having otherwise apparently normal development
a. What’s the most likely causes mention 4?

- Constitutional
- Obstructive Causes (Imperforate hymen, Transverse vaginal
septum)
- Mullerian Agenesis
- PCOS
- Androgen insensitivity
b. Mention 3 important investigations you would request

- US for uterine abnormalities (absent uterus) & obstructive
causes
- Hormonal Profile: (LH:FSH ratio, estrogen, testerone)
- Karyotyping for Genetic abnormalities
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18.A 20 year old girl presents to A&E with high grade fever and offensive
blood stained vaginal discharge. Ultrasound confirmed retained products
of conception
a. What’s the most likely diagnosis
- Septic Miscarriage
b. What are lines of management

- Hospital Admission & Resuscitation (Maintain circulation &
blood transfusion if needed, antipyretics & analgesia)
- IV broad spectrum Antibiotics “3rd gen Cephalosporins +
Metronidazole”
- Baseline investigations “CBC with coagulation profile, LFTs,
U&E” & endocardial swab for culture & sensitivity
- Prepare patient for evacuation after stabilization & follow up
c. Mention 3 possible complications of such condition, if left without

treatment
- Hemorrhage - Septicemia
- Renal Failure - DIC
- Anemia - Shock
d. If inspite of all measures, she becomes toxic and septic, what would
be the problem?
- Formation of Pelvic abscess
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19.A 12 weeks gestation, a 28 year old woman presents with recurrent
vaginal bleeding for one month, severe vomiting and uterus equal to 20
weeks gestation. Fetal heart could not be detected by sonic aid.
a. The diagnosis is most likely to be?
- Molar pregnancy
b. Confirmation of diagnosis is by?

- US
- Serial B-hCG increasing not proportionate to GA
- Histopathology
c. Management Is best by?
- Admission & resuscitate if vomiting or severe bleeding
- Suction & Evacuation under anaesthesia
- IV oxytocin following evacuation
d. Subsequent follow-up is by?

- follow up by serial b-hCG levels
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20.A 39 year old woman in her first pregnancy presents with diminished fetal
movements at 40 weeks. The CTG didn’t detected fetal heart and this was
confirmed by US.
a. Mention three possible causes of this situation
- Unexplained intrauterine fetal death
- Pregnancy idiopathic Hypertension
- Abruption Placenta
- Cord Accident
b. How would you deliver this baby

- After proper counselling, Expectant management within 2
weeks, if failed induction of labor & vaginal delivery.
c. A possible serious complication is?

- DIC “Disseminated Intravascular Coagulation”
d. How would suppress lactation in this lady

- Bromocriptine
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21.A 26 year old primigravida presents at 8 weeks gestation with a history of
nausea and vomiting for the last two weeks. However, over the past 48
hrs, she has been unable to keep any food or drink down and her urine
analysis shows acetone.
a. What’s the most likely diagnosis of this lady

- Hyperemesis Gravidarum
b. Mention 3 conditions that might cause such condition
- Molar Pregnancy
- Multiple Pregnancy
- UTI
- Choriocarcinoma
c. What investigations would be most helpful

- CBC - Urea & Electrolytes
- US - sB hCG
- Urine Analysis
d. What treatment options are appropriate?

- NPO, fluid therapy and rehydration (avoid dextrose).
- Small frequent meals. And Thiamine therapy
- Antiemetic therapy & Antacids.
- Steroids If no response to above.
- Monitoring: vomiting stops; give oral nutrition, discharge and
reassure.
What are the complications of such a case?

- Hyponatremia & Hyperkalemia “cause of death”
- Wernicke's encephalopathy & Korsokoff psychosis.
- Mallory Weiss tear.
- Thromboembolism.
- Dehydration: shock, hypercoagulopathy state.
- Long standing: small for gestational age and anemia.
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22.A 25 year old primigravida is referred to antenatal clinic by her midwife in
the third trimester with fundal height less than gestational age.
a. What’s your differential diagnosis?

- Wrong dates
- Oligohydraminos
- IUGR
b. If she has been diagnosed as IUGR what are the possible causes
- Uteroplacental Insuffienicy
- Chromosomal abnormalities
- Maternal causes (Malnutrition, Hypoxia, HTN, drugs)
c. What other parameters would you like to look for in the scan
- Biophysical Profile (BPP):
o Fetal body Movement
o Fetal Respiratory Movement
o Fetal Tone
o Amniotic Fluid Index
o CTG
d. How are you delivery this lady.

- By C-Section if abnormal BPP or Doppler, when extra uterine
environment is unhostile & more suitable for the baby than
intrauterine life. Or Vaginal delivery
e. Complications:
- Increase risk of perinatal mortality
- Polycythemia
- Hypoglycemia
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23. Samia M A is a 36 years para 2 lady admitted for induction of labor because
of gestational diabetes at 40 weeks gestation. Her antenatal course was
unremarkable except for increased amniotic fluid index. Before induction
started she reported regular abdominal pain. Vaginal examination revealed
fully effaced cervix 4 cm dilated. While the registrar on duty is preparing
for ARM you are called to see her because her membranes ruptured
spontaneously. On vaginal examination you felt a loop of cord in the
vagina.

- Cord Prolapse
b. What will be your immediate action?

- Call for help (Senior Obstetrician, Anesthetist, Neonatologist and
midwife)
- Position: Keep cord inside: Knee-to-chest /or/Trendelenburg /or/
By hand (NS gauze)
- Avoid excessive touch and manipulation
- Inflate the urinary bladder (to move the presenting part upward)
- Infuse vagina by warm normal saline
- Cover the Os by the Ventouse cup
- Tocolytics; to stop the presenting part from compression
- Deliver the baby
c. How are you going to deliver her?

- In this case it’s 1st stage, so deliver by emergency C/S.
- depending on (Stage of Labor; Bishop score & Fetal viability)
✓ Fetus dead → vaginal
✓ 1st stage → C/S
✓ 2nd stage → according to Bishop score:
- → Favorable: VD with forceps and ventouse
- → Unfavorable: Emergency C/S
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d. Mention 6 risk factors?
- Polyhydramnios
- Multiple pregnancies
- Cord presentation
- Breech presentation
- Transverse lie
- “High Head” AROM before head engagement in the cervix
- Prematurity
e. Considering the risk factors in her case, could this condition be

prevented and how?
- Could be prevented; by induction of labor in 37 Gestation weeks;
& serial amniocentesis
- !?????????????!!?!??!
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24.A 26 years old woman from Al-Jazeera, attends a routine antenatal care at
31 weeks. She is para 5 all spontaneous vaginal deliveries at term. Last
delivery was 18 months ago and was complicated by post-partum
hemorrhage requiring transfusion of 4 units of blood. The pregnancy has
been uncomplicated to date. She feels generally tired but reports good
fetal movement. BP 120/70 mmHg. Investigations:
TEST Result Normal Range

Hb 7.8 g/dL 11 – 14 g/dL
Mean cell volume 68 fL 74.4 – 95.6 fL
Urine Analysis Negative
Blood Group ARh Negative
No Atypical antibodies
a. What’s the likely diagnosis?

- Anemia in pregnancy
b. Mention four further investigations you will request for this lady
- Iron Profile (↓s. ferritin, ↓Iron, ↑TIBC , ↓ %Sat)
- Coagulation profile
- US
- CTG
-
c. How will you manage this woman for the rest of her pregnancy?
(mention 5)
- Iron Supplementation
- Folic Acid Supplementation
- Dexamethasone Injection
- Education about supplementation
- Blood Transfusion if needed
d. Mention 5 risk factors for this condition

- Inadequate Diet - Multiple Pregnancy
- Poor compliance with iron supplementation
- Breast feeding - Poor Absorption
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- Malnourished
e. When do expect her to respond to your treatment of choice?
- 0.8 g/dl/week
f. Mention 3 measure to reduce maternal mortality and morbidity from

this condition.
- Prophylactic Antibiotics
- Adequate Hydration
- Prophylactic Heparinization if needed for DVT
- Shorten 2nd stage of Labor & Active management of 3rd stage of labor to
prevent PPH.
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25. While you are attending the labour room round with obstetric registrar
the nurses rushed in carrying a 25 years old primigravida woman at 37
weeks gestation, who had an eclamptic fit on her way to the hospital.
a. Very briefly, just outline the steps of management without going

into details. (5)
- Call for Help
- ABCs (Left lateral position & mouth gauge, Give High flow Oxygen, Fluid
Restriction
- Drugs to Abort & Prevent the seizure: IV MgSO4
- Drugs to Lower BP:
- Definitive management by Termination of Pregnancy
b. What measures that can be taken to reduce the incidence of

eclampsia in your unit? Mention 4
- Regular Maternal Monitoring (BP monitoring & Urine Analysis & invx)
- Prophylactic MgSO4
-
c. What is the drug of choice for the management of eclampsia?
- IV MgSO4 in 5% Dextrose; Loading Dose 4 g, Maintenance 1g
d. How do you monitor your anti-convulsive drug of choice?

