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OSPE for MBBS: Obstetrics & Gynaecology V
TABLE OF CONTENTS
Preface vii
Chapter-1: OSPE as an Examination Tool 01

• What is OSPE
• Format of the OSP E stations
• Marking of the OSPE
• Types of the OSPE stations
• Possible topics for OSPE stations
Chapter-2: How to approach at different stations 13

• Communication/Counseling Skills (Examiner/Ro le Player)
• Counseling Stations
• History Taking
• Clinical Skills
• Ma nagement/ Treatment Options
• Surgical Instruments
• Obs/Gynae Emergencies
Chapter-3: How to attempt OSPE 19

• Guide lines for the candidates
• What happens in the examination centre
• Protocol of the examination cabin
Chapter-4: OSPE circuit with keys 25
<vPractice session one with keys

• Practice session two with keys
• Practice session three with keys
6 Practice session four with keys
vi
7
OSPE for MBBS: Obstetrics & Gynaecology
Chapter-5: Model Papers 287

• Model paper one
• Model paper two
Appendix 314
i
I
--~=~-•~-----~....-,-.•--•·-e-cr------------..--- X
LIST OF ABBREVIATIONS
BSO Bilateral salpingo oopherectomy

bpm Beats per minutes
coc Combined oral contraceptive
CPD Cepha lopelvic disproportion
CTG Cardio toco graph
CT Computerized tomography
CA Cancer
DIC Disseminated intra vascu lar coagu lation
D&C Dilatation and curre tage
DOP Duration of pregnancy
ECV External cepha lic version
EDD Expected date of delivery
GPE General physical examination
GTD Gestational trophoblastic disease
hCG Human chorionic gonadotrophins
HIV Human immune deficiency virus
HSG Hysterosalpingogra phy
HRT Hormone replacement therapy
IUGR Intrauterine growth restriction
IUS Intra uterine system
IUD Intra u ten ne contraceptive device
IUD Intra uterine death
LMP Last menstrual period
MC Monochorionic
MRI M agnetic resonance imaging
NG Nasogastric
NVD Normal vaginal delivery
OP Occipito posterior
OCP Ora l contraceptive pi lls
PIO Pelvic inflammatory disease
PMS Premenstrua l syndrome

Sexually transmitted diseases
STD
TVS Trans vagina l Ultrasound
)( OSPE for MBBS: Obstetrics & Gynaecology
TITS Twin twin t ransfusion syndrome

TAH Total abdomina l hysterectomy
FBC Full blood count
LSCS Lower segment Caesarean section
CPR Cardiopulmonary resusci tation
AIDS Auto immune deficiency syndrome
osPE 10 , MBBS Obstetrics & Gynaeoology
Introduction
The MBBS final yea r examination comprises of two parts. a
written paper and a Clinical exam.
The written papers are 2.
Obstetrics paper
, Conlaining 7 short essay questions, o f 35 marks (5 marks for
each question) and
, 35 MCQs of choose the best type or 35 marks (1 mark each)
, Time allocated for S~Q~ IS 2 hours. and for MCQs paper is
l hour
, Total marks for obsletncs paper 1s •• 70
Gynaecology paper
, Consists o f 10 SEQs of 3 marks for each question, total 30
marks
• i,me allowed ,s 2 hours and l S minutes and
• MCQ paper 1s of 35 marks, conta,mng 35 choose the best
type questions, 10 be solved in 4 5 minute s
• Total marks for gynaecology paper ,s 65
• Internal assessm ent = 15 marks
Total written part = 150 marks

The oral exam 1s d,v,ded Into 2 parls
long Cases 2
• 60 marks (30 internal• 30 e~1ernal)
• One from obstetrics and one rrom gynaecology
OSPF
• 75 mark\ (1o1~I 1~ •,1.111011~ l'JCh s1a11on of S mMks)
OSPE for MBBS. ObstetflCS & Gynae<olog~
Internal assessment
• 15 marks
Total oral part = 150 mar ks
What is OSPE?
Conven tional practical examination was having severa l problems,
especially In terms of its outcome. Although grading/marking should
depe nd only on student's competence yet variability in experiments
selected and examiners, both affects grading in conventional
examination significa ntly.
In such examination the marks awarded, reflect on ly the general
performance of the candida te without evaluating the individual
competencies. Outcome does not match with the purpose of
examination due \o problems or non -obiectivity in the whole
procedure, lacking the test of all tudes as well .
Io overcome such defects ,n conventional practical examina tion
UH$ introduced OSPE
Obj ectives of OSPE

• To rest factual knowledge
• To assess clinical competence.
• To demonstrate common sense.
• To asses analytica l thinking and communication skills .
•
OSPE stands for Objec, Ive Structured Performance E,yaluation.
"I t is an approach to the assessment of clinical competence in which
the components of competence are assessed in a planned or
structured way with attention being paid to the objectivity or the
examinalion 11
In year 2008, ma1or SubIecl1ve Components o f Practical/ Clinical/

Viva vice examinations were replaced by OSPE
()IPE for M8BS Obstetrics & Gynaecology
It is designed to expose the candidates to .a greater number of

examiners and topics and consequently to reduce the effect that
a•nY one examiner has on the candidate's score. Thus making the
system more structured and organized.
OSPE has made the exam

, More homogenous by having the same questions for all
students on the same day
, Remova l of the examiner's bias.
, Ab11ity to fa ce .all examiners even those from the same
insti tute .
• Tests a wide range of skills thus greatly reducing the
sam pling error
, Significantly improves the reliability of the examina tion
Format of the OSPE

• Total stations are 20 (05 rest stations).
• OS mln at each station.
• 05 mark for each station
Tfpes of station:
i. Unobserved/ sta ttr stations.
II Observed/ 1nterac1lve stations.
15 stations (05 marks for each station)
•
·1- - - I
Obstetrics
7
Gynaecology
08 stations 07 stations
•
llr,observed obsen,ed Unobserved observed
s 3 s l
OSPE for MBBS Obslelncs & Gynaecology
0
Features of the OSPE station s
• Stations are short.

• Stations are numerous.
• Stations are highly focused, candidates are given very
specific instructions.
• A pre-set structured mark scheme is used hence reduced
examiner's input and discretion.
The marking syst em

The marking of all the stations is structured thereby objective. This
means whoever is the examiner; one should score the same marks,
if their answers match the key.
• Each OSPE station carries 5 marks, giving a total of 75
marks.
• For static stations candidate write the answer on the
response sheet which 1s checked at the end of the day
according to preformed keys.
• For each observed OSPE station the examiner is given award
sheet in which the marks are allocated to different
components of the answer, this is to ensure consistency of
ma rking system. However the examiner has the latitude to
explore the candidate's knowledge and understanding of
the subject.
Types of OSPE Stations

Following are the types of stations
• Uno bserved/ Static station
• Observed / Interactive with examiner
• Re st station
MBBS. Obstetrics & Gynaecology
osPE for
7
uno bserved/Static Stations

are the stations where the candidate has t d
TheSe o
rea the
instructions and a~sw er accordingly on the response _sheet On
these stations a scena rio ~ith question, some instrument for
identification with re levant questions, a photograph, a partogram,
CTG, Lab report or a drug with questions can be given.
E><ample 1
unobserved station
candidate's Instructions
see the photograph carefully and answer the following questions
fig 2 fig 3
1. What are the 3 types of breech presentations shown in the

photograph?
2 What 1s the 1nc1dence of breech at term?
3. What.are the pre -requisites for vaginal breech delivery? Give 3.
KEY:-
l. Types
• Fig 1 comple te/ fle><ed
• Fig 2 incom plet e/foo tling and
• Fig 3 extended / frank breech. (0.5)
g OSPE for MSBS. Obnetnts & Gynaec0 ~
1
2 8 o f all t erm pregnancies present as bre ech (0.5) •
(3)
3 Pre-requisites··
~- The presenta tion sho uld be either extended or flexed breec

(fee t ~hou ld not be below the feta l buttocks.) ✓
No fetopelvic di$pr□ poctjon . ✓
Fetal weigh t less than 3500g . /

? -
No evidence of tw oer extensiop of.thP. fetaLhead. ✓
F~ abnor111al11ies have been ru led out. ./
Examplei )
See the photograph and answer the following q uestions
Q. 1 . What is this diagram showing?

Q. 2. How long the capacity of sperm las ts for fertiliza tion?
Q. 3. For how l ong the ovurg remains ca pable of bei ng fertili zed
after ovulation?
Q 4. How much tim e is needed by fert ilized ovum to r~acl1 the
uterus ?
KEY:-
1 Process of fertilizat ion 1
2.
~-
24-48 hour§ and less 1f remain in vagina. 2
3. About 21\ hrs J
4 About 7 days 1
-E•I MBB~ Ob\tP.trltl & Gynaecology
9
observed Station/Interactive with examiner .
r~ese are the sta t10ns where the can-dldate has to give the answers
01
the questions •asked by the examiner and at times of the role
player Th! exam,iner '.11arks the candidate according to the award
sheet. There may be g iven some $cenario and examiner w ill ask the
Q uesttons
• rega rdi ng that or you wjll be asked to perform some task
like general phys.ical exam inat ion / abdominal examination, l!,!gl
insertion, demonstrat ion o f breech delivery, normal vaginal delivery
0~ counseling_ e.g. regarding IUD. some disease or breaking some
bad news.etc .,
(§mple D
Observed station
Candidate's inst ruetions
A 42 year old P3 presented to you in the OP0 with co mplam t o f
he~~gular va,&fili!I ble~_for t ~st one year. How will you
counsel her, discuss treat m~t OP!if>ns with her?
KEY:-
d) {ntroductio n?)
• Ev.e to ey_e con tact
• Non medica l Jargon
• Po lite and sym pa thetic t o the patient 0.5
2, (Explain about t he di<Pas§) tha t she needs to be

investigat ed. These include rq qtine invesrigatloos .and
-·= =-= -
(endometrial sarno!ioe eitbec h~, diagnostic D&C or
l_hYste~o,scopic guided D&C 10 o l!e out any malignancy.
3 Treatrnen1 opt ions

Ckiedjcal therap•e-s (H- .,.
- t -liffe1
-
• Combined ocp
• Danazol
10 OSPE for MBBS: Obstet nc:s & Gynaecology
• GnRH analogues, Mirena, (~evonorgestril releasing

IUCQ.s.), anti-fibrinol ti and anti-prostaglandins
~gents. 'mc. #,•,, ,._P sl "'P' ,., c
( Surgical therapiti) ©
• Endometrjal resection and ablative terhoiq11~.
• tfysterectom'l with or wit hout ~
~ Discuss HRT
--4 Ask about any patient's concern
Gxample ~ ~
Primigravjda at 34 weeks of gestation presenting with complaints of
~ainless vaginal bleeding) On her abdominal examination, abdomen
(7#,~:-; is non tender: head is five by five pa lpable and fetal heart sou nds
~ al]" oo croal.
Answer t he questions asked by the examiner.

1. What is the most likely diagnosis?
2. How will you manage this patient?
I
3. Would you like to do the vaginal examination?
KEY:-
1. Placenta praevia
2. (8!st~ry;:G:xamin~tion)including ~ Q.,eral physical/ apdomjnal

exariJnation and on pelvic examination only
examination to rule out.any local cauJ.e._OJ bleeding -- speculum
@aterni> Investigations --FBC. blood grouping, cross match and

arrangement of blood, USG for localization of placenta
~nvestigations---<;ni USG for fetal well being
osPE rorMBSS. obstetnt> & Gynaecoloev 11
Then manage according lo the type of placenta praev,a
If type (!)placenta praevia, then NVD. For type 11, 111 and IV
pJgcenta graevia L~cs is recommended.
/7.) A~r. yagi.?..e.Li>Ya miQat-ion. allowed only i @lacenta
V 8'.aevp.,.__....
Rest Station
At t hese s tations candidate do nothing, they sit and orga nize for
further stations,
Possible Topics for OSPE Stations

• Communication/counseling skills
• History taking
• Clinical skills/interpretation of lab results
• Managemenr/ trea1ment plans
• Operative s kill;.
• Surgical instruments
• Obs/gynae emergencies
• Pictures
• CTG trace, Pa rtogram
• Dummies
• Antenatal cards
• )( rays, Movie rlips e tc
II "
How to
Approach Different
Stations
'
1,1 OSPE for MBBS. Obstelrics & Gynaerol
Ogy
"The curriculum tells the staff what to

teach ....
The OSPE tells the students what to learn!"
osPE for MBBS: Obstetrics & Gynaecology
15
This chapter will teach you how to perform at different types of
station, in order to get best possible results
1. communication/ Counseling Skills {Examiner/Role Player)
At this station, candidate should keep certain t hings in her mind to

score good marks.
• Introduction/put patient at ease
• Appropriate eye con tact/listen attentively
• Avoid technical language (medical jargon)
• ln:iite/answer questions
• Empathy/sympathy
• Establish rappQLt with patient (role-player/examiner)
• Follow verbal/non-verbal clues
• Use diagrams/drawings if appropriate
• Adgguate explanation of intended course of action
• Remain professional
2- Counseling Stations
They are bit difficult and tricky stations. After giving a scenario you
are asked to counsel the person, couple or parents e.g. you can be
asked to counsel a woman fou nd to have ovarian cancer or counsel
a Woman who has an intrauterine dead fetus etc. At this type of
st
ation one can easily get througbjl.y k~_e_ping..certain things in mind.
• Introduce you c..~lf
OSPE for MBBS: Obs tetrics & Gynaet ology
16
Inquire about patient's e~ucational status and asses abilitv
•
to understand
Ewress ceeret at the poor outcome, report or bad news

•
• Ask about patient's physical wellbeing
Acknowledge anger. fear. and sorro~ wh ere appropriate

•
like I understand you are angry, worry, upset.
• Try 19 identify the problem, like I realize t his must be

difficult for you; thi s meeting is to answer your questions.
• ·-
• Invite open ended questions, this will let the person to talk
free ly to you
• An swer the questions in P21ite. la.Y.man language. Do not

use medical Jargon.
• B~ sympathet ic to the patient but do not overact by

stroking or patting the patient
• Have a set of prepare d st atement tha t can be applied to all

dist ressing cases such as
o I am very sorry about your loss
o This must be a difficult time for you
o I am feeling very sorry w hile telling you
o Do you have family frie nds or religious support

centers nearby?
o Do you want to seek some counselor advice?
o Here are some leaflet's for yo u to read at home
, t M88~. ()bste11 1(:5- & CiynaecoJogy
olPE ,o 11
o Here is our hospital n umber, i f you wan\ any further

1n!ormatior1, vou can contact us
, Plan for the future trea tment options
, Give follow-up appointments
3_History Taking
, Exhibit a polished performance
, Adopt a methodica l appro.ich. Take full history starting

from present complaints, the pas1 obste tric, GyneGolog,cal,
. --- --"- -
medica l and surgical h1storres, the social and family history.
, Concentrate on the role-player, not the exam1ner.
4. Clinical Skills
-
Like delivery o f breech, shoulder d~tocia, pa~ sm1tar, etc
• Demonstration on dummies (GPE, abdominal exam).
• Insertion of speculums/scopes.
• CPR .
• Sutures
5. Management/ Treatment Options
• Follow sequence (~O!)', e~mina\i~ns,

investigations, management plans/op!!_ons and their
pros and cons).
• Fina I opimon/c~clusion.
OSPE f01 MBBS. Obstetrics & (\y~•ecotoe)
18
6. surgical Instruments
ouse laparoscope, hysteroscope,
• Forceps, Vent , ~•
,uco,, myo.. , -ectomy screw ' s1m's speculum casco-
~ 05
\.~pecului'.fj instrument for D and C etc
• How to assemble .
• How to use.
• Indications and contra-indica tions .
7. Obs/Gynae Emergencies
• Like Post partum hemorrhage, shock, eclampsia,

✓. --- ~ -c; ♦
Antepartum haemorrhage, pulmonary embolism,
ruptured ectopic pregnancy, shou;a:,:" dystocia,
Myocardial infarctions, drug abuse, snake bite,
neonatal resusc1tat1on etc
• Be precise, practical, direct and qu,ck.
• Follow proper sequence of proposed actions
u58S Obstetrlos & Gy~aetology
oSl't It",.,
19
How to attempt
OSPE
r,1eBS Oh,tt•tncs & Gvnaecologv
I I
0sP£ • 21
Guide lines for the Candidate
like a doctor; Behave like a doctor
Loo k
• Must take b(eakfast
• wear dean, properly ironed, soft/subtle colou~ed dress

• No Jewellary, properly trimmed nails
• Tie hair neatly
• wear neat anol properly ironed overall ,
• Clean shoes pr eferably without noisy heels
• Wrist watch, big dial with promlnen1 needles. Fancy and

small watches can create a mess In time management
• Try to reach one hour before the reporting time.
• Listen/ read lhe question very ca refully, understand clearly

and then at1empl.
• Think twice before speaking/writing.

• Answers have to be written on response sheet after writing
the station number
• Try to get an overall fee l of what In formation ,s being asked
at that particular station.
• Only answer the question that ,s asked.

• E•hlbit conftd.ant a1111ude, appear calm and speak in a clear,
non-aggressive voice.
• Display your ability to perform under pressure.
• Do not argue.
What Happens in examination centre?

th
• In the exam ination centre, the convener will brief abou t e
examination protocol
OSPE for MBBS: Obstetrics & <ivnaec
22 1
Oat,
. . be divided into two/three main gr0 ~
• The candidates w1 11 . h . Ps
.
depending upon the teaching unit In respective osp1tal
• Each group compn·s·ng

1 of 20 students will go to each unit.
-11go through the same set of OSPE stations in
• Each group w1
each unit
• The set of stations will be different on each day till the last
day of OSPE,
Protocols of the eKamination cabin

Before the bell rings
• You can write down your roll number on answer sheets
• Look at the direction in which you have to move once bell

rings.
• Once bell rings, start attempting stations
• OSPE are arranged in the circuit starting from station 1

onward which usually comprise of 20 stations
• Out of these 20 stations 05 are rest stations.
• Out of remaining 15 stations 08 stations are from obstet rics
and 07 stations are from Gynaecology.
• Among these stations OS are intera ctive stations while
remaining are static stations.
• Each station is of 5 minutes, with a change time of one
minute for the candidate to move from one station to
another.
• Candidates move from one station to anothe r when the bell
rings and their movem ent is guided by arrows.
• The station would either be unobserved/ static or observed/
Interactive usually with examiner and rarely with a role
player
_ro, ~•BS: Ob•t~l<IC5 & Gvna«ology 23
• Structured chnical task 1s placed on each station. Every

candidate has to move through same set of stations on that
particular day.
• The simflar sets of stations are changed on the next day and
aga,n the same format is revised with another group of
students.
• In each unit and m all centers the OSPE will start

simultaneously at 9.00am
for MBBS: Obstetrics & Gynaecology
27
oSPE
-- I
unobserved
2
Observed
3
Unobserved
4
Rest
5
Unobserved
6
Observed
Abdominal OHSS 0 and C IUCO
1mplanon exami nation
-20 7
Unobserved
Rest
Doppler
USG
8
19
unobserved
Rest
Fibroid
uterus
Possible Circuit Of OSPE Stations
9
l8
Observed
Observed
Cord
CA uterus
prolapse
10
17 .
Unobserved
Unobserved
OCP
ms
12 11
16 15 14 13
Rest Observed
Rest Observed Unobserved Unobserved
Ectopic
HIV in Bony pelvis Placenta
pregnancy
pregnancy
~
< tor r,.,iBBS obstetrics & Gynaecology 29
0sP•
Practice
Session One
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oJII "' ~ass Obs1e11,cs & Gvnae,ology
11
Station 1
candidate's instruction s
see the photograph carefully and answer the following questions

Q. J What •sshown io •be pbatng,:aph
Q. 2 What 1$ it vsedJor?
.. . ~,~
~• ~·
..
~
Q.3. What ,s ,ts mechanism of act,on? $1'"1'1' o _,_,..1,.t'" '
Q. 4. Give its 3 side effects. i \t,..• 0,. v,'"C, '
KEY:•
1. l!!)planon 1
2.v Used for co ntr~cep_tion 1
3. The capsule constd11tly reJ ~mall amounts-olan
~rtificial hormone called proge stm. This prevents
pregnancy by t.h1cke.i1ing the cervical 0111r11s SP-that
sperm can' t ge t Into \!Jr 11tPJus-aru:Lby_stoppmg
1.5
~
4. Women with implants may have. 15
• Menstrual lrreg11lari!,ies
nd
• '6!eight gain, headache, mood swjngs, awe- a
dep_ressiOn,
3l OSPE for MBBS: Obstet<ics & Gvnaecol
og~
·
• Other possible s1'd e e1,e •q----=w
" cts are vagiral mOarnmatio nor
dryness, breast pain, stomach or back pa in, nausea.
dizziness and pain where the implant was inserted.
Explanation
tmplanon Is a soft single rod, about 1 ½ incl)

long. Its effect lasts three ye:ir,. ll i> placec1
under the skin in \;be_e1,_:inner ar m. The
' capsule constantly release syntheti£_hormone

called progestln. Th,s prevents pregnaicy by
thickening the cervlca~ m ucus and by
stopping ovulation ,,
Effectiveness: lmplanon is _2,W effective
ln$tructions for its Use • •

• Rule out pregnancy be fore its insertion .,.
• Usually inserted within the{first 5 days)of a menstrual period ✓
• For the first two weeks after insertion, use anot her method of
birth control to avoid pregnancy
• Pregnancies are very rare with the Implants but if 1t occurs than
higher chance of ectopic pregnancy.
Insertion and Removal

Insertion: The Implan t is Inserted under sterile condition Clean the
arm with antiseptic and Infiltrate the area with lidocaine The
f •
Implant w,11 be inserted by special 111se.r.ter, w hich puncJ1 1tP~ the
skin. Then the Implant is slipped 1n Just under the skin A pressure
bandage applied to prevenLS bleeding for the first 24 hours. There
may be some bru1s1ng or soreness ,n Ille arm for a few days
osPE IOI MBBS' Obstemc, & Gynaecology
Rernoval: The implant is removed through a ..

. . srna111nc1s1on under
I cal anesthesia . lt_!_s gently pulled out w·thi
o- • , creeps. New one b
nserted at the same time when the o ld on . can e
1 e 1s removed ....
contraindications
_. • History of g1;eo venous tbrambosis
• History of heart attack or stroke
• ~nexplained vaginal bleeding
• .
Liver disease
• Any brea st cancer now or in the past
• Allergy to anytbmg in the impla nt
women who have diabetes, high blood pressure, high cholesterol

levels, headaches. epilepsy, depression, gallbladd er disease, kidney
disease or are breast feed ing may no t be able to use the implant.
Side Effects: Women with implants may have
• Menstrual irregularities I.--- •

• (Weight gain,\headache, mood s~ings, acne and depression.
• Other side effects are vaginal inflammation/ dryness, breast pain,
stom.ach o r back pai n, nausea, dtiziness and pain where the
i~plant was •GSe.r:teL-
• Rare side effects are extra ha ir on the body or face
• Trouble w ith contact lenses and spotty darkening or the skin
especially on the face .
Advantages
• fasy to use
• Effective for 'three yea rs"
• Does not interrupt sex play
• following Its remova l ovulatio n resume sooner
Disadvantages
• Does not protect aga ,inst~,
,.,,0,._,nc
I Iu ding Hi:i/AiDS
34 OSP€ for MBBS: Obstetrics & Gynaeco1ogy
-
• Raised risk of heart attack and stro~ , ~
• Requires a rirescription •1
-
OSPE for M88S: ObJ"t1'ICS & Gynaecology
Observed Station 2
Candidate's instructions
Perform the abdominal examination of the pregrant lady in front of

the examiner and the e_xaminer will just observe you and ma rk
accorclirJ8 to tile l\e,y, •'
KEY:-
Inspection:
~ - (1.5)
• Look for con tour of abdomen

• ✓ / ✓ ✓
• Um~ licus s~ r k s , striae, linae nigra or abdominally
visible veins or scar mark,;, •
<a=-
Palpation: (2.5)
• Assessment of fundal height

- C
Bl'. f!~lpator~ method with u lnar border of the le ft hand o,id

tell rhe gestational age ,n weeks or by measuring taoe. In
cm from 1he IPP of the svmphysjs pub,s to the too of the
uterine fundus
'!!!. = week from 16·36 weeks of gestation
• Assessment of fetal part's
By Leopold maneuvers 1:- de_termine the fetal part

occupying the uter ine fundus that is breech or vertex .•
Leopold maneuvers 2:- f9r lateral palpation
OSP£ lor MBB~ Obstetric> & Gynaecology
36
Leopold maneuvers 3:- for presenting part (powhk's gnp)
Leopold maneuvers 4·- for attitude of fetal head by using

both haods oo either side of ttie uterus.
(1)
• \Auscultatioryof fetal heart
. -
,.
OSPE for MBBS : ObJt"IICS & Gynaecology 37
unobserved Station 3
eandidatels i nstructions
Carefully see the photograph and answer the following questions
Q. 1. What 1s the condition shown in photograph?

Q. 2. Whal is Its incidence?
Q, 3. What is Its enologv7
Q. 4. What is the risk factors for its development?
Q. 5. What are its complicalions, give any three?
KEY:-
1. Ovarian hyperstimulation syndrome (OHSS) D.S
)
2. It complicates about 5% f cycle with ovarian stimulation 0.5
3. 1\ j~ij p.iatrggpa,( CQOclifihO fo!lq,uine ovaricJP ,th:nufation 0.5
4.[Rlsk fattg,\ :are 1.0
• Po ly cystic ovarian disease P~~$·

• Women under 35 yea r of age
0SPE for 1\,1885 O bs1etncs & Gyna•catoe,
38
s. complications are 2.s
•
r , rddents deep vein tbcomhns,s
l\lasculiji-cerbrovascu la ~
a-- ~thromboem boIic phenomenon
-
-""-'---- ff1Y
• (¼gulopat~) ~~ ~·
• QJver
, dysf unctions)--
• Adult resplrat~ d"-'•ess

1>" caused by ascities/hydrothorax
----✓-
• Rgna1 ra,-1ure due to hypovolaemia
• Gastroin1estinal disturbances
•
• Ti?rs,o_n !!...,o.d.Jlaemorrhage in the ovarian cyst
Explanation
'
Definition: OHS$. is an iatrogenic conditio n occ urring m the luteal
phase or early pregnancy due to 12Yul11,t~on 1nduct1o]J
Incidence: Occurring in8 o f c~ses
Etiology
• More common in FSH/LH therapy th an clom iphene or

pulsatile G.!!_RH drugs
• More i;ommon in PCOD, anovulatory infertillt,v and woman

under age 35 years
• In OHSS HCG should be avoided as it worsen t he condition

'
Clinical features ; N.ausea, vomi ti ng, blgatedness, abdominal
.. - .
swelling, ascitiS-? and abdominal pain
oSPE for MBBS; ObstetroC>- & Gyna~cology 39
complications
• vascular cerbrovascular accidents, thromboembolic

phenomenon, deep vein thrombosis.
• Coagulopathy, Liver dysfunctions
• Adult respiratory distress cau_sed by ascities/hydlothora x
• Renal failure due to hypovolaemia
• Gastrointestinal disturba nces
• Torsion and haemorrhage in the ovarian cyst
Investigations and monitoring
• CBC, platelets count, Urea, electrolyte, RFT,LFT and

coagulation profile
=--=
• .
Central ve,nous pressure recording.
Prevention
• HCG should be with held: In cycles w here more than 20

follicles recruited and E2 level rises to 3000pg/ml and in
PCOD
• Albumin 5% Infusion ,n 500 ml ri nger lactate during and

after egg retrieval
•
Treatment
• Hospita l adm ission + med ica l therapies
• Jtj_ fl uid for hypovolaemia, colloid expanders or huma n

albumin
•
OSPE for MBBS: Obstetrics & GynaecOogy
f
40
TED stocking_ prevents deep venous thrombosis

•
• 1/V immunoglobulins
do pamine infusion
• Glucocorticoids, ~nticoagulants,
(improve renal flow)
• gAvo1d diuretics and NSA1.f0X
OSPE 10, MBBS owne11Ics & Gv••ecology
41
unobserved
Station 4
candidate's instructions
see the photograph carefully and answer the questions,
Q. 1. what is the procedure shown in above photograph?

Q. 2. what is the indica tio ns for it? (give 2) ~
_,,
Q, 3. what isJh~ instrumen!QJsed for this procedure? ~
Q. 4. what is the compl ications of thi s procedure? {any 3)
KEY:-
1. dilatation and curettage 0.5
2. Indica tions are
1.0
• Abnormal vaginal bleeding
• Pos t-menopausal bleeding

=
• ~sed
z (incomplete\ abortions
• Therapeutic abortions
•
3, Instrument used are 1.5
• \Stms speculum]
42 OSPE for MBBS: Obsletrlcs & Gvnaecoior,.
• Uterine sound
• Vulsellum
• Graduated uteri ne dilator's
• A paleof narrow ow 1m forceps
• l:J ~rine cureltes
4, Complications are 2
• Tearing and laceration of cervix '
• Perfora tion of the uterus1
• Peritonitis diie co perforation
• Bowel damage
• Pelvic celluht1s and parametritis
Explanation
•
This procedure involves dilatation of the cervix and scraping away of
the endometrium, or inner lining of the uterus. The procedure may
be performed under general anaesthesia, spina l or paracervical
block
Indications are:
1. Abnormal vaginal bleeding
2. Post-menopausal bleeding
3 Missed (incomplete) abortions
4 Thera peu u, abortions
OSPE for MBBS: Obstetncs & Gynaecology 43
contraind ications include:
1. Normal, desired intrauterine pregnancy
2. Acute cervjcjtis ./
Instrument used are :
• Sims SP-eculum
• -
Uterine sound
~
• Vulsellum
• Graduated ute rine dilator's
• A pair of narrow ovum forceps

• Uterine curettes
Procedure : Explain the procedure to the patient. Take info rmed

consent, clean the vu lva and vagina with antiseptic solution and
drape the patient with sterile towels
Then perfo rm the fol lowing steps.
• Do pelvic examination to find the uterine posit ion

• Insert a co mfortably warm, sterile speculum into the vagina to
retract the posterior vaginal wa ll
• Grasp the ~~r~ with a tenaculum forcep or Vulsellum at the six
o' clock position
• Wipe the entire cervical stump three times, in a ciL<Jd.J..&lr fa shion
outward with antiseptic solution. ✓
• Gently insert the sound until resistance is met. Read the depth
of the uterine cavity by noting the level of the mucous or blood
on the sound .
OSPE for M88S. Obstetrics & Gynaec0 fot.
44 d'lator dilate th e cervrx up till

. 'th the smallest Hega r , ,
• Starting WI
size of /L from t he entire diameter of

ta ke scrap Ing - .
• With sharp cure tte • ·t with an jn and out mot1011-:'
-~!_;an
the cervical can!! ~ d!_u
~t~e~rl~n~e,;c~::,:1:.:cYL,. .:.C-'-'-
av
complications
• Tearing and laceration of cervix
• Perforation of the uterus
• Peritonitis due to perforation
• Bowel damage
• Pelvic celfulitb d11lf pd rdrne trilis
Postoperative care
• Watch for vagina l bleeding and vita I signs

• Monitor patient for any s,gns :if infection during the recove ry
period.
Try to attend patient 's emotional needs and concerns during the
recovery period.
oSPE for MBBS Ob~tetncs & Gynae<ology 4S
observed .Station 5
A 28 year old 1'3 who has delivered 2 months back is sitting with you
-
,n family planning clinic. She has heard about fUCD. Now she wants
to have birth spacing by IUCD . How will you counsel her?
KEY:•
l. Introduction : 1.S
• Eye tc eye contact
• Non-nedlcal 1argoo
• Be polite to the patient

- $
2. Explain 3.5
• Types of IUCO,
7 • Ncn hofmonal: copper~T, multilo~rt,
7 • Harmon~ progesterone r e J l l i n @
--/. used for 5 years -12 year .,,.
/ . M~dc o f action :
- .,,
Induce inflam matory CCSPPP§f in the en~ometrium that
-
prevenls Implantation; CoJl!ler has tpxic e (:(5cl to the
-'•perms; the hormone releasing IU&P prevents pregnancy
bv /i local hormone effect on the cervical rgucus and
endometri11m.
OSPE for MBBS Obsletrfc5 & Gynaeco101y
Advantages:
/
• Once inserted effective fort!}i;ars ,/

• ~ar of forgetting as in pills ✓
• Frj!edom of Intercourse ✓
•
• Very htlle failure rate: easy to Insert V
/ .No efferl 00 breast milk prod 11ct1on ✓
..,,.,✓• NQfear of weight gain V

Side effects:
fvf;j,
• Increased menstrual blood flow with non-hormonal IUCD
GO G
• Increased dvsrnenorrhea ✓
• In eased risk of elvie Infection follow1n 1nsert1on if not

done ,n proper fashion
' Explanation
An IUCO 1s a small d~v1ce lha1 is shaped in thP form of a " T", and
places 111~ide Lhe utetus.
IUD with copper (Paragard T 3_SOA)
es Obitetrics & Gynaerofogy
os,£,orMB
,..acte of action:
, The arms of the Copper .