- Reflexes - Heart Rate
- Respiratory Rate - Level of Consciousness
e. Two hours after the initial fit your patient developed a focal
seizure, what is the possible Aetiology?
- Local brain damage due to Cerebral Hemorrhage
f. The patient is planned for an Emergency C/S because her cervix is
not favorable, what are the major two risks from general
anaesthesia, and major two risks from spinal anaesthesia.
- Spinal Anaesthesia:
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26.A 29 years old nullipara presented to your gynecological clinic 6 weeks
following her 3rd miscarriage. All her previous miscarriages were at 10
weeks. She is anxious; worried that she may never carry a baby to term.
a. What are the possible causes for her recurrent miscarriage?

- Immunological (APLS & Thrombophilis)
- Uterine & Cervical Abnormality (Cervical weakness)
- Polycystic Ovary Syndrome
- Infections (Bacterial Vaginosis / TORCH)
b. What relevant investigations will you request?

- General Investigations (CBC & Urine Analysis)
- APLS screening (APL antibodies; Lupus Antibodies)
- Thrombophilia Screening (Protein C & Protein S)
- Infection screening (TORCH screening & high vaginal swab)
- Cytological analysis of the POC
- TVS & HSG for assessing cervical incompetence
c. The patient told you that two of her sisters had venous thrombosis,
what is the likely cause of her miscarriage? What’s the treatment
plan if you confirm the diagnosis?
- Antiphospholipid Syndrome
- Aspirin & Heparin Prophylactic dose
30 | P a g e
27.A 35 years old lady presented complaining of increased tiredness and
shortness of breath for three months, with frequent headaches. Her
periods occur every 24 days with heavy loss on second to fourth day. She
uses tampons and sanitary towels together. She has no pain, she had no
previous gynecological or medical problems. On examination; she is slim
and pale. Systemic, abdominal, bimanual and speculum examination were
unremarkable, apart from the uterus being palpable = 14 weeks.
Investigations:
Hb 6.3 g/dL, MCV 66fL, WBC Normal, Platelets Normal, Blood Film
Hypochromic Microcytic Red cells.
a. What’s the most likely diagnosis?

-
b. How would you further investigate and manage this woman? 4
c. What’s the possible late complication of this management
option?
31 | P a g e
23 yrs old presented with periods of fainting, abdominal pain and slight vaginal
bleeding after 6 weeks period of amenorrhea
1. List two most common differential diagnoses

ECTOPIC pregnancy
miscarriage
2. Mention points in history that support the likely diagnosis

Bleeding ( onset, caused?, amount, clots, part of fetus )
pain ( type and site, regularity)
breathlessness , shoulder pain
risk factors: previous surgery to abdomen or tube, PID, intrauterine
contraceptive devise use, invetrofertillization
3. What is the cause of fainting episodes?

Rapid distention to fallopian tube causes autonomic stimulation causes heart
rate drop
4. Mention important points in examination

Hemodynamics: pulse, bood pressure, tempreture
abdominal: tenderness, rebpind tenderness, regifity
per vaginal : cervical excitation, denexal tenderness
speculum examination: for debris
5. What is your investigations to assess general condition and specific

investigations to reach the cause
Full blood count for bleeding amount, blood grouping and cross matching,
urinary BhCG, Transvaginal USS for ( empty uterus, fluid in douglas uch,
adnexal mass), laproscopy ( diagnostic and therapeutic)
6. What is your emergency management and definitive management

ABC fluid ressucitaion, urgent laproscopy , identify of ectopic mass and
pefromr : salpinectomy of the affected stie, or salpingotomy and follow up by
BhCG
7. Mention one modality of medical treatment
32 | P a g e
Systemic methotrexte
8. 2 days later BhCG still high, what is the name of this condition
Persistant ectopic pregnancy
33 | P a g e
2.
32 yr multigravida, at 37 weeks, presented with sudden severe abdominal pain and
collapse before 2 hours, the pain is severe and central, sharp in nature, continues,
associated with nausea and vomit twice, then she become drowsy, she looks ill,
Glasgow scale is 12, pale, pulse 100, BP 120/80, uterus is board like rigidity,
tender, more than dates, fetal heart sound not heard, there is vaginal blood
spotting, no vaginal examination was done.
1. Mention three possible differentials

Concealed Abruptio placentae
uterine rupture
acute polyhydroamnions
2. Ultrasound showed upper segment placenta with concealed mass of clotted

blood. Mention three possible causes of the final diagnosis
Idiopathic
traumatic
acute polyhydroamnions
3. Mention three important serum investigations in order to resuscitate

Blood group and cross match
renal function test
coagulation profile
4. Mention 5 points in resuscitations of this patient

ABCs
bed elevated at foot
analgesia for the pain
intravenous fluid
blood transfusion
fresh frozen plasma prepared
fluid chart/ central venous line
CTG monitoring of the fetus
5. After stabilization what is the next step in management

34 | P a g e
Artificial rupture of membrane
oxytocin
6. Mention two important complications to the mother of this condition

Acute kidney injury
dissaminatioed intravascular coagulation
7. After delivery there is vaginal bleeding continues for 30 minutes, mention two
possible causes and how to treat
DIC/ coulvaire uteruns
fresh frozen plasma/ hysterectomy
Ergometrine
continue blood transfusion
35 | P a g e
34 yrs old female Para seven, she complains of lower abdominal heaviness and
suprapubic pain, she reported pain during cycle for which she takes
medications and reported clots during menstruation, she completed her
family
1. What is the most likely diagnosis?

Fibroid
2. Mention the possible site?

Submucous
3. Mention two relevant investigations in this patient?

Abdominal USS for diagnosis
HB level
4. How to manage this patient?

Correct anemia by: ovarian suppression for two months till condition embroves
(Hb) and size regress or blood transfusion
Surgical removal: based on patient age and fertility wishes , total hysterectomy
5. Mention one modality of treatment, and two complications of this treatment
GnRH analogue with low dose hormonal replacement therapy HRT
tumor regrows after stoppage
it bring menopausal symptoms ( sweating, flushing, vaginal dru)
and osteoporosis
6. Is there any chance to develop carcinoma from this condition?

There malignant potential is minimal
7. Mention two factors associated with decreased risk to have this condition?
Oral contraceptive pills
depot of Medroxyprogesterone acetate
8. Mention one imaging technique required before surgical intervention?

pelvic MRI
36 | P a g e
23 yr primagravida at 32 weeks, presented with painful abdominal contractions and
vaginal gush of fluids, the pain started gradually before one day, colicky and
rhythmic every 20minutes, severe to degree preventing her from daily activities,
today associated with vaginal clear fluid. Fetal momvent was appreciated.
1. What are the predictors of preterm labour

Fetal fibronectin
transvaginal ultrasound of cervix length
2. What are the complications may arise (mention two)

Fetal: prematurity
maternal: risk of C section
3. Mention one organism responsible for this condition and how to prevent
Bacterial vaginosis
clinamycin
4. Mention 5 lines in management of this lady

Admition
vital signs/ uterus/ cerix/ swab
fetus: ultrasound for amnion, CTG, estimate weight
betamethasoins for 48hr
tocolytics for steroid
intrapartum antibiotics +- anti D
neonatal nursery
5. What are the chances to get another premature delivery at the future
20%
37 | P a g e
First edition
A journey
In an Obstetrics and
Gynecology Clinic
(Collection of Dr.Talab Cases & Rounds

in addition to Skill Labs & Check list)
By: The Academic Secretory

of 9wa3i8 (87) : 2015 – 2016
U of K, Faculty of Medicine
Page #
Index
Chapter 1: cases
Case 1: Cardiac diseases. 2
Case 2: PROM. 2
Case 3: IUCD. 3
Case 4: Cord prolapse. 5
Case 5: Septic miscarriage. 6
Case 6: Hyperemesis gravidarum. 7
Case 7: Molar pregnancy. 8
Case 8: Asherman's syndrome. 9
Case 9: Missed pill. 9
Case 10: Postmenopausal bleeding. 10
Case 11: Severe anemia with bleeding. 11
Case 12: Menorrhgia. 13
Case 13: Imperforate hymen. 13
Case 14: Pre eclampsia. 14
Case 15: Episiotomy. 19
Case 16: Thromboembolic disorders during pregnancy. 20
Case 17: Antiphospholipid syndrome. 21
Case 18: Intrahepatic cholestasis of pregnancy. 22
Case 19: Counseling. 23
Case 20: CTG. 25
Case 21: Uterine prolapse. 26
Case 22: Vasa previa. 28
Case 23: Cervical weakness. 28
Chapter 2: rounds
1. Multiple pregnancies. 32
2. Cardiovascular disease and diabetes with pregnancy. 35
3. Pelviometry. 37
4. Early pregnancy bleeding. 37
5. Management of diabetes during pregnancy. 40
6. Contraceptives. 43
7. Partograph. 47
8. Fetal wellbeing. 48
9. Postmenopausal bleeding. 52
10. Menorrhagia. 53
The Academic Secretory of 9wa3i8 (87) V

CHAPTER 1
CASES
Case 1: cardiac disease.
A 25 year old multiparous lady known to have a heart disease went into
spontaneous labour.
She is stable and all her parameters are satisfactory.
Answer the following questions regarding her management during
labour:
1. What are the content of cardiac tray that should be available for such a
patient in the labour ward?
2. What is suitable analgesia for her?
3. If she needs prophylactic antibiotics which drugs are the most suitable?
4. What are the measures that should taken during the second stage in order
to avoid maternal complications?
5. What are the serious complications that can occur during labour?
(Mention 2)
Answers:
1. Digoxin, morphine, diuretics (Lasix), aminophylline, Syntocinon, Wrigley's
forceps, ventues.
2. Epidural if available.
3. Both 1-amoxicillin or vancomycin (if allergic) 2- gentamicin
4. Aim make 2nd stage as short as possible by instrumental delivery.
 To shorten the 2nd stage by outlet forceps.
 Syntocinon / syntometrin to guard against PPH
 Ergometrein should not be given unless the patient develops PPH.
Notes:
 Commonest cause of induction: postdate pregnancy.
 Best position of mother with cardiac disease during labour: left
lateral, semi brought up, however she feels comfortable.
5. Arrhythmia pulmonary Edema heart failure.
-------------------------
Case 2: PROM
A 27 years old primagravida at 32 weeks gestation presented with pain
less watery vaginal discharge.
General examination revealed no abnormalities
Abdominal examination, no tenderness, fundal level corresponding to
date, cephalic presentation, fetal heart 146 /min
Speculum examination confirmed ruptured membranes with closed
cervical os.
Outline your management...

The Academic Secretory of 9wa3i8 (87) 2
Answer:
 Admission.
 Look for signs of infection.
 Steroids administration.
 Prophylactic antibiotics.
 Maternal investigations to rule out infections: CBC, HVS for C & S(
high vaginal swab for culture & sensitivity) / urine analysis, CRP)
 Fetal surveillance ( kick count , U.S., BPP and Doppler )
 + / - tocolytics / in utero transfer.
 Conservative management up to 34-37 weeks if no problems.
 Delivery if she develops infection or fetal compromise.
 Pediatric care.
Notes:
 Aim of examination and investigations is to exclude signs and symptoms of
chorioamnionitis.
- Signs: tachycardia, fever, tender uterus.
- Symptoms: offensive discharge, increase temperature.
 Investigations :
a) Leukocytosis
b) Increased CRP
c) Biophysical profile
d) Doppler
e) Culture
 Give antibiotics erythromycin for 10 days
- Give beta or dexmethazone
 Beta 2 days 12 mg 24 hrs apart.
 Dexa. 6 mg 12 hourly for 48 hrs.
 Monitor mother for signs of chorioamnionitis
 If she got into labour, She has got chorioamnionitis better to let labour
proceed.
 If probability of labour give tocolytics.
 Continue this conservative management until 34 -37 weeks provided that
there is no evidence of chorioamnionitis.
 indications of tocolytics :
o Premature labour 24 -36 weeks.>> aiming at giving time for steroids and
uterotransfer
(First line nifedipine).
-------------------------
Case 3: IUCD.
A 35 year old multiparous women presented to gyn. Clinic requesting an
IUCD for contraception after failure of other methods of contraception.

Answer the following questions regarding IUCD
1) How does it act as contraceptive, mention 2?

2) What is a suitable time for its insertion in multiparous women who delivers
5 months ago?
3) For how long can such a method be used?
4) When could it be removed? When would the fertility would return after
removal?
5) What determines the duration of it is action?
6) What are its absolute contraindications?
7) What are it is side effects / complications (mention 4)?
8) What are the possibilities if the women missed the strings (the thread)
mention 2?
9) What are the investigations would you do in either case?
10) Mention one of it is major disadvantages?
Answers:
1)
 Inflammatory reaction make the endometrium hostile to sperm.
 Kill the Soren and ovum direct toxins to them.
 Interfere with implantation.
2)
 During or immediately after period
- Cervix will be lax because of menstrual flow.
- Make sure she is not pregnant.
Generally:
o 3 weeks after deliver and onward usually 6 weeks.
o Immediately after delivery but increase risk of expulsion.
o Immediately after evacuation and miscarriage or at any time.
3) 5-10 years.
4) Could be removed at any time and fertility can be gained immediately.

Failure rate = 1-2%
5) The copper content of the device, the more the longer.
6) 1. pregnancy
2. undiagnosed vaginal bleeding
3. active PID
4. HIV
5. distorted uterine / bicornate cavity
6. Allergies to constitute.
7) -Its side effects:

1. Menorrhagia especially first few months.
2. Infection due to insertion usually in the first 2 weeks
3. HSR
4. Dysmenorrhea.
5. Excessive mucoid vaginal discharge
6. Hx of bacterial endocarditis.
-Complications:
1. Perforation:
If retroverted -- adjust length of the device.
2. Failure
3. Expulsion usually first few periods "always ask pt to feel
strings"
8)
1. Expulsion
2. Perforation
3. Migration
9)
 Ultrasound to see if it is still in the cavity or not!
 Plain X Ray if not found by U.S.
 If not found --->>> expulsed.
10) Does not protect against STD.
-------------------------
Case 4: cord prolapse.
At 11:30 pm in Soba delivery suite, a female young doctor was in an
uneventful labour.
Suddenly the CTG showed prolonged and deep late declaration. The
midwife performed vaginal examination and shouted CORD prolapse.
Explain:
1- The immediate steps that you would take?
2- Further management by presuming different scenarios.
Answers:
1- immediate actions :
 Keep the cord inside the vagina.
 check the fetal heart sound by any available tool
 keep pressure off the presenting part on the cord by :
Changing pt position like elevating foot of the bed, chest knee portion,
modified trenderburg's position, filling the bladder with normal saline.
2- further actions:
 Depend on stage of labour, station of the presenting part and
whether the body is alive or dead.
 CS if : -
- she is in the first stage of labour
- she is in the 2nd stage of labour and the head is not
engaged
- Non cephalic presentation.
 Instrumental delivery if :
- She is in the 2nd stage and the head is engaged
 Vaginal delivery if:
- The body has already died.
- Breech extraction in case of 2nd twin in certain
circumstances.
-------------------------
Case 5: Septic Miscarriage.
A 20 year old girl presents to the accident and emergency with high
grade fever and offensive blood stained vaginal discharge
U.S. Confirmed retained product of conception.
1) What is the most likely diagnosis?
2) What are the lines of management?
3) What are the possible complications of such a condition? If left without
treatment (mention 3).
4) If in spite of all measures, she becomes toxic and septic what would be
the problem?
Answers:
1) septic miscarriage
2) 1-maintain circulation(by IV fluid and blood transfusion if needed)
2-IV broad spectrum antibiotics
3-analgesia and antipyretics
4-prepare for evacuation after stabilization
3) The possible complications:
- Hge. (Haemorrhage). - septicemia - renal failure
- DIC - anemia - shock and death
4) Think of pelvic abscess.
 Condition in which uterus is easily perforated:
1. Septic miscarriage
2. Molar pregnancy
3. Disease of uterus e.g :endometrial CA
4. Missed miscarriage
 If you perforate the uterus, what would you do?
- Measure the length of the cavity so you can know if you can perforate it
- immediate step:
1. Stop everything
2. tell anaesthetist and theatre
3. insect the laproscope and resume under direct visualization + GA
If no laproscope not available  laparotomy
4. If there is no bleeding  conserve and monitor
If there is bleeding  repair damage, then go for laproscope or laparotomy
5. Tell the patient
Case 6: Hyperemesis Gravidarum
A26 year old primagravida present at 8 weeks mild gestation with a Hx

of nausea and vomiting for the last 2 weeks. However, over the past 48
hours she has been unable to keep any food or drink down her urine
analysis show acetone
1) What is the most likely diagnosis?
2) Mention 3 conditions that might cause such a scenario.
3) What investigation would be most helpful
4) What are the appropriate treatment options?
5) What are the complications of such a case (mention 3)?
Answers:
1) Hyperemesis Gravidarum.
2) 3 conditions that might cause such a scenario:
a. Molar pregnancy.
b. Multiple pregnancy.
c. UTI.
3) Investigations:
a. FBC.
b. US.
c. Urine analysis.
d. Urea and electrolyte.
4) Treatment options:
a. NPO, fluid therapy and rehydration (avoid dextrose).
b. Small frequent meals.
c. Thiamine therapy (B1 or B complex injection).
d. Antiemetic therapy.
e. Antacids.
f. Steroids If no response to above.
g. Monitoring: vomiting stops oral nutrition, discharge and
reassure.
(H.G. decrease by the fourth month)
(5) The complications:
a. Hyponatremia.
b. Wernicke's encephalopathy (coma + severe illness + CVA:
paraplegia or hemiplegia).
c. Korsokoff psychosis.
d. Mallory Weiss tear.
e. Thromboembolism.
f. Dehydration: shock, hypercoagulopathy state.
g. Long standing: small for gestational age and anemia.
Notes:
Differential diagnosis of nausea & vomiting in early pregnancy:
1. H.G (Hyperemesis Gravidarum).
2. Gastritis.
3. DKA.
4. Malaria (fever).
5. Thyrotoxicosis.
6. Ectopic pregnancy.
-------------------------
Case 7: Molar pregnancy
At 12 wk gestation, 28 yr old woman presents with recurrent vaginal
bleeding for one month, severe vomiting and uterus equate To 20 wks
gestation, fetal heart can't be detected by US (sonic) aid.
1. The diagnosis is most likely to be?
2. Confirmation of diagnosis is best by?
3. What is the method of choice for evacuating the uterus?
4. Subsequent follow up is by?
5. What is the malignant form of disorder?
Answers:
1. Molar pregnancy.
2. Expulsion of vesicles through vagina, US scan, histology.
3. Suction evacuation.
4. Serum Level of βhCG.
 Usually goes back after 8 weeks of ttt, then the pt can get
pregnant after 6 month from there.
 If not goes back by 8 wks wait until become normal and from
there take 6 months.
 Pregnancy will interfere with BhCG level, so should avoid pregnancy which
interferes with follow up.
 Normal HCG level is <5
 Spectrum of trophoplastic disorders:
Molar pregnancy  Invasive mole, placental site, trophoplastic disease locally
invasive  Choriocarcenoma, 100% curable
 Risk factor for trophoplastic disorder:
1. Extreme age <15 or >50
2. blood group A
Case 8: Asherman's syndrome.
A 25 years old lady underwent evacuation for missed miscarriage, she

developed amenorrhea and cyclic abnormal pain.
a) What is the most likely diagnosis?
b) Mention 3 common causes of this condition?
c) Mention 3 common presentation of this condition?
d) What do we call this condition during pregnancy?
e) How do you treat this condition?
Answers
a) Asherman’s syndrome or uterine synechiae.
b) 1 - traumatic : DC and evacuation (The commonest cause)
2 – Infection: TB, schistosmiasis and chlamydia
3 – Uterine intervention: CS and myomectomy
c) 1 – Amenorrhea. 2 – Dysmenorrhea. 3- secondary infertility.
4– Recurrent miscarriage. 5- hypomenorrhea.
d) Amniotic bands (sheets).
e) Hysteroscopy to release the adhesions:
 IUCD or catheter insertion to prevent re-occurance.
 Give oestrogen to build up the endometrium.
-------------------------
Case 9: Missed pills.
A 26 years old woman taking the combined oral contraceptive pills has
missed 2 consecutive pills in her current packet. She had a burst
condom the condom the following day and attends requesting
emergency contraception.
 What advice would you give this patient?
The most serious time to miss a pill is:
 The first 7 days.
 Then the last 7 days.
BUT the safest is the middle 7 days, if up to 4 pills are missed won’t be very
serious.
If she missed 2 pills in:
1. The first 7 days :
A – Give emergency contraception
B – Alternative methods (e.g. condom) for at least 7 days
2. The second 7 days :
- Alternative methods for 7 days, no need for emergency contraception.
3. The third 7 days: continues the next package without a pill free period,
no need for emergency contraception.
If emergency contraception needed options are:
 PC4 (yuzupe): 4 pills, 2 immediate and 2 in the next 12 hrs. Better given
within 72 hrs of unprotected sexual intercourse, but can be given up to 10
days. The earlier used the less failure rate.
 levonelle: 2 pills, 1 immediate and 1 after 2 hrs. The most commonly used.
 Mifpristone: progesterone given mid-cycle suppresses FSH.
 IUCD: can be inserted up to 5 days after, to prevent implantation.
-------------------------
Case 10: Post-menopausal bleeding.
A 52 years obese and menopause lady presented with episodes of
vaginal bleeding, she is so concerned as her sister had an unfavorable
outcome at that age:
1) What do you call this condition?
2) What is the aim of your investigations in this lady?
3) What are these investigations?
4) What are the possible causes of this condition? (Mention 4).
5) Mention the treatment for three possible causes.
Note:
DM, HTN, and post menopause are the triad of risks of environmental cancer.
Answers:
1. Post-menopausal bleeding. Most common cause is atrophic vaginitis.
2. To exclude malignancy.
3. 1\ Trans-vaginal U/S for endometrial thickness.
2\ Hysteroscopy
3\ Biopsy (endometrial sampling).
4 & 5. 1\ atrophic vaginitis → short course of estrogen cream.
2\ endometrial cancer → TAH + BSO.
3\ cervical cancer → radical hysterectomy ± radiotherapy or chemo-
radiation.