T IUCO contain copper wh ' h
, 1c stops
fertilization by preventing sper~ -11:.om making their way up
through the uterus into the fallopian tubes.
, 11fertilization does occur, the IUCO would prevent the fertilized
egg from Implanting in the lining of the uterus.
. The
,
. -
Copper T IUCO is effective up to 12 years.
It does not protect aga inst STDs or HIV.
-
, This 1s~ effective at preventing pregnancy,
Intrauterine System (IUS, Mirena IUD)
IUD with progestogen
• The~ is a small T-shaped device, placed inside the uterus.

• Releases a small amount of a levonorgestrel daily that causes the
cervical mucus to thicken s ~rm cannot reach the egg.
• f ffect1ve for up to five years.
• It does not protect agalns~STOs or HIV.
• The IUS is 99% effective.
Advantages of [UCO (Intrauterine Devi~e):

• Sare
• Once inserted, eflecllv,e for S years.
• No fear of forge 1t1ng_as in pUls, highly convenient.
• Fr!edom of intercourse.
OSPE for M99S ObSl!!rlC> & Gynaecology
48
• Very little failure rate; eas•t to insert.

• No effect on breast milk production.
• fllo fear of weight gain

• Immediately effective, over 99% effective
• Requires no daily attention
• Can be used by women who canno1 use estrogen .cont aining
birth control pills.
• The abllity to get pregnant retu rn s immediately after
removal of an Intrauterine device.,'
• Ca n be used as an emerg_~y contraception. To work for
emergency contraception, it must be inserted within about
72 hours of unprotected interco_\!ill
• Intrauterine devices remain In place until removed by the
health ca re provider. Rarely expelled ~ontaneously.
Side effects:
• Heavy menstruation with ~on-hormonal IUCD .
• Increased dysrneno11 hed,
• Increased risk of pelvic iQfgction following insertion .
'f'Contraindication
• Previous pelvic inflammatory dise ase.,,....
• Previous~oP.iC pregnancy. ,,
• Known malformations of the uterus.
• Copper allergy. /
Insertion Technique
➔• Explain the procedu re to the client. ✓
• Use ~septic _me~sures, seecu lun, exami.clatlon and bi manual
pe 1v1c exam Ina t1on ./ -=-c.....::.-:..
.v~oundingjof the uter1,1s slowly and gently to determine its
dep.!!1 _and dlrectionv'
• IUD placement high in the uterus (1.e ta t the fL ndl I
• Most IUD ' -...:..:..c..;:.:...i..:.:.::... I us - .
. s are inserted by th e w it hdrawal" technique The
ins~rter tube, loaded with the IUD is Inserted to the depth
indicated by sounding Then t he l~serter tube Is withdrawn
osPE for MBBS: Obstetrics & Gynaecology 49
while the inner plunger is helsuteapy. This leav~s the IUD in

position. Then the pl unger is withdrawn . _
• The IUD should be loaded in to the inserter tube not more
than five minutes before insertion .
IUD Removal: can be done easily by any trained health care

provider at any time du_ring the cycle b_utRreJe.r.aQ.[y during menses.
Be sure to:
• Fo llow infection prevention guidelines
• Be slow and gentle
• Counsel client that cramping/ bleeding may occur
• Refer difficult removals to specially: trained provider
If desired, a new IUD can be inserted immediately following removal
-
,
osPE for MBBS Obstemrs & Gynaecology
Station 6
Unobserved
Candidate's Instructions
Carefully see the photograph and answer th e questions
1. What 1s shown in the photograph?
2 Give 3 mdlcat 1011s for ,ts use
3 Wh ich blood vessels are usuall'( stud ied d .

unng pregnancy?
KEY:-
/
l. Dapple r USG
(1)
2, Used for prediction of JLl Vi 6l-
f.t (3)
• IUGR baby / y-f ·
• Pre ecla mp$ia
• A_bru 110 placenla
oSP£ for MBBS: Obstetrics & Gynaeco logy S1
• Ovarian tumor~ /
• Rhesus disease/
• Cardiac malformation.✓
• Neura l tube defect .
• Abdominal mass
3 urerine, umbilical and midd le cerebral arteries. ( 1)

• aan:; <
Explanation
Doppler USG works on Doppler frequency shift phenomenon that is

the @?unc: waves refleqed from the moving object e.g) red blood
cells within- the blood vessels, will be at different frequency from
the waves transmitted from tran,sducer. When the RBC are moving
towards the beam the reflected signals will be at a higher frequency
than the transmitted one and when the RBCs are moving away from
the beam the reflected signals will be at lower frequency. This is
Doppler frequency shift phenomenon. ➔, tf
~ --R
Using thi~ phenomenon the USG is used to assess the bllood flow
through the uterine, umbilical and different fetal vessels for fetal
wellbeing.
Indication for Doppler USG are

• !UGR baby/ Pre-eclampsia
• Abrutio placenta
• Ovaria n tumor
• Rh esus disease
• c;a rdiac_rr;ig!fo.u:na,tion .
OSP£ for MBBS Ob st• trl u & GynJ0
<04ocv
• Neural tub e defect
• Abdominal mass
• Cardiovascular stu dies (sono
graphy of the vascular sys tem
heart) and
• Blood flo w ,n the IIver vascula
ture 1n po rta l hy pe rte ns ion
Uterine art ery doppler

The volume flo w m the ute
rin e arteries increases w11h
advanci11~ gestation. When the
re is notch in the ute rin e artery
wave for m in early diastole,
indicative of inc om ple te or
Inadequate trophobiastic mvas
ion of spiral arteries (resulting
increase uteroplacental resista 1n
nce). This notch in ute rin e art
around 20- 24 weeks of ge ery
station give the pre dic tio n
preeclampsia, IUGR and abrup for
tion placentae in 60-70% of cas
es.
Um bil ica l art ery doppler
In obstetri cs usually the resistan
t to flo w 1s seen, which is reflec
m the d1astohc component. ted
•When these indices are high, md

1cates high resistance 10 flo w.
• Absent end diastolic flo w
is the sign of fetal hypoxia an
d may
appear up to 5 weeks hPfor efu
tal de mi ci)
• Rersrsed d1astohc fl.Q.w is a
more se rious sign of fetal hypo
xia and
ma y occur 1·2 days beforej j\~
I deC!l!SC.)
M idd le ce reb ral ar ter y evalu

ati on 1s used for diagnosis
of fetal
an emia and IUGR (Increase flo
w, low resistance)
fe ta l ren al art eri es on fetal ren

al anomalies
S3
obser\led Station 7
candidate's instruct ions
You are a ooctor on duty in labour ward, a staff nurse called

you in hurry to attend a patient G6 P4 + 1 presented with
history of 39 weeks gestation witb mild labour pains for 6
---
hours and sudden gush of watery discharge for 5 minutes. On
.
examination FHT term with Ion itudinal lie, fetal he'ad 5/5
palpable and cord prolapsed through the vagina .
---
How willy~ manage the case?
KEY:-
• Call for help and explain the situation to the patient and
1
.
relatives 0.5
• ✓,(u'scultate for fet I heart sound to ensure fetal viability 0.5 ./

.J,e,
• If fetus_ge~ then wait for fgginal~y 3-e:.A/ 0.5
• If b_gby alive, immediately qq peJ)Q.£ ~amination if cervix

fully dilated, immed iate instrnrnen1.aldelb!ery1 Other wise 0.5
8 Replace the cord within the vagina to keep warm and

relieve co.!'..d compression while preparing for the
caesarean section by G) "v
G) Knee elbow/left latera ls with Trendeleobecg position.
(} Maternal elevation. of the presenting part
G) M9:nually push the fetal part high 1.5
and
en damp catheter..,/
~ . t·
d for routine invest1ga ,on,
• save 1/V line take bloo
cross matching and arrangeme~ ~
-e t of blood
h t e inform
• Shift the patient immediately to t ea r '. . '
-=
anesthetist, . . and senior obstetrician
paedjatnpan 0.S
• EmptY the bladder before opening the abdomen. o.s
• Ensure fetal hearts before comme n cing cae~ean

section. 0.5
E11planation
Cord prolapse is an obstetric emergency requiring gulck actiop.
Incidence 1s around\! m SOO drllv-e-rie2,.J
Definition: When a loop or loops of cord are below the presentm.g

part and membranes are ruptured thP cord may fall through the
cervix and eventually the vulva so cord prolapsed, but when the
1
membranes are in1ct and cord felt below the presenting part t'han
condition is called cord presentation
Causes: Both cord prolapse and cord presentation occur in

association with ptematuri!Y and mal presentations.
Pathophyslology: the umbilical vein is compressed between t

presenting part and the pelvis thus reducing or sl'Opping the
Ol(ygenated blood to the fetus leading to deep variable decelerat
on CTG, ultimately bradycardia and in severe or prolong
compression may lead it to IUD.
OSPE for MBB5: Obstetrics & Gynaecology
55
Management
• ✓c:'11 for help and explain the situation to the patient and
re latives
• /4n lateral
•V100% oxygen by fa ce mask
-=-:=:..
•,✓Replace cor in vagina and avoid handl in cord a ch as

\
possible\/°
~
• elieve cord ression while preparing for the caesarean

s~ \../ ~ o , ~e ~ rJt( 11,uV
0~anuall! push th~ part high&?
• Knee elbow/left latera I with Trende lenberg position

~
~ M aternal elevation of the presenting pa rt
• Cathete rize and fill the bladder w ith 500ml of normal

saline then clamp catheter
Asses' fetal viability

by pinard/ Doppler/ CTG
I
If baby alive, cervix not fully If baby dead--- dilated-
Immediate LSCS wait for NVD
v'"
Baby alive, cervix
Fully dilated,--in strumental delivery
OSPE for MBBS: Obstetrics & Gynaecol°t/
56
• Save 1/V line take blood for routine investigation, cross matching
and arrangement of blood
• Inform anesthetist, paediatrition and senior obstetrician, shift

the patient immediately to t heatre
• Empty the bladder before opening the abdomen
• Ensure fetal hearts before commencing caesarea n section
OSPE for MBSS Obstetrics & Gynaecology
S7
unobserved
Station 8
See the photograph carefully and answer the foll owing questions
Q.1. What is the co ndition shown in the above picture?
Q.2. What are it s complications to the fe tu s?
Q.3. How thi s cond ition can be treated?
KEY:-
1. 1_win transfusion syndrom~

1
2 Complications
I. Donor twin suffer from

2
• Hypovolaemia due to blood loss
• Hypoxia due to place·o1a l ios11fticiency
• IUGR
, ----
• Oligohydramnios
58 OSPE for MBBS: Obstetrics & Gynaecology
II. feapient twin suffer from
.A Hypervolaem,a
~ Polyurla and polyhydramnios
.,/Myocardial damage
-"' High cardiac outp~t failure
/ • Sgp1e tim e fetal death

r .
~I cj,., .,,;i,,;JJ!,i, 2
- j v•' r- . ...(<i;.
~A
3 Treatment options
. ,£,,---. ,- ·7· .
- 1,p/,__, . . .
• [ Serial amniocentesi every 1-'2 weeks w,th the drainage of
large amount nf arnrnotic 0111d to prolong pregnancy and
=
imf)rove fe tal survival
ntal
of the two
Septostomy
/ •
Explanation
'
rn all monochorionic twin pregnancies there are placental vascular
anastomoses, leading to communication between tw o placental
circulatmns. Imbalance in the now of blood across these arterio
venous communication results in twin• twin tra nsfusion syndrome.
Chronic ms
occurs in@% of MC twms~nd is responsible for~
( 20%bf perinata l deaths 1n twin
Severity of ms syndrome depend upon degree of imbalance

be tween two circula tions
MB&S. Obsletrlts & Gynaecology S9
c,SPE for
r tWI" su ffer fr om
oono
• Hypovolaemia due to blood loss
• Hypoxia due to placenta l insu fficiency
• tUGR
• Oligohydramnios
• Stuck twin, IUD
Recipient twin suffer from
• Hypervolaemia
• Polyuria and polyhydramnios
• Myocardial damage
• High cardiac output failure
• Some ume fetal death
Mother will suffer from
• Sudden Increase in abdominal girth with abdomina l

discomfort
• Polyhydramnios
• 90% of pregnancies complicated by ms end in

miscarriage or sever preterm delivery because of
polyhydramnios or due to Intrauterine fetal death of
one or botb_fetuses.
\Doppler ultrasound}vil! hele._in_making diagnosis of IDS .,/
Treatmen t options
• Serial amniocentesis every_ 1·2 weeks with the drainage of

la rge amount of amniotic fluid tb prolong pregnancy and
improve fetal survival
60 OSPE for MBBS, Obstetrics & Gy
naeco1oay
• Recently laser coagulation is used to disrupt the pla
centa1
blood vessels that connect the circulation of the
tw0
fetuses.
• Septostomy
o5pffor 1',1885. Otlstetrlt> & Gynaecology
61
~ ;,• Station g
A 24 year
. old, primigravida
- presen ted to you with
. history
. of 6 w
~ •ooa l hrneaaccbea and vaginal bleed·mg f or 1 day H eeks •
· · er unne
-~,oona n · •~•_ . I pit';
he has severe- lower abdo mina in for
2 hours; . she also
• had syncopial attack at h ome. On pelvic
examination she Is very t ender aAd her B·p is ,l00/G0 with
. thready
pulse.
1. What is the most likely diagnosis?
2. How will you confirm the diagnosis?
3. How will you manage the patien t?
KEY:-
1. Ectopic pregnancy 1/'nfY"

' \((.r" ~
l .,'7t,,
1
2. Oiagnosed by ...q 1
1. Ultrasonography pre ferably TVS) Small uterus for

ge~tational age with no gestational sac or small pseudo
sac (decidual reaction) on TVS Adenaxal gestaiional sac
or mass with or without pelvic fluid on TVS.
2. erum BH CG level. Normal or low for gestational age
(discrimina tory level) eJP'~

\ i"'e. ~ f6' C.
3. Managemen t
/10~
Adm l\ her, do all inve.stigations and arraAge blood •
•
. d'ng the sltuatlon
• Counse l her and relative regar 1 -
OSPE tor MBBS Obstetncs & Gy'~:111
62
Sa(.Di.ngecromyjrE!lllQVa.LQf the tube and gestatiotiii
sac) QJ sa lpingostomy (opening of the tube~
r;moval of _!!le Gestational sa.c only) via lapr~l!'I
If the gestationaL.sac. is Intact and no signs _OJ
rupture o_!:.by lapai:£!._q_my if t he pa t ien t 1s_t.[J 2hock.
-=---
Explana tion
fctopic mean s "oul of place." In an ect opic pregna ncy, a f ertilized
egg has implanted oulside the uterus. The most common site 15
Jllopian tubes [in 95% of cases), The other sites are the ovary.
abdomen, or the cerv1K.
Incidence: occur ;r{!!;),t all pregnancies
Causes and risk factors
• An mfection or Inflammation of the tube

• Pelvic 1nllammal0ry diseasel{_PIDl -
• Endometriosis - - '
• Scar tissue from prev1O~ ab~ominal or fallopian surgeries
can also cause blockages.
•~ore rarely, 15irth defects or abnormal grow t hs can alter
lhe shape or the lube and disrupt th ' -
• A e elig s progress .
I
. prev ous (!ttopic pre!lnancy
• fnfertih roblems Or cf .
• Increase maternal me ic~ t1on to stimulate ovula tion
age, smoking
• Multiple sexual partner
• Use ot tUCO ✓
Signs and Symptoms
Abdominal pain, amenorrhea a d .

symptoms of ectopic pregnan~ n vagina l bleeding are th e classic
/• 6d .....c..-=e.:,:::~Y
L- vagina I sppttiqg
,- dizuness or fainting (caused b bl
_,. lo't,'. blood 0,,,~$ure (als Y ood loss)
•
Iower bac~ pa n ' - o caused by bl
,,. Ood loss)
• breast tenderness nau
~ ' sea, vom1 t1n f
g. o r requent urination
osPf for rv,88~ Obstetric.s & Gyoa~cology
63
nosls:
pi88 diagnosis Is usually made clinically based upon
file . g studies {ultrasound) and laborat~ry tests (hCG) resu 1ts of th e
i111agin
l . Clinically: Hi~tory and examination
2. fltrasnnngrapliy preferably (TVs)~ small uterus for

gest ational age with no gestational sac .Visualization of an
extraut erine gestational sac containing a yolk sac or embryo
is diagnostic of ecto pic pregnancy.
3. Serum BHCG level; Its levels double every 2 days for the first
severa l weeks of pregnancy, so if hCG levels are lower than
expected for stage of pregnancy, indicative of an ectopic
pregnancy. The thresho ld of discrimination of intrauterine
pregnancy is around 1500 IU/ml of -hCG An empty uterus
with levels higher than 1500 IU/ml may be a evidence of an
ectopic pregnancy.
4. A laparoscopy can also be performed to visually confirm an

ectopic pregnancy.
5. Culdocentesis, if blood or fluid found, may be due to a

ruptured ectopic pregnancy.
An ectopic pregnancy should be considered in any woman with

abdominal pain or vaginal bleeding who has a positive pregnancy
lest. An ultrasound showing a gestational sac with fe tal heart in the
fallopia n tube is clear evidence of ectopic pregnancy.
Treat ment opt ions:

Treatment of an ectopic pregnancy depends upon patient condition
and the size and location of the pregnancy.
An early ectopic pregnancy can sometimes be treated with an

✓ '1tttton of methotrexate, which stops the growth of the embryo
64 OSPE for MBBS; Obstetrics & Gyna,,
If the pregnancy i~ advanced surgery either salpingect

or salpingostomy is needed via laparoscopi'cally or by laparot °111y
0111 Yto
remove t h~ea bnorma I pregnancy.
A chance of recurrent ectopic pregnancy is 10%.
..
., 9s· ObstetrltS & Gyr1"ecologv
asPE"'',..8
Station 10
idate's instructions
cancl
··'er the followtng quest ions
,AnSw•
Q1. Identify th e organ

Q 2. Describe its fu net ions
Q 3. Name the hormon es it produces.
Q 4. what are Its abnormal forms? {Name any 3)
KEY:-
1. Placenta 1
2. Exchange of nu tri ent and w~ e product between

the m..Q_ther and fetus. 1
.-
3, Hormones procluced by the placenta are 1.5
1 Protein hormones
..
• • • Human chorion,c gonadotrophin
• •
'
' ... -
.. Human placental
'
lactogen
' '
-
66 OSPE ror MBBS Obstetrics & Gynaecoto«y
2. Steroid hormones
• Estrogen
• Progesterone
• Testosterone
I • Corticosteroid
4. Abnormal forms of placenta are 15
• Placenta extrachoria lis
• Battle dore pla r.ema
• Suc.centuriate lobe of placenta
/ Bipartite placenta
./' e!!'cemal infarcts
/ Chononic cys1s
Explanation
Tne placenta is an organ that connects the developing fetus to the

uterine wall to allow nutrients uptake, waste elimination and gas
exchange via the mother's blood Slllpply.
The placenta has two components, the fetal part (Chorion

frondosum) and the maternal part (Decldua ba salis).
Structure ••
•
~
Jn humans, t'1e placenta averages ~ inch) In: i.e~gth
..
and 2-2.5 cm (0.8-1 inch) In thickness ••
fol 11,tS&S. Obstett1CS 8c Gynaecology
o¢ 57
• 11 weighs approximately 500 grams (1 lb).
It has a dark reddish-blue or maroon color,

•
• It connects to the fetus by an umbilical cord or
approx1matelv 55-60 cm (22-24 inch) in le ngth that
contains two arteries and one ve in.
• The umbilica l cord inserts into the chorionic plate (has an

eccentric attachment). Vessels branch out over the surface
of the placenta and further divide to form a network
covered by a thin layer of cells. This results ,n the formation
of vlllous tree like structures. On the maternal side, these
vlllous tr<1e structures arc grouped into lobul~> called
cotyledons. TI,ere are about 120 cotyledons ,n mature
human placenta
Functions of placenta
Nutrition and immunity
The placenta allows the t1ansfer of nutrients and t>xvgen from the
mother to the fetus and the transfe1 of w9ste produ(..lS d11U tdl bun
dioxide back from the fetus to the mother filutriwls transfer to the
fetus 1s both actively and passively mediated by proteins called
nutrient transporters that are expressed within placental cells
lgG antibodies can pass through the human placenta, thereby

providing pratect,on lo the fetus in utero
M@tabolic and endocrine activity
The Placenta also has metabolic and endocrine actlvitt , It produces

~ormones
OSPE. tor M88S• Obstetr,c.c & Gyt1accology
t. Protein hormones: hCG and Human placental lactogen

2. Steroid hormones: estrogen, relaxin, testosterone and
corticosteroio
3. Somatornammotropin (also known as placental lactogen), acts
to increase the amoun t of glucose and lipids In the maternal
blood.
4. Beta human chorion ic gonado trophin Beta-hCG is excreted in

urine and this is what pregnancy test detects.
5. Progesterone and oestrogen thicken and maintain the uterine

lining as well as inhibit the production and release of more eggs.
6. It also produces insulin-like growth factors (IGFs)
Cloaking from immune system of mother
The placenta and 'etus may be regarded as a foreign allogra ft inside

the mother and thus must evade from attack by the
mother's immune system . For this pu rpose, the placenta uses
severa l mechanisms:
• It secretes Neuroklnin B, conta ining p'1osphocholine

molecules. This avoid detection by the immune system of their
host.
• Also, there is orese nce of small lymphocytic suppressor cells in

t he fetus that inhibit materna l cytotoxic T cells by Inhibiting the
response to interleukin 2.
osPE ro• r,,1885; Obstetrl<> & Gynaecology
69
1. Describe the bo undaries of gynaecoid pelvis

2. Describe diameters, antero posterior and transverse at
1. Pelvic inlet 1 ) - f -""
2. Pelvic cavity ;,;. f
3. Pelvic outle t /t-J'i) •
KEY:·
Boundaries of gynaecoid pelvi s 2.5
• Pelvi c inlet : ,v;:;p.per boarder of pubic symphysis,
lllopectin6lline, ala of sacr'urn an,9 sac;ral pro montory,
'
• Pelvic cavity: P.Oilecior sur{acP of syrnphySis pubis,
obturator fascia, inner <rspect at ischial bones and spine and
s_;rospinous ligarnenl's laterally
• Outlet: pelvic arch. ,schial tuberosjtjes and coccyx jojned.2v
s~c£9.tube rous ligament.
2. Diameters antero posterior and t ransverse 2.5

Diam·eters
1 . Inlet AP 11.5cm
2. Cavity AP
Transverse
-
13.5 cm
12 cm
Transverse 12 cm
•
3. Ou tlet AP 13.S cm
Transverse 11.5 cm
70 OSPE lor MBBS Obsletrocs & Gynaecology
Observed Station 12
A 31 year old, woman has come to you . She has multi ple sexual
partners. Her screening test revealed t hat she had betome HIV
P.OSitive She also complains of cepeated throat iotect iaos. Answer
the questions asked by the exarnin~r.
Examiner's Instructions
Please ask the following questions and t;rade accordingly.
Q. l. Apart from multiple sex partners, what co uld be other risk

factors for this infectio n?/
Q.2. What is the incubation period of this infection?
Q.3. What may be the initial m.;nifestations of this infection?
Q.4. How the risk of vertical transmission from mother to fetus can
be reduced ?
KEY:-
I 1. Other risk factors

/ 1 n1ravenous drug abuse. /
• Bisexuals and haemophilliacs Jj
1.5
tA/' Unscreened blood transfusion✓

V Breast feeding by HIV positive motherJ
2. ln~~ba tion period:[One to five yet3rs) 1 _ S ':IAJ • 0.5
3. ln1t1al manifestations are V
1
• Op,po.rtun,istic jnfe<;J jp ns(bacteria I,
viral\ ~fungal, parasitic and
• Kaposi's sarcoma
greatly
2.S
caesarean
sertjon delivery
after dellve red;;;- th
risk from 30% to less than 2%. ✓ es e
• A zidovudm e infusion shou ld be
.
sta L· 1 f
- -- r e,., our hours l)efore
beginning the caesarean section and sh Id .
. ou continue un1il
th mbllical cord as been clam ed. ✓
• Women who opt for a planned vaginal delivery should have
their membranes left intact for as long as possible . Use of
fetal scalp electrodes and fetal blood sampling should be
avoided .
,,., A((f .~
Drug the rapy ,i:,·c\ol!J" ,t11l1
, ,!\nti-retrov,ral therapy Zodovudine and µb11
• Potent combinations of three or more an tl-relroviral drugs

(HAART) should b~ con ti nued after delovery.
0 Zidovudine os usua lly adm1ms1ered orally to the neonate for

fou r to six weeks
Explanation
HIV is a retro virus . Its gencttc code 1s ,n single strand of RNP.. It

produces the infection by binding 10 the CD4 recep1ors, which are
present on the T-helper lymphocytes, macrophages, dendritic cells
and neuroglia and destroy the immune system .
Incubation period is one to five year. Around 20 milloon people are

Infected with HIV worldwide. More common in subSaharan Afrka
HIV causes AIDS by damaging the immune system cells. Without

-h
lreatment it takes around ten years on average for someone w i t
HIV lo develop AIDS,
••
72 OSPE tor MBBS. Obs tetncs & Gynaecology
,._/
Symptoms; Clinical features include a flu-lrke illness, ge~r_aliied
lymphadenopathy, a macular erythermatous rash, pharyngitis and
conjunctivitis. Long standing infection leads to recurrent oral and
vaginal candidiasis, persistent warts and geoital ulcers. Skin
problems include seborrhoeic dermatitis, fol l iculitis, dty skln.~ a
pedis and high frequency of allergic reactions.
Mode of transmission are
• Intravenous drug abu se.

• Bisexual s and haemophllliacs
• Unscreened blood transfusion
• Vertical transmission
• Breast feeding
Risk of HIV infection in preg nant women

Spontaneous abortion, low birth weight baby, pre term delivery and
increased perina ta l mortality
Vertical transmission
Vert ical transmission of HIV from mother-to -chil d accounts for

about 70% of the cases of HIV in childre n (in-utero t ransmission
-
30%, intr.apartum transmission 70%).
• The risk of mother-to-child transm ission of HIV varies
between 15% and 20% in non-breastfeeding wo men and
between 25% and 40% In breastfeeding African populations
• Risks of mother-to -child transm ission is increased with
higher levels or maternal viraemia, HIV core antigens, lowe r
maternal CD4 count, primary HIV Infection during
pregnancy, chonoamnionitis, other STD, invasive procedures
(e.g. fetal sca lp electrodes), rupture of membrane s
(especially if delivery is more than 4 hours after ruptured
OSf'E for MBBS: Obstet ncs & Gynaecology
membranes), instrumental deliveries (I f

.e. creeps or
vacuum), vaginal ~ very & advanced maternal age
• Factors that decrease risk of t ransmission are h. h
.. " 1g er levels
of neu tra lizing HIV antibody titres, elective caesarean
section, zidovudine. less invasive monitoring and
1ntrapartum procedures.
Management
Mother- to -child tra nsm issio n of HIV infection can be greatly
reduced th rough
• Screening fo r .!;!.!Y_ ea rly in pregnancy because appropriate
antenata l interventions can reduce ma ternal-to-child
transm ission o f HIV infection .
• Interventions t o red uce mother-to~ hild transmission of HIV
during the antenata l Qeriodi incl ude antiretrovira l thera py,
elec tive caesarean section delivery and avoidance of
breastfeedi ng after delivery. It reduces the risk from 30% to
less than 2%.
• A zidovudine Infusion should be started fo ur hours before
beginning the caesa rean sec tion and should con ti nue until
the umbilical cord ha s been clamped.
• Women who opt for a planned vaginal delivery should have
their membranes left intact for as long as possible. Use of
feta l sca lp electrodes and fetal blood sampling should be
avoided.
Drug therapy
• Anti-retroviral therapy is given to prevent mother-to-child
transmission and to prevent maternal disease progression.
The optimal regimen is determ ined on a case-by-case ba~is.
• Zidovudine is indicat ed for use in pregnancy for prevention
of mo ther-to -child 1ran smissio n.
e anti-retrov1ra l drugs
• Potent com binations of three or mor
(HAART), is the f tandard care Women with advanced HIV
OSPE for MBBS; Obstetrics & Gynaecology
74
should be treated w1lh a HAART regimen . The start of

treatment should be deferred until after the first trimester,
11 possible, and should be continued after delivery.
• Zidovudlne is usually administered orally to the neonate for
four to six weeks.
• Antibiotic should be grven at the time of delivery to avoid
other infections.
osPf fol M BBS Obstetrics & Gyoaecolol!'I
75
unobserved .
Station 13
see the photograph carefully and answer thn f0 11 • ,.

• owing questions
Q. 1 What is tl'\e specimen 1
Q. 2. Explain Its mode of action.
Q. 3. Give 3 contraindications for its use
KEY:-
1. OCP (oral contraceptive pills) ✓ O.S
2. CDC acts both centrally and peripherally l .5
~ nh ibition o release of
FSH and LH
• Peri pheral effects by endometrial atrophy, making sperros

ascending difficult into the uterire cavity by !hi5.keni!_! of
th~ cervical liucu~.
,nii,t.110
,1, f)iv
OSPE for MBBS Obstetrics & Gynaecology
76
3. Absolute contraindications: 3
✓ lschem ic heart disease
.,. cerebrovascular accident

C
.,. SL&rJifica nt hypertension
,. Art;ria l or venous thrombosis
,,. Ac.ute or sever liver disease
... Focal migraine & breast canc;,er

=
Relative contramdlcations : ge_nerahzed m igraine, lo_rig_ term
immobilization, irregular vagtna l bleeding, smoking and diabetes.
Explanation
Introduction ✓
• OCPs are the most popular type of birth con trol
• They come in packs o(ft or 28 pills. On~II is taken every day.
• The first 21 pills have a com bination of synthetic est roge n and
progesterone hormones
• The last 7 pills of a 3J)·day pack have no hormones and ~
called spacer pllls. y
• The Pill is 92-99.7% effective as birth control met hods.
• It does not protect against genital tract infections including
HIV/AIDS.
Mechanism of actio n
• The Pill stops ovulation, preventing the ovaries from
releasing eggs.
• Thickens cervical mucus, making it harder for sperm to
enter the uterus
• Endometna l atrophy.
ees: Ob$t._t r1cs & Gynaecology
oSPf for M 77
use
The Pill is effective immediately, when started within 6
1. f
days of the start o a period or within 6 days after an
abortion. Take one pill every day uf1'tll one finish's an
entfre pack.
2. If a 28-day pack, sta rt a new pack immediately after
fi nishing th e first pack. if a 21-day pack, take one pill
every day for 21 days, no pills for 7 days and then start
the new pack imm ediately.
contraindications
Absolute contramd,ca tions:
• 1schemic heart disea se
• Cerebrovascu lar accident
• Significant hyperte nsion
• Art erial or venous thrombosis
• Acut e or sever hver disease
• Foca l migraine & brea st cance r
Relative contraindications: generali zed migrai ne, long te rm

•mmobilization, irregular vaginal bleeding, smoking and diabetes
Side Effects
• Irregular bleeding or spotting

• Nausea
• Breast t enderness
' Weight gain and/or water retention
' Spotty darkening of t he skin
' Mood changes
OSPE for MBBS: Obstetrics & Gynaecolog-,
Periods may be lighter or more regular .

•
• Easy to use .
• Does not harm future fertility .
• Does not interrupt sex play .
• May protect against uterine and ovarian cancers.
• May reduce acne.
• Can be used for emergency contraception .
• Pill decreases the chance of developing ovaria n cancer,
endometrial cancer, and pelvic inflammatory disease .
Disadvantages
• Does not protect against sexually transm itted infections,

including HIVLAIDS~
• Must be taken every day .
• Less effective when taken with some drugs.
• Raised risk of heart att ack and stroke .
• Requires a prescripti on .
• The effects of the Pill on breast cancer are st ill unknown
oSPEfor M8B5. Obstet11cs & Gynaecology
79
observed
~ )" Station 14
candidate's instruction
A nulliparous , 54 yea r old, women presented with history of

t irregular vagina l bleeding for L months. S_he ba~ IJ§tory of weight..,...
loss and generalized weakness. USG showed eggqm§!ri~ness
of 10 mm .
1. What is the probable diagnosis?
2. How will you confirm the diagnosis? --

3. What are the treatment options for different stages of
disease?
KEY:-
l. Endo.metrial'carc.inoma ✓ 0.5
2. Endomet!,ial sampling ideally by hysteroscooy ~ulded D&C 1

-:....:__;;---- V •
3. Stage I: TA'H + 850 3.5
~iotherapy if jnvasiao af myoroetrjum more than the

i,nner ha lf of the myometriurn:/
Stage II
/ IJ patient is surgically fit then R,adica l bvsternctGmy with

BSO + bilatera l pelvic lymphadenectomy with pa ra aortic
n9 de sampling. If patient is surgically unfit than
radiotherapy.
==•
Stage Ill
/ Surgery+ Radiotherapy
<-.
. Obstetrics & Gynaecology
OSI>£ for MB BS
so
Stage IV
to the patient.
Individualized according
Treatment is
and •
Qrcas10i=ia ,i,,, resid11aJ disease ma¥ be
Radiother•r¥
tr;;;;by surgical intervention.
Endomet rial cancer . • of the u terus. It is the

n 1 tn!l!BLl!!..-!=-:;'':
·ses from t' fh~e~- :!!l!!n[
Endometrial cancer a ·.:. ic cancer dea t h. The most
third most common eause of gynecolog__ . ,,
common subtype is.endometno, · ·d adenoca - - rcmo ma,-
Signs and symptoms . /

• Premenopausal or perimenopausa l bleeding
• Abnormal vaginal discharge f
• Pelvic pain or pressure, usua lly occurring ,n late r stages o
the disease
, Weight loss ✓
Risk factors
, High levels of ~strogen. en-dometnal hyperplasia ✓
, Obesi ty. hypertension. polycystic ovary syndrome v'
• ~ulliparity. !nfertility ✓
• Early m enarche, late menopa use,,-
• Endometrial polyps or other ben ign growths of th e uterine
fjnln_g_
• Diabetes, Tarnoxifen use ✓
• High lnta~e of anim al fat
• Pelvic radiation therapy
• Breast cancer, ovarian cancer
• H~a.YY. daily alcohol consumption (possibly a risk factor)
Diagnosis
Clinical evaluation
• Rou1ine screening of asymptomatic women 1s not ind icated
• Pelvic examination helpful only in advance disease
• A Pap smear may be either norma l or show abnormal
cellular changes.
81
• A dilation and curettage (O&Cl is necessary for diagnosing

the c;ancer. ✓
~
HystteroscoP._y_guided D and C is the method of choice

•
(allows the direct yisua li~i!lion of the uterine cavity).
inal ultrasound to evaluate the endometrial
•
t icl<ness m postmenopausal bleeding is helpful In
diagnosing endometriaJ cancer.
• But most important oJ thf;?se Is ,!:Jysteroscopy guided biopsy,
which gives 90-95% of positive predictive value.
Staging
-1)-Endometrial carcinoma is surgically staged using the FIGO cancer

staging system.
• Stage IA· tumor lim11ed to the endometrlum
, Stage 1B: invasion of fess than half of the myometrium
• Stage IC: invasion of more than half o f the myome1rium
• Stage IIA: endocervical glandular invo lvement o nly
• Stage 11 6: cervical stromal invasion
• Stage IIIA: tumor invades serosa or adnexa or malignant
peritoneal cytology
• Stage 111B: vaginal metastasis
• Stage IIIC: metastasis to pelvic or para-aortic lymph nodes
Stage IVA: invasion of the bladder or bowel
Stage IVB: dis!ant metastasis, including intraabdominal or
inguinal lymph nodes
Treatment
Surgery:
The prima,y surgery for uterine cancer Is a tola l abdomina l

hysterectomy with bilateral salpir.igo-oophorectomy.
Obtain washings of the abdomfnal cavity 10 de1ect any further
evidence of ca ncer.
1. Stage t
TAH + BSO
82 OSPEfor MBBS: Obstetrics & Gynaecology
Radiotherapy if Invasion. of myometrium is more than the

inner half of the myometrium.
2. Stage II
If patient ,s surgically fi t t hen Radica l hysterectomy with

BSO + bil,teral pelvic lymphadenectomy with para aortic
node sampling. If is patient surgica lly unfit t han
radiotherapy.
3. Stage Ill
Surgery (TAH+BSO) + Radiotherapy
4. Stage IV
Individualized according to the patient. Radiotherapy,

Progestogens and occasionally residual disease may be
treated by surgica l intervention.
OS'f'°' NIBBS: Obstetrics & Gynaecology
83
Unob~d-' ~ ' ~tatione)
see the photograph carefully and identify the condition

1. What is the diagnosis?
2. What are the risk factors for this condition? Give 3
3. How 1t ca n be diagnosed?
4. What are the treatmen t options for such disease?
KEY:-
l. Fibro id uterus 0.5
Y. Nulliparity. '&besity, a 'positive fam.i ly histor y and African

- C • . 1.5
,,-racia l origin. & 30"year of age woman
3. Clinical examina tion aod \ JSG

0.5
4. Cgg<l!rvative management-of asymptomatic fibroid 3

,
I. W,edicil' treatment by using a GnRH agonfst helpful in
shrinking fibroids
OSPE for MBBS Obstett1C$ & Gynaecology
11 . surgical treatment, myomectomy o r hysterectomy,

depending upoo severity of symptoms, age of patient
and fert ility desired
-=
111. Uterine artery embglization'
EKplanation
A fibroid is a benign tumor arising from t he uterine s mooth
musd es, termed as a leiomyoma./'
Incidence: seen in 5-20% of women of reproductive age
Ri sk factors and Pat hophysiology:
• Oestrogen, growth hormone, possibly human placental

lactogen play part In the growth of myoma ,✓
• Oestrogen has stimulatory effect evidenced by association

of fibroids with hyperplasia, dysfunctional metropathia,
bleeding and endometrlal carcinoma .
• Myomas increase in size during pregnancy and with oral

contracept ives
• Occur usually In nulliparous women and also has some

fam ilial predisposition
•
• ln_Q_jfo of cases malignan t change can occur in myoma Le .
leiomyomasarco1 11a, ✓
• Other risk factors are ~besity, African racial origin and

reproductive age group
Clinical features
I
1. Common presenting complaints are menstrual disturbances
like menorrhagia
05PE for MBBS: Obstetrics & Gynaecology
85
2. Pressure symptoms especially ur·,nary f
_ _rem 1eocy•
3. ~Q._may occur due to acute degeneration
4· ~ubfertility may occur due to mechanical distortion or
~cclusion _of t he f~llopian tubes or may interfere the embryo

implantat,on by d1stortiog the endometrial cavity,/·
S. On abdomina l and pelvic exam ination firm mass may be

palpable ./
Diagnosis
1. By history, examination and investigations
2. USG
Treatment
1. Conservative treatment
• If fibroi d is asymptomatic or size less than llim-do nothing or ·

use GnRH a~onist for shrinkage of fibroid. ✓
2. Surgica l treatment
If symptomatic and large fibroid choice depends upon age, parity

and fertility wishes.
• Myomectomy
• Total abdomina l Ca n be facilitated by grior use of
Hysterectomy GnRH ana lo;~s foe sbcio kage of.fibroids . /
• ljysteroscopic guided removal of small (s 3 cm) submucous

fibroids.
3. Uterine artery embolization .
.·
CMlllfllr MIi$ 0tn111r,u & (;vnaocotogy 11
Practice
Session Two
Ul,.._
r"'' "'
"o·'·
l'i,Jt,,\
~,,1
(,.~x--...i.'•~)
\i.,, .. ~,.,_ \f\)V..,4,,.4:1...,..
O•Utf) di,\....,., !IQ
(..H'"' E'•I 1~ ·l
'· "' 9 \'lo • ..,..,. ,,..
"'"''u1~7 ,..,."' ')'
~'< •~>
Gvnaetoloav OSPE for MBBS: Obstetncs & Gynaecology
89
Carefully see the diagram give n and answer the following question?
l. Which measurements are taken?
2. This measurement is used for what? G~indlcations.
3. What ls prediction of its accuracy .
kEY:-
(1 .5)
1. CRL measurements of fetus
2. For measuring
✓
alculating EDD / (i )
51
3, Early Cfil,_taccwat: h~:)!'.ed!G!i@Rli:-5,days _,, (l
Explanations
Cr e I of the length of
own-rump length (CRL) , Is the measurem n
hu of the head (crown) to
lllan embryos and fetuses from the top
90 OSPE fo, MBBS. Obstetncs & Gynaeco'°II,
the bottom of the \butt ocKsJ (rump). It is measured by ultrasound

and used to estimate gestationa l age.
Measuring
• The embryo and fetus float in the amniot ic fluid usually in a

curved posture resembling the le!!fil._C
• The measurement needs to be in the na t ural st ate with an

unstretched body which 1s actually C shaped.
• The measuremen t of CRL is useful in determining the

gestational age and thus the expected date of delivery (E DD).
• Different babies do grow at different rates and thus the

gestational age is an approximation. Early in pregnancy it is
accurate within +/· 4 days but later In pregnancy due to
different growth rates, the accuracy is less. In that situation,
other parameters can be used in addi tion to CRL.
• After 1 2 weeks, the accuracy of CRL in predict ing gestational

age diminishes and is replaced by measurement of th e fe tal
blparietal diameter. /
• From 6 weeks to 9 1/2 weeks gestational age, t he fetal CRL

grows at a ra te of about 1 mm per dav.
I
• The folJowing formula can give approximate meas1Jrement
• Gestatfonal age (week-s, of pregnancy] = crown -rump length

(cm)+ 6 .5
~ fo! MBBS ObsletnC$ & Gynaecology
91
-r Station 2
oi,served
A 23 year old Mrs. K.J. presented in the OPD with complains of

reeling of bloatedness, cyclical weight g<Jin, mood changes,
depre~sion and b r~ st tenderness. Her LMP_is lQ_days back. S'he Is
vg worried. How will you counsel her?
KEY :-
1. Introduction (O.~)
2. Explain that you are suffering from PMS

✓
- (0. 5}
3. Advice her about c;l.iel modificatiori P><g.rrlse or

,$tress r.,~@El.ti.Ou..te.cbnigues
~sychothe rapy
Y5uppression of ovulation using oral contrace tive,

~nazol, G~RH~ analogues and se ective serotonin,
recepto r inhibitors i.e. fluoxeti ne / (3)
6. Ask about patient concern (1)
E•planation
Premenstrual syndrome (~S) - is' a collection of physical,

Psychological and emotional symptoms re lated to a
woman's menstrua l cycl e.
Incidence: 2 to 5%
OSPf for MBBS. Obst.etrics & Gvnaeco
92
Symptoms
Three most prominent symptoms are irritability, tension, and

dysphoria (unhappiness). Others are stress, an~iety, difficulty in
falling asleep (insomnla), headache, fatigue, mood swings, increased
emotiona l sensitivity and changes in libido,
Signs: breast tenderness, abdominal bloating, hea dache, and

swelling of hands and feet.
Risk factor·s
• High caffeine intake
• Stress may precipitate condition
• Increasing age
• History of depression
• Fami ly history
• b ietary factors (Low levels of certain vitamins and minerals
particularly magnesium, manga;;'ese. and vitamirm)
Diagnosis: There is no laboratory test or unique physical findings to
verify the d.iagnosis of PMS. The three key features are:
• The woman's chief complaint is one or more of the

emotiona l symptoms associated with PMS (most typically
irritability, tension, and/or unhappiness).
• Symptoms appear p redictably during the luteal
(premenstrual) phase, reduce or disappear shortly before or
duri ng menstruation, and remain absent during the
follicular (pre-ovulatory) phase of the menstru al cycle.
,
• The symptoms must be severe enoug~ to disrvpl or
interfere with the woman's everyday li fe .
M anagement
• Diet or lif estyle changes
• Supportive therapy includes evaluauon, reassurance, and
informational counseling, in addition, ae robic exercise, reduction
•- .., r,188S: Obstetrics & Gynaecology
"
of~e, S.\!.Car( and sodium intake and i~crease use of fiber and
adequate re ~t and sleep. Calcium, vitami n E, : Vitamin 86 ~nd
~esium are also of help.
, M ical intervent ions are
9
, Hormonal treatment co mbined oral contraceptive ptll and the
contraceptive patch, danazol, Progeste rone, Gonadotropin-
releasing hormone agonists.
, SSRls like fluoxe tin e
, Diuretics (Spironolactone), ~ ening primrose 9il and Clonidine

can also be used.
OSPE for MBBS; Qb,tetrics & Gynaecology
Station 3
unobserved
er the fo llowing q uesrions

Carefully see the photograph and answ
'? <'-~ -
1. Wh at is the diagnosis. /
2. What 1s the etio logy of the disease? Give 3.
3, What are the trea tment optioris?
4. What neurologica l problems can persist 1n such babies?
KEY :-
1. \ .Spina bifiaj 0.5
2. Folic acid deficiency, ch romoso mal ab normalit ies &

d!__ugs: e g. egileptic drugs 1.5
3. (su,rgica l removal -G-rhe sac:i Prognosis will depend

ori.. whether or not the sac contained any nerve
roots. 1.5
1.5
spioa bifida is an open neura i tube defect caused by the incomplete

closure of the embryonic neural tube and exposure of the meninges
and neural tissue to the amniotic fluid .
• The most common location of the malformations 1s the

lumbar and sacral areas.
• The incidence of spi na bifida can be decreased up to 75%
when daily folic acid suppleme~ are taken prior 10
conception
Epidemiology
• Spi na bif1da 1s one of the most common birth defects with

(incidence of \-2 cases per 1000 births./
• It has risk of recurrence
• This condition 1s more likely to appear in females; the cause
fo r this is unknown.
Etiology and Pathophysiology
• Spina bifida is caused by the failure of the neural tube to

close during the fir st month of embryonic development.
Normally the closure or the neural tube oceurs around 28
days afrer fertilization.

• Medications such as some ant1convulsants, diabetes, having
a relative w ith spln a 1J1f1da, obesity, and an increased body
temperatu re from [ever or external sources such as hot tubs
()SfffQ;!M8&5:0bSlt'lr<CI&
" ...
find electric u,an e
,
k 15 can tncrease thl! chance of spina blfldt
In baby.
. " nf the cases cause is still unkoown
• However, ,n maJOfl1, u
Genetic and poyironmenta 1facrors may play part
• tack of folk acid jlolate) is a contnbuting factor in the
•
pathogenesis of neural tube defects, mcluding spina blfida
·
Supplementa1ton •I
u
•he
,
mother's d1e1 with folate
(0.4 mg/day) can reduce the incidence and severity ol
neural !ube defects by about 70 percent.
Signs and symptoms

Spina brnda may be associated with
• \Hydrocephalus) le•cess,ve accumulation of cerebrospina l
fluid in the ventricles of the brain)
• Accordin~ to the Spina Blfida Assocjat,on of America (SBAA),
over 73 percent of pe1JOpl1' with spina bifida develop an
faiiergyjto latex (exam,narion gloves, condoms, catheters)
Diagnosis: amniocentesis .-+ raised alpha fetoprotein and USG

for fetal wellbeing
Treatment
• There ;s no known cure for nerve damage due to spina

b1fida.
• By surgical closure further damage and infection of the
nervous tissue can be prevented During the operation the
Spinal cord and its nerve roots are put back inside the spine
and covered with rnemnges. In addition, a shunting may
install for continuous drainage of the tereb,ospinal fluid
produced in the brain, a~ happens wrth hvdrocephalus
Shunts mosl commonly drain into the abdomen However,
fO' 11,19BS. obstetrlc5 & Gynaecology
97
If spina bifida is detected during pregnancy, then open f~tal
surgery can be performed.
• Intrauterine surgery for spi na bifida has also been
performed and the safety and efficacy of this procedure Is
currently being investigated.
prevention
• Dietary supplementation with folic acid in a dose of

o.amg/ day, three mont hs before conception, and
continued for the first 12 weeks of pregnancy.
• Higher dose of 4-5 mg/day needed for women who have
already had a baby with spina bifida or other type of neural
cube defect or are taking anticonvulsant medications,
OSPE for MBB$: Obstetr,cs & Gynaecology
98
Unobserved
See the photograph and answer the following quest ions
1. What is this instrumem shown in the figure?
2. What it is used for?
3. Give 3 indications for its use.
KEY:-
.L [ cusco / (bivalvedl speculum J l
2. l Fajlie visua lization of the cervix and the vaginal walls\ 1
3. Indications 3
- • \li~ualization of cervix
• Taking pap smear

-
• Removal of IUCD
• lhserttr!l of IWCQ
r MOBS Ob~IOlnts & Gvn,1ecol9gy
OS,f IO
99
• Re,q,oval of polyp
-
• cervical cau tery
• To obtain samples of the discharges f h

. rom t e cervix and
vagina.
Explanation
A vaginal speculum, developed by J. Marion Sims, consists of a

~ollow cylinder with a rounded end that is divided into two hinged
parts, somewhat like the beak of a duck. The speQJlum is Inserted
Into the vagina to dilate it for examination of the vagina and cervix
Construction:-
All specula were formerly made ot metal and sterilized after use.
While now plastic speculum are also available which are srerile,
disposable, single use items. Those used in surgical suites are still
commonly made of metal.
Cusco
.-.. specula are the bivalve vaginal specula; the two blades are
hinged and are "closed" when the speculum is Inserted to facilitate
its entry and "opened " in its final position where they can be
arrested by a screw mechanism, so. that the operator is freed from
keeping the blades apart.
Technique of using Cusco speculum
• To insert a vaginal speculum, the lntroitus or vaginal

opening must be stretched open by two moi stened fingers.
• The speculum must then be warmed and moistened with
lubricant o r warm water, after which it Is inserted laterally
OSl'E fa/ M8&5. Obsletr,n & G y ~
Into the va1lnal opening so as not to cause paln o,

discomfort
Once the speculum passes over the fingeus holding the
• introitus open, they are turned horizontally.
Insertion is continued to the back of the vag ina, the
•
speculum must be held at a 45 degree angle to the
examination table,
• The specu lum blades are then opened to reveal the cervix
and the vaginal sidewal ls
• The blaOes are secured by compres,ing them moving the
top one forward until a click ,s heard
• Then the speculum is locked by rotat ing the screw
dockw,se.
• The ex~mination and sampling of the cervi~ and vaginal
sidewalls may then be performed.
Indications for using Cusco specu lum
• V!suali1ation of cervix✓
• Tqking pap smear ✓
• Removal of IUCD ✓
• Insertion of IUCD ✓
• Remova l of polyp .,
• Cervical cautery ✓
• To obtain samples of the dlsch

. arges from the cerv,·, ••d
vagina ~"
• For taking high vaginal swab
~aas· obstetnc1 & Gynaecology
jjlflll 101
oi,served Station 5
oernon~t(ate In front ot the examiner general physical examination

of patient
f"'1rlliner will observe you .
E,amlner's instruction:
Student will perform G.P.E of patient and vou will mark according_ to
Key,
KEY:•
• Confidence
• 'Ey~ tel-eye con tact with the patient 1

/
• Keepirig the patient at ease while examining
Examination: (4 )
' of lhe
• Height and weight ' oatjenl. lit weight machi□!: 1s oat
available at least mention v,erbally)
• Pulse b~m for 1 minu \e, B.P- mmHg,

Temprature °F for I minute.
• Los,k for patjent's palm's. nail, tongue, mucosa of mou th.

~
S~ra (Qr ~nernia, cya,U&is a11d Jaundlte

• Pa!pate thyroid and palpate For assessable lymph nodes
• Auscultate chest for heart sounds.
102 OSPt tor MBBS: Obs1erncs & Gynaecology
• CougJ respiratory rate and loo~ for symmetry of the chest
• Breast examination in all four quadrants along with al<illary

lymph nodes
• Look for pedal edema just above the medial mefliofus.

- l
'
'
rifl for M8SS Ql,;t~IIICS & Gynaei o)ogy
103
er· Statio~
-~!date's instructions
ca""
carefully see the diagram and answer the questions
1. What ,s the procedure shown ,n photograph?
2 Whal Is 11 used for)
(§/ What 1s ,deal t i me to do this test?
@what are 11 s complications. Give 3
KEY:-
1. H~terosaJpingoera@
I' 0 l
2. To see the patency of fallopian tubes and to seek

out any uteri ne cavity or tubal abnormalfti~s l
void
3 Day 8" to 101 f menstrual C •
-
nadvertent exposure or the early embryo 10 the
ioniiing radiation
1.5
l.S
4 Complications
OSPE for MBBS: Obstoetncs & Gynaetolacv
104
• Qve aUece¥
• pnfertipruif asepti, technique
• Very rarely uterine perforation
C
Explanation
Hysterosalpingography (HSG )
, procedure to ·mvest,ga
Is a radiologic · te the shape of t he uterine
cavity and the shape and patency of the fallopian tubes. A radio•
opaque material is injected into 1he uterine cavity through cervical
cana l and X rays are taken (or fluo roscopy With image
intensffica tion) A normal result shows the filling of the uterine
cavity and the bila t eral filling of the fal lopian tube with the injection
material.
This test is done within the first 10 (follicular phase) of the cycle
preferably on day 9 or 10 to avoid inadvertent exposure of the early
embryo to the ioni zing radiations.
Tubal patency is confirmed wi th free spillage of the dye from both

tubes into the peritoneal cavity,
If there is loculated spill it indicates peritubal adhesions and club

shaped dilated appearance of tubes suggest hydrosalpinx, bilateral
cornual block with extravasations of the dye is suggestive of
tubercu lar sa lpingitis.
Filling defects in tlhe uterine cavity are us1,1ally due to submucous

fibroids, polyps o r adhesions. Other uterine abnormalities like
Asherman's syndrome, uterine bicornis, arcuate, septate uterus can
also be seen w,th HSG.
()bstetrlcs & Gynaecology
It gives permanent record

shows the site of tubal blockage
·,nimallY invasive__grocedure with rare compl'1cat1ons.
.
M
"oelatively short procedure that can provld e valuable
information on a variety of abnormalities that cause
,nfertilitY or problems carrying a fetus to term.
_ Hysterosalpingography can occasionally open fallopian
5
tubes that are blocked allowing the patient to become
pregnant afterwards.
_ No radiation remains in a patient's body after an x-ray
6
examination.
7. x-rays usually have no side effects in the diagnostic range.
eomplications
1. Pelvic infection(endometritis, salpingit is)

2. allergic reactions to the materials used
3. lntravasation of the ma terial
4. If oil-based material is used, embolisation.
5. Pain and colla pse w hich ca n be avoided by injecting
atropin e half an hour before the procedure
6. Perforation of the uterus
HSG should not be performed in
1. Post ovulatory periods

2· Presence of genital infection, suspected genital tubercu losis
3 1f th~
' patient is seosltive to iodJf1e'
•
4. If the patient is Qregnant
Statlon 7
unobserved
A ZO yeors old corl, w,tl1 ,1 reel height and teatures (as sh~w~ ,n
photograph) presentc d lo Vou Wl!h compl,imt of failure to ,mt,ale
the menstruatoon
Q. Whot ia the diagnosis?
q Wha 1 are the clinieo I feature.:; of this r.on;:Hti on i'
Q Whal 1s the treatment?
KEV :-
l.
-
TiirnerSyndrome
2. Short stature, webbed neck, w ide carrying ang le of tl1e arms,

-
broad chest with widely ~eparated nipple
puberty by hormone rcp lecernent therapies,

oses ov~r fi rs and progeste.r
year.5
11,1ses. obstet, ,cs & Gvnaecology
-~ 107
egnanc'{ ne~ded then, by donor egg and sperm b
1f P( s v partner
fllplal'lation
rurner syndrome ('' Gonadal dysgenesis" ) monosomy Xo
11 ,s a ct,romosomal abnormality in which all or part of one of the

se~ chromosomes 1s • absent. A typical female has two x
chromosomes, but in Turner syndrome, one of those sex
thromosomes is missing or has other abnormalities. In some cases,
the chromosome is missing in some cells but not others, a condition
referred to as mosaicism or 'Turner mosaicism'
Incidence: Occurring ir«'.fo:w}r every 2500 girlsJ
Clinical features: Presentation may be in number of ways
• There are characterisllc physical abnormalities such as short

stature, swelling, broad chest, low hairline, low-set ears and
webbed neck . Poor breast development
• Lymphedema (swelling} of 1he hands and feet
• Gonadal dysfunction which results in amenorrhea (absence
of menstrual cycle) and sterility.
• Other problems including congenital heart disease,
bypothyroidism (reduced hormone secretion by the
thyroid), diabetes, vision problems, hearing concerns and
many autoimmune diseases may be present.
Diagnosis
• Ci<'aryotype.lor a !J)romoso.me analysis, is the 1est of cho,ce 10

diagnose Turner's syndrome.
OSPE for MBBS: Obstetncs & Gynaecot°l'I
• Turner syndrome may be diagnosed by a ~ s

during pregnancy.
• Sometimes, fetuses with Turner syndrome are identified by
abnormal ultrasound findings (i.e. heart defect, kidney
abnormality, cystic hygroma, ascites).
• Alt hough the recurrence risk is not increased, genetic
counseling is often recommended for families who have had
a pregnancy or child with Turner syndrome.
Treatment
As a chromosomal condition, there is no cure for Turn er syndrome.

However, much can be done lo minimize the symptoms. For
example:
• ( \irowth hormone) either alone or with a low dose of androgen,

will increase growth and probably final adult height.
• Estrogen replacement therapy to promote development of

secondary sexual characteristics. Est rogen in low doses over five
year and progesterone for two years
• Modern reproductive technologies have also been used to help

women with Turner syndrome to become pregnant if they
desire, for example, a donor egg can be used to develop an
embryo, which is carried by the T1Jrner syndrom e woman.
, ObStetrlcs & Gynaecology
Station a
ate's instructions •
.,ad the scenario ully and answer the questions asked ~y the
,.a111iner.
~ year old Mr~. . P6Al pr~sented in emergency with
36
complaint of heavy vagina l bleeding :after delivery of a male baby of
weisht 4 kg at home 2 hours back. On examination her pulse is
t20bprn, BP 80/SOmmHg ~r~ 98.6°F, and R/R 24/min. On
abdominal examination ter sis re laxed.
....(~,Jd
e,aminer's instructions .,.., v,P-'
___::..:::----
Please ask the fo llowing questions from the candidate.
Q.1. What is the most likely diagnosis?
Q.2 What winl be your immediate step?
Q.3. How will you further mange th is case?
@,vhat is the long term com plicat ions of such severe condition?
KEY:- 'f pf.I t}at ~ r//rr· ,f,Pj ·

0.5
i ,PPH due to uteriQC a~nv.
I .,. -
2· Call for help, initiate resuscitation, and check_air way,

start, 100% oxygen. Save 2 wide bore t/V lines, ta~
4
blood for CBC clottin rofile an matchin of 1.5
unit of blood.
0SPE for MBBS. Obstetncs & Gynaetoll&Y
uo
~a:Gtf!it1id\ once blood available s
3. l,, u enne m s
~ ) start
e, pelvic examination to n,1le ou any
retained products of cnnceorloc a□d 10 n•le au1 any
• al cause of bleedln
lo Ilk rvic I ar etc if no
RPOCs or tear than b1 a . '
,v-intravenous uterotonjcs •. Insert 800 mgs (4 Pessari es)
Misoprostol rect ally, PGF2 alpha injection
intramyomevially. If still bleed ing, hyctrostatic balloon
v<!Si~ inflated with 300-400ml water~
• ~
If still bleedmg shift to theatre do taaaratomy
uterine artery ligation, apply B lynch. If still blee rli ng----
internal Iliac • lip~linQ•···•-still bleeding -----
hysterectomy 2.5
~ Sheehan's syndrome./ . 0.5

:
Explanation
Definition eJ<cess blood los s. more than 500 I • h

a rPr rlPlivPry ; rief d . m wit m 24 hours
f 5 me as prlm-arv PPH.
Secondary PPH from 24 hou rs up t1ll

. 6 weeks postpartum.
Etialogy: common causes are
• Ulenne atony';;:,A • .,,

-~
• Rel.;;.ac.:.
i n:.:::e:::.
O..tP:'..:ro~d~U~C:!:;tS'...!O~f~ .
conception ✓
• Injury to genital tract ✓
• ~lotting di sorders ✓
• Uterine infccllon /
. obstetrics & Gynaecology
J1188S·
,. - , LU
ent ~.l.J.J.Lt~a.tlt~
_,,a,efll /.\ J.A...v.,t .,,,«-- o u
,..- u.,·l • . . , Lt lt'hC ti •
~ diate steps (i;J J,.t ~~~
,
call for help, initiate resuscitatio n and chec~,. air
.
way. Stan
1
oor. oxygen .
• save
- -z-w ide
- bo r e 1/V lines, take blood for CBC
__ .
, c10111ng and
cross mat ching of 4 unit of blood -
---··
, Star t 1/V fluid, once ~lood availa~le, start blood , ,
further ma nagement :
, ✓Pass folly's ca 111e1e1, ke_.:• p record of intake. an.d ..ouJpu t

1yowly, r~cord o r pulse , BP. temperature
• Start uterine ma,,a~c
• Pelvic exam in at ion to rule out any retained products of

conception and 10 ru le ou t any local cause of bleeding like
cervical tea r e t t, 1f no RPOCs or tear than bi manual
cornpre~~ion ol utC'ru~. 1ntfilvenm1s uterotonics
• Insert 800 rngs ('I PPssanes) M1soprostol rectally, PGF2

alpha in1ect1on 1111ramyo rnetria lly.
• If still bl eed ing . hydrostatic balloon vagina lly innated
W i l h ~t e r . /
• If ·11 d 10111 y ----uterine

st, bleeding shift to thea tre o 1aparo ..
. _ internal iliac
artery lig,i tion, B lynch if still bleeding--···
liga tion - ---st ill bleeding .. - hysterectornv .
• If ate the u1erus

retain ed product o f co nce puon, evacu
• homeostasis.
If any tear found st itch tl1e tea r and secure
OSPE for MBBS; Obstetrics & Gynaecolor,
112
plasma,
• If clotting disorder ----give fresh frozen
cryoprecipitate, and rarely platelets.
Lon term com lication of PPH Is Sheehan's s ndrorne in which

s_upply to the pituitary glaod is cornpcocnised due to massive
ti,aemorrhage leading to cteficieocv of anterior pituitary gland
hormone~
--
•
s:obstetrics & Gynaecology
Station g
!date's instructions
cacefullv observe the photograph and answer the following
questions.
1. What is the condition that baby is suffering from? C:,Chi"~

2 Is this abno rmality associat ed w ith other abnormalities?
3. What is its management? ,:rll.W->' (

~ffe-\r
4. What is its prognosis? ?
KEY:-
1\Gastroschisis\ in which part of the anterior abdominal

wall is deficient and bab!es are born ,,vitb intestines and
sometimes other abdomina l o rga ns appearing on the
1.5
outside of the body.
2 The, defect Is oat 11,JJ.a.t.ly associated with Oth er

o.s
maJfprl'lations.
OSPE for MBBS: Obstetrics & Gvnaeco1oa,,
114 . nt option. The
·Immed.Ia t e
1 h main treatme
3.\ SJJnrery 15 t e ting heat loss by wrapping
manage,neo
1involves p.-even
.
-
film and general intensive care
osed gut in Cling -
the eKp . carried out 1n a11 emergef1£Y
support. Surgery is
4
.
Prognosis •s goo ,v
d (o;rdure rate after neonata l surgery. 1
Explanation:
,sIs
Gastrosch1 . 1s
• a me d'cal1 condition wh ere part. o f. the
. . anterior
.
abdominal wa 11 ·Is deficient and baby is born w it h intestin es and
•
sometimes other abdomin al organs appearing on t he outside of the
body.
Incidence: aboutfl in every 2000 birt hs)
cause: This happens beca use of a congenital defect in the

abdominal wall and the peritoneal covering over t he in test ines
w hich are thought to occur because part o f the abdominal wa ll did
not close correctly. The size of the actual hole w ill often be very
small, but due to the fact that t he Gas troschisis occurs in the
begi nning weeks of gestation, t he organ s often grow on the outside
as opposed to the inside of the body.
Diagnosis: Gastroschisis is diagnosed by ultrasou nds as early as 14

weeks of pregnancy. -
Management
As soon as the baby is born the intest ine . .