4\ cervical or endometrial polyp → polypectomy.
5\ decubilus ulcer in uterine prolapsed.
6\ E2 secreting tumor → TAH + BSO ± chemotherapy.
7\ urethral furnicle.
8\ HRT
-------------------------
Case11: Severe anemia with pregnancy.
This is a FBC of a para 8 woman at 37 weeks gestation presenting with
shortness of breath and palpitation:
Normal range
TWBC 4.5 x 10 m/l 4 _ 11
RBC's 4.34 million/ml 3.8 _ 5
HB 6.0 g/dl 12 _ 14
HCT 20.5 % 37 _43
MCV 58.8 fl 85 _95
MCH 13.8 pg 28 _ 32
MCHC 23.5 g/dl 32 _ 34
Platelets 161 x 10 m/l 150 _ 400
1. What is your diagnosis?
2. If untreated, she is likely to have? (Mention 3).
3. The most logical treatment option is?
4. What precautions you should take during labor for this patient?
5. What are the indications of blood transfusion during pregnancy in such a
case?
6. What are the fetal complications of maternal anemia?
7. How can you give iron therapy in case of Fe deficiency anemia?
8. Depending on HB % how can you categorize the severity of the anemia?
9. What are the complications that may occur during puerperium?
ANSWERS:
1. Severe anemia with pregnancy.
2. If untreated , she is likely to have:
a- Heart failure
b- DVT and thromboembolism
c- Sepsis
d- Pancytopenia (severe folic acid deficiency).
e- Hypovolemia( HF)
3. Blood transfusion (packed cells), why? Its severe anemia and late
pregnancy.
4.
a- ABC intermittent O2 inhalation.
b- Reducing and correcting blood loss.
c- Analgesia and anaesthesia
d- Prophylactic antibiotic and aseptic technique to reduce intra-partum
infection.
e- Avoid episiotomy if possible
f- Shorten the 2nd stage by ventouse/ forceps.
g- Active management of 3rd stage of labor.
5.
a. Incipient or established heart failure
b. Less severe anemia co-existing with serious condition, e.g. renal
failures, sepsis, hemorrhage.
c. Anemic patients in whom major surgery or major operative delivery
is inevitable.
d. Anemic patient seen for the 1st time while aborting or during labor.
6.
a. Reduction of Po2 → placental insufficiency.
b. Late miscarriage.
c. IUGR & LBW.
d. Premature labor.
e. IUFD.
f. intrapartum and early neonatal death.
g. Baby born without iron stores.
- No risk of malformation (pica eaters).
7.
a. Oral: 1 tab every day (ferrous sulphate, ferrous gluconate, and
ferrous fumerate).
b. I/M: iron sorbitol 100 mg every other day.
c. I/V: iron dextran (total dose infusion, which is calculated by an
equation, precautions of transfusion reactions).
8. Degree of anemia: mild (10 _10.9 g/dl), moderate (7 _ 10), severe (<7), v.
severe (<4).
9. The complications that may occur during puerperium:
a. Puerperal sepsis, infections, pyrexia.
b. Failure of lactation.
c. Sub involution of uterus
d. DVT and thrombo-embolism.
Case 12: Menorrhagia.
35 years old multiparous lady presented with heavy periods for the past
18 months. She says that it interferes with normal activities and fed up
with it and seeks advice:
1) What is your diagnosis?
2) What are the investigations that you can do for such a case?
3) What are the possible underlying causes?
4) What are the options of treatment for such condition?
ANSWERS:
1. Menorrhagia.
2. 1. FBC. 2. U/S pelvis. 3. Thyroid function test.
4. Coagulation profile.
3. Possible underlying causes:
 Non organic: DUB (most common).
 Organic (fibroids, adenomyosis, PID, pelvic congestion).
 Blood disorders (VWD is the most common, treated with
transexamic acid).
 Hypothyroidism.
4. Treatment:
a. Medical:
 1st line is mefaminic acid + transexamic acid
(antifibrinolytic).
 Compound oral contraceptives (↓amount,
↓dysmenorrhea, and regulates).
 progestrogenes (oral or injections) for 3 weeks are very
effective.
 Mirena coil.
 Danazol (androgenic).
 GnRH agonist.
b. Surgical: endometrial ablation or hysterectomy.
-------------------------
Case 13: Imperforated hymen.
This is a picture of the vulva of a 16 years old girl with well-developed
2ndry sexual characteristics but has not menstruated yet:

2) Mention 3 ways by which this girl may present clinically:

3) What are the complications of untreated imperforated hymen?
4) What is the treatment?
Answers:
1) Imperforated hymen.
2) May present clinically with:
a. Cyclic abdominal pain.
b. Abdominal distention and swelling.
c. 1st degree amenorrhea.
d. Urine retention.
e. Constipation and back pain.
3) Complications:
a. Collection of mucous, fluids and blood in vagina or uterus
depending on age.
 Hydro colpus/metria.
 Muco colpus/metria.
 Hemato colpus/metria.
 Hematosalpinx.
b. Can go to tubes causing endometriosis.
c. Amenorrhea.
d. Infertility.
4) Surgical incision (hymenotomy) + spontaneous drainage.
-------------------------
Case 14: pre-eclampsia.
19 years old G1 P0 +0, 39 weeks, Antenatal care outside your area.
Having 3-4 contractions /10 minutes.
The pregnancy was uncomplicated, except a UTI in the 1 st trimester.
O/E: facial and generalized swelling, BP 164/102
Urine dipstick showed +++ protein.
Vaginal examination: cervix 4 cm, 100% effacement, station 0,
membrane intact
CTG: reassuring.
 What concerns you about this situation?

o She’s likely having severe pre-eclampsia. There are both maternal and
fetal risks, including:

1. Risk of eclampsia
2. Intra cranial hemorrhage.
3. Risk of pulmonary edema (iatrogenic fluid overload)
4. Hepatorenal failure.
5. Fetal Intracranial haemorrhage.
 How would you calculate MAP (mean arterial pressure)?

o Diastolic + 1/3 pulse pressure.
o Or, (systolic + 2x diastolic)/3.
 Can you use automated blood pressure assessment?
o Yes. But it can under read BP by up to 5%.
o Always check BP by hand with mercury or validated aneroid
sphyngomanometer.
o Monitor BP every 15 minutes. The size of the cuff matters in obese
patients.
 What lab investigations would you order?

1. RFTs.
2. LFTs.
3. CBC (platelets).
4. Clotting profile.
5. Mid-stream urine (MSU) including G-stain.
6. Urate.
 What other data would you need at this point?

o Her handheld antenatal records.
 Would you give antihypertensive and/or Mg sulfate at this point?

o Antihypertensive are probably not needed at this stage, since her MAP
is <125 (Actually 120) and she’s asymptomatic. However, persistent
systolic blood pressure < 160 mmHg should be treated.
o Magnesium Sulfate can be started as prophylaxis.
o GIVE NEITHER.
 30 mins later: while awaiting lab results the patient has a grand
mal seizure that lasts about 1 min, there is fetal bradycardia.
o 5 lines of management.
o Answer :
1- Call for help.
2- ABCs, Resuscitation.
3- Give loading dose MgSO4, Abort fits.

4- Foley catheter / fluid balance (fluid management).
5- Keep NPM (nil per mouth) – review need to treat BP.
Also:
 Control blood pressure by giving perenteral
antihypertensive.
 Inform (consultant/anesthetist/theatre/blood bank/lab).
 Would you use Diazepam to shorten the fit?

o No, most fits are self-limiting.
o Avoid polypharmacy.
o Diazepam is kept for recurrent fits or when MgSO4 is not available.
 What is the significance of fetal bradycardia?

o Usually it is a side effect of MgSO4.
o It occurs frequently during an eclamptic fit.
o Proceeding to immediate caesarian section because of the
bradycardia may endanger the mother’s life
o Stabilize the mother (resuscitating the mother will resuscitate the
fetus) i.e. unless you stabilize the mother you cannot proceed to
CS.
 How would you deliver when the mother is stable?

o LSCS (lower segment caesarian section) or induction with vaginal
delivery.
o Induction can usually be considered if :
 Gestation < 32 weeks.
 Cervix is reasonably favorable (i.e. delivery likely within
12 hours), cervix is often favorable in preeclampsia.
 Fetal condition is stable (i.e. no severe IUGR).
o After the seizure:
 Admit to HDU.
 Hourly assessment of fluid balance.
 4g loading does MgSO4 then infusion of 1-2 g/h
 Total IV fluid limited to 80-85 ml/h or 1 ml\kg\h. usually
Hartmann’s solution or normal saline.
 Foley catheter. But CVP is the best to monitor fluid.
 Fluid balance is very important, overload  pulmonary edema, and

under perfusion  RF.
 Fetal bradycardia recovers with control of seizures: O2 and left lateral
position.