' s are covered w it h sterile
gauze or wrapping to avoid heat loss and th b b .
, emergency to repair th G e a y .Is eventu a11v
taken to sureery ,n
e ast rosch1 sls.
Repairing Gastroschisis involves pushin th
,
abdom,nal •
cavity of the body and repa· .I?. eh organs
, back in to the
iring t e perit oneal defec t, as
<eSflE for MBBS: Obstetrics & Gvnatcoloiw
us
well as closing t he hole in the abdo . 1
mona wall. During the ·
repair of the Gastroschlsis, the doctors h . . surgical
may ave difficulty repl •
the organs into the abdominal cavity. acing
When the intestines are formed on the out 'd f

. , s, e o the stomach
cavity, they are in contact With the amniotic fluid for the duration of
the gestational period. lntestin~I contact with Lhe amniotic fluid can
cause serious flaws in the growth patterns of the inte.stine or a
thickening of ,the intestin~. The longer the intestine ,s in contact
with the. amniotic fluid, the worse the permanent damage may
become.
Many obstetricians choose to plan a C-Section in cases where the

Gastroschisis has been noted via ultrasound; though there is no
clear proof il makes a significant difference in outcome. Cesarean
sections are often done to t ime the surgica l repair.
-
Post surgery: After surgery, the NG tube used to keep the stomach
and the bowel empty_ will ,:.e.lJlain i.l} place until the baby exhibits full
bowel function. The majority of the Gastroschisis cases are
corrected with surgery without any further complicatio.;-; alsociated
-with the condition.
Prognosis is good, 90% cure rate after neonatal surgery.
OSPE for MBBS: Obstetrics & Gynaecolol'I
116
Station lO
Observed c,'W1
A 36 year old, g_@Jla..QLu.iliPa(a, presented In emergency w it h history
'-/49 rnoc.tb.ge.sta,tl9n with l@bour pa ins for~ours. On exa mination
her fundal h e i g h t ~ ~ithfObliq~e lie, h~.lQ~ in the right
ili~_i:. a, nd bree .h lie in the left hypocho ndrium. FHS 152b-;;.,_
On pelvic examina tion cervix ~ and 50% effaced.
8 What is the diagnosis? t

2. How will you manage t he case ?
KEY:-
i .G~:;j;,:;-
er;:-::r;::e::
se~n:::t~a:: - -.J's_e_li_e_/_o_b_l_iJ,...-~
ti-o-n-/;T::-r-a-n-sv
1
2. Management
4
• ~ e nt .
~xplain the situation to the patient .

(leeds delivery by caesa . and relat ives t hat she
rean section.
• T~tt ·inf on:ned consent

v '
• Prepa e her for caesa
• rean section · f
pediatrician, save J/V I" in orm anesthetist
ine draw blood f . •
matching and arrangement of blood. or investigation, cross
Explanation
Shoulder presentation occur .1n 1:300 d . ,

e11venes
Shoulder presentation o .
of the f CC1Jrs as a resu lt of tr
etus and Ca1Jses of this abno I' ansverse or oblique lie
rma I ty lncl ude.
MBBS: Obstetric. & Gvoa~(Clcgy
u,
-
d mu_!!parity, placenta
~rmality and contracted pelvi:;.
praevia, pel)I.Jf·, U1,mors, uterine
<?
\JSUilllV the condition diagnosed 111 antenatal period and patient

admitted for observation.
eomplications of shoulder presentation are
1, Cord prolapse ✓
2. Arm prolapse /
3 Obstructed labour Y
4. In negle cted cases may lead to uterine ruptu,e
118 OSPE for MBBS. Ob~tetrics.& Gynaecology
Unobserved Station 11
Answer the following questions
Total marks s
Q. 1. What is this diagram showing?
Q. 2. What is the indications fo r the use of this instrument? Te ll any

four.
Q. 3. What is the prerequisites for its use? Tell any fo ur. '
KEY:-
1. Forceps delivery_ /
1
2. fndications
2
1. Delay in the second stage of Labour . /
2. Feta l distress in the second stage of labour ✓

~
3. Maternal conditions requiring the short second stage of

labm1c ✓
fol M98S: Obstev,c~ & Gynaecology 119
r FJ¥! presentation ./ I
/ sleeding from fetal blood sampling site..,.-
r After com ing head of the breech✓
;(. Oelive'.Y befori(9 weeks of gestati®
2
. prerequisite
3
1. Full dilation of the cervix
2. Fetal membranes should be. ruptured
3. Pcesentation vertex, face or afte r comi ng head of the

breech
4. Position of the presenting part should be known
5. Head should be engaged at zero station or below
6. Cephlopelvic disproportion should be ruled out
7. Bladd er should be emptied
Explanation
U V- PMl"'(I 1,c_
PMtl
-c:. ,,,..
f ,Pa ,11v ~
•
I
Introduction
• Incidence of instrumental delivery varies from 1,5%-2.6%.

,,
• Forceps consists of•two blades with shanks, joined together at a
~ with\lj.andle~ to provide traction.
Types of forceps
Currently 3 types of forceps are in use
QSPE for M88S: Obstetrics &
outlet forceps: Short in length,
below station, with sagittal suture

head at +2 or
. r diarnete r
anteroposterio
Larger in length, used to deliver h"'l

2.
iero or -t 1 station
Mrilldl# for(el>f :Pta tiona l forceps: Ca n be applied ..

3, __,,... .,
malrotated, m idcavity head, needs expertise r ot comlllOrfr
use now.
Indications for use
• Delay in the seco nd stage of Labour
•
-
Fetal distress in t he second stage o f labour
• Maternal conditions requiring the short second st!S~
•
-
labour
Face presentation
• Bleedin~ from fe ta l blood sampling site
• After coming head of the breech
• Delivery
- befo re,., .
.,,. weeks of gestation
Prerequisite for use
• Full dilation of the ce rvix
• Fetal membr
anes should be ruptured
MBBS! Obstetrics & Gynaecology 121
• Presentation: vertex, face or after coming head of the

breech
• Position of the presenting part should be known
• Head should be engaged at zero station or below
• Cephlopelvic disproportion should be ru led out
• Bladder should be emptied
Technique
• Asses ma ternal and fetal condit ion
• Fulfill all pre requ isite
• Take informed conserH
• Apply forceps in lit~otomy (commonly used), supine or left

lateral position
• Give good analgesia preferably epidural
• Clean the vulva and perinec m and drap the patoent with
sterile towels
• Check the forceps by assembling in front of the patient

vulva with pelvic curve upward
• AJJply the forceps to the fetal head, first introduce left blade
""
in the vagina and then Introduce right blade and lock the
both blades
• Now apply tne traction intermittently synchronous wlth

uterine contraction. the direction of traclion is along the
OSPE tor M88S. Ob~letrlcs & GynaecolC)tv
122
axis of birth canal i.e. first downward and than in the
upward direction
.. . • n when the head is distending the
• Ep1s1otomy 1s give
•
perineum and b'par·,etal
1 diameter is at the level of ischeal
spines. Once head deliver remove the forceps and allow the
rest of the baby to deliver in usual way.
Complications
Maternal complications
L Trauma
• lower genital tract traum a: to pe rineum, vagina, exte nsion

of the episiotomy and 3•• or 4 1" degree perinea! tears
• Upper genital tract trauma to t he cervix or lowe r seg ment

uterine tear
• Urinary tracr tra uma to the bladder or urethra mo re with

kielland's forceps
2. Haemorrhage: due to maternal tissu e injury

'
3. Infection may occur following repeated vagi nal exam ination
and tissue injury
Fetal complications
1. Skull fracture
2. lntrac ranial ha emorrhage and trauma
3. Cephalhaematoma
or,£ for MBBS; Obstetrics & Gyna~cology
123
ur,observed Station<!i)
caooidate's instructions
See the photograph carefully and answer the following questions
Q. 1. What is t he diagnosis?
Q. 2. How the patient can present with suet'! problem?
Q. 3. How you wi ll make the d1agno sis7
Q. 4. H9w you will treat t he condi tion?
KEY:-
L \.-'tervical polyp \✓
_ '-
0.5
2
2. Patient may present as
• Asymptomatic_
'
l ntermenstrual bleeding,
[: Ab rm
II
heav menstrual bleedin
Post-menopausal blee.ding,1
• gost soiral bleeding. _f ~
mel)orrhagia)
Jhick white vaginal d1scharpe (leukprrboea) .

•
OSPE for MBB~ . Obstetrics & Gyo-01ocy
124
3. Diagnosis is by l
• SpeJ.ulum examinat ion
• CelJLical polyp biopsy
4 Treatme nt 1.S
• Surgica l re_moval bY ovum forceps or by evulsion o!l_he

polyp
Explanation
Introduction
A cervical polyp is a common benign polyp or tumour on the

surface of the cervica l canal They can cause irregular menstrual
bleeding but often show no symptoms.
\~a~
0 Is uncertain, but they are often associate d with
inflammation of the cervix. <~
• May also occur as a result o~ v e l s of~ogen or
clo~ed cervica I blood vessels
• Mos common in women w ho have had children and
penmenopausal women .
• Rar ~strual and post -menopausal women .
Structure
Cervical polyps are finger-like growths, generally less t han l cm 111

diameter, bright red in colour, with a spongy texture . They may be
attached to the cervix by a stalk (pedunculated) and occasionally
prolapse into the vagina where they can be mistaken for
endometrial polyps or submucosal fibroid.
for MBBS, Obstetrics & Gynaecology
12S
ptoms
• May be asymptomatic
• lntermenstrual bleeding
• Abnormally heavy menstrual bleeding (menorrhagia)
1 Vaginal bleeding in post-menopausal women
• Post coita l bleeding
• Thick white vaginal discharge (leukorrhoea)
Diagnosis
• On speculum Examination: red or purple projections

protruding from the ce rvica l canal.
• Confirmation on cervica l biopsy which will reveal the nature
of the cells present.
Treatment: Surgical removal by
• Ring fo rceps
• May be removed by tying surgical stri ng around the polyp
and cutting it off. The remaining base of the polyp can then
be removed using a laser or by ca uterization
• If the polyp is infect ed, an antibiotic may be prescribed.
Prognosis
• (99~b-f cervical polyps are benign _

• 1% will ilt some point show neoplastic change.
• Cervical polyps are unlikely to regrow.
OSP£ for MBBS: Obsterrrcs & Gynaecotaa,,
126
Unobserved
see the diagram and answer the following questions
Q. 1. What is the condition shown In the figure ?
Q. 2. What is its etiological facto rs? Give 4.
Q. 3. What is the treatment opti ons fo r this conditio n?
KEY:-
Ans 1. Uterovaginal prot~pse 0.5
Ans 2. Aetiological factors are 2
• M e,!lo~ause, Birth in jury
I 0
Peripheral nerve injury e.g. Pudenda! nerve
• • Prolong 2"" st a6e of labp11r and excessive bearing down

during delivery before full dilatation of the cervix -
i • l ntpuse extraction.before the cervix fully dilatefl
for MBBS: Obstetncs & Gynaecology 127
pelivery of big bab¥

~ ~plit pelvis support
• Co ngeni tal pro lapse

1
, • Rai~ed intra abdomina l pressure due t o chronic bronchitis,

large abdo minal t um ors, smoking, ch ronic co ugh and
--
co nstipation are fhe predisposing fact ors
• Abdomino perinea! excision at the cect11ro and radical

vulvectomy may lea d to pro lapsed post operat ively
Q. 3. Treatme nt options are 2.5
I. Conserva t ive
• Perinea! floor exercises✓
• Pessary treatment v
2. Surgical
• V~ginal hysterectomy w ith pe lvic floor repair
• Fothergill;s repair (Mancheste r operation)

.. ~
• Sacrohysteropexy
• Lefort's repair {:!, LJ w "JJ(f/,N'JJ

Explanation ,
Prolapse is mainly the problem or old age woma n. There may be the
descent of either the vaginal walls or uterus. Incidence ls variable.
IIUlliparous prolapse is seen In 2% and vau lt prolapse in 0,3%
lotlowing hysterectomy.
OSPE for MBBS Obstetrics & GYflff<Oloav
The mQst important aetiological factor In prolapse is atoniclty and

asthenla tllat follows menopause. Child birth may also lead to minor
degree of prolapse, can be overcome by regular pelvic floor
exercises, by increasing muscle tone other factors are as above in
answer key.
Classification of the prolapse
Anterior vaginal wall

Upper two third - Cystocele
Lower one thlrd--urethrocele

} Cysto ureth rocele
Posterior vaginal wall

Upper one third - Enteroceie (pouch of douglas hernia
Lower two th ird --Rectoce le
Uterine descent
1" degree - descent of the ce rvix into the vagina
2nd degree - descent of the ce rvix up to t hP. introitus
3rd degree - descent of the cervix outside th e introitus
Procidenti a - The entire uterus outside the introitus
Complkations of the prolapse are

1 l Decubitus ulcerldue to congest ion and circulatQry changes in
the dependent part of th e prolapse leading to ischemia and
ulceration
2 ~Kera [nizatpij) and @gmentatioj)) due to friction and
congestion in prolapse part
3 llflongatron of the cervjx\when the supravagina l portion of the
cervix well sup.ported by Mackenrodt ligament but the vaginal
portion of the cervix is prolepses w ith the vagina, the
supravaginal portion gets stretched and elongated.
4 Urinary tract obstruction
5 Incarceration of prolapse( rare )
for MBBS: Obstetrics & Gynaecology
119
oi,ucal features
•i som.e_!hlng CQ.,.ming out_ ~f vagina, perinea! heaviness,
bearing down feeling
+.
• ---
Backache, midsacral discomfort
-
Some vagina!_discharge
~·• - Micturatioo__cii s_turbances

~
Recta l symptoms{(are)
• Coita l difficulties w ith Procide ntia
prophylaxis
• Antenatal physiot herapy and postnatal pe lvic floor exercises
a_nd early postnatal ambu lation
• Proper management ot2"" s1age;of labou r
• Avoid traumatic birth delivery and ca reful instrumental
delivery
• Avoiding multiparlty ,and proper birth sp~t:ing
•
- HRT in menopausal women ca n avoid or delay occu rrence
of prolapse
Treatment
1 Conservative
• Perinea! floor exercises

• Pessary treatment: -is a t emporary treatment, need to be
change every 3 month, can cause vaginititis and prolong
use may cause ulceration.
2 Indications for use of pessary are
• A young w oman planning a pregnancy

During early pregnancy
I
____._ Et_u_e_toerium,____________________.
Temporary use while clearing infection and Decubitus

•
ulcer
• A woman unfit for surgery
• A women refuses for surgery
3. Surgical treatment
Relieve symptoms, rest ore anatomy & restore sexual

dysfunctions
Options are
• Anterior colporrhaphy ./
• Posterior colporrh aphy and colpoperineorrhap(y°
• Vaginal hysterectomy w ith pelvic floor repair
• Fothergill;s repair (~c;1nchester operation)
• Sacrohysterope xy ·
• Lefort' s. repair
'''
"''' Station 14
Q. A 40 year old male has presented to you in family pl;innfng

clinic. He has heard about vasectomy. He wants to know about the
procedure. How will you counsel him?
KfY:-
Explanalion of procedure, advantages and complications

Vaf\_ectnmv involves the division of Vas deferr □ s on each
side to prevent the release of sperm du11ng e1~c:ulat ion o .5
ll is te(hnically an ea:;;er more straight forward and gukker
-
procedure and is usually performed under local anesthesia .
Following vasectomy he st ill needs to use addition

contraceptive me thod as sperm continue to release after 3
months . So he should have semen analysis at 12 weeks and
then at 16 weeks to check for the presence of the sperm _ If
two consecutive samples are fr~e of sperm then the
vasectomy can be considered complete 1.5
Complicat,ons:
'
• l"lrnediMe wound infection, bleeding and hemato~a,
• (Sg_errn granulornas/a sma ll lumps at the cut ends of the vas asa
result of mfla rn matorv response, may need surgical exc1slo,n
• AQ\i•sperm ao11bintics .
132 OSPE for MBBS. Obstet rics & Gvnaeco 1oay
Explanation
Vasectomy is a minor surgical procedure; Involve the division of the

vasa deferentia on each side, to prevent sperm from entering the
seminal stream (~~te).
Effectiveness: Failure rate of about 1 ,n 2000
Procedure
Usually done in an ol!!J.latienr se!ti.og, a traditiona l vasectomy

involves numbing (local anesthetic) of the scrotum after which 1 (or
2) small incisions are made, allo~ing a surgeon to gain access to the
vas deferens. Th e " tubes" are cu t and sealed by tying, stitching,
cauterization (burning). pr otherw ise cla mped to prevent sperm
from entering th e seminal stream.Vasect omy can be done either
surgically or by percutaneous injection of sclerosing agen ts or
occlusive substance such as silicone
Procedure:
• The entire procedure usually takes about 20-30 minute s.
• Change gown and lie down patient on the examination table.

The incision site will be washed, shaved, and sterilized, usually
with an iodine solution. Steri le drapes will be placed to guard
against infection.
• Afte r a local anesthetic is administ ered, a small opening is

made in the scrotum. Either the right or left vas deferens is
li fted through this opening. The vas is cut, and a section may
be removed .
• The two ends of the vas are cauterized (heat sealed), tied, or
clipped
• The opposite vas deferens 1s then lifted through the opening

for the same procedure
(Qr. MSBS: Obstetrics & Gynaecology
133
The remaining open ing can heal with closure by stitches or

naturally without stitches.
operative care
• Little recovery time
• Apply 2n ice pack to the scrotum for the first 24 hours after
the p r ocedure .✓
• Avoid heavy lifting or exercise for at least 1 week. Return to

work within]__days unless the job involves physical exertion .
- --
• Wait at least a w ee k before resum ing sexual act ivity.
• Following vasectomy still needs to use additio n
contra ceptive method as sperm co ntinue to release after 3
month s. So patien t should have se men ana lysis at 12 weeks
and then at 16 weeks to check for the presence of the
sperm . If two consecutive sam ples are free of sperm then
the vasectomy can be considered co mpl ete
Complications:
Short-term complications include :
• Temporary bruising/ bleeding, leading to hematoma .
Irritation in stitches applied over incision. This can be

•
min im ized by covering them wit h st icking plaste rs.
• Post-Va sectomy Pain Syndrome .
Some earlier st udies suggested that vasecto my may be

•
associated with an in creased risk of heart disease and
prostate ca ncer. Acco rding to t he Nati onal Institutes of
Health t he risk o f hea rt disease and prostate cancer 1s not
J
in creased amo ng vasectomize d men.
• No pro tect ion agai nst STD
OSPE- for MBBS< Obstetrtcs & Gynaecology
Long term complications:

Within one year after a vasectomy, 60 to 70% men develop
ant1sperm antibodies.
• The entry of the sperm into the scrot um causes sperm
granulomas to be formed
Reversal
• Tliere is a procedure to reverse vasectomies using
vasovasostomy. Vasovasostomy is effective at achieving
pregnancy in only 50%-70% of the cases, and it is costly, the
rate of pregnancy depends on such factors as the method
used for the vasectomy a nd the length of time tha t has
passed since the vasectomy was performed .
• Since the body often produces antibod ies against sperm, so
sperm counts are rarely a t pre-vasectomy levels.
tor MBB~ Clb~leHrc$ & Gynae OOQgy
I
135
unobserved Statio@
f. Gs Pl + 1 presented w ith H/0 of 16 w k

bleeding vaginally, since one d - ee s amenorrhea and
ay. Her USG showed following
appearances.
Q. l. What 1s the d,agnos,s,
Q. 2. What is the signs and S'(mptoms for such condi tion?

•
Q. 3. Describe its types?
KEY:-
0.5
1 Hydatidiform mole
2 Excessive oause'a and vomitin bleedin va inall w'th

passage of vesicle's. Uterus large fo r dates and soft
d~ghy In nature No fetus pal pable or no fetal h.e~
2
sound audi~, very hi h BHCG for estati n e
3• TVPes are 2.5

Cqn,gl
-1t P. mole ~
1 !'lo identifiable embryonic: or fetaLlli~..n.uvJgence of feta l
vessels .
OSPE for M8BS Obstetr1tJ & G
\11111>; 1
13& I s . f ·1·
t egg with no nuc eu __11 w 1IZec:f by
~
ii,
2. Arise when an ei~o~mal sperm; tofa l hydatidiform ~ne(o,
occasional't.JWO of tro hoblastic cells · f'\,,J
1
3. Marked rohferat otnl aternall derived) ~
e· a
4. Karv......_
'<'"d from haploid 23X sperm
• oenve . • 5- cbtcroosames w1'tho u t ce II d'1v1s1on
··
• Sperm dupI1ca.e
5 Higher risk ro·r malignant change
,:.,<'1efl~~~
Partial mole: t, .;>0,-(::;..J
~.!
~
. d with non-viable fetus o r vessels only 71 ~C'
1. Associate ,:::::::....:::=:,,~:...;...--;~_ - - /
Moderate \rophoblastic proliferation /'
2._ A normal egg is fertilized by two Ior occasionally three]
3
spermatozoa,
4. Karyotype :(TI1nlojdf{69XXX o r 69XXY)
5. Malignant change less likely t han in co mplete mo.I:;', J
Explanation .J-~- :yJft
~✓f Ji-;"\1 ~
Molar pregnancy is an abnormal form c f preg nancy. wherein a non·
viable, fertilized egg implants in the uterus. It is characterized by the
presence of a hydatidif.orm m ole
Epidemiology: Incidence
•
0 N~rth America and Europe: 1:1000 to 1:1500 pregnancies

0 A5,a and Latin Ame rica: 1:400 to 1:200 pregnancies
Etiology: Not completely understood .

.
Potential risk factors may Include
1 lB OSPE tor MBSS Ob)ltlrlCS & Gynat<olog,
Clinical presentation
ty,olar oregnandes !)Svally presed wi lh
1 Painless vaginal hleedine dupng pregnancy in 3rd-4th

•=
mont'l
2. Hyperemes1s Grav,darurr ✓
3. Passage of gra pellke villi from the uteru~ v
4. •_Abdominal Pain ear)y IQ pre11na ,1cv ✓
5. Pallor or dyspne~ ✓ • •
6. "!Yperthyro1dism,v
7 lnc,ea·sed hum~n chorion1c gonadot ropin level V
•
Signs:
1 Vterus larger than experted for gestational age

~2 - ,fetus ahseni-
.l, 3 Fetal Hean Tones abse'l!
--
•
b4 Absent [eta! pacts ,
s ' i;ivarlan enlargement (theca lureal cysts In 10%)
6 ~ ypertension ear•v ,n pregnancy
Complications:
1. Malignant transformation 10 Chnriocarciooroa ia. l0R20o/o

• locally Invasive Mole ~
• 1estat1onal
L
ChonocacriooroaJ33%
2. .,t1vperthyroidism •
3. Pregi:1ancy Induced Hj!Pl\@.:cOWi.
•
Diagnosis:
MBBS Obstetrics & Gynaecology
139
ernbJes a bunch of grapes (" 1
~ b d ,, ,. c uster of grapes" or
nevcom e uterus or ~now-s_torm,").
~
High levels of hCG, also helpful InfOIIow Up of GTO
•
2. ,...X ray chest to see presence of lung me tastas1s
. ,
3. ,. CT Head and Abdomen •
•
4. Other tests
a. Complete Blood Count
'- To rule out anemia
ii. Platelets
b. Liver Functio n Testing
c. Thyro id Function Testing
1. Thyroid Stimulating Hormone
ii. Free T4
,
Treatment
l. Hydatidiform moles should be treated by e1Lacuatjng l he •

uterus by u terine sucLton or by surgical norerrage 1s soon as
possible after djagnosjs
2. Chemotherapy lndicatioos aftec O&C if
1. Quanti tative BhCG persistently elevatJ?d
2. Persistent uterine bleeding
3 . Evidence of trof)hoblastic metastasis
I. tBrainJ-
11. Lunss /
3. ~l~
n.!o!lr~d~er_r_!to2Ja!.:!VtfO!,!!idL J~.l'..is~~Lll'.:~~~::-:~~ts are
followed up until their serum human chorionic
(hC:G) level bas fallen ra an 11odetectahle
gonadotro9.hln
• level,_
O~Pr for M88~ Obste111c, & G osPE tor MBBS: Obs1,1 ..c,
YOiP\Oi1,61
!40
4, I
nvasive or metaitatic moles ca ncer
,/_
ma re u11e .
chemotherapy_ and 2ften r;spond well to melhotreMte. The
response , 0 1reatmen1 is neaclv 100%. :::;-.
7
S. •PP!at~ie~n!t~s~a~re~ a~d~vi~se~d~ n~o~L~t~o~c~o~n~c~eiv~e_f~o~r~o~n~e~ve~a
- !!..!"
lhe• chances of having another-.
a,,er a
_,m~o:'.:l~ar:_J:;:re:Jg:.:.n:::a::.:ncy.
· molar
Rregnancy are approximately 1%.
• .
Management Is more complkated when the mote occurs to@ethei
w,th one or mo(e norm~I fetuses. -
•
Prognosis
More than \so%}.if hydat1d1form moles are be1.11gn, The ou:come

after treatment is usually excellem Close lollow-up is essenuai
Highly effective means of contraception are' recommended to aV<>rd
pregnancy for at least 6 to 12 mo 11th;.✓
! ecurrPQC<' rate lo ft 1t11re pregnancies is@
•
• Ses.
• •
.•
osPE for MBBS: Obstetlics & Gynaecology 1~3
carefully see the pho tographs and answer the following questions
Q. 1. What" Lhc d,agnos,s ?
Q. 2. Wha t fs the etiology of this condition?
Q. 3. What is the mode of delivery?
Q_ 4. Can it happen in next pregnancy?
KEY:-
1. Hydrocephalus. 1
2. Congenital causes. in{#ctiao< and folic acid

deficiency. 1
3. Oeoending upon de.cree of hydrroc.eohah1s 11 ":>u ld
be ~ormal vaginal delivery (NVO),alter araiAoge-of
cerebrospfnai fluid or it rould be tower sogi>\ent
caesarean section. L SC S• 2
4 . Yes. Rec1,1rrence rj<~ 1s present 1
144 OSPE for M88S Obste trics & Gynaecology
Explanation
Hydrocephalus: is an abnormal accumulation of cerebros

pina l fluid
(CSF) in the ventricles, or cavities, of the brain . This
may cause
increased intracranial pressure inside the skull and
progressive
enlargem ent of the head , convulsion and men tal
disability .
Hydrocephalus can also cause death .
~
Epidemio logy : effects one in ever 500 live bi rth~
1
Etiology: The causes of hydrocephalus are still not well

understood. Hydrocep halus may resul t from inhe rited ge netic
abnormali ties (~ue d u~ stenosis) or deve lopm enta l diso rder s
(neural tube defe cts including fspina 61t1da{ and encephal
oce le).
Other poss1tile causes include complications of prem ature
birth such
as ~av entricular _ hemorrhage, diseases such as men
ingit is,
tumors, traumatic head in1ury or subarachnoid hem orrha
--= 1 ge, whic h
block the exit of CSF from the ventricles to the cisterns or
elim inate
the passage of CSF into the cisterns.
Patho logy
Hydrocephalus is usua lly due to blockage of ce rebrospin

al fluid
(CSF) outfl ow in the ventricles or in the subarachnoid spac
e over th e
brain. Alternatively, the condition may resu lt
from an
overproduction of the CSF fluid, from a congenita l ma
lform ation
blocking normal drainage of the fluid, or from complicat ions
of head
inJuries or infections . The elevated intracranial pressure
may cause
com pression of the brain, leadi ng to brain damage
and othe r
complications.
Symptoms: Symptoms of increased intracran,·a1

pressure may
include he~ hes , vo'!l],ting, nausea, pa@!edema, sleep
-
iness, or
PE for MBBS: Obstetrics & Gynaecology 145
coma, Elevated intracranial pressure may result cerebellar tonsil

herniation, w ith resulting life threatening brain stem com pression.
Diagnosis: Hydrocephalus is diagnosed through clinical neurologica l

evaluation and by using crania l imaging techniques such as
ultrasonography, computed tomography (CT), magnetic resonance
imaging (MRI), or pressure -monitoring techniques
Mod e of delivery Depend_ing upon degree of hydrocephalus. It

could be normal vaginal delivery (NVD). NVD after drainage of
cerebrospinal fluid or 1t could be lower segment caesarean section.
Treatment: Hydrocephalus trea tment is (iurg1c~ It involves the

placement of a ventricu lar catheter (a tube made of silastic), into
the ce rebral ventricles to bypass the flow obstruction /
malfunctioning arachnoidal granulations and drain tbe excess fluid
into other body caviti es, from whe re it can be reabsorbed.
Shunt complications: include shunt rnalfunctio n, shunt failure and
shunt infection.
Prognosis; is difficult to predict. Success of treatment with shunts

varies from person to person.
Recurrence risk is present
,
•
,
••
OSPE for MBBS.: Obstetrics & Gynaecology
146
Station 2
Observed
--
A P4 present ed to you in the OPD with report of ~smear showing
-
CIN II. How will you counse1b.e.r:?
-
KEY:-
1. Introduction 1
• Eye to eye contact
• f'!on -medical jargon/
2. Clli, 11 is a pre-malignant condi t ion of ce rvix. The risk

of conversion of CIN II to invasive d isease is not
clearly deflned 1
3. [ C,olposcopy }s needed for further diagnosis of

1
abnormality found. 1
""'
4. Tr..e_atment options are: 2
• Fle&-isiona l technique or
• Destroying t he abnorma l epithelium to a depth of S

mm (ablative techn ique)
Excisional Techniq ues
• LLETZ / ~
Knife cone biop~ .._/ .
• Carbon dioxide laser ✓ .
E for M8 85 Ob<reu,cs & Gyna~colog
v 147
Ablative Techniques
• Cry oth era py
• Lase r vaporization
E11.planation
n cance r affecting wo me n
• Cervical can cer is the mos1 commo
aft er breast cance r
r 90% of cervical cancer
• Pap / papan,colaou smear det ect ove
cases
n aged 20·64 at s year or
• Screening is recommended m woma
at some pla ces 3 year inte rval
(IN has a long natural his
tory, therefore suitable for
•
to develop cancer e n if
screening; it wil l take several years
it ,s CIN Ill Prospective data sug
gests tha t at least 6~ of
p invasive cancer, if left
wo me n w,t h CIN Ill would develo
n wil h min or cytological
unt rea ted Mo re than 409' of wome
mal wit ho ut tre atm en t
abn orm alit ies w,11 rev ert 10 nor
16-47 tomes Increased
Ho we ver maid dyskaryos,s have a
red wit h the genera l
incidence of invasive disease cornpa
pop ula tion .
Cervical lnt rae pit hcl ial Neoplasia

) Is a pre malignant con dh ,on
Cervical intraep,thehal neoplasia (CIN
oth er cerv,cal examinations,
Iha! Is detectable by Pap smears and
ls ,n the hning of the cervix.
CIN 15 the gro wth of abnormal cel
the potential to progress l o
Though CIN it ,s no t cancerous, it has
tln cl'r if lef t unt rea ted.
CIN
There are three stages (or grades) of
ls are confined to
lld dysplasla): rhe undofferent,ated cel
flP,i,i )lm
lh, lower one th, rd of the epo thehum
148 OSPE for MBBS; Obstetrics & Gynaecology
g:1N II lmoderate dysplasia): Undifferentiated ce lls occu py the lower

50-75% of the epft helial thickness.
CIN 111 (sever dysplasla and carcinoma insitu): the entire thickness
of the epithelium is replaced by abnorma l cells,
Sign/Symptoms and causes
The premallgnant lesions cause no symptoms and are not
recegnizable with the na ked eye , common among women who are
sexually active, multiple partners, and earlier age of onset of
Intercourse and who acquired HPV infection .
Diagnosis by
• (Pap smear) if any abnormality detected than furt her testing
' colposcopy
by
• Indication for colposco py re ferra l are
-
Bo rderline Cellular appear ance Repea t smear in/6-12 I
changes that can not be months, refer for
described as normal col posco py if any
- -
Mild dyskaryosis
t--
Cellular appearance
abno rmality persists
Refer for co lposcopy
cons1stent with
underlying CIN II
Sever dyska ryosis Cellular appearance ~efer for colposcopy
consist ent witti
immediately
underlying CINIII
Suspicious of Possibility of invasive
Refer for colposcopy
invasive CA cane.er
---
Glandula r
Neoplasia
Cellular appea rance
immediate ly
Refer for(colposcopi)
--
suggests an
and Gynaecological
abnormality ln the
assessment
endocerv1c211cana l or
l endometrium
J
Treatment
cervical lesio ns are treat ed depending on the degree of seve rity.
High grade lesion CIN 2 and 3 lesions are usually surgically removed
however t here is debate about low grade CINl , whether or not or
wtien to be t rea ted as propo rtion will resolve spontane,Q_usly.
..
Options are
• Excisional techniques (removal of abnormal tissue)
• Ablat ive techniques (destruction of abnorma l tissue)
Removing t he entire t ransforma tion zone has the advantage of
allowing a large specimen to be examined. Destroying t he
transformation zone does not allow this, so it is mandatory to
establish the diagnosis by taking a sma ll biopsy before treatme nt
(, ervica l gland ca n go as fa r as S mm into the stroma of the cervix,
therefore t reatmen t must be directed to a depth of S mm) the
success o f treatment is usually defined as negative cyt ology 6
, · roonths-fo llowing intervention.
Ablative techniq ues

Excisional Techniques
Radical electro diat hermy:
tlE]Z: removal of TZ using ar\ electro
burning the TZ ,requires general
diaili'ermy loop ,requlres general
anesthesia
anesthesia
Cold coagulation: destroying TZ
laser cone: removal of TZ using
by applying probe heated 10 100
laser, requires local/general
120 ' ,requires local anesthesia
anesthesia
l aser · vapori2mg the tissue,
Hysterectomy: sui table i~women
requires local/general anesthes,a
has asso ciated other gynaecologtcal
problems
OSPE lor MBBS Obstetrics & Gynaecology
150
Station 3
Unobserved
Identify the instrument and answer the foll owing questions.
Q. 1. What is the mstrument shown in above photograph'
Q, 2 What is the types of this instrument and in wh ich sizes these

are available?
2.
Q. 3. How much pressure is needed for its app lica tion' o -1 /.ff(c,.. .
Q. 4. It applied at what part o.r the feta l body? r;J~
Q. 5. What is its complications' . b-o}

J,<:J._7
KEV:-
@vacuum Extractor cup J./ ¥:~ 0.5

2. ~Jali,c cups and soft cups)
0& 1.0
1. Metal cu p available in 30, 40, SO. and G ~izes.
2. SQf! cup, these are Silastic cups, Sile cup and CMI cup
commonly available in 6c:t,m1
3 The pressu re is taken up to_O.Skg/cm' \ o.S
4. Applied to the fe tal head ma,inly midli".. e over -h .

t e occopul 0·5
OSPE for MBBS: OIJstetncs & Gynaecology 1S1
s. Complications. 2.5
• Tra uma to the genital tract
• Injury to the cervix
• Chignon
• Cepha lhaematoma(Sub peritoneal bleed)
• lntracran ial haemorrhage
• Retinal hemorrhage to the baby and jaundice
Explanation
Ventouse is a vacuum device used to assist the delivery of

a baby when labour has not progressed adequately. It is an
alternative to a forceps delivery and caesarean section
Indications for use of vacuum extractor
There are three generally accepted indications to use a ventouse to

aid delivery:
.,.
• Delay in second stage of labour
• Fetal distress in second stage ✓
• Maternal condition requiring shortening the second stage
Types of Vacuum Extractors
There are two types of vacuum cup metal and soft cups .
•
More recently, bell-shapeil and hemispheric silicone rubber
cups have came into use.
OSPE for MBBS: Obstetrics •· G
"' vnaecotog.,
152
Metal Cup
The metal-cup vacuum extractor is a mushroom-shaped metal
cup varying from 40 to 60 mm in diameter. A centrally attached
chain connects the cup to a :Jetachable handle that is used to
apply traction. A mechanical or electrical suction device is
attached to the metal cup via a peripherally located vacuum
port.
The advantages of meta l-cup ove• soft-cup extraction include
• A higher success rate and easier cup placement in the

occipito posterior (OP) position, especially when an OP cup
is u~ed.
Disadvantages
• Unfortunately, the rigidity of metal cups can make

application difficult and uncomfortable,
• The ir use is associated with an increased risk of fetal scalp

injuries.
Soft Cups: Traditionally, the soft cups are bell or tunnel shaped. A
newer variety, the mushroom-shaped vacuum cup, or M-cUP,
combines the advantages of soft and metal cups. The Silastic c~ps,
Sile cup and CMt cup com tl'lonly availa ble in 60cm
Advantages
• Cause fewer neonatal scalp injuries.
OSPf for MBBS: Obstetrics & Gynaecology
153
• Can be used with a manua l vacuum pump or an electrical

suction device. Some have a built-in vacuum-release valve
that allows pressure to be rapid ly attained aAd accurately
controlled. This results in easy maneuverabilil•1 and
simplicity of operation .
• Soft-cup vacuum extractors may be disposable or reu~able.
Disadvantages
• Soft cu ps have a higher failure rate.
[contraindicationstof Vacuum Extraction

. ~ • Fetal prematurity (<34 weeks of gestation)
• ' Feta l scalp trauma
• ✓ Unengaged head •
• ./incomplete cervical dilatation
• Active bleeding or suspected fetal coagulation defects
• Suspected macrosomia
• Non vertex presentation oc other mat presentation
• Cepha lopelvic dispropor\ion
Complications
Maternal
Trauma to the genital tract

•
Fetal
• ~hignonJ
• Cephalhaematoma, intracranial haemorrhage
• Retinal hemorrhage to the baby and jaundice
• Subgaleal hemorrhage
OSPffor MB8S· Obs1e1Ncs & Gynaecology
155
Unobserved
Station£}
What is shown in photograph? Identify it and answer the foll owing

questions.
..-' ..
.
Q. 1 What is the diagnosis?
Q. 2. Wha t are the nsk factors for this disease?
Q. 3. What is 1he clinical presenta tion of such disease?
Q. 4. What single test is most helpful in diagno sing above

disease?
KEY:-
1. Endome trial carcinoma o.s

2.
_,
Risk Factors
Obesity impaired ca ~te-tG!er.a.nce, nulliparity, lat e

menopause, unooposed estrogen therapy,
1.5
functioning
ov~riao tumor, pr~vious pelvic irrad iation, family H/ 0 of
cars;•oorna of breast. nvary or colp.n
r-
3. Menorrhagia, inter-menstrual bleeding, blood sta in ed vaginal
-
discharge and po§( menopausal bleeding
4. ( Hysti;roscopic guided D&C )
OSPE for MBBS Obstetrics & Gyr,a
156 ecology
Explanation
Endometrial cancer arise from the lining of the uterus, is the third
most common cause of gynecologic cancer death (fo llowing ovarian
and cervical ca ncer). The most com mon subtype, is endometrioid
adenocarcinoma,
Clinical presentation
• Premenopausal or perimenopausa l bleeding
• Abnormal vagina l discharge
• Pelvic pain or pressure, usua lly occurring in later stages of

the disease
• Weight loss
Risk factors
• High leve ls of estrogen, endometrial hyperplasia
• Obesity, hypertension, polycystic ovary syndrome
• Nulliparity ,infertility
• Early menarche, late menopause
• Endometria l polyps or other ben ign growths of t he uterine

lining
• Diabetes
• Tamoxife n
• High intake of animal fat
• Pelvic radiation therapy
• Breast ca ncer, ovarian cancer
• Heavy da ily alcohol consumption (possibly a risk factor)
OSPf for M88S'. Obstetncs &Gynaecology 157
Diagnosis
• Clinical evaluation: Routine screening of asymptomatic

wo men Is not indicated, since the disease is highly curable
in its early stages. Results from a pelvlC examination are
frequently normal, especially ,n lhe early stages of disease.
Changes in the size, shape or consistency of lhe uterus and/
or Its surround ing, supporting struclures may exist when
the d isease is more advanced.
• A Pap smear may be either norm~I or shJw abnormal

cellular cha nges.
• Endometrial c.ireuage 1s lhe trad1t1onal diagnostic method .

Both endometrial and endoce rvical curetting should be
sampled .
• Hysteroscopy directed D and C 15 gold standard allows the

direct visual ization of the utenne cavity and cin be used to
detect the presence of lesions or tumours. Hysteroscopic
guided biopsy give 90-95% of positive predictive value.
• Transvaginal ultrasound to evaluate the endometrial
thickness in women with postmenopausal bleeding
OSPE for MBBS: Obstetri cs & Gvnae I
coogy
Unobserved Statior, 5
1. 2. 3
Q.1. Identify the above 3 obJects
Q.2 . What it is used for?
Q.3. What are their advantages?
KEY:-
• 1. Diaphragm 2 Cervica l cap 3. Condom (1.5)
• Fw contraception (1)
• PrQj_ection against sexually transm itted disease and

ascending infect ions
= (1.5)
Explanation
Barrier methods are some of the oldest and safest forms of

contraception (oirth control). These met hods work by acting as
barriers to keep the ma n's spe rm from reaching t he w oman's egg.
OSPE for MBBS: Obstetrics & Gynaecology 159
Types of Barrier Methods are:
1. Spermicides: are chemical barriers

2. Condoms (male and fema le)
3. Diaphragm Physical barrie rs
4. Cervica l ca p
r-, ...... ...,......,,,....,.,_

• Combining chem ica l and physical
..,_ ...
,.,.,.,. '"'.
barriers- such as spermicides and a
diaphragm
protection.
provides more --
,.._,_,...,.,w
M.il'l'-
1-i,
.llliofll• .....
C.-1: .. (1"
.
","
,.
• Barrier methods are less effective. lb•l"'l'd ,t,1111
llu1Uf110h hdll
"
However, when two barrier methods
are used together, they become highly
~--·__...
...-i,..... _ " ' _ _.,.....,
effective.
• Usually have no side effects. Those who are allergic to latex
should avoid barrier method that contains latex (rubber).
• If barri er method breaks or becomes dislodged during sex, than
consid er emergency contraception.
Condoms
M ale. A male condom is a th in sheath made of latex {rubber),

polyuretha ne {plastic), or animal membrane. It preve nts sperm from
entering the ce1vix and getting to the egg.
Advantages
• Easy to buy, simple to use & best protection aga inst STDs.
Disadvantages
OSPE for MBBS: Obs1emcs & Gynaecology
160
• High failure rate, pregnancy rate of 10-14 perlOO woman years &
~s!l_sexual satisfaction
• If allergic ro latex. then consider using condoms made from
(pot~uretfijine)and(tactylonlmaterial
r
Female Condom
The female condom is a thin plastic

pouch that lines the vagina. It is held
in place by a closed Inner ring at the
cervix and an outer ring al the
opening of the vagina.
Advantages
• Provide some protection against STDs, more effective when
used with a spermicide.
• Female condoms can be bought over-the-counter and do
not need to be fitted
• The female condorn can be inserted up to 8 ho urs before
sex.
Disadvantage s
• Female condoms should be used only once. They are

difficult to insert and require careful use.
Diaphragm
The diaphragm rs a small, round rubber deme

with a firm, flexible rim that fits inside the
woman's vagina and covers her cervix . It is
used w ith a spermicide. Diaphragms arP
available in diameters of l ~Omml 10 105mm
(about 2-4 inches).
OSPE for MBBS; Obsletrocs & Gynaecalogy 161
Advantages
A diaphragm can be used for about 2 yea rs, reduces the risk of
some STDs. The diaphragm may be put in place up to 6 hours befo re
sex.
Disadvantages
• A diaphragm may incrpase the risk of urinary tract
infections.
• Can cause a reaction m those who have an allergy to
spermicides or latex
• It cannot be used Just after giving birth.
Cervical Cap
Th e cervical cap is a small, thin robber or
pla stic dome shaped like a thim ble . It fits
tightly over the ce rvix and stays in place by
suction. Cervical caps come in four sizes.
Advantages
• Unlike the diaphragm, it can remain in place for up to@.8 hours)
• Less spermicide is needed with the cervica l cap and it does not
need to be reapplied before each act of sex.
• It does not require strong vaginal muscles to use.
• It is less likely than the diaphragm to be felt by partner during

sex.
• It reduces the risk of some(ilQv
Oisadv~ntages
• Sometimes causes trritation or odour In the vagina, if it is left in
too long.
• 11 also may increase the nsk of urinary tract infection
OSPE for MB8S· Obstetric, & G
162
'"•"°lit;
Observed
49 years old, p1 presented wilh the huge mass arising from lhe
pelvis. Her CA 125 was 480 iu/ml. She was told t hat she has an
ova nan tumor. Your task ,s to discuss diagnosis and further
managemen L
KEY:•
1. Introduction (0.5)
• Eye to eve contact
• Introduce your self
• Ask patient introduction,(educ.at1on status)
• Explain her disease and invite quesUQ.AS

'
2. Expl;anat,on of t~mor marker (1)
3. USG CT scan and other routine investi at ions (1)
4, ~anagement; } (2.51
• S'!!]•Cal "!a£la.!l;!!1ent according to stage of tum;ir
• Chemotherapy
Explanation
Ovarian cancer is the second most common gynecologic

malignancy.
oSPE for MBBS: Obstetrics & Gynaecology 163
The 90 percent of primary ova rjan tumors are epithelial in origin,

the remainder arise from other cell types (germ ce ll tumo rs, sex
cord-stromal tumors, and mixed cell tumors), or metastatic tumors,
especially from breast ca ncer or Krukenberg tumor s from the
gastrointestinal (GI) tract.
Clinical Manifestations
• Epithelial tumors are common between the ages of:JO and 6S.
• Nonep1thelial (germ rell tumors. sex cord-~tromal tumors, and

mixed cell tumors) arp more commo11 111 girls and you nger
women.
• Sympto ms of edrly stage disease are often vague and ill-defined
• Advanced disease is tyfHCillly associated with abdominal
--- - ·-
disten tion, nausea, a,1orexia, or ea rly satiety due l o t he
presence of ascil es and omen tal o r bowe l me tastases; dyspnea
is occasiona lly present due to a pleural effusion
2. Tumor markers
•
-
CA 125 is commonly used mark er, it is a glycopro tein su r face
antigen raised In 80% ol epithelial tumo rs. It also raised in
benign cond itions like endornetrios1s. CA 125 is useful for
monitoring women receivi ng chen1otherapy to asses' response.
A pe rsistent rise in CA 125 may precede clin ical eviden ce of
recurrent disease.
• Oestradiol - increase in physiological follicular cysts and sex

cord strornal tumors.
• Androgen - increase in Se rtoli- Leydig tumors
• Alpha fetoprotein - increase In yolk sac tumors
OSPE for MBBS: Obstetncs & G
164 Ynaec
• B HCG, } increase in
Placental alkaline Phosphatase other germ cell tu
• niors
Lactate dehydrogenase
•
lnhibin - raised in granulose cell tumors
•
CEA - raised in endometrioid tumors
•
3 . Diagnosis
USG, colour Doppler USG, CT scan, tum~r markers and other routin
investigations
FIGO staging for primary carcinoma of the ovary
Stage I Growth limited to the ovari es
Stage IA Growth limited to one ova(¥; no ascites containing

malignant cells. No tumor on the externa l surface; capsule intact.
Stage 1B Growth limit ed to both ovaries; no ascit es con taining

malignant cells. No tumor on the external surfaces; capsules intact. (
Stage IC T,umor either stage la or lb but w ith tumor o n the surface \

of one or both ovaries; or with capsule ruptured; or With ascites
present containing malignant cells gr w ith positive peritoneal~
washings.
Stage II Growth involving one or bot h ovar ies with ~

eJ.tensiOA.
Stage IIA Extension and/or metastases to the uterus and/or tubes.
Stage 118 Extension to other pelvic tissues.

--
th
Stage IIC Tumor either stage Ila or llb but with t umor on e
th
~rface of one or both ovaries; or with c~psule(s) rup!ured; or wi
OSPE for MBBS. Obstetrics & Gynaecolqgy 165
ascites present containing malignant cells or with positive

peritoneal washings.
Stage Ill Tumo r involving one or both ovaries with perito&_gj_

implants outsidL ibe... pelvis anc!for positive retroperitoneal or
inguinal nodes. Superficial liver metastasis equals stage Ill. Tumor is
limited to the true pelvis, but with histologically proven malignant
extension to small bowel or omentum .
Stage lltf< Tumor grossly limited to the t.rouelvis _witb negative

n.9des but with histologically confirmed microscopic seeding of
abdominal peritoneal surfaces.
~ :S h
'z.,_...__
Stage IIJB Tumor of ooe or botb. nv.acles... with~logically
confi~ d implants oL'l_~dorninal pedtoneal sorfa(e~ no ne
exceedi3 2 cm in diameter Nodes negative.
-- -
Stage IIIC Abdominal implants >2 cm in diameter and/nr rositive ~
retroperitoneal or i~guina l nodes.
Stage@:::trowth ln'lolving one or both ovaries with <fil_tant

metastasis.
If pleural effusion ,s present, there must be positive c-;tologic l est
results to allo t a case to stage IV. Parenchymal liver metastasis
equals stage IV.
These categories are based on findings at clinical examination or
surgiral expl·o ,ation
•
Treatment
7 A. 11 - /:;, 6~
Stage I and II Total obdominal hysterectomy and bila teral
salpingo oopherectomy with ln[racolic
ome.ntectomy + chemotheraphy
OSPE for MBBS: Obstetrics & Gynae, 010
166
~ tage Ill and 10 (Q_@~lk~g _surgery] and re~oval of tf!mor +

post operative chemotherapy and
radiotherapy
PoL
Chemotherapy
• Is given to prolong clinical remission and survival, fo r palliation

in advanced and recurrent disease, commenced soon after
surgery and given for 5-6 cycles at three to four weekly
intervals.
• Post operative chemotherapy is used for epithelial ovarian

cancer, in stage Ill and IV, possibly stage ICl
• Drug used are Carboplatin or C1splatin and taxol.
• Carboplatin or Cisplatin are platinum drugs and cause cro ss

linkage of DNA strands and stop cell multiplications. Most
effective for ovarian tumors.
Side effects
• Cisplatin is highly toxic drug, lead to severe nausea, vomiting

and renal damage (can be avoided by adequate hydration with
1/V fluids), peripheral neuropathy, hearing loss and anemia may
occur.
• Carboplatin has less side effects than cisplatin, like less nausea
and vomiting, no renal damage, neurotoxicity is rare and
hearing loss ,is subclinical
Paclitaxel
• Promotes assembly and stability of microtubules and inhibits

mitosis
OSPE ror MBBS- Obstetrics & Gyn~ecology 167
• Side effects nausea, vomiting, neuropathy, neutropenia,

myalg1a and arthralgla_
Radiotherapy
• Is rarely used on ly in ra aiosen.sitive n:imors
•
•• ',
168 ~
Station JI 1
Unobserved
Candidates Instructions , ~
~~' ~,~
~
See the photograph and answer the followi ng questions
Q. 1. What is the inst rument shown in the photograph?
Q. 2. It is used for wha t purpose ?
Q. 3. What are its complications? (Give any 3)
KEY:-
(Hgars Dilators ) 1
2. It is used for the dilatation of cervi ca l os 1
3 Complications are 3
• Cervical tears
• Uterine perforation
• Creation of false passage
• Excessive cervical dilatation may lead to cervical

incompetence
QSPE for MBBS: Obstetrics & Gynaecology 169
Explanation
Introduct ion
• Hegars dilators are approximately 8 inches in length and double

ended. One end being 1mm larger than the other.
• They have a general overall slender "S" stiw~

• They are hollow stee l, but closed ended (no fluid flow).
• They are sized in millimeters of diameter NOT French, and the
size is stamped on the dilator.
• They are available singly or In sets of 8. The sizes are as follows:
3-4mm, 5-6mm, 7-8mm, 9-10rnm, ll-l 2mm, 13-14mm, 15-
l&mm, 17•18mm.
Indications for use
It Is used for th e dilatation of cervical os fod.D & gor In cases of

cervical stenosis.
Complications are
• Cervical tea rs ,
• Uterine per foration •
• Creation of false passage
• Exces·sive cervical dilatation may lead ·to cervica l

incompetence.
OSPE for MBBS· Ob~tetrlcs & Gyoa«o!otv
170
Q. l . Identify the specimen
Q. 2. What is the drug used in 1t7
Q. 3. How it is used?
Q. 4. What is it's mode o f action and How long it can be used?
Q, S. Give 3 advantages.
Q. 6. Give 3 disadvantages.
KEY:-
1. ~orplanl] 05,
I
2. li:vo□aqiestcil 0.5
3. It i~aced subdermally l n th,e medial aspect of upper

arm under local anesthesia
4. Superession of ovulation, suppression of endometri_v'YI,

it proviqe con I raception for 3 - 5 years
OSPE for MBSS: Obstetrics & Gynaecololl" 171
5. Advantages: 1
• Long acting with sustained ettect - complla nee is good
• [Systemic side effectsl are few aod first pass effect on the
C
liver avoided
Vc;~n be used by-1ac:taling~ her~ and over the age of 40

years
• No__'. nuisance' of daily oral or freq uent injections
6. Disadvantages: l
• ~tm>ugh bleeding; irregular cycles

<
• - ~eflf'-lleil occur as with 01her progesterone

contracep tives
• Ectopic pregnancy is reported , @

<
• Local infection may occur
~
• Expensiv~,
Explanation
Norplant Is a form of birth control. The original Norplant consisted

of a set of six small {2.ll mm x 34 mm) silicone capsules, each filled
with ~ f levonorgestrel, Implanted subdermally in the upper
arm and ettective for five years.
Insertion
Norplant Is implanted under the skin in l he upper arm of a woman,

by creating a sm~II •nclsion ard inserting the capsules in a fa nlike
172 OSPE for MBBS Obstetrics & Gynaecology
shape. Insertion of Norplant usually takes 15 minutes. Once

inserted, the contracept ive works within 24 hours and lasts up to 3-
5 years.
Mode of action
Norplant slowly released progestogin and works by
• Preventing ovulation,
• Thickening the mucus of th e cervix, and
• Thinning the lining of t he uterus, this makes implantation of

an egg less likely.
• Norplant has been shown to be 99% to 99.95% effective at

preventing pregnancy.
Like all hormonal contraception, Norplant does not protect against

sexually transmitted diseases.
Advantages
• Do not require daily administra tion or access to a hospita l
• It is a highly effect ive, low cost and effecti vf'> fo r 5 years.
• Can be safely used in breast feeding woman
• Can be used in older women, women who smoke, and women

with high blood pressure as Norplant does not contain est rogen .
Contraindicatio ns
Norplant should not be used in women with
• Liver Disease, breast cancer, or blood clots.
• Pregnancy
• Va~inal bleeding
OSPE for MBBS: Obstetrics & Gynaecology 173
Removal:
Norplant can be removed at any time, by withdrawing the ca psules

through small incision. Norplant is normally removed when the five
year period is over, or if:
• Pregnancy is desired
• Different birth control is preferred or
• Complications arise
If desired, a new implant can be inserted at the time of removal of

old one.
OSPE to, MB8S: Obsu,trics & Gynaecology
174
Station 9
Unobserved
See the photograph carefully and answer the following questions
Q. 1. What is the condition baty ,s suffering from ?
What are the risk factors for development for such conditJon
during pregnancy? Give any 3.
Q. 3. What are the materna l and fetal complicat,ons of such

condition? Give 3 each.
KEY:-
1. l\4l/CCOCOsrnic baby ✓ 1
2. Risk factors are

1
@ pbesity /body mass jnctei>30) ;
0. Fam,ly htstorv of diabete'i ✓
~ Pr:.v,ous baby ~ a.s Kg ./
(j Previous unexplai□ed s!illbirth ,,.
• PreviotJ< coope□it.il abRortllaJJ.lv
()SPE /or MBBS: Obst,trlet & Gynaecology l75
3. Maternal complications are: 1.5

• Risk of miscarriage ✓
• Polyhydramoios· ~
•
•
-
Increase risk pf infections ✓
Increase risk of pre Eclampsia ✓
• Increase risk of nephropathy ./
4. Fetal complications are; 1.5

✓
• Fera} c~f]genital abnormaht,es: neu~I tube defects,

congenital hei(rL d1sgase, spinal abnor01al1ties like cauda l
C
regression syndrome
G> Macrosomrn /
(lJ Trauma\~ ✓
G) Shoulder dysto.9a ✓
G Growth restriction ✓
G) ,;;tal death ✓ --
Explanation
Diabetes occur in 2-5 ~ o f all UK pregnancies

.
oefin1 t1on: The WHO J1d~ defined dfobetes mellitus as eithc l' il
raised fa~rlng blood .sugar level of> 7.8 mmol/Ul,jOmgdl) or a level

of > 11.1 mmol/1 (20..Q.mg/dl) 2 hours following a 75 g oral glucose
load. /
Pathophysiology: carbohydrate metabolism altered during

pregnancy beca use of hormonal changes. puring pregnancy there is
an increase in human lacental lacto en or cortisol both are insulin
antagonist sp create a state of relative insulin esistance. To
compensate this maternal pancreas secretes more insulin and try to
mamtam carbohydrate me1abolism. When this balance is disturbed
it leads to diabetes.
176 OSPE for MBBS: Obstetrlcs & Gynaecolot
Diabetes may complicate a pregnancy either because a woman ha

preexisting insulin-dependent (IDDM) or non insulin depender
diabetes (NIDDM) before pregnancy or develop glucose intoleranc
during pregnancy (gestational diabetes).
Risk factors for the development of diabete s in pregnancy

• Obesity (body 1mass index ~30)
I
• Family history of diabetes

I
• Previous baby~ 4.5 Kg
• Previous unexplained stillbirth '
• Previous congenital abnormality
Fetal and maternal complications
Unco ntrolled diabetes associated with number of maternal an

fetal complication s
- --
Maternal complications
--- - Fetal
- -complications
--
• Risk of miscarrfaee / • fetal congenital abnormalit ies: neural
• Polyhydramnios ./ l!!,be..d.efects, conge nital heart disease
• Increase nsk of infections ✓ sp·nal
1 b '
a norma lilies like caudal
• Increase ris,k of pre Eclampsia 1 " regression syndrome. j.,.,,-
• Increase risk of nephropathy/ • Macrosomia- birth asphyxia •
• Hyperglvcem,a/hypoglyc • Traumatic birth e.g. brachia I plexus·
em ,a/ketoacidos1s ./ ,n1ury
• Thrbmboembloc disease • Shoulder dystocia
• Coronary artery disease , • Growth restrjct ~on
• Feta l death • I
Neonatal risks I
• Respiratory dist ress syndrome j

• Hypoglycemia • '
• Polycythaemi a
• >
- - - - · - ~ liyperb1hrubmaem,a
-~ '
OSPEtor MBBS Ob>tetnts & Gynaecology 177
Management of diabetic pregnancy
The aim of m anagement Is to m aintain the blood glucose level as

near normal as possible by appropriate mea l planning, increased
physical actlv[ty and properly-instituted insulin treatmen t.
Management should be in _JOint clin ic with an obste tricia n and
physician along w ith dietitian.
Prior to pregnancy
• Diabetic w omen should be offered preconceptio n counseling
• Keep BSL between 5- lOrnmol/I and HbAlc below 10
During first trimester

~, "
• Dati ng scan and scree ning for diabe tic complications
• Assessment and optimization of glycaem ia keeping fasting
SSL< 5.8 mmol/I and postprandial < 9.1 rnmol/1.
• Advice on hypoglyce mia prevention
During 2"" trimester

• O tim,zation of glycemic conrrol
creening for congenital abno rmalities by scan at 18-22 weeks
ot gesrauon
• Screen,ng fo r chromosomal anomalies, by seru m atpha
fetoprotein
• Surveillance for rn ical obste ric complica tions like
hypertension, preec ampsia & nep ropathy etc
• l\ssessment of fetal growth by seria l growth scans from 24
week onwa rd
During 3•• trimester

• Opl!m1zat1on of glycern,c control
• Serial growth sca ns to detect rnacrosom ia
178 OSPE for MBBS: Obstetrics & Gynaecolog
• Ti me and mode of delivery, aim is to deliver between 38-4

weeks . If BSL is well co ntrolled pregnancy can be al lowed to
continue till 40 weeks but not beyond 40.
Intra partum management

• During labour BSL are maintained near normal by giving 1/V
insulin by sliding scale method and BSL are done hourly. Keep
BSL between 4-6 mmol/1.
• Continuous fetal monitoring by CTG and if CTG abnorma l then
fetal sca lp blood sampling for Ph
• Give good analgesia li1ke epidural to avoid re lease of
catecholamine
• Delivery by experienced obstetrician and in place where
neonatal resusc1ta tion facilities are available.
Postpartum care
• Readjustment of insu lin dose
• E~courage breast feeding
• A fu ll glucose tolerance test is performed a
t ~ ensure diabetes has resolved
• Discuss con traception
QSPf for MBBS: Obsterncs & Gynaecologv
Observed Station 10
(J l-:,,1
Candidate's inst ructions
A para 1 delivered at ho'1)e 3 days back, oow sbe bas presented in

emergency with history of high grade feyer abdomioal teodeco,.ss
-
and foul smel ling vaginal discharge.
Answer the questions asked by the examiner
Q. 1. What is the condi tion she is suffer,ng fro_i:n?/
Q. 2. Give any 3 causes of such condition. /