 Contractions 4-5 in 10 mins, lasting 60-90 sec, ARM- meconium
staining – FSE (fetal scalp electrode) applied, FHR=160 bpm with low
variability. Consultant anesthetist, obstetrician and theatre are aware of
the situation. BP 180/110.
 What are you going to do?
o Parenteral antihypertensive (MAP=133) hydralazine or
labetalol.
o Adequate analgesia: because she is in labor.
 Are you worried about her BP?

o Yes because maternal complications occur with high BP.
 How would you control her BP?
o IV labetalol (bolus +/- infusion)
o IV hydralazine (bolus +/- infusion)
o epidural analgesia may help (if platelets are OK)
 Indications of CVP use in preeclampsia:

1- Persistent oligouria despite fluid challenge (if there was renal
impairment, urine output is not reliable), (urine output > 100 ml over
4 hours).
2- evidence of fluid overload
3- Need for transfusion/ major hemorrhage.
4- prolonged surgery
 Will the MgSO4 itself lower the BP?

o No it is primarily for seizure prophylaxis.
 What are the signs of Mg toxicity? ( in order).

1. absence of deep reflexes
2. somnolence
3. Respiratory depression
4. paralysis
5. Cardiac arrest (at the end).
 What is the antidote for Mg toxicity?

o Calcium Gluconate 1g IV over 3 minutes (10 ml of 10% CG).
 What actions should be taken for absent reflexes?

o Stop MgSO4 until reflexes return.
 What actions should be taken for respiratory depression/ somnolence?
1. Stop MgSO4.

2. Give O2.
3. Recovery position.
4. Monitor closely.
 What actions should be taken for respiratory arrest?

1. Initiate BLS.
2. Intubate/ventilate immediately.
3. Stop MgSO4.
4. IV calcium gluconate.
 What action should be taken for cardiac arrest?

1. Initiate BLS.
2. Stop MgSO4.
3. IV calcium gluconate.
4. If antenatal  immediate CS.
 You detect decreased fetal heart variability on internal monitoring.

What is the significance?
o It’s likely to be related to MgSO4.
o Also common (temporarily) post-eclamptic seizure, or following
fetal bradycardia.
o But, consider fetal compromise if it persists > 45 minutes
(especially if there are other CTG changes).
 Blood results return: Pulse 90, BP 140/95, Respiratory rate 12,

Temperature 37.8 C. Urine output 30 ml past hour. Blood results are
normal except for high WBC count.
 The patient had another grand mal seizure. What would you do next?
o General supportive measures (ABCs).
o Second bolus of MgSO4 2 g. should be given even if the levels
are already therapeutic, as long as there are no signs of toxicity.
o Consider another neuroleptic or GA if seizures continue despite
the 2nd bolus.
 Would you deliver? And how?

o Do a vaginal examination. If the cervix isn’t favorable, deliver by
urgent LSCS.
 Is she septic? ( temperature 37.8 C, WBCC 21X109 )
o No. the high WBCC and pyrexia are more likely to be related to
the grand mal fit.
o Antibiotics should not be given. Unless there are other overt
signs of infection.
 Does she have HELLP syndrome?
o No.

 Would the management be different if her seizure was a focal?
o Yes. A focal seizure might suggest intracranial bleeding and it
should be confirmed with a CT scan.
 Vaginal examination showed 7 cm dilation. Oxytocin was given. A

normal baby was delivered. No PPH.
 When would you discontinue MgSO4?

o 24 hours after the last fit. (Possibly 48 hours if recovery is
protracted).
o More than 40% of all eclampsia occur post natally.
 If uterine atony occurs, what drugs would you use?

o Oxytocin 5-10 units (slow IV bolus) + IV infusion.
o Prostaglandins: hemabate IM and/or misoprostol
o Ergometrine is usually avoided because of unpredictable
intractable severe atonic bleeding.
 Would you have changed the treatment of the initial fit given that the
patient had a history of grand mal epilepsy?
o No. still give MgSO4 because of the possibility of eclampsia.
-------------------------
Case 15: Episiotomy.
25 years old primigravida presented 6 wks after delivery with inability to
control flatus and soiling vagina with feces. She gave Hx of prolonged
and difficult labour and delivery was achived by forceps.
1. What is the most likely diagnosis?
2. What are the types of episiotomy you know?
3. What is the best time to perform episiotomy?
4. What are possible indications for episiotomy?
5. What are complications of episiotomy?
6. what are the degrees of perineal tear
Answers:
1. rectovaginal fistula.
2. Medial and Mediolateral.
3. With crowning of the presenting part.
4. Indications: fetal distress, inelastic perineum, Shoulder dystocia,
Instrumental delivery, Prenous pelvic floor surgery and Breech
presentation.
5. Complications: Pain, Dyspareunia, Extension to 3rd/4th degree tear
and Bleeding.
MANAGEMENT OF INFECTED EPISIOTOMY
1-Open & drainage
2- Clear the wound.
3- Take swab.
4- Cover with broad spectrum antibiotics till c and s results appear.
5- Clean wound every day.
Either leave it to heal by granulation or re suture after at least 3 months.
Degrees of perineal tear:

1st: involve skin only
2nd: skin + perineal muscle
3rd: 2ed degree + and sphincters
4th: 3rd degree + anal epithelium.
Best time to repair 3rd and 4th degree = immediately (first 24 hrs)
If not discovered immediately; after three months at least
-------------------------
Case 16: Thromboembolic disorders during
pregnancy.
A 25 yrs old primigravida at 20 wks GA diagnosed as having DVT.
1. How can you initiate the anticoagulant therapy?
2. Mention 3 objective test for diagnosis of DVT?
3. What are the baseline investigations that idealy should be done for this
woman before starting anticoagulant?
4. Mention 2 types of parental anticoagulant and their route of
administration:
5. For how long do you recommend therapeutic and prophylactic therapy
for this woman?
6. How do you monitor Heparin therapy?
Answers:
1. Unfractinated Heparin (UFH) , Continuos infusion:
Loading dose by 5000 IU given IV, followed by: IV infusion of 1000-2000IU/hr
or by SC injection loading 5000 IU Iv .Maintenance unfractionated LMWH the
available 1000-2000 / 15000-20000 SC 12 hourly LMWH bolus dose of 5000
 Enoxaparin. Clexane. 1mg/kg. SC. Bd
 Daltepdrin. Fragmin. 100mg/kg. SC Bd
 Tinzaparin enohep. 175mg. SC Bd
Based onearly preagnancy weight
2. Duplex u/s, ventilation perfuion lung scan, venography with shielding

and MRI.
3. FBC, RFT, LFT, Thrombophilia screening and Coagulation screening.
4. UFH IV or s/c, LMwt H s/c
5. Therapeutic therapy for: 6 month, Prophylactic therapy : 6-12 weeks
6. For prophylaxis  no need for monitoring.
For therapeutic:
 ATPTT for UFH
 Anti Xa for LMwt.
-------------------------
Case 17: Antiphospholipid syndrome.
The following about lady diagnosed to have Antiphopholipid syndriome:
1. define antiphospholipid syndrome:
2. What are pregnancy complications that are associated with APS?
3. What are the lab investigations that you do to confirm your diagnosis?
4. What are the differential diagnoses associated with recurrent
pregnancy loss, IUFD and IUGR?
5. What is the treatment??
6. What are the prognosis of APS in pregnancy?
Answers:
1. A presence of: anti cardio lipin abs or lupus anti-coagulant, On 2
occasions 8 weeks apart, in association with history of thrombosis
(arterial or venous) or adverse birth outcomes. 3 or more unexplained
miscarriage before 10th week of gestation or a premature birth less
than 36 weeks due to severe pre-eclampsia or IUGR.
Note: It's not defibed solely by the presence of lupus anti-coagulant or anti
cardiolipin bodies.
2. Recurrent pregnancy loss, ftal loss,Pet, Iugr, thrombocytopenia,
preterm delivery, utero placental insufficiency, arteriovenous
thrombosis, seizures, stroke
3. Positive Elisa test: for antiphospholipid, anticardiolipin, anti B2,
glycoprotein-1, ANA.
Positive coagulation teat for lupus antibodies
4. PCOS, chromosomal abnormality, anatomical uterine abnormality,
cervical incompetence, hereditary thrombophilia, other causes of
thrombocytopenia and intrauterine infection.
5. Treatment: Aspirin 75_ 100 mg. & Heparin prophylactic dose 5000 Bd
6. * If untreated 90% fetal loss
* If treated with aspirin and Heparin  70% live birth
* If treated with aspirin alone  40% live birth.