Q. 3. How wil l you manage her )
KE/
.~erp-e,-a~,-
p-yr_e_x_.,..ial 0.5
2.~ uses/ol Puerperal pyrexia. 'll{,\\~~f/,~ 1.5

1✓Endometritls. • 6;),;(I ::l"'r. ~ u
2~ llcioary tract infection."" @vq97i:f'
3✓ Respiratory tract Infection. t' /
@vwound infection.
e) V M astitis.
'
3. Management 3
• Admit the patient
0 he.ck rbe 1111al signspulse; blood pressure and lemperature

a ve 4 hour
Ke_ep record of urine ,ntake & out put
~el/V hne
180 OSPE for MBBS. Obsteuics & Gynaecology
~ ,,
• Take blood for CBC, blood culture, TLC, DLC, renal function
liver lunctioA •es•s, coag11la1ioo profile.. urine completl!7~rin~
and higb vagjnal..swab-f-0r--eulture aod ~eositivity
•• •
• USG to rule out any retained products of concreption
~~tart triple antib,oti; co\lllr
EMplanation
Pue , I'"' di pyrex,a Is defined as the presence of a fever of up to 38'C
or more In a woman within fourteen days of giving birth .
Symptoms:
May be variable depending upon the system involved .
Ma lais( heada~t<e. feve( ngors";;bdominal discomfort, vom iting,
diar rhea, offensive lochia and secondar~ PPH ..,,,
Aetiology:
Specific causes o~ puerpfral pyre<ia may include:
Urinary tract infection:
• Frequency, dysuria, haematJrta
• Rigors from pyelonep~ritis / • /

',
• ~caused by f. di;, Prote,s spp, KlebsieYo spp.
Genital tract infection:
• Tender bulky uterus (l; '
• Prolonged bleeding / pink or-discctJl.lred lochia
• Pa inful inflamed perineum

by£. coli anaerobes Group A streptococcus
• M ay b e cause d · • - -,--,- ' ,
tophylococcus spp., Cfostridium welcflll (rare, bUJ.
SJI.P·,,=S:;.,_....:...._____
serious)
Mastitis:
• Painful, hard & red breast abscesS
OSPl for MBBS; Obstetrics & Gynaecology lS!
• "!_ipple trauma and cellulitis
• Usually caused by Stophylococcusspp.
Post operative in fection following Caesarean section

Increased risk of post-partu m septicaem ia, wound problems and
fever. Presenting fea tu res may include
• Painful, red suture line
• Deep tenderness on palpation
• Discoloured lochia
Deep venous thrombosis:

• Caused by venous stasis
• Painful, swollen calf
Other infect ions:

,. Viral infection or chest infection
Management ✓ ✓
Ta ke detail History regarding any history of vagina l leaking, length of
labour, any instrumentation or cornplica t1on during delivery.
Examination: ta_ke pattent vital signs pulse, BP and temperature,
examine the breasts, auscultate chest for signs of infection, do
abdominal examj!J2.tion. on ee lvic examination pa lpate the uterus
to assess size and tenderness. look for any perineal wounds and
-
l~ch ia. Examine the legs for possible thromboses • ·
Investigations: Ta ke blood for CBC, blood culture, TLC, DLC, renal
function, liver fun ction tests, coagula tion profile, urine co mplete,
urine for culture and microscopy, '1igh vaginal swab and other swab
lf._necessary e.g. wound swabs, th roat swabs for culture and
s~ sitiv,ty.
USG to rule out any re tained products of conception
Treatment
General measures
• lc_e pa cks lor pain 1elief from perinea I wounds or rnastitls
• Rest and adequate fluid inta ke, give analgesia

• Broad spectrum antibiotics should be co mmenced after taking
specimens if infection is severe than triple antibiotic cover may
be needed .
Surgical
Surgical intervention may be required in case of an abscess
Complications
• Septicaemia, pulmonary em bolus, DIC and pneumonia
• Genita l tract infection may lead to abscess formation,

adhesions, peritonitis, and subseq uent infertility if left
untreated
• Urinary tract infection may progress to pyelonephritis and

renal scarring, 1f left untreated .
• Mastit,s may lead to the formation of breast abscesses if

treatment 1s not started early.
OSPE for M88S: Obstett1C$ & Gvn•e~ologv 183
Unobserved O b 5, Station 11
Answer the Following Questions
Q. 1. Write down the name of the structures cut down while

performing mi;?d iolateraJ ~jsiotomy incision 7
Q. 2, Name the sutures commonly used for repair of episiotomy?
Q. 3. What is the recommended rate of episiotomv by WH O @
Q. 4. What can be the common causes of pain at episiotomy site?
KEY:-
~
1. Structures cut down are ,y 2.5
* - Skin ./
0
(i;)->"~ s ...
~ I
*
Subcutaneous tissue
Bl--
**
8ulbocavernosus
~ c,"l
'i
T(1!nsverse perineal muscle
v:tJJJ.I .
Pu bore:ctalis muscle
*
*
Vaginal wall
2. Suture material used are 1
• Catgut
• Vicryl
OSPE for MBBS: Obstetrics & Gynaecol
0
w,ommended Rate is 109&
• Excessive tension on sutured tissue /

~
• _Hematoma at episiotomy site / °f.f /
Explanation / \ ~ \;\W
Definition: Episiotomy Is a surgical incision of the perineu m made to
increase the diameter of the vulval out let during child birth.
The WtiO recommends an eplsiotomy rate of 10% for normal

deliveries
✓ Indicationsfor episiotomy
1. Fetal distress
2. Short or inelastic perlneum
3. Shoul!er dystocia
. . •
•
• ••
•
• •
••
•
.
•
• •
ne• .....
• ""' vertically from th
e fourchette down towards th
OSPf for MB8S: Obs1e rrlts & Gyna&ologv 185
comparison o f midline versus M ediolateral episiotomy

M idline Mecliolateral
1.. M ore in use in UK
L More in use In USA
2. Less blood loss 2. More blood loss
3. Eas1er [O repair
3. Shghlly di/f,cult lo repaH
4. wound heahng .de.laved
4. The wound heats qulcker
s. Less dyspareunia 5. Chances of dyspareunla
6. Less pain 6. May be more paln full
7. More ( hances of extension and 7, No such disadvantage
invofvement ol anal sphincter
3''/4171 degre.e tear
For episiotomy either epidural or local anesthesia with 2% xylocaine
is needed.
Episiotomy should be performed with large sharp straight scissors in

one single cut, which should begin in midline position at the
fourchette and exlend either m idline or med,olaterally, to increase
lhe diameter of vulva I orifice. It should be suture w ith either catgut
no l or O or preferably with vicryl either interrupted or preferably
subcuticular ·manner. Antibiotic should be administered to avoid
infection
Structures cut down during M ediolater al episiotomy

• Skin
• Subcutaneous tlssu:/
• Bulbo cavernosus ✓
• Tra nsverse perinea l muscle
• Puborectalls muscle
• Vagina l wall
Complications
1 If cut more late rally it may cause d,<image to the bartholin
glf_nj_; decreases vaginal secretions, more pain full and more
c9mpl icated to suture
2. Ep1s1otomy may extend and may lead to 3•• or 4th degr ee
•
Perinea! Jear
3. Heavy bleeding may occur
4. If homeostasis is not secured proper ly, may lead to perinea!

hematoma formation
5. Infection may occur
6. May lead to dyspa reunia
•
•
•
OSJ>f for MBBS; Obstetnc:s & Gynaecology
0 lo S ·
Station 12
Observed
A 32 year o ld G,P,Ao came in antenatal clinic at 34 weeks of

gestation with the report given below. She had complaints of
weakness, lethargy, and having dyspnieay.,hile performing normal
house_hold activities.•
• Hb 8 gmjdl 'V
• ESR 30 -
• ~ 60 fl ,~
• MCH
•
28 l)g J
• MCHC 35 g/dl
Examiner's instructions
Please ask the following questions from the candidate and n'lark
accordingly
Q . 1. What is the diag_llQ§is?
Q . 2. What are the important points you will asked in her history?
Q. 3. What investiga tions would you lik,e to offer for anemra?
Q.4 In th,s patient what can be the probable cause and how will
you manage her?
OSPE for M BBS Obstetrics & Gynaecology
188
KEY:•
0.S
1. Severe iron deficiency anemia
1
2. History:-
• Mode of deliveries
• Eating haWts
0 !l).eeding from any si_le .
• Haemateoesis haeg;,optysis, or ma lana
* . Chronic diseases worm infectiOJlS
- • Any evideore of baernoglobinopathies in family -
3 Investigations 1
V'Serum ferritin / II BC peripheral blood picture
• Transferrin receptor saturation
4. Probable cause and management o.s

Probable cause : m ultiparity
Management; after investigations:- 2
• Counseling of the patient
• BloQd transfusion wilb 'asix cover preferably pack cell to
ma~e the Hb % at around llgm at the time of delivery
>
• Initially blood transfusions at least 2 then can be put on
ogl or(I.V iro~
• Fetal surveillance@
• Regular antenatal check ups v
• Delivery spontaneously✓
~ Po.st partum Hb a ~ n supplements
Explanation --..
• The WHO defines anemia as a hemoglobin concentration of <

11.0gm/dl.
• During pregnancy (ed-cPH-rnass i.;ueaF) but Plasma volume

Increases more In oronortion to red cells leading to dilu tional
anemia.
()51'E for MBBS: Obstetrics & Gynaecology 189
• Iron deficiency anemia is most common during pregnancy,

;;counting for 90% of cases . During pregnancy, iron demand
increases from 2 mg to 4 mg daily. The total amount of extra iron
required during pregnancy is about 1000mg.
causes of iron deficiency

• Multipar ity
I
• Eating habits, diet lacking in iron like meat, fish poultry etc,
pure vegeta rian, malabsorption and hyperemesis
•
• Bleed ing from any site like haemorrhoids
• Haematemesis, haemoptysis, or malar ia

I . "-
• Chronic diseases, worm infections, amebiasis and gia·diasis.
Clinical features
• Mild anemia - asymptomatic
• Moderate anemia - weakness, lethargy, lack of

concentration, f.25igue and po_or appetite
• Severe anem ia ---dyspnoea, palpitation & in v!!rv severe

- -· :-:-- -x::::::.
cases may lead to cardiac failure
Investigations
• @and haematocrit estimation
• Peripheral blood film: microcytic, hypoct\romic red cells
• Red cell indices--•··· MCV (N 75-99fll,_ MCH (N 3l-37 pg),

MCHC (N 32·36 g/dl) attdecr-;ase in iron deffciency anemia
OSPE to,r MBBS· Obstetrics & Gynaeco~o
190
• erum iron s,erum TIBC--· serum iron «N J 3-27um 0JZ'8 TIBO ~

(N 45-75,umo,I /I). ln iron deflciiency anemia serum iron fall
below 12u mo1/I a1nd {[le\§is increased
• erum err1t in (N .15- 30Opg/l) if fall below lSpg/1 ind icatlv

of iron defici,ency anem ia
• Bone m a r,ro w exarn nat io n
Management
Aim 1s t o ach ieve norma I haemoglobin levels towards the ,e nd of
1
pregr,ancy
Treatmen opt~ons are Iron therapy or blood tra nsf usio n in case of
severe aIinem1a
Iron therapy: Can be pr~I iron 60 mg da ily pra l iro n is suf ficient -
sid effe,ct nausea, vomiting and const1pa tion
injectable iron: either inbram uscular --- side effect pa1

iinful,, skin
tanning. Intr avenous lofus,io n can be given as total iron do.se but
1
may cause allergic r-eaictions.
Blood tran_!!usion only recommended i,in severe an,e m i.a, Hb less

~ n 6 m_g/d!_))r when delivery ,s very nearby.
ostE f or MB BS·· obstetrics & Gynaecology
unobserved
Station 13
Candidates instructions
Q. 1. What is the procedure shown in the picture?
Q. 2. What are the indications for t his procedure,
Q. 3. What are its risks 7 Give any three.
--,_ ht.irf
-
•-1
-
c.....
kEY:-
1. ~niocentesii)
2. Indications
~
r ~
i. S}ttogeneti.c, analysis for major aneuoloides, the use of

fluorescence in-situ hybridization {FISH) can facilit:te
r~pig resu lts wfth amniocentesis.
OSPE for MBBS· Obstetrics & Gynaec01'1,
192
1i DNA analysis foI conditions
1. Haemggloblnopathies-li~ 5ick!e cell disease
2. Cystic fibrosis
3, Fragile~ syndrome
4 _ For polymerase chain reaction.
iii.Biochemical and enzymatic analysis
3. Risks
1. Miscarriage in 1 % of cases
ii. Feta I Iraurna
iii. Leakage of the amniotic fluid may lead to

Olisohydramnios
Iv. lnfecrion
Explanation
Amniocentesi s is invasive diagnostic test for prenatal diagnosi~

usually done around 15-16 week of gestation.
Procedure: a_ thin needle is passed trans abdominally undel

ultrasound guidance into the amniotic cavity and a small amount ol
amniotic fluid is removed, which conta in '" fetal fibroblasts;• it is
performed at 15 weeks of gestafion or later..Amniocentesis as early
as 14 weeks of gestation can also be performed but associated wit~
high culture failure rates and fetal trauma.
Indications for amniocentesis
i. Cyt ogenetic ana lysis for major aneuploides, the use ~

fluorescence in-situ hybridization (FISH) can facilitate rap1~
results with amniocentesis.
oSPf for MBBS: Obstetrics & Gynaeco logy
193
II.
ONA analysis
-
for conditions
1. Haernoglobinopathies-like sickle cell diseasp

2. Cystic fibrosis
3. Fragile X syndrome
4. For poly1nerase cha in reaction.

•
iii. Biochemical and en zyma tic analysis
Risks associated with amniocentesis
I. Miscarriage in 1 % of cases
II. Fetal t rauma
Ill. Leaka~e of the amniotic fluid may lead to

Oligohydramnios
IV. Infection
V. Amniotic bands
OSPE to, M88S: Ob<telr!CS & Gynaecoloi.'I
Observed olo &- Station 14
Candidate's instruction
Read the following scenario and answer the questions asked by the
examiner.
A G6Ps previou on caesarean section at 39 week of gestation

presented in tli emergency with history of labour pam since
morning and trial o f labour at some pnva te clinic with inJec ta ble
Oxytocin. On examination she looks pale, pulse 120 bpm weak and
thready, blood pressure of 90/60 mm Hg, fundal height term, fetal
pa rt fell through the abdommal wall, fetal heart sounds were
absent. On pelvic examination cervix was S cm dllated, fully effaced
preseriting part high and bleeding+.
Ariswer the examiner's questions.
Examiner's instructions
Please ask the following questions from the candidate and grade
---
accordingly
1, What Is the most likely diagnosis?
2. What are rhe causes o f such problem ? Give any 3.
3. How will you manage this case J
KEY:-
1. ~l,\!!ine rupture o.S

2.Ca~be 1.S
QSPE for MBBS: Obstetrics & Gynae<:ology 195
• Previous caesarean section scar
• Myomectomy scar where uterine cavity opened
• lnludicious use of Oxytoci n . /
• Gr!Jnd multipariiy✓
• Obstructed labour due to malpresentation or CPO
• lnte.r:nal podalic version, ECV ✓
• Manual removal of placenta
• Instrumental delivery
3. Management 3
Immediate management
Call fo r help
• i ation : Give oxygen, maintain airway, sa line with

two wide bore cannula. and ta e ood for investigations, cross
•
matching and arrangement of blood.
• Start 1/Vfluid initially with crystalloid flu id and then blood

• Counsel the relatives about the condition of the patient
• Take informed high risk consent
• Inform the anesth etist and theat re staff, prepare and shift for
emergency laparotomy
•
• Either do "hysterectomy for uterine rupture if the rupture Is
•
extensive or not repairable or if the tear is small aod repa1rable
then do repair,
Explanation
Uterine rupture is an obstetrical emergency and is associated with
high maternal and perinatal mortality rate
196 OSPE for MBBS Obstetrics & Gvnoeq>logy
Its mcidence fn devl\loped countries is 0.3/1000 deliveries, but high

in developing countries because of grand mult,parity, lov,
soc,oeconom,c class, maccess,bility to proper medical facllities and
deliveries by untrained Dai/LHVs etc.
Causes for uterine ru pture
• Previous caesarean section scar
• Myomectomy scar where ute rine cavity opened
• Injudicious use of Oxytocin
• Graind multiparity
• Obs tructed labour due 10 malpresentation or CPD
• Internal oodahc version ECV

'
• Ma nua I remova I of placenta
• Instrumental delivery
Sign and symptoms
Patient usually complains of continuous abdomina l pain, with some

vaginal blood loss, uterine contractions cease, the fetal part may be
palpable through the abdominal wall. The fetal heart pattern
beeome abnormal and if immediate laparotomy js not done fetus
may die.
Types of uterine rupture
Incomplete rupture or scar dehiscence: when only the myometrium

Is rupt ured but covering peritoneum is Intact. The baby is usually
not affected at early stage, if action is taken at early stage than baby
can be saved and lhe uterine repair can be done successfully.
oSPE to, MSBS Obstet11cs & Gyflaecology 197
.'
complete rupture: in addition to the myometri um, cove ring
peritoneum is also torn . The baby may be extruded o ut from the
uterine cavi ty into th e peritoneum cavity. The fetus usually died and
tear is extensive in any direction.
Management:
Call for help
Restiscita tion : give oxygen, n1aintain ai rway, save 1/V line with 2
wi de bore cannu la, take blood fo' investigations, cross matching
and arrangement of blood.
Start 1/V fluid 1nit1ally with crystalloid fluid and then blood
Counsel the relatives about the condition of pa tient
Take informed high risk consent
Inform the anest hetist and thea tre sta ff, prepare and shift t he
patient for emergency lapa rotomy. Either do hyst erect omy for
uterine rupture if the rupture is extensive or not repairable or if t he
tear is small & repairable do repair.
l.98 OSPE for MBBS, Obstetro(S &Gynaecology
Station 15
Observed
A 32 year o ld P,1 ca me to you, for contraceptive advice, She wants

tubal steriliz<stion. Take an informal
, consent
KEY:•
• Eye lo eye contact
• r~on-medical j argon
• Polite to the patient
ri~ Fe~~~~ 1
I
• Take written consent
• Pre pa re the part
1.5
• Yn11og •·· · so need counseling. couple to be seen
• High infa nt mortality rate in Pakistan
• Reason for such a request

'
• Previous use .of contraception/ compliance
• "'
Offer o ther reversible methods
• D~cuss failure rate (1· 2/100~
• Sh~uld be considered irreversibje
~ lo• M88S: Obstetric. & Gynaecology
199
• Nature of procedure sbn.uld-ile..expla1ned/risks
• Consider <lnd offer vasectomy of the husband . (less

il'IV,aslve)
'
• Menstrual sequlae as a result of cessation of hormQnal
contraception rather than a direct consequence should
be discussed
• Documentation o f the counseling
4. Explain 15
---::,
• Tha t sterihza t1on 1s a , oermanen1 metbod for
contraceptmn but occas,onal1y 1t can fail. It will not
affect the health or menslrJal cycle.
• PreQJlrat,on lo.r_proc.e.d.u1e._under local oc...geoeral

anesthesia
• E•t~er laparoscop1cally or by mini laparotamy with a

small transverse supra pubic 1nC1s1on or throu~b the
posterior vaginal fornix (colpotomy)
"'
• Explain about comolication: anesthesia complications.
sometime laparoscopy needs to be converted In to mini
lapar,9tomy, hemorrhage pain, infection. l;i_te
c.omptlcation, Ecto pic pregnancy.
Explanation
lubal ligation, 1s a surgical sterihzat,on technique for women
• rh,s Procedure closes the fallopia n tubes, and stops the egg from
travelil\g to the uten.1s from the ovary. 1l also prevents sperm
from rea~hing the fallopian tube to fen,llze an egg
OSPE for MBB5: Obstetrics & Gynaecolog1
200
• In a tubal ligation, fallopian tubes are cut, burned, or blockerj

with rings, bands or clips. The surgery is effective immediately.
• Tubal ligations are 99.5% effective as birth control. They do
not protect against sexua lly transmitted infections,
including HIV/AIDS
Procedure
• Tubal ligation is a relatively simple out-patient surgery. 11

can be performed under local or general anesthesia .
• Mini-laparotomies and laparoscopies are the two mos1
common techniques for femal e sterilization.
• Other procedures nnclude laparotomy, culpotomy,
culdoscopy, hysteroscopy, and hysterectomy.
Each procedure carries different risks and benefits. ~iscuss su rgical

options with patient, describes the risks, benefits and answers all
questions asked by the patient before the surgery
Techniques of tubal sterilization
Techniques Special features

L1gat1on Pomeroy method used in min, la pa rotomy and
' laparotomy
Electro cautery / Associated with increased risk of ectopic pregnancy
dia1hermy and difficult to reverse,. may damage surroun ding
struc_tures, e.g. bowel, bladder, blood vessels. It has
relatively higher fai lure rates.
Falope nng Used Lapa roscopically, easy to apply.
Clips Simple, easy to use, technique of choice used
Laparoscopically, damages 2- 3 cm of tube ~aking
subsequent reversal more difficult. ~
Laser Very expensive, not widely used J
After surgery, it is recommended that w

and only perform light activities for a w omen take 2 _t~ 3 days o#
again when a woman feel f eek. Sexual act1v1ty can sta~
s com ortable, usually after a week.
s& Gynaecology
l)SPE for MBBS: Obstetnc 201
Advantages
ro l
• Pe rm an en t bi rt h co nt
• Im m ed ia te ly effective
• Allows se xu al free do m
nt1on .
• R eq u, re s no da ily a11e
• No t m es sy
ng ru n .
• Cost ef fe ct iv e ,n th e lo
Disadvantages
.
ec t ,ig am st se xually tr an sm itt ed ,nfecttons
• Do es no t pr ot
includtng HIV/ AIDS
• Requ,res su rg er y
w ith surgery
• Has ns ks as so ci at ed
M or e co m pl ,c at ed lh
an male stenl,z.iuon
•
• May nor be re ve rs ib le
• Po ssible re gr et
ss ,b ,h ty o f Po sr Tu ba l lig au on Sy nd ro m e
• Po
C-Omplicatio n
ns
• A ne st he s, a co m pl tc at •o ur e
ag e to 1n tra ab do m in al organs during pr oc ed
• Dam
re la te co m ph ca uo n
• Ecropic pr eg na nc y, a ra
Future fe rtili ty
rol
ns id er ed a pe rm an en t m et ho d o f birth conr
Tubal ligation 1s co ,o n ,s no r always ef fe ci iv e In
ba l hg at
Surgery to re ve rs e a
tu
n. re ve rs al s ar e bo rh difficult an d expensive.
additio
• \& y ff{ ,
Practice
Session Four
.,.
.... •
\ ' ..
' ' ;\ I.
' I
\ -
_,.-=i &Gynaecology osPE for MB6S; Obstetncs & Gynaecology
20S
unobserved f ation 1
see the photograph and answer the following questions.
Q, 1 Wha t Instrumen t 1s shown rn Figure?

Q. 2. How does il wo rk?
Q. 3. Give 3 indications fo r its use.
KEY:-
(1)
l, tr;y,svagina l USG probe)
2• §¥ ~roitriae bieb tceoueocv q-7.sMHZl, low iatensitv
(!)
sound wayps.
3• Mi<<ed abortion, sctopic pregnancy, early pregnancy
(3)
and follicular t racking,
EMplanation th
This test Is carried out by placing a specially designed probe in e
vagina. This technique gives the petter gualit'i of image of uterus.
o · ~ f I0 ser proxll'n lty of
vanes and other pelvis structures, because o c
th f Quencv used In the
e probe to th e pelvic organ~ and higher re
206 OSPE fo, M88S: Obstetrics & Gvnaetolog;
tra nsdu~er array. Transducer emfl& high frequency (3-7.SMHZ)~ low

intens11y sound waves.
Patient Preparation· no pat,ent preparation required

Duration of this procedure: a bout 10 minutes
Use s
• It provides better images (and therefore more informatio n)

in patients who are fu~ and/ or in the§_;;!~g~
(eregn] ncJ)
~
• t I cardiac pulsa!ion ca'!.!?e clearly o~erved ~

we ks of estation
•
• , . , .,. . ., __,,.~.,. ,. ------------------------.
-
Dlagnose retal a bnormalities in the first trimester and
,,-...,.,--...,-..,....-..........,......
second trimester of the pregnancy.
--
• ~etp I locali~atton and typing of low lying p~erlla
•
• For easuring endomet~ ~~ wua
ysfunction and in postmenopausa l bee ,ng
-- -
• Help,,,-.,~ ~~::-~t=::-::-::-::-.-::-:--....0;.::-=..
·11 diagnosing d ifferent ty es of abortio n
- -
M88S Ob>t•tNI & Gyna•tology
~,al 207
Station 2
c,flllldate's Instru ct ions
A pt1m1gra111da a1 34 week of gestation presented with h/o BP

1~0/100mmHg protein urea ••r She had Ots for last 3 hours
Answer the follow,ng questions
1 What is the d,agnos,s'
2 Whal spec1f1c lm,eSllf\illlOn you will perform In her case?

Give 3
3 Outline management plan
KEY:-
1 Eclamps,a l
l (Al uver function tests (BJ Renal func11on test (urea,

aeatm,oe) (Cl 24 hour urinary prote,n/creat,nme clearance,
ID) Coagulation prof1leJE!_a1elet coun1, PT. APTT) U S)
3 Management (2 5)
• Admit the patient
• Take de1a,1 hlslory from relatives and side by side

manage lhe pauen t
• Tur.[! thit woman on bee s,de with her h,:ad d0.w.

• MJ)l,1.110-.m- w..v-fllvLOXYll&!Li1Y.Jace2n,1sk, sR\/e
I/VJ1n1 <frdw blood for 1nvrs11g,1110.n
'208 OSPE fo, MBBS; Obstetrics & Gynaecoloty
• Sta rt Majlnesium
-
~hatels gm 1/V.bg!usland t~e
"¼;.11
mai.(ltance dose for 24 hou rs
• Start antihypeftt1nsive; keep systolic B.P. below l60

mm Hg and diastolic 100 - 110 mm Hg_. --..;__
• Deliver the patient once stable and asses' condition

of fe~s by 1/SG aod CIG..Jf(.l'iablek,cefecabl.v..d.e.li;;,
patient by caesarean section and if in labor
pro ressing well then deliver vaginally otherwise, if
0
fetus is dead then induction or labor wi th good
b1shop score can be tried Aim :s to d~ljver (be
, -
patient within 8 hours of fit;.
'"'-
Expl;inlltion
Eclampsia Is an acute and life-threatening complication of

pregnancy, is characterized by the appearance of tonic-clonK
seizures, usually In a patient who had developed preeclampsla. Key
warning signs of [clampsia, may be severe headaches, blurred 01
double vision, or seeing spots.
• Approximately 5-7% of all pregnancies are complica ted by
preeclamps1a.
• Preecla mpsia usually occurs in a woman's first pregnancy but
may occur for the first time in a subsequent pregnancy,
Hypertension In pregnant women can be broadly classified as
1. Chronic hypertensiQn
2. Non proteinuric hypertension (pregnancy induced
hypertension)
3, Preeclampsia
Sign / Symptoms
• High blood pressure and Protein urea.
r,,1ssS: Obstetrics & Gynaecology
osPf tor 209
• Tne ri.;.~~k;co~fitec~la~m~p~sl~a~ri;::se::s~as~b~l£02:0d~p:!,!r~e~ss~u!!_re~~~
0
above 160/110 mm Hg. increases
• Nervous system changes; blurred vision •

-'-...;.;::c::._~ ~ , seeing spots,
severe hea daches, convulsions, and even occasionally
blindness.
• liver changes ca n cause pai n in the upper part of the
abdomen; excessive bruising can be seen by altering
platelet count.
• IUGR baby
Diagnosis: Based on clinical features and investiga tions
Investigations: Liver function tests. (B) Renal function test (urea,

creatinine), (C) 24 hour uri nary protein/crea tinine clearance, (D}
Coagulation profil e (platelet co unt, PT, APTT)
Fetal assessme nt
./
Should be checked by@ :,:n::::on:.:;s:_:::r~ e..::SS:_:=.:.-c--;;i'----'-~- •'·
protll'f\;
Treatment
The treatment of eclampsia requires prom pt intervention and aims

are to
1. Prevent further convulsions

2. Control the elevated blood Rressure
3. Deliver the fetus.
• Admit the patierit I
• Take detail history and side by side manage th e patient.
• Turn the woman on her side with her head down. . · •
• M• k save 1/V line, draw
bl a,ntaln air way, give oxygen by f~ ce mas '
00d for Investigation and cross mat<:hlng.
210 OSPE for MBBS: Obstetrics & Gynaecoi
°tr
• Start Magnesium Sulphate. 4-6 g loading dose in 100 ml IVfluid

over 15-20 min., then 2 g/hr as a continuous infusion for 24.48
hr.
• Start antihypertensive; keep 8.P. below 160 mm Hg systolicand
100- 110 mm Hg diastolic. Hydralazine (5-10 mg IV every 15-2o
min until desired response is achieved) or labetalol (20 mg bolus
iv followed by 40 mg if necessary in 10 minutes; then 80 mg
every 10 minutes up to maximum of 220 mg}
• Deliver the patient once stable and assess condition of fetus by
USG and CTG . If viable preferably deliver patient by caesarean
section and if in labor and progressing we ll, then deliver
vaginally otherwise, if baby is dead then induction of labor with
good bishop score can be tried.
• Aim is to deliver the patient within 8 hours of fits.
(liVf. for '-"BBS Obstetrics & Gynaecology
211
Station 3
Af\Swer the following questions
II Ill IV
J Identify the d iagram what 1s 1t showing?
L What is lhe treatment options for condition shown in Fig. IV and

Fig I?
3. What are the risks to the mother in condition shown on figu re I?

give 3.
KEY:-
{1)
1. Showing the four types of placenta praevia
2- Fig IV : Placenta praevia type I treatment is normal vaginal
dj!liver~
Fig I =; placenta praevia type IV treatment is caesare:n
It)
delivery
a. Risk to the mother . ✓
• During antenatal geriod risk of vaginal bleed~g
~ d of bleeding.
• 'illfmia due ta cepeated ep1so es - .
=;.c---
arean secuon
• Rlsk_ol heavy bleeding durlli&$2.,.e,_,s
212
OSPE for MBBS· Obstetrics & GynaecoJo
gy
• Risk of placenta increta, acreta or percre!_a
• Risk of caesarean hysterectomy
• Difficulty in deliverfng baby through placenta (3)
Explanation
Definition: When the placenta lying partially or wholly within the

lower uterine segment
Incidence: during Second trimester (16-20 weeks) @nd at term·

0.5% (90% of low placentas resolve by term )
Types of placenta praevia
Type 1:@?w Implantation~ Lower placental margin dips into lower

uterine segment, edge lies within 2 to 3.5 cm of int ernal ce.rvical os.
Type 2:\Flarginal Placent!i) Placenta within@f interna l os, does

not cover the cervical os.
Type 3: fartial Praev,a ~ Placenta covers internal os whenJ! is

closed, & does not cover os when fully dilated.
Type 4: Complete Praevia (Central Previa): Placenta covers internal

os even when fully dilated.
MBBS: obstetrics & Gynaeco logy 213
oSPE Ior
Risk factors for placenta praevia

, ~revious Cesarean Section or uterine cu rettage
, High parity or Mu ltiple gestations
, Older materna l age
,
-
Uterine structural anomalies
, Tobacco abuse
symptoms
, Painless uterine bleeding "Sentinel bleed" m<!Y be provoked

with intercourse & uterine con tractions
' ft
• Abdomen soft and no n-tender
• Presenting part not engage and 5/5 pa lpable
• Patient may rarely present with shock
• Asymptomatic
Diagnosis: by USG preferably§
Counseling issues
✓
• Risk of severe life-th reatening hemorrhage, need for blood
transfusion
• Risk of feta l death
• Risk of maternal death
• ~ysterectomy may be needed to control bleeding
Management Protocol: The management of placenta previa

depends upon
• The amount of bleed ing

•• The co nd ..
1t1on of mother & baby.
The location
· of the placenta .
OSPE for MBBS Obstetrics & Gynaeco10gy
214"
• The stage of the pregnancy

Avoid d1grtal cervical exam, gentle spec1Jlum exam is
•
permitted
Delay delivery until lung maturit.Y.Jf possible
•
NSVD indications
1 Engage\! head (can tamponade marginal previa)
2 No brisk bteedmg on examination
3. Type 1 placenta praevia
Cesarean delivery indications

1 Type 1(11Yand 1-.r;;iacenta praevia
2 Unstable lie, heavy bleeding, hypolension and fetal
distress
3. Cesarean section at tertiary care center is r ecommended
MBBS obstetrics & Gynaecology 215
osPE for
unobserved ~ Station 4
Answer the following quest ions
Q. 1. identify t he specimen.
-
Q. 2. Wlhat is its mode of action?
Q 3. What are Contraindications to 1ts use

I
Give 3
KEY:-
1. C-op per T (an _lli,g2) 0.5
2. Mode of act ion 2.0
• The armJ of the Copper ~ IUCD contain copper wb1Cb s.tops

fertilization by preventing sperm from making their way_ up
throu_g_h the uterus into the fa llopian t11bPs.
• If ferjilization does occur. the IUCD waidd pre..\!,e nU.he.Jertill~ed

eg&1,roa@plant1ni in the lining of the uterus.
3- Contraindications 1.5
• Pelvic inflammat0ry disease
• Previous ectopic pregnancy
• Known ma lformation of uterus

=
• Copp~r _?llergy
216 OSPE for MBBS: Obstetrics & Gynaecol
og~
EXPLANATION
• An ICUD is a T shaped device Places inside the uterus.
• The arms of the Copper T IUCD contain copper, which stops
fertilization by preventing sperm from making their way up
through the uterus into the fallopian tubes.
• If fertilization does occur, the IUCD would prevent the fertilized
egg from implanting in the lining of the uterus.
• The Copper T IUCD is effective for up to 12 years.
• It does not protect against STDs or HIV.
• IUCD is 99% effective at preventing pregnancy .
•
Side effects
✓
• Increased !Jlens.trual Elood flow with non-hormonal IUCD
• lncreas.ed@:ysn;ienorrb~ '
• Increased risk of pelvic ~tion following insertion
Contraindications
• Previous pelvic inflammatory disease

• Previous ectopic pregnancy
• Know n malformation of the uterus
• Copper allergy
MBBS Obstetrics & Gyna&ology
o,PE 101 217
Stations
vou are a doctor on duty. A pregoant lady comes to you with H/O
lower abdominal pain. How will you take the history of this patient?
examrner will only observe you.
examiner's instructions
Student will take patient's history In front of you. You have 10 only
observe and mark according to Key. ·
KEY:•
, Confidence 0.5
, Eye to eye contact with the patient
• S~thetic with patient
• Use of non·m~d•c~_I jargon
Patient's profile 0.5
./
Name, ~Occupation, G.I'
Reasons for being in hospital/outpatient
~ .fi)icii -
Planned or accidental pregnancy
0.5
Pr'!!_enting Compla ints
• Deta ils of comglains. S1gns/sy,!!!Jlloms
•
-
Gestation on onset
-
Any treatment taken
218 OSPE /or MBB5 Obstetric:, & Gyna,,,Olt,c,
• He r con cer ns
• Uk_ely o bst etr ic out com e
• U.SG don e
0
AIJY pro blem in 1", 2°• o r 3' trim est er.
•
Me nst rua l His tory:
o.s
• M/C
• LMP
•
• H/ o of con trac eption
j
OS
Obste t rica l his tory.
• Marrie d for
...,,
• Gra y,ga, Para_
• QetaflSreg arding previous bab ies' duration of pregnancy,

mo de or deliven: we,eht of babies and any com plication
dur ing or afte r pregnancy.
• Bab ies breast fed . va ccinate d or no_!.

o.s
Past h isto ry:
• Medical and surg ical history

o.s
Fam ily his tory:
ase orT B
• H/ 0 dlabergs, Hypeqeosioo, cardia c djse
219
o~E for MBBS: Ohs.tetrlcs & Gynaecology
0.5
So(ioeconomic history:
• Husband occupation 1 monthfy income, socioeconomic
status etc.
220 OSPE for M8BS: Obstetrics & Gy~•
eco.,r,
Unobserved Station ~
l'.? b-S,,
Answer t he following questions
1 What is shown in photograph?
,,i , "'' '" I,

- --
; .
- --
2. What is feta l heart rate in the above trace?
3. What clinical situation it is showing?
4. What is the treatment option if patient is in labour with 3 cm

- -
dilated c.ervi~ and above said trace?
KEY:-
1. ~TG trace } (1)
2. €etal heart rate ~30-140 bpmj (I)
3.
7
F t~ glHCtSS with decrease beat to beat variability
(1.5)
and ?ecelerati9ns
~
4. Lwer segment caesarean section /1 S}
l ll
oSPE fol MB8S Ob>tt(tlcs
& Gyna•cology
fJ<planation
cardiotocography (CTG )
rdia c
te ch nr ca f "'! ea ns of rec ord i1JILJ •9rophy) th e fe ra l ca
• Is a g
or d, o- ) an d rh e ut er in e con1 ra ct io ns ( roco•) du rin
act1v1ty (c
la bo ur
eg na nc y, ty pi ca lly ,n th e th ird tri m es te r.a nd ,n
pr
s re co rd ing s ar e pe rfo rm ed by tw o separa te
• S1mul1aneou r
' on e fo r rh e m ea su re m en t o r rhe fera l he ar
r!Jlnsducers, ch of
d a se co nd on e fo r th e ut er in e cont ra ct io ns Ea
rate an
1her external or in te rn al
rhe tra nsducers m ay be e1
fo r 20
rd io to co gr ap h, c re co rding is usually m ad e
• A ca
ased IHI 12 0 m in ut es
minutes bu t can be mcre
Interpretation ·
• • •
·A
• •f
. . - • • C
bo ur.
A tyPi'cal CTG ou t pu t fo r a wo m an no t in la
he r
8: In di ca to r sh ow ing m ov em en ts fe lt by m ot
A· fe ral he an be at;
a bu tto n) ; C: Fe ta l m ov em en t; D. Ut er in e
(ca us ed by pressing
contractions
1 fo llo wi ng fin di ngs

" CTG one has to lo ok fo r ba se
.
hn e
lJr,r, ne al he ar t ra te feat ur es ·
d fo ur fe t
h- cont ra ctions an
tra te , .
lera r,ons an- d decelerat,ons.
•·~r - , va..;; r1ab ilit y, acce~:
:;:,;.!!
.;:.ar
-:-:.l he ..::=(FHR.:.):::: -'' -- ---
,..s Ii fe_ t rate
e ne ta
m
• Ranges fro m 110-16 0 bp
OSPE tor MBB~. Obstetncs & Gynaecolag,
222
• II is de~l?rmme d over a 11me period o f 5-10 minute1

expressed as beats per minut e (bpm).
-·
• Bradycard ia: - Fetal heart less than l lObpm occur in fetal
hypoxia, cord compression, 2:uoine hypotension,
hypotension associat ed wi th epidural analgesia.
• Tachy·cardia:- FHR more tha n l 60bp1n may occur In

matern al tempe rature , mater nal anxiety, exhaustion,
dehydration, feta l infection and fetal hypoxia.
Baseline variability
• IS the minor fluctua tion in baseline FHR
• It is asse ssed by esti mating the difference in bpm between

the highest peak and lowest trough of f luctuation in one
minute segments of the trace
V.
• FHR vari<1 bility is reduced in fetal h leep,ng phase of
the fetus, ma ternal administration of narcotics and
analgesics
Accelerations
• Are r i nt increases in FHR of 15b m or more above the

baseline and lasting for 15 second s.
• Loss of acceleration at CTG may be the first sign of fetal

hypoxia fo llowed by loss of beat to beat variability
Decelerations .,
• Are transient episodes of decrease of FHR below th e baseline 01
more than 15 bpm lasting at least 15 seconds. the re are 3 types
of deceleration, which are:
MBBS: Obstetc'ICS & Gynaecology
f
-• m
I, ~ rly - uniform, repetitive decrease of FHR with slow onset
early in the contraction and slow return to baseline by the en~
of t he contraction
variable - repetitive or intermitt ent decreasing of FHR wit"
2. ''
rapid onset and recovery. Time relationships with contraction
cycle may be variable.
J. complicated variable decelerations · the following additional
features indica te the likelihood of feta l hypoxia:
• Rising baseline ra te or fetal tachycarc;l ia

• Reducing baseline variability
• Slow return to base line FHR after the end of the contraction
• Large amplitude (by 60bpm or to 60bpm) and /or long
dura tion (60 seconds)
• l oss of pre and post deceleration shouldering (abrupt brief
increases in FHR base line).
• Presence of post deceleration smoo th overshoots
(temporary increase in FHR above baseline)
• Prolonged decelerations - decrease of FHR below the
baseline of more than 15 bpm for longer than 90 seconds
but less than 5 minutes.
• Late decelerations - uniform, repetitive decreasing of FHR
wilh, usually, slow onset, mid to end of the contraction and
nadir more than 20 seconds after the peak of the
contraction and ending after the contraction.
CTG RESULTS
CTG results can be interpreted in follow ing three groups
1· Normal antenatal CTG trace: has following fea tures
• Baseline fetal heart rate (FHR) is between 110-160 bpm

• Vanab,lity or FHR Is between 5·25 bpm
• Decelerations are absent or early
• Accelerations x2 within 20 minu tes,
OSPE tor MBBS, Obstetric1 & Gyna
22~ ecoJQry
• g CTG ·t race·• has following features

2 . N on-reassuron _
Th~se are unlikely to be associa ted with s1gni f1ca nt_fetal
comoraro1Se wh en occurring in isolatio n. However the presence 01
t:,o or more feature s is considered abnori;na l as th~ be
associated w ith fetal com promise and require further act ion
- • Baseline FHR is between 100-109 bpm or between 161-170
bpm
• Variability of FHR is reduced (3-5 bpm for >40 minu tes)
• Decelerations are variable without complicating features
• Absence of acceleratio,ns
3. Abnormal CTG trace Is whe re:

The following features are as~oc1ated with significant fet al
comprom1se and require further act io n
• Two of Lhe features described in no n-reass uring CTG trace
are present
• Baseline FHR Is <100 bpm or >170 bpm
• Variabi lity is absent or <3 bpm
• Variability is si nusoida I
• D
.•_e:c~e::;
le~r-:-a-:-
ti.:.
o7"
ns:...::a~re::....i:p~r:::!o.!.!lo~n.!.l,g~e:gdc..tll..~..lll!lll.
- - or >3 m io_utes / late / ~e
compl icated varia bl es
Use of CTG during the th· d .

,r trimeste tO •
called a nonstress test. r monitor feta l wellbeing 11
2,(ltress ~ se of th· .
n.;;;,, 1s machine d .
~ unng labor Is call ed a_{stressJ
MBSS obstetrics & Gynaecology
oiP£ ror
22S
unobserved
Station 7
()ndidate's instruct ions
carefullvsee the diagram and answer the following questions
I
'
I
.
.
.• • •I
-1~
I~· l_;;, l
. ~
Q I. What is the diagnosis ancl how you will define il? (2.. 5)
Q. L What are the srgn and symptoms or this condition? Give two.
Q.3. What is the treatment options?
KEY:-
1. lm~rforate hymen: It is the simplest congenital abnQrmfillt\Llll

Ou.!flow genita l tract, where menstrual blood is tra12ped behiad
a~mena l membrane:-- - - - - - - (1.SJ
2 Sign and symptoms (1)
• CJcllc lowe r abdominal pain
• Fail lo initiate the menstrual flow
• B~sh bulging membrane seen at lntroit~s
226 OSPE for MBBS: Obstetrics & Gvnaecol
ogy
3. Condition is resolved by giving cruciate incision at hymen WlJich

releases the roeostc11al blQod . (2)
Explanation
Definition : lmperforate hymen; It is the simplest congenital

abnormality of outflow genital tract, where menstrual blood is
trapped behind a thin hymenal membrane.
Frequency: It is the most frequent obstructive anomaly of the

female genital tract; varies from 1 case per 1000 population to 1
case per 10,000.
Etiology: lmperforate hymen result from abnormal or incomplete

embryologic development.
Clinical features: Patient may present with
• ~lie lower abdominal pain or pelvic pain
• Abdominal mass due to a large hematocolpos and

hematometra .
• Failure to initiate the menstrual flow
• Bluish bulging membrane seen at introitus
• urinary retention, and constipation due_!Q hematocolpos and

hematometra
Examination
An fmperforate hymen is visible on vaginal examination as a

translucent thin membrane just inferior to the urethral meatus that
bulges with the Valsalva maneuver. This bluish discoloration is due
to the presence of a hematocolpos visible behind the translucent
hymenal membrane. Vaginal septa do not typically appear
translucent.
r,,1ees, Obs1etncs & Gvnaecology
os,(for 227
ding on the size of the h
and volume
oePe11 h 1. ematometra
ocolpos, or ematosa p1nges, a pelvic or abdominal •
he,na t . bd . mass may
lpable during a omrna 1or rectal exam ination
3
beP ,.,,.....,-,,---:--:-:--:--...,... ·
tovestigations: Pelvic and abdominal ultrasono ra h Is the Initial
di ~st, followed by MRI 1f any doubt about the anatomy.
Treatment
Medical Therapy
OCPs or NSAIDs can be tried for temporary relier & to buy suitable
time for surgery
Surgical Thera PY
The timing of surgica l therapy is based on the presence of

symptoms.
E~pedient treatment is appropria te when it manifests with

hematomet ra and hematocolpos. Surgical correction should be
definitive.ie hymenotomy (opening up the hymenal membrane).
The hymenal orifice is enlarged by using a circu lar incision following

the Imes of the norma l annular hymena l con figuration,
Alternatively, a cruciate incision along the diagonal diameters of the
hymen is given; avoid injury to the urethra, inci,sion can be enlarged
by removal of excess hym enal tissue. In either approach, hemostasis
15 required by using in terrupt ed stitches w ith fine all~orf)able suture
(eg, 4-0 Polyglycolic acid suture) .
PoS!operative Det ails
The Patient should be(lnformed}ibout con tinued drainage of dark.

th
't~, old blood for several days to a week after the procedure
228 OSPE (or MBBS: Obstetrics & Gvna,~
6 rofe.hothe NSAID may be prescribed for the uterine

cramglng. Topica l lidocaine ·ell is recommen ed fo r the vaginal
orifice.
Complications
col OS
Stenosis and reaccumulation
•
mucocele. ✓
• Pelvic inflammatory disease
• !~jury to the adjacent urethra, rectum, or bladder is possibl
if the anatomy is disturbed.
ass. Obstetrics & {iyMecotogy
01P< tor 111
229
I> 1' /::,. Statioe)

can d1
·date's instructions
A35 year old nulliparous Mrs. - presented to you with history

of exce;sive cyclic vagio;iJ bleeding f~r 1 year. She also complained
of freguency of roic1 11 catioo since 6 months. on examinallon
,bd~m?n is di~tended w ith 20 weeks size firm rnpss arising.from the
pelvis USG done showed a 12 x 10 cm mass arising from the
poster10r wall of th e uterus and also distorting the endometrial
cavity,
Q. l What 1s the d1agnosis7
-·
Q. 2. V/hat Is the risk factors for the condition?
Q, 3. What is the treatment options for this woman?
KEY :-
1. l i~oid uterus) 1
t Nulligai:lty, ob!;?sity, a posit!<e' fami ly history and ~ n

rac,al origin & age 20 - 35 y~ rs of age LS
3 Conservative management w i~ 2.5
• •
Medical ther<!J)tes, ant1prostag1an ct·in 5, GnRh analogues,
• Uterine artery emboliiation,
• Myomectomy
;=3z;!:._ '
OSPE for MBBS: Obstetrics &·Gynae I
230 coor,
Explanation
A fibroid ls a benign tumor arising from the uterine smooth muse!e,

termed a leiomyoma.
Incidence 5-20% of woman of reproductive age
Risk factors
• Nulliparity, obesity, a positive family history, and African racial

origin & age 20 - 35 years of age Oestrogen, growth hormone,
possibly human placental lactogen play part in the growth of
myoma.
• Myoma rarely found before puberty and regress following

menopause
• In 0.5% of cases malignant change can occur in myoma i.e,

leiomyomasarcoma.
Clinical features
1 ~ommon presenting complaints are menstrual disturbances,

rnenorrhagia due to submucous fibroid that distorting the
endometrial cavity and increases the surface area leading to
menorrhagla.
2. Pressure symptoms especially urinary frequency
3. Pain may occur due to acute degeneration
4. Subferlillty may occur due to mechanical distortion or

occlusion of the fallopian tubes or may interfere with the
embryo implantation by dlstort,ng the endometria l cavity
5. On abdominal and pelvic e>caminatlon firm mass can be

palpable
tor MBBS: Obstet11c, & Gynaecology
oSPE
231
Diagnosis
history examination an d invest iga tions

8y ~
@ielps in making diagnosis
Treatment
J. conservat ive t reatm e nt
• If fibroid asym pto matic or size less than 12 cm- do

nothing or use GnRH agonist for shrinkage o f fibroid
2. Surgica l trea tm ent
If symptomat ic and large fibr oid, choice depends upon age, parity
and fertility wishes.
• Myomecto my Can be facilitated by prior use

of GnRH analogous for
• Uterine ar te ry em bolization shrinkage of fibroids
r
•
232 -·~.
OSPE for M88S: Obstetrics & Gyn~L
Unobserved
Carefully see the photograph and answer the following questions
Q. 1. What is the procedure shown in photograph?
Q. 2 What it is used for?
Q. 3. How ii is used? ..
~ h a t are the abnormal fea tures seen wi th this instrument.
KEY :-
1. Colposcopy 05
2· Used ~or examining the cervix, vaginal wall and
vulva m case of s~s~idon of malignroisease. l
abnormal v
3- Fjrsr used to exa mine
· "blood vesse ls
1>atterns th en@a~cetlc acid is applied to the area
which h.1 hi"1 --
- 6 Shts dvsplastic areas as wh ite
es:obstell ,cs & Gynaecolocv
,or!VIB 233
cor!)Pared with the pink of the squamous
~~ - 1.5
4- ~ S ,
~f)Q gsaicjsm or punctuation, {aceto white epithelium

and ab norma l sub epithelia l ca pillary pa ttern may
be revealed as mascaicism or punctua tion)
/ ~ty_gical blo-0.ci..y.ess.e.ls... -
~ _Abnormal branching blood vessels.
~ (lnv s,ve cancer shofsLcomma sha ped Qr cork-

2
screw shaped vesse ls with wide, irregular mosaics
Explanation
• Colposcopy is a binocular instrument to examine an

f
illuminated, magnified lQlo timesUview of the cervix and
the tissues of the vagina anc vulva.
• Helps in diagnosin man remali nant and ma li nant
lesions of cervix, vulva and va~ina
• The main goal of colposcop is to revent cervical cancer b
detecting precancerous lesions ea rly and treating them.
1ndications for colposcopy
iagnostic indications 1
~~
• Cytological abnormality on pap smears.

• An abnormal appearance of the~er9
• ~rmal area on the vagina and vulva V-- .
• P__reoperative assessment in ea rly slages of cancer rervix 1
• u h patliologlca
- sefu l for taking biopsies for furt er '-'
examination
OSPE for MBBS. ObsteUICS & Gynaec
234 ""'rv
. th lstilbestrol ex osure fn utero,
• Assessment o fd ,e .
• . ., In imm uno suppression such as HI'·
• Help ,n screen1nt> . ~
,nfect1on, ~ran organ transplant pat!~nt .
✓ l assault in forensic examina tion
As a part o f a sexu a -
Therapeutic indications
•
conservative treatment with laser and cone

• HepI ·in pre c·se
1 -
biopsy in CIN 1 lesion
Help in follow-up in conservative treatment
•
The procedure
A colposcope is used to identify visible clues suggestive of abnormal

tissue. It functions as a lighted binocular microscope to magnify the
vlew of the cervix, vagina, and vulvar surfa ce Acetic acid solution
and iodrne solution {Lugol's or Schiller's) are applied to the surface
fo Improve visualizallon o f abnormal areas.
Colposcopy is a si mple, 10- to 15-minute painless office procedure

Colposcopy is performed In Lhe£m6otomy positipnJA specufurn is
inserted in lhe vagina after the vulva 1s examined for any suspicious
lesions and cervix is exposed,., colposcope focused on the external os
at a distance of about G,,Cl£!J: The cervix is gently swabbed and
cleaned with the saline to remove-mucous. The squamocolumnar
1unct1on is inspected before and after applying 3% acetic acid
solutton Abnormal epi1helium appears acetowhite due to
preciplta1ion of protein. Areas or the cervix which turn while aftef
th: appllcallon of acetic ;rtid or have an abnormal vascular pal;';%
are often considered for biopsy. •
Colposcopic finding
Normal
• Normal columnar epithelium looks/red grape like \1ructure

with furrows. • ·
• Squamous epl1hel1urn looks homogenou~y .
. Ob 5tetriC.S & Gynaecology
,orMB85 235
olJf
al findings
~bflor"'
Abnormal areas appear acetowh ite after application of
• acetic a9-d .
• AZetowhite area shows coarse rnosaic pattern with irregular
mosaic formed by the vessels running parallel to the
surface.
• vessels runn ing perpendicular to the surface show up as
irregular, large punctuate red spots.
• Acetowhite area is irregular with raised papillae.
, Invasive cancer shows comma shaped or cork-screw shaped
vessels with wide, irregular mosaics.
Colposcopy of the vagina

Because of the wide su rface area, colposcopic examination of the
vagina is difficult; however it is indicated in the following conditions
• Abnormal papsmear but normal colposcopic findings of the

cervix.
• To rule out extension of CI N
• Gross lesion present
• Women with HPV vira l infection.
• Follow up of hysterectomy or conse rvative therapy
performed for CIN d isease.
Colposcopy of the vulva
Difficult due to Keratinization and deep seated vessels
Complications/Risks
• The procedure is relatively safe. Major risks include

bleeding, infection, and pelvic or abdominal pain
• Failure to identify the lesion.
• Col rcations with
Poscopy during preghancy may cause comp 1
th e pregnancy, including early labor.
236 ,..,..
OSPE for MBBS. Obst.et<lcs & G
~
1i
Unobserved Station lo
Candidate's instruction
Carefu lly wat ch the photograph and answer the following

ques t ion
1. What is the procedure shown in photograph?
2. What are lis 111dica tions? Give any 4
3. What are the major concerns of this p rocedu re? Give two.
4. What is its success rate?
KEY:-
,°t:.{, 1. Intra cy_toplasmic soerrn ,niection (ICSI)

o.s
1
~~U"tl'( . Jc. . Indications
1sJ~~ • Tubal damage
• Unexplained infertility
.r: Endo me trioses
Polycyclic ovarian disease
• Male factor infertili ty
!BBS. Obstetncs & Gyna~,ology
~Spf fO' N
237
Major concerns
3 2
• Ova~a n Hyper stimulation syndrome O~ &5

• -
M ultiple pregn,;1Ju::ies
,
• High COS!
• Success rate 30- 40%
4. Success rat.!!@J@ o.s

Explanation
1($1, stands for intracytoplasmic sper m inJection. ICSI may be used

as part of an IVF treatment. During ICSI, a single sperm js injected
directly into an egg.
Indications
Male factors infertility
L In cas•e of sperm abnormalities, including:
• Very low spe rm count (also known as oligospermia)

• Abnormally shaped sperm (also known .as
teratozoosperm ia )
• Poor sperm movement (also known as asthenozoospermia)
2· If a man does not have any sperm in his ejaculate, but he is

producing sperm, they may be retrieved through testicular
sperm extr action, or TESE. Sperm retrieved through TESE
require the use of ICSI.
3 In ca . . h are retrieved from

se_s of retrograde eJac1Jlat1on, t e sperm
1~e man' s urine.
4
ICS! may also be done ,r regular IVF treatment cycles have not
ach •eved
' lertil,za tion.
OSPE for MBBS: Obstetrics & G
238 Ynaeco1o
r,
Female factors infertility include
1. Tubal damage
2. unexplained infertility
3. Endome trioses
4. Polycyctic ovarian disease
Procedure for ICSI
• ICSI is dlone as a part of IVF, ov aries are stimulated With
ovarian st imulating drugs,
• Progress w ill be monitored with blood tests and
ultrasouinds.
• Once enough good-sized follicles, are available, the eggs are
re t rieved with ultrasound-guided needle.
• Sperm sample is taken on the same day
• Once the eggs are retrieved, then placed in a special
culture, by using a microscope and tiny needle, a single
sperm will be injected into an egg. This will be done for each
egg retrieved.
• If f ertilization takes place, and the embryos are healthy, an
embryo or two will be transferred to the uterus, via a
ca t heter placed t hrough the cervix, two to five days after
t he retrieval.
ICSI Cost?:ICSI typically cost s between 250,000-350,000 Rs.

Risks
1. Multiple pregnancies
2. Ovarian hyperstimulation synd rome
Safety of ICSI for the Baby?

• · h t Iy increased r isk o f ~~/
ICSI trea t ment carr,·es a s11g
~
• An increased risk of~.x c5.tomosome a!5nortnal!tle@occur
th
in less ain l% of babies conceived using ICSI w ith IVF.
• There is some increased risk of a male baby having fertility

problems in the future . Th is is because male infertility may
be passed on genetica lly.
success Rate for ICSI is 30-40%
'
'
I
:
I
',
'
OSPf for lll!BBS; Obstettoc, & G
-,~
't'n~t...
Unobserved Statio,,
11
Q, 1. What type of delivery Is shown in the above Ogure?
Q. 2. What is the indications for such delivery? Tell any four.
Q. 3. What is the prerequisites for its use? Tell any four.
KEY:- l/
1Gi.a,wm deliv;,;\ ~foe/~\- I
--=
2. lndic-atlo~s ,,
/ 0~ -~
2
G Qela,y in the secpod stage of Labou.1

II. fe tal distress jg the serond st;Jge of labour
111 01
~ternal condit ions requiring the §bPC\ ,:;econ~
Wlp1.1r
• •
Pr9J,o,nged second stage of labour
V. Ma;,ernal distr~
MBBS: Obstetrics & Gynaecology
,~ 241
3
prerequisite
I. ✓F~ 'I dilation of the cervix however in mutt'1grav1

stretchable cervix can be applied at > 8 cm •
-
.da with
m case of
2
emergency
, I
11 / Fetal membranes should be rup~ed
111/ / Vertex Presentation v~J....,

IV. Position of the presenting part should be known
v. Head should be engaged at zero station or below

- ~
VI. Cepj)lopelvic disproportion should be ruled out
VII. Na'dder should be emptied "'
Explanation
Ventouse is a vacuum device used to assist the delivery of a baby

when labour has not progressed adequa tely. It is an alternative t o a
forceps delivery and caesarean section. This technique is also called
vacuum-assisted vaginal delivery or v.acuum ewtraction
1ndications for use of vacu~m
• Delay in the second stage of Labour
• Fetal distress in the second stage of labour
• Maternal conditions requi ri ng the short second stag,e of

labour
• Prolonged second stage of labour
• M aternal di stress
Types of vacuum Extractors
OSPE lor MBBS· Obst01r.t1 & c;
·~
y"'"•
There are two types of vaccum cup metal and soft cups_"'
01
· h . 'II
recently, bell-shaped and hemrsp enc s1 cone rubber cups na,'
11
come into use.
Prerequisites for vacuum delivery
Select the correct size and type of the vacuum

•
Proper indication for its application {delay in second stag,
•
of labour, feta l distress in second stage, maternal condition
requiring to shorten the second stage).
•
•
-
Cervix should be fully dilated and head engage
.
Bladder ShOUld be ~mpued
• Membranes are ruptured
• Good uterine contractions should be present
• No cephalo pelvic disproportion
Procedure
F'IGURE: P,oper placement of the cup used in

I
vacuum extraction. The tenter of the cup should
be over the .saglttal ~uture .and 1bout 3 cm U ,2 .l

In} In front of the posterior fontanelle. The cup rs I
generally place~ as far postenorlv as POSSible
After fulfilling the prerequisites, give adequate anesthesia either bV

1 spinal or pudendal block, The fetal present~ion,
an ep,"dura,
.,oos: Ollstetl ics & Gynaecology
,ilf'flOI••• 243
and station a re then confirmed and the worn , 1

~ _ an ,spaced in
the l ~ n, A suction cup is placed onto the head of the
babY, on
_.the flex,on point, about 3 cm anterior from the ace1pita1
; tenorl fontanelle. PreJ.-~ure is build up up tli;,0.8 kg/cm:)hen the
1
tractton is applied with each utetine contraction, ,n line with the
pelvic axis and coofdinated wjtn.mate.raal expulsjve efforts The cup
nould not be reapplied more than twice. When the head 15 born
~ e is detached, allowing the w.oman to complete the
delivery of her child.
1
r the ventouse attempt fails it may be necessary to deliver the
infant by force ps or caesarean section.
Contraindications for Vacuum Extraction
• Fetal prematurity 1<34 weeks of gestation}
• Fetal scalp trauma
• Une ngaged head
• Incomplete cervical dilatation
• Active bleedlng or suspected fetal coagulation defects
• Suspected macrosomia
• N.2_nve~tex presentation or other malpresentation
• Cephalo pelvic disproportion
OSPE·for MSBS: Obstetrics &Gy
244 •ate,
Complications
Ma ternal
• Trauma to the genital tract
Fetal
• Chignon
• Cephalhaema toma, lntracranial haemorrhage
• Retinal hemorrhage to the baby and j aundice
• Subgaleal hemorrhage
i-100s· Obstetrics & Gynaecology
osPE '°' 245
Statio,fu.)
A 45 year old P6 presented with the history of postcojtal and

intermenstruat bleeding for 6 months. A cervix is as shown in
photograph.
1. What is the mos t likely diagnosis'

~
2. What are the ca usative factors for such disease?
3. What ,s the treatment options depending upon stages of this

condition?
KEY:-
0.5
1.
-
Carcinoma Cervix
2· Causative factors are 1.5
V. Early marriage V
Multiple sexua l partners

~-
14,
f/i I/,
.,. •<:,.
/\
Human papilloma virus infection

c
_ _ _ __,A-Pd__
OSPE for M88S' Obsll!trlCS & Gvnif<ol
"«v
246
• Smoking
Im munosuppression
•
3
3. Trea tment options
cone biopsy, trachelectomy or
• Stage O ano ! Al
h y~terecto my
Early stages {1B1 and IIA less than 4 cm) ----radical
• liys1ececwm¥ wit,b 1emoval of the lymph npdes or rad,a1ign
t herapy.
t arger ea;IY stage rumors (1B2 and IIA more tha11 4 cm) -
• (,radiation thera y 1, and cisplatin-oased. chemotherapy,
hysterectomy + radiotherapy, or c,splatm chemotherapy
f ollowed by hysterectomy. '-
Advanced stage tumors (11B-IVA) are treated with radiation
•
t herapy and c,splatin-based,chemotherapy
Expianation
• Cervical cancer arise s from the interior lining of Lhe cervix.