Remember these points:
 potentially malignant = complex with atypia
 Most common : Endometrial Adenocarcinoma
 Least effective: POPs (progesterone only pills).
 Least complication of intrahepatic cholestasis= still birth
 First step in the assessment of post term gestation= determination of
the length of gestation.
 Pregnant women of sickle cell trait is at Risk for an ↑ risk of UTI
 Most significant factor responsible for the ↑ in the CS rate = repeat CS
 Most common cause of IOL (induction of labour) = prolonged
pregnancy.
 Most successful assistant reproductive technique is = ICS (You need
only one sperm for fertilization).
 Most likely sites for implantation of endometriosis; (commonest)
ovarian fossa & In the Q = punch of Douglas.
 DUB (dysfunctional uterine bleeding) frequently associated with
Anovulation
 Major health hazard related to changes associated with menopause is:
osteoporosis
-------------------------
Case 18: Intrahepatic cholestasis of pregnancy.
30 years old lady at 33 weeks gestation presented with sever pruritus

especially of the palms and soles which worsen at night. There was no
skin rash apart from scratch marks seen on examination.
1) What is the most likely cause of her problem?
2) What is the adverse effect obstetric cholestasis on the fetus and mother?
3) How can you diagnose this condition?
4) How can you monitor the pregnancy with such condition?
5) What treatment (if any) can be given for this woman?
6) What is the role of vitamin K in the treatment of this condition?
Answers:
1) Intrahepatic cholestasis of pregnancy= Obstetric cholestasis.
 Due to estrogen which causes edema in the liver leading to retention of
bile.
2) On fetus: 1. IUGR. 2. IUFD & SB. 3. Premature labor (spontaneous or

iatrogenic). 4. Meconium stained liquor & distress (aspiration
pneumonia).
5. increased CS rate & PPH.
On mother: 1. Sleep disturbance. 2. PPH.
3) History is suggestive: unexplained pruritus with increased bile salts level +
abnormal TA (transaminase) levels which resolve completely after
delivery.
- PT may be resolved.
- Diagnosis is by excluding other causes of generalized itching
(transaminase "moderately elevated" … bile acid … PT).
4) Maternal: 1. LFTs weekly + BP & urine check. 2. Coagulation profile.
3. LFTs 10 days postnatally.
Fetal: fetal wellbeing tests.
5) No specific treatment/ Smptomatic:
1. Chelating agent: clolestyamine.
2. Systemic antihistamine: to relief itching Or topical calamine lotion.
3. Ursodeoxycholic acid (UDCA): improve itching & LFTs (drug of
choice).
6) Vitamin K (water soluble) should be given orally 10 mg daily especially
when prothrombin time is prolonged to decrease risk of PPH & fetal &
neonatal bleeding. ** Usually in 3rd trimester.
*Should such a woman be offered on an elective delivery & when?

- Yes, after 37 weeks. The risk of the fetus after this gestation
outweigh the risk of intervention.
-------------------------
Case 19: Counselling.
29 year old lady with history of primary infertility presented with severe
abdominal pain, distention, nausea, vomiting, and dehydration. Few
days after she had gonadotrophins injection as fertility treatment.
2) What are the differential diagnoses?
3) What are the classifications of severity of ovarian hyper stimulation
syndrome? (OHSS)
4) Mention the risk factors of OHSS?
5) What are the complications of OHSS?
6) How can you manage OHSS?
Answers:
1) Ovarian hyper stimulation syndrome. (Usually follows
gonadotrophin therapy).
2) ** Gyn. Conditions:
1. Complication of ovarian cyst- torsion, rupture.
2. Pelvic infection.

3. Intra-abdominal hemorrhage.
4. Ectopic pregnancy.
** Surgical: e.g. appendicitis.
3) 1. Mild. 2. Moderate. 3. Severe. 4. Critical.
Depending on: 1. Ovarian size. (Mainly) 2. Presence of ascites.
3. Hydrothorax.
- Mild: abdominal bloating & mild abdominal pain.
Ovarian size usually 8 CM.
- Moderate: moderate abdominal pain, nausea, vomiting.
US evidence of ascites.
Ovarian size usually 8-12 CM.
- Severe: clinical ascites +l- hydrothorax.
Oliguria.
Heamoconcentreation - Hct < 45%
Hypoprotinemia (cause of ascites)
Ovarian size < 12 CM.
- Critical: tense ascites or large hydrothorax.
Hct < 55%
WBC < 25000lml.
Oliguria, anuria.
Thromboembolism.
Acute respiratory distress syndrome.
4) Risk factors for developing OHSS:

1. Those with PCO.
2. Those under 30 years.
3. Using GnRH agonists.
4. Those exposed to HCG.
5. Development of multiple follicles during treatment cycle.
6. Past Hx of OHSS.
7. Cycle resulting in pregnancy especially multiple
pregnancies.
5) Complications:
1. Severe dehydration, hydrothorax, ascites.
2. Thrombosis.
3. Renal & liver dysfunction.
4. ARDS.
5. Cerebral infarction.
6) The management depends on grade & severity

# Mild & moderate: as an outpatient:
- Simple analgesia - Paracetamol, codeine. (NSAIDs not
advised- affect renal function).

- Fluid intake to thirst rather than to excess.
- Avoid sexual intercourse & heavy exercise (to avoid ovarian
trauma & rupture).
- Progesterone foe luteal support. Not HCG.
#Severe & critical:
- Analgesia – parental opiate.
- Antiemetics.
- Fluid replacement (orally/IV).
- Paracetesis – if the woman is distressed due to abdominal
distention.
- Thromboprophylaxis.
- Surgical intervention for ovarian accident.
** Monitor for:
- Pain, breathlessness, hydration, weight gain.
- Cardiovascular HR & BP.
- Abdominal girth, distention, ascites.
- Intake & output.
** Investigations:
- FBC, Hb, Htc, WBC.
- RFT, LFT.
- Clotting profile.
- Pelvic US (ascites & ovarian size).
- CXR (if respiratory symptoms).
- ECG & Echo (if suspect pericardial).
-------------------------
Case 20: CTG.
1- 25 years old primagravida, No antenatal complications, Hx of SROM

36 hrs ago, Clear liquor, Now for acceleration.
Medium risk (SROM > 24 hours, augmentation)
C 4 in 10
B-Ra 130
V 10
A present
D none
O reassuring
Including plan: continue observe

2- 35 years old primagravida induction of labour a 35 weeks gestation
for pre-eclampsia and IUGR, BP 160/100 with protein. ARM at 3 cm
dilatation, 4 hours ago, on syntocinon.
C 4 in 10
B-Ra > 160
V 5 bpm
A none
D variable deceleration
O non reassuring, pathological
3- 30 years old gravid para 2+0, two previous normal births at 41 weeks
reported reduced fetal movements n previous 24hours, Admitted at 42
weeks gestation for induction, prostin 3mg given 4 hours ago, now
contracting and so CTG recommended .
C 2 in 10 min
B-Ra 90 baseline bradycardia
V 5- 10
A none
D variable
O non reassuring
Base line  ↨ Variability (small square5bpm)

(Line in the middle).
-------------------------
Case 21: Uterine prolapse
60 years old lady presented with pelvic heaviness, dragging sensation
with something coming down below with occasional spots of blood.
1. What could be the problem?
2. What is most likely the cause of her bleeding?
3. What are the possible etiological factors?
4. What are the degrees of uterine prolapse?
5. What are the classification of genital prolapse?
6. What are the modalities of treatment?
7. What are the indications of pessaries insertion?
Answers:
1. Uterine prolapse.
2. Decubitus ulcer (atrophic ulcer).
3. Related to weakness of pelvic floor muscles, this could be either:
1. Congenital.
2. Related to childbirth and high intra-abdominal pressure.
3. Age- estrogen deficiency.
st
4. 1 : descent within the vagina.
2nd: descent into the introitus.
3rd: descent outside the introitus (procidentia).
5. According to location and organ contained within it:
Anterior vaginal wall Posterior vaginal wall Apical vaginal prolapse
Urethrocele Cystocele Uterovaginal – uterus +

Rectocele Enterocele inversion of the vagina
Cystourethrocele Vault prolapsed
6. Modifications of treatment:
1- General:
- Correct obesity.
- Recurrent chronic cough.
- If ulcerated – course of estrogen cream.
2- Medical:
- Ring pessaries.
- Shelf pessaries.
3- Surgical:
- Cystocele, urethrocele – anterior repair (anterior colpo).
- Rectocele – posterior repair.
- Uterovaginal prolapse / procidentia- vaginal hysterectomy + vault
support.
- Vault prolapse – sacrocolpopexy, the vault is attached to the
sacrum by a mesh.
7. The indications of pessaries insertion:

1. Patient’s wish.
2. As therapeutic test.
3. Child bearing not completed yet.
4. Medically unfit patients.
5. During and after pregnancy.
6. While awaiting surgery.
-------------------------
Case 22: Vasa Previa.
1. What does this picture shows?
A Placenta with vilamentous insertion of the cord (vasa previa).
2. What are the conditions that may result in this problem?
 The following consider as risk factors for vasa previa:

 Velamentous insertion of umbilical cord
 Accssary placental lobes
 Multiple gestation
 IVF
3. What is the classical presentation of this condition?

The classical triad of vasa previa is: membrane rupture, painless vaginal
bleeding & fetal bradycardia. It occurs as bleeding when membrane
ruptures or intrapartum hemorrhage.
4. Mention one diagnostic test?

Rarely, confirmed before delivery by US with color flow Doppler.
After bleeding occurred, it diagnosed by Apt test.
5. What is the most serious complication that could occur?
Fetal death
6. How could this be recognized clinically?

a. Vessels may be palpated within the membranes and head of the
presenting part
b. Compression of these vessels may cause sudden irritation of fetal
heart pattern acute fetal distress or death
c. Antepartum haemorrhage if the membranes are ruptured.
7. Is there any blood test that may be used with this condition?
APT test (alkali denaturation test), It depends on the fact that: fetal Hb is
more resistant to denaturation by alkaline in presence of 1% NaOH than
maternal blood, +ve test means the sample is fetal blood.
-------------------------
Case 23: Cervical weakness.
1. A 36 years lady complains of dragging sensation at 20 weeks of
gestation. Past history of: premature delivery and early neonatal death.
diagnosed as having cervical weakness. How to manage?

1- Rescue or emergency cerclage – shirodkar stitch.
2- wait and preterm delivery will occur.
Note:
 Cervical cerclage involves stitching shut the cervix, which is the outlet of
the uterus. Cerclage can be done preventively at 12 to 14 weeks before the
cervix thins out, or as an emergency measure after the cervix has thinned.
It is rarely used after 24 weeks.
 Cervical incompetence in primigravida:
o Mid trimesteric miscarriage 16; 17; 18 weeks
o Painless gush of water (cervical dilatation without uterine
contraction).
o First, the membranes bulge, and then uterine contractions occur,
which is the reverse of what happens in normal delivery.
o The baby comes out alive but dies soon after.
 Diagnosis :
o In-between pregnancies, PV shows patulous cervix. Hegar’s dilator
size 8 can be introduced easily.
o HSG (histosalpingogram) shows funnel shape cervix (not use now )
o During pregnancy: TVUS (transvaginal U/S) done 13-14 weeks to
visualize cervical width and length, funnel shape.
o If incompetent : do cerclage in 14-15 weeks
o If normal cervix but history is suggestive of weakness: repeat ultra
sound every 2 weeks.
2. A lady with history of premature labor. You do a screening of cervical

incompetence at 23 weeks. if cervical length is less than 25 mm there is
high risk of preterm labor. In this case how to interfere?
1- cerclage.
2- Progesterone pessary till 34 weeks, 200 mg /d ay. It keeps
cervical tonicity and more effective than cerclage.
Notes:
 With screening of cervical weakness at 23 weeks, also do uterine
artery Doppler to know risk of PIH (the presence of a notch: high risk of
PIH). The notch resembles V.
 During cervical cerclage emergency, there’s a risk of membrane
rupture and preterm labor. The patient should be informed about the
risks.

 When to remove cerclage?
o 37 weeks or more.
o Whenever the lady gets into labor.
o IUFD
 If the lady delivering by C/S, leave it in situ.
 Complication of cerclage :
1- Irritation of cervix causes increased discharge.
2- If you apply it tightly, ischemia occurs distally.
 Contraindications of cerclage:
o Infection
o Membrane rupture
o Unexplained bleeding
o Acute labour.
 To reduce the risk of membrane rupture:

o Reduce the amniotic fluid
o Keep the patient’s head down
o Push the membranes back inside.

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Faculty of Medicine

b. Mention the important aspects of your clinical examination?

c. Mention the investigations that you would like to arrange?

d. What’s the differential diagnosis?

c. What are the maternal investigations to rule out infection?

d. How would you perform fetal surveillance for wellbeing?

b. Areas to examine (Mention 5)

c. Important investigations and its objectives? (mention 3)

c. Mention four additional investigations you like to perform to her

d. What are the main lines of management?

TWBC 4.5 x 10 m/l 4 _ 11

a. What is your diagnosis?

b. List two most likely causes for this problem

c. What are the long term complications of PID?

d. What are the commonest organisms that cause PID – mention 2?

Or Just Answer (1- Insulin sliding scale. 2- Continuous CTG monitoring 3-

a. What’s the most likely cause of her problem?

c. How can you diagnose this condition

a. What’s the diagnosis?

b. What’s the most likely cause?

c. How does this condition develop, what’s the source?

d. How can you manage this patient?

e. When is surgical intervention indicated?

b. Mention 3 maternal complication of this condition

d. Mention two tests you will perform for this lady

f. What are the underlying causes for the fetal complications

a. Name two fetal organs you want to check by US scan?

b. Name one blood test you want to perform on the mother

d. While she is inpatient, she complained of sudden gush of fluid

e. Why? Mention 4 Causes

f. What are the main risks associated with this condition?

a. What’s the aim of your investigations in this lady?

b. What investigations are required to reach the diagnosis?

c. What are the possible causes of such bleeding?

d. Mention the treatment for 2 possible causes?

a. What’s the most likely causes mention 4?

b. Mention 3 important investigations you would request

b. What are lines of management

c. Mention 3 possible complications of such condition, if left without

b. Confirmation of diagnosis is by?

d. Subsequent follow-up is by?

b. How would you deliver this baby

c. A possible serious complication is?

d. How would suppress lactation in this lady

a. What’s the most likely diagnosis of this lady

c. What investigations would be most helpful

d. What treatment options are appropriate?

What are the complications of such a case?

a. What’s your differential diagnosis?

d. How are you delivery this lady.

a. What’s the diagnosis?

b. What will be your immediate action?

c. How are you going to deliver her?

e. Considering the risk factors in her case, could this condition be

TEST Result Normal Range

a. What’s the likely diagnosis?

d. Mention 5 risk factors for this condition

f. Mention 3 measure to reduce maternal mortality and morbidity from

a. Very briefly, just outline the steps of management without going

b. What measures that can be taken to reduce the incidence of

d. How do you monitor your anti-convulsive drug of choice?

a. What are the possible causes for her recurrent miscarriage?

b. What relevant investigations will you request?

a. What’s the most likely diagnosis?