• Most often diagno~ed ,n middle-aged women, usually between
the ages of 35 and 55.
• The five year survival rate of i nvasive cervical cancer is currently
71%
• lmpr ovementJ; in screening and the deve lopment of
prophylactic vaccines have decreased the incidence of late-stage
cancer.
0
Types of Cervical Cancer: There are two main types of cervical

cancer: squamous cell carcinoma (90%) and adenocarcinoma (10%)
• Bo th '.ypes have similar risk factors, prognosis and trea tments.

' '
Risk Factors for cervical cancer

• • th
• Human paplllomavlrus (H PV) Infection Is associated w i
v irtually all ca~es of cerv,,at cancer.
tor M885: Obstetrics & Gynaecology
- N7
, A family history of cervical cancer doubles th .k
, Most ly cerv1ca cancer occurs after the age ofens_ .
• 1
,
20
Increased numbers of sexual partners and lower age at first
sexua l act have both been associated with increased risk.
• Smoking increased t he risk of CA cervix.
symptoms
, lnterm enstrual and postcoitaf bleeding
, Profuse offensive vagina l dischar~e(may be blood stained)
, Pain at late sta~
Examination: On inspection there may be small ulcer or nodule on

the cervix or cauliflower like growth. --
Diagnosis; is by
, Pap smear, Colposcoey & biopsy
• HPV tests are available to detect the presence of viral DNA
Cancer Staging
Cervical cancer is staged by th

O!) clinica l examination.
Stage O • full-thickness involvement of the epithelium without

Invasion into the stroma (carcinoma in situ)
Stage I - limited to the cervix .
• · 'bl e lesions
IA . diagnosed on ly by microscopy; no vIsI I depth and
, IAl . stroma l invasion less than 3 mm n
7 mm or less 1n horizontal spread d S mm with
• IA2 . strornal invasion between 3 an
horizon tal spread of 7 mm or less w·ith more than
• •
18 - visible lesion or a mIcrosc opic lesion th•n 7 mm
. ad of more "
5 mm of depth or honzonta1spre . reatest dimension
• JBl . visible lesion 4 cm or less I0 g
• 182 • visible lesion more th an 4 cm
tncs & Gu colog,
OSPE fo r MBBS. Obste ,nae
248
. . .
yo nd cervix
Stage 11 - inva des be
pa ra m et na l rn vas, on, bu t involve uPPer
• IIA . w ith ou t
.
2/ 3 o f vagrna
et rial invasion
• lfB - w ith pa ra m gina
s to pe lv ic w al l or lo w er th ird o f th e va
Stage 111 . extend th ir d o f vagina
■ /IIA • involves lo w er causes
ex te nd s to pe lv ic w al l an d/ or
• 11/B .
on ep hr os is or no n- fu nc tio ni ng kidney
hydr beyond
o f bl ad de r or re ct um an d/ or extends
a
IVA . invades mucos
true pelvis
astasis
• IVB - distant met
Trea tm en t
ag e o f th e ca nc er , su rgery can be cone

e st
• Depen ding on th ra d ical hysterectomy,
and
st er ec to m y,
biopsy, simple hy
Or
pelvic externation . apy are
ex te rn al ra di at io n and ch em o ther
• In ternal o r
fo r cervical canc er
poss ible treatments
n be tr ea te d w ith cone biopsy, ff a cone

l ca
1. Stage O and lA m argins, one m or e po
ssible
t pr od uc e cl ea r
biopsy does no w an t to preserve their
r pa tie nt s w ho
tr ea tm en t op tio n fo at te m pt s to surgica
lly
he le ct om y. Th is
fe rt ili ty is a trac ng th e ov aries and uterus .
while pr es er vi
remove the cance r ic al cancer which has no
t
fo r st ag e / ce rv
It is a viable option
is st i ll unde r tra il. with
spread; however, it cm ) ca n be treated
l and IIA less than 4
2. Early stages (/ B m ov al o f th e lymph nodes or
y w ith re
radical hysterectom ap y is given as extern
al
R ad ia tio n th er
radiation therapy. lvis and brachyth
eraPY
er ap y to th e pe
~eam rad io th
(internal radiation) . Y
m or s (/8 2 an d /IA m or e th an 4 cm) ma
e tu
3. Larger early stag ap y and cispla tin -bas
ed
ra di a tio n th er
be treated w ith ap y, or
· platrn
crs
hy t ad io th er
chemotherapy, s erectomy +r y
wed by hysterecto m
chemotherapy follo
-f- rv,eas, obstetrics & Gynaecology
Adva nced stage tumors (IIB•IVA) are treated with d. .

4, therapy and c1sp
. 1atin•
. based chemotherapy. ra 1a110n
~
p,ogmosis
oepe nds on the stage of the cancer.

. With . treatment• the
, 5-year
1 tive survival rate for the earliest stage of invasive cervical cancer
:: ; 2%~ the overall (a II stages combined) S·year survival rate is
abou,tWJ () •.!I
"'(S.'-0
OSPE ror MBBS: Obstetn" & GvnaecoloiY
250
Station-~
unobserved
h d answer the Following questions
Carefully see the photograp an
--
Q. !. Identify the specimen . What is it used for?
Q. 2. What is its mode o f action?
Q. 3. Give fts 4 side effects.
KEy:-
J
l ~ ct ion Deoo-erovera, used for contraceetion J
2. Mode of action : 2
\
• Inhibits ovula,tion
• Altering the c,ervical mucous, make il viscid and ereve~ts

penetration of seerms in to t he cervical cane I
3. Side effects 2
• Weight ga in of around 6 lb In the first year
• (?elay in return of fertility. 11 may take about s,!1< to 9

months longer to col')ceive after stopping injection
os,t for l';IBBS: Obsterncs & Gynaecology
251
• ..-1>erslstent men strual irregularity
• Very long term use may7'i"htl .
. ~ Y increase thP risk of
osteo porosis.
,
• Head ache
• W eakness/fa tigue
Explanati on
oepo-Provera is a hormonal cont "acept,ve.

- - =.::.:...-..:="r ' · It_ contains
medroxyprogesterone acetate without oestrogen, and is
. dministered to women in the form of an intramuscular injection
every 3 mo nt~s.
Mode of action:
• Inhibits ovu lation
-
• Altering the cervical mucous, make it viscid and prevents
-
penetration of sperms in to the ce rvical canal
• It is 99 .7% effective in preventing pregnancy. It does not,
however, protect against AIDS or any other sexually
transmitted diseases.
Benefits: Depo-P rovera has several advantages:
• Highly effective, i nj ected every 3 months. .,,.

• No oestrogen, so no increased risk of DJf, pulmona ry
embolism ~ stroke, or myocardial infarction.
• Minima l d rug interactions
• 80% ecreased risk of endometrial cancer. The reduced risk
of endometrial cancer due to bo th the direct anti•
the endometrium and
proliferative effect of progestogen on .
ls t>y su1
ppress1Qn of
the indirect reduction of oestrogen IeVe
ovarian follicular development. .
. anemia pe1v1c
• Decreased risk of iron deficiency ' .
. . regnancv. and uterine
inflammatory disease (PID), ectopic P ~---
fibroids.
252
toms of endometriosis .
d
Decrease sy mp
• Decreased incidence of primary dysmenorrhea, ovulation
• pain, and functional ovarian cysts.
Decreased incidence of seizures in women with epilepsy,
• and its effectiveness is not affected by enzyme-inducing
a ntiepileptic drugs.
Safe during breastfeeding
•
Side effects
• Menstrual irregularities (bleeding or ameno rrhoea or both)
• Abdominal pain or discomfort
• Weight changes
• Headache, weakness/fatigue, ne rvousness
• Use for more than 2 yea r is associated with risk of
osteoporosis.
• Delayed return of fertility. The average return to fertility is 9
to 10 months after the last inject ion
Contraindications
• Arteria l cardiovascular disease
• Current deep vein thrombosi ~ o r pulmonary embolus
(PE) '
• ~ 'if!r~ine
• Unexplained va&qal ble~ding
• Cancer of th e breast or reproductive o rgans,
• Known or suspected pregnancy, or allergy to the medication
in Depo-Provera.
• Active liver disease
• H!story of ischemic heart disease/ stroke
• Diabetes for > 20 years or with
. nephropathy / ret1nopat
· h''1 /
neuropathy or vascular disease
( MBBS: Obstetrics & Gynaecology
osPE(0 ' : 253_].:)
~ Station 14
Candidate's inst ructions
A,8 year G. Pi presented with history of 22 week gestational

amenorrhea wjth funda I height of 28 weeks. She is unable to feel
fetal movement till now. Her ultrasound done yesterday, this
showed snow storm appearance and absent fetus
-► ~ ~'¾-::- - '
Q. 1. What is the oiagnos,s?
Q. 2.What Is the e: iology, Give 3?
Q. 3. What is ,ts incidence?
Q. 4. How will you manage her?
KEY~-
1. Hydatidifo_
r m mole • 0 .5
2. Etiology 1.5
/ Extrem~ of maternal age. (age less than r15 iracs and

.mo re than 40 years).
/ Previo us history of pjolar er:snancy,)

•
✓ Multiparity • •
I •
....,. J.owersocioeconomic group on a p9gr rice diet
✓- • Dietarv deficjeQCY jg a,Ptein, folic'apdanQIcon

omen are
1 arents. Blood Grou A
a:i-the higher risk JbQO Bloodero11POwomen.
OSPE for M88S: Obstetncs & Gynaecology
254
3. lncidence:(Lpg)i-000 - 2000 pregnan~es o.s
4. Management.
2.s
• cour<e! tbe --JlalieAt. f;ifplain file coAElitioA its risk and
t9mplications and t_r;atment options.
• S;!}lserum fHCG and explain its significanc~.
suction evacuation under general

• Explain surgi[al
•
.,,_
anesthesia.
•
' . I
• (quo,.,ing surll:!:_V RHCG fo(toictitii/un til unde tectable and
-
then monthly tjll 6 months in partial mole and for one year
in~
Explanation
Molar pregnancy is an abno/mal form of pregnancy. where m a

non-viable, (ertifii ed eggimplants in the uterus. It Is chnracterlzed
•
by the presence of a b~rlatiditorrn rnole
•
Epidemiology: Incidence
• NQ!!hflrnerica and Europe: 1:1000 to 1:lSOJ nregoaocies
. • Asia and Latin America: 1;400 to 1:200 pregna ncies
Etiology: Not completely understo~ d. ~oten1,af -,sk factors mav_

include • " •
trio· molar pregnancr •
~xtremes of reproductive agf, ugder 20 years or•over '!.5
5
ea~
win Gestation
igh parity
5 • alnutrition i ein folk acid an earotene.
~ De eels in the egg, abnormalities within the uter_y_
s,
,:/ Women w,th'blood group A'has higher risk 1t,a11 wo~an
•
.
with blood group a -
oSI'( for MBB~: Ol>steulcs & Gynaecology 2.SS
Molar preg_nancies are categorized int~artial and complete molt>s.
complete moles
• No- ielentifiable emb-,:anic or fetal -tissues

-- ·ct ence o f
, no ev1
feta 1vesse 1s.
• Arises when an e,rnpty egs_with QO nucleus is ferijlized by
<U1e (or occasionally two} normal sperm; total hydatidifor,;,
c_!!ange , "
0
• •
• Marked rolif • 'IJ□n °t tropboblastjc ceus
• Karyotype. 46XX ' II paternally derived) 0
• Oenved from h~ ploid 23X sperm

• ~perm duql!cates chromosomes without cell
'
division
• ~igher nskCoematieoaoJ chagge
•
Partial mole
• Associated with non-viable fetus or vessels only

• !11oderate trophoblastic proliferation
• ~ normal egg is fertilized by two (or occasionally three)
spermatozoa,
• Karyotype: Triploid (69XXX or 69XX_::!:}
• Malignan t change less like ly tha n in complete mole
. - ,
Hydalidiform moles-may develop into chor-iocarGinoma •
.
h
Clinical presentation: Molar pregnancies usually present \\iil
•
3r 4
1. f'.!!inless vaginal bleeding during pr~gnancy in ct· !:'
month
2 l:!YPeremesis GravidaruT
l PasSilgc: of_gt.alliilikP vesicles from the uterus
4 Abdommal Pain early in pregnan"Y.
OSPE for MBBS: Obs tetn cs & Gynaecofogy
25b
5. Pallor or dyspnea
.
6. t!yp erth yroidis m ,n leve l
Increased human cbo dao ic gaoadg trop
7.
•
Signs
rus largen than expected for gestatjonal
gge
1. [Ute
2. Fetus abs egt v
ab ~t • •
3. Fet al Heart sounds
4. Absent fetal arts •
s. varian enlargement {theca luteal cys ts in 10%).
••
/ 'Hypertens ion early in pre gnancy•
•
• • •
Com plications
1. Maligna r1t tran sfor m ation to ~ho rioc ard
nom a irV;t20Jl of
~ 'V'
i. Locally Invasive Mo le: (66%
:
) V ~.
ii. Gestational Chorioc arci nom a (3) %)
2. Hyperthyro idism
3. Pregnancy Induced tiYperten sion
Diagnosis
diagnosLs requires
1. Mainly by ultrasound, but def init ive
aso und, the mole
histopathological exa min ation. On ultr
er of grapes" or
resembles a bunch of gra pes ("clust
"honeycombed ute rus" or "snow-sto rm" ).
up of GTD
2. High levels of hCG, also helpful in foll ow
3. .( ray chest to see pceseoce of 1, mg
me tastasis
4. CT head and abdomen
5. Other tests
a. Complete Blood Count
i. Hb
ii. Platelets
b. live r fun ction testing
•
c Thv rojd fµo'1ion test irg
1• Thyroid stim ula ting hormo ne
i1. Free T'1
QSPE /qr MBBS: Obstetrics & Gy naecology
257
rreatrnent
l. Hydatidiforrn moles ~hould be treated by evacuatJDe tbe

ut erus 6Yuterine suction or by surgical curettage as soon as
.ll.,OSSible after diag.nosis ,. •
2. c;_hem otherapy ln~ icati~ns after D&C if
• Qua n tit ative ~hCG persistently elevated
• . Persistent ut erine bleeding
• gvidence of trophoblastic metas tasis
1. Brain
2. Lungs 0
3. ►In order t o avoid the risks of choriocarcinoma. Patfeo ts ;ire

•
followed up until their serum human cho[i~ic
0
~onadotrophl!LU:1£:Gl level has fallen to an undetectable
level.
4. Invasive or metast~~s cancer
c emot erapy and often respond well to, me
response to treatrnent is nearly JOO%.
5. Pati en ts are advised not o nceive for o e ear after a
molar p regna ncy. The, chances of bavios aPolbec 17l□lar
2regnancy are approxima tely 1%.
Prognosis
i n. The outcome
is recommended
a er treatment is usuall excellen · contra ~-~
1, re 17 rnootbs.
t_£avoid pregnancy fo r at least
·es· -2%
Recurrence rate in fut ure re nanci ·
OSPE for MBBS: Obstetrics & Gvna
ecology
258
Observed Station~s
A 24 year old primigravida at 36 weeks of gestation came to you ih

the antenatal clinic, she wants t o d iscuss regar_ding breast feeding.
How will you counsel her?
•
.
KEY:-
'i. Introduction (0,5)

•
2. Tell advantages of breast feeding to mother • /2)
•
-" Protection agai~t breast can ce r -
\/
v Helps In weight reduction following delivery
,
• Cost effective, no botheration for cleaning and
boiling bottles.
3, Advantages to baby :- 2
• Prot.ected from gastrointestin~ and other infections,

avoid allergies.
• Need to tell th at 1/reast milk is ideal food for the fir~t 4-

6 months of life.V
• Give newborn lnfani-s oa food oc drink other than breasl

milk-unless medically i'nd'1cated .
• Initiate breast fe d'

e ing within half an hour of deliv~'i-
-*
, fo• MBBS: Obste1rlcs & Gynaecology
051'•
259
• Any concern of the patient'
ardlng breast feed ing.
0.5
Explanation
1115 much better to_counsel the woman rega rd ing breast feeding
during antenatal period.
After introducing yourself to the patient tell the patient that

Breastfeeding allows you to provide your baby with all it needs for
growth and development. Breast milk not only contains all the
nutrients your baby needs, In an easily digested form, but it also
contains antibodies to pro tect your baby from all kinds of infection.
There are substances in breast milk., which ca nnot be reproduced.
~
You alone can provide these ~ng factor: for your baby. It ,s not
only good for your baby. ,t is goo~u.
The advantages of breastfeeding for your baby are
• Breast milk is the only food. se_ecificallx designed, by natur~,

to meet your baby's individual needs.
• It contains the right balance of nutrients in a very easily

digestible form.
• Antibodies are passed on through brea st milk to protect

.nf ec1,on.
your baby from all kinds of 1 - The longer you feed
your baby the bette r it is but even 'fI you breastfeed for the
•
first three or four months this pro tect'on
1 ca n last for up to a
year.
to be admitted to
• Your baby is much less likely to nee d
hospita l,
nstipation.
• L~s. Hkely to deve lop diarrhoea or ce -
osPE for MBBS: Obstetncs & Gynaecology
260
Breastfeeding reduced the incidence of allergies such as
•
ectema and asthma.
•ik contain< growth factors and hormones to help
• Breas t m1 __ - - ---- _
1a!J?y_'~J}~e!'
vee!l:<JoPie=-
.:m ent. These ca nnot be reproduced in
your b-.2 y s -
formula milk. Children who have breast fed for eight
months or more have been shown to achieve more at
school than those who have been bottle fed.
The main advantages of breastfeeding for you
•
-
Breastfeeding helps your body to return to no rma l after the
bi rth and burns up to 500 calorie.s..a. day.
• Breast milk is always readv._and it costs nothing
• Women who breastfeed often feel a special bond with their
baby and may be less likely to develop postna tal
depression.
• Breastfeeding may offer you some protection against
developing ovarian cancer, breast ca ncer and hip fractures.
The main disadvantages of breastfeeding for vou
• Blood borne ,virusel su.c.b as bepatitis{i)~r ~ nd some

medication can be passed on to your bab_y in bLeas.Lmilk.
•• ySome women find breaSl feedmg . painful
. - ful· and tiring
stress
ou are unable to m '
has consumed· th· easure th e amount of milk your baby
, is can be a dts d f b .
havmg problem . a vantage i your ba y 1s
5 putting on weight
• It can be difficult for O br ·
baby tor more th ea stteeding motne.r_ to leave her
feedoaby unless she
1
°
an a couplf' f h
ou~s as no one else can
eaves expressed milk.
The most important thmg to k
position your baby dur' now about breastfeeding rs how 10
h mg a feed If
1 en everything else will follow. · your baby is in the right positron
osPE tor M88S'. Obstetrics & (jynaecology
26!
when can breastfeeding begin?
• Brea stfeeding can begin With· .

babies. m minutes after birth for most
• The first milk the mother rod

best food for a newbo Tp ~ 5
e. ,t9lled colostrum, is the
rn , 1 n, P sttm lat· h
during b re a s t f ~ u ron t at occurs
· S.O.llf!P..s the uterus contract and can
h_eIp stop uterine ble.edlag. - - ~~ - - --
• ~hen a baby begins to open its eyes, look around, and µu1
hrs or her frst rnto his or her mouth, then ·t . .rme to o ffer
, rs 1
your breast. The baby should not be given sugar water or
ot her types of bottle feedings In the hospital unless
specifica lly prescribed by the doctor. '
Proper technique for breastfeeding?
• After the mother has assumed a position comfortable fo r

her, she can nestle the baby in a cradle hold (cradling the
baby wrth the mother's arm on the same side as the breast
being presented). The baby s body should be on its side. so
that the baby does not have to turn his or her head to reach
the nipple.
• 1. First, manually express a few drops of milk to moisten the
nipple.
• 2. Cup the breast wrth your hand and using the milk-
moistened nipple; gently massage baby's lips, encourag,ng
the baby to open his mouth.
• 3. When the baby's mouth is opened, the 11,pple is inserted
into the center of the baby's mouth while pulling the baby
very close. The baby's gums should take in at least a 1-inch
radi us of the areola.
• 4. l h e mot h er may have lo ne ke adjustmen ts. for
.
thP ha hy'<
.
breathing by changing the angle o-f baby~ posrt,on slrghtfy
or using the thumb 10 press gent ly on !he breast to uncover
the baby's nose.
• 5. Hold the breast throughou1 the feeding so the wefgh1 of
. ewborn's mouth.
your b reast does not 11re your n
OSPE for MBBS: Obstetrics & Gynaecolor,
262
• 6. When feeding is over, to avoid trauma to your nipples, do

not pull your nipple from baby's mouth without first
breaking the suction by inserting your finger into the corner
of baby's mouth.
os,rlo• rv,ses: Obstetrics & Gynaecology 263
l'
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264 OSPE for MBBS Obstetr
IC\&G
Y••tco1oe,
osPE wr
u11obse
~ Q , oefin
~~ Q . What
Q What
?~ ..
~-~
KEY: •
1. C
~,J~ 8
~ 1/
2. 1
Half knowledge is worse than ignorance. -
Thomas 8. Macaulay
~
d-~~/- \fl~. -
~/ I 3. .£
~t31/
~ I•
(/JI£ tor MBBS: Obstetrics & Gynaecology
265
unobserved
Statio~
Q. Define abortion.
Q. what are the different types of abortion?
a.what are the common etiological causes for abortion? Give 3

•
KEY:•
1. Define as pregnanry tha t deliv;ftfore 24 weeks.of

gest ation or of less tha (?.oogms eight 1
2. Types: 2
• Threatened mlscartlage
• Missed abortion
• Inevitable misGarriage
• Recurrent miscarriage
2
3. fbrgmaso:roal abnormalities
Endocrine disorders
Abnormalities of uterus
Il.)_[e Ct ioi:!,.,
Chemica l agent
Psychologica l disorders
266 OSPE tar M88S Ob>tetrlcs & Gvnae lo
co a,
Give the Bishope score of following scenarios
1 A primigravida at 38 weeks with moderate u terin e contraction has

presented ,n labour wa rd. Her vagina l findings are ce~ J cm
dilated, 1 cm long; presenting part at · 2, cervix is soft and
anterior.
2 A G2Pl at 39 weeks with mode rate u terine contrac.tion has

presented in labour ward . Her vaginal findings are cervix 4 cm
dilated, fully effaced; presenting part at -1, cervix is soft and
anterior.
3 A pn m1gravida presented at 40 weeks of gestation with mild

labour pa ins of 3 hrs duration on vaginal examination her cervix Is
full length firm posteriorly placed with head at brim .
4 A G2Pl presented with labour pains on vaginal examination cervix

is I cm dilated 2cm long, presenting part at -3, moderate
consistency, mid position.
5 G 3 P0+3 with labour pain for 6 hr. on examination cervix 3 cm

dilated, 2cm long, head at •1 station, moderate mid position
cervix.
KEY:-
1. Bishop score is 8
2. Bishop score Is 10
5. Bishop score Is 7
OSPf tor M88S, ObJtetrlts & Gynaecology
26?
observed Statio0
A primigravida 25 year old known cardiac patient With mitral
stenosis admitted ln the labour ward with history of 39 week
'
gestation. How you will manage her during labour?
KEY:-
Management 5
• Multid1sc10tinarv
+
i!ppco~ch ,n.,olue •be card,olog,st
• Avoidl odurt)oo;iod wa•t toe ~poolaneous onset pf labour if

possible
• Give prophylactic antibiotics

,,.
• Ensure adequate fluid balance r
••
• Avoid the supin{"-posHion
_,_ '
• .
Give regional/epidural ana Ige sia durln~ labour
~
• Shorten the second stage of labo~
• Avoid the use of ergometrine ✓
• Use syntocinon Judiciously
268 OSPE for NIBBS: Obstetrics & G•
,na,c,,!Qgy
Observed Station 4
Read the scenario and answer the questions asked by the
examiner:
Mrs, KS, scho.o l teacher PG at 36wks of gestation presents to yo~

with breech presentation and wants lo know about external cephal~
version,
Q. l.What 1s the ideal time for ECV?
@Nhat 1s pre-requisites for ECV?
Q. 3,What 1s nsks of ECV?
Q . 4.What 1s contramdications of ECV?
Q. S What is important in post ECV care'
KEY:-
1. Ideal time for ECV is a@vks

2. pre-requisites for ECV
• T_hin & la~ abdominal wall
• Ne)!her tense nor irritab~ uterus
• Suft!cient amount.of liquor-
• Breech not engaged iri peivis
• No uterine anoma -
• - Bicomuate uterus or fib•oid In
co~e.a I region
3. Risks of ECV '
Maternal Risks are•
• R~t~or mem~nes
• Preterm labour
()5PE for MBBS: Obstetrics & Gynaecology
269
• Cord accidents
• Placental abruption
• Uterine rupture
Fetal Risks are:
• Fetal bradycardia
• Fetal Death
C:
4. Contrai nd ications of ECV
• Dead or malformed baby
• Al'}X indication for elective C/section
5. Post ECV care
•
-
Monitoring of fetal condition by CTG
• Look for any signs of labour
• Anti-D to every Rhesus negative mo~er
• Follow up after few days
OSPE for MBBS: Obstetrics & Gynaecoogy
I
270
Station 5
Unobserved
A G2 Pl at 39 + 4 day of gestation presented in the labour ward with

history of bleeding vagihal ly.
What are the most likely causes? give any 5
KEY:- 5
1. Placenta praevia
2. Pla cental abruption
3. Vasa praevia
4. T,@pma to th e genital tr;ict

\
5. Labour(heavy show)
IJIPf for MBBS Obstetric5 & Gynaecology
271
unobserved (Jlo .s. - Station 6
Give any 5 Ind ications f o r induction of labour
KEY:• 5
.. .
1. Post dates (i.e.12 days or more beyond EDD)
2. F~eta l growth restrictions or placental insufficiency e.g.

•
Oligohyd ramn~s
3 Preeclan112sia/hypertenslve disorder of mother
4. g_et_eriQ!at ipg_n1 0,ternal 11!n:t?.e,s
5. P_rolgnged pre labour rupture of membra ne
6. qiabetes rnellitU§
1
7. S~ s
8. Rhesus iso• immunizat ion
OSPE for MBBS: Obste_trlcs & Gy~
272
Observed Stati0ri7
A 24 year old nulliparous, married for 3 years came to You With
inability to conceive. She got laparoscopy 1 month back showeG
mild endometriosis. Her husband's semen analysis is normal. Ho.,
will you counsel her?
KEY:-
1. Introduction /0.5)
2. Explain; that, exgcl mechanism, by whfch ~ild
endometriosis prevent conception is not cl~ar.
However, same endocrine disorder, anovulation,
altered prolactin secretion, leutinized unruptured
follicle syndrome, oocyte or sperm function
disorder may be the reason . (1.51
3. Options:
Ovulation ind Uct1on
Ovulation Induction+ intrauterine jnseminatlon
IVF/ICSI ( 1.SJ
4.
Ask, about any Patient concern (0.5)
iC)r NIBBS: Obstetrics& Gynaecology
273
¢Pf
Statio'(!)
A year old nulliparous woman underwent surgery and the

26
speci 11 en removed at surgery is shown in figure.
Q. 1. What 1s the diagnosis from the s;>ecimen ?
Q, 2. What five symptoms might she have presented with?

Q, J. Which two common organisms l'>ay be responsible for the
pathology?
Q. 4.What additiona l treatment will you offer her?
KEY:-
L Bilateral hydrosa lpi.nges from chronic in flamma tory disease.

. 1
2
2 Sym~toms
• Lower abdomina l pa in
• Vaginal discharge
• Infertility
• Deep C
dyspareuoia
• Dysmenorrhoea
• Menorrhagia
OSP£ fo r MBBS . Obs tetric s & GYnaeco1°1)
274
3. Organisms 1
• C hw nydi a tra ch om at is
<
• Neisseri a go no rr hoeae
o rganisn1s
4. Antibio t ics to co ver bo th 1
=
as,E for MBBS: Obstetrics & Gyna ecology
27.S
unobserved
Station O
Read the scenario and answer the questions
A P7 Presented in emergency in st at e of s11Qft following home

delivery . one hour back, Write down b.a~ic st eps involved in
-
resuscitation o.!_?atient in shock.,_lGive S)
KEY:-
5
1. Save two IV lines
2. Main tain airwa_¥
3. CLeft l ateral position & give oxygen
4. Maintain blood vo lume by cyrstalloids or colloid
S. Take blood for Hb, blood grouping, cross matching,

coagulation and renal profile
6. Arrange 4 uni ts of blood
7. Catheterlzatlon for monitoring of urjne outp.ut.
OSPE for MJ)BS; Obstetrics & G
vna,col
ogy
276
Station 10
unobserved
A -year old known epi lept ic and her husband have .come to see
33
you for counseling. She is currently taking sodium valproate (Epilim)
which was found to be the only drug to control her fits effectively.
They wou ld like to start a family.
Answer the following questions.
Q. 1. What prepregnancy advice wou ld you offer her?
Q. 2. What is the main adverse effect of sod ium valproa te on the
fetus?
Q. 3• What needs to be done du ring pregnancy?
Q. 4· What may happen to her epilepsy during pregnancy?
Q. 5. and W'rly?
KEY:-
1. C~tinue with the drug

l
2. ' eural _tube defects'} l
MBBS: Obsterrics & Gynaecology
osPEfor 277
3. D~tail~d feta l ultrasound scan and maternal serunn alpha-

fetn gcotein- take folic acid Smg/.da.\l. fn r first IJJ!ln.ths..of
3
p~ naoc,y 1
4. Increased drug req uirements

- 1
s. Because of nausea and vomiting incceasecl..blond yolu!)!e &

increas,ed binding globulins 1
OSPE for M88S: Obstetrics & G
278 Ynaecofog,,
0
Observed Station 11
A G3 Pl+l at l2 week of gestation presented to you in the OPO for

routine antenatal checkup .Her blood group is B negative.During
history she told that her last child was mildly jaundiced following
birth and he got some phototherapy.
1. What is the likely cause of jaundice in her baby? 3
2. How will you manage her during t his pregnancy?
3. What could be the effects of rhesus disease on the fetus?
KEV:-
l\£Jl\&fi 0 1ogical jaundice or Rh

_,
diseas~ l
2. Management 3
• Ask for husband blood group if husband blood group also

negative•- -- do nothing reassure patient
• If husband blood group po~itive----
i. ask history of Ant'1 D · .

- rn Previous pregnancies
II. do~direct coombs test on maternal blood to C!!!ect

an1t1bodies
• If no antibodl far
. es • --give prophylactic lntramuscu
Ant, D at 28 k post
. wee sand or 34 week or an feaSt
de.!jyery with· 7 2
•n hours (must be given).
, MBBS: Obstetrics & Gyoaecology
-• l~
• If indirect coom bs..t~Lpositive look_ f
. , , or antlbQdy
iev~ at 2-4 week intervals if remaio. belO!N. lOtu}ml
baby is less likely to be effected, just keep patient
under observation and reassu re . -- •
r
But if antibody titre > lOiu/mi reler to fetal
medicine cen tre to check for early sign of fetal
anemia by ultrasound and if required by invasive
assessment and management accordingly
3. In utero feta l effects are 1
• In mild disease ---may be no effect or baby mildly effected
• In moderate to severe disease···••may be
• retal anemia{Hydrops fetalls)
• Polyhydramnios
• Fnlarged fetal heart
• Ascites and pericardia! effusions
• I f n in mlddle
• Hyperdynamic c1rcu a 10
cerebral arteries on doppler USG
• Reduced fetal movement
tt
--
• Sinusoidal patter
n at CTG•
r
l
OSPE for MBBS, Obstelri~s & G
280 Yllat,b!at,
1 . What is the present ation shown in above picture?
0 h a t is its incidence?
3. What are its causes?
4. How will you manage such condition?
KEY:-
l . <;h011ider presentation 0.5
2. Occur in lin §oo deliveries) o.s

3. Causes 2
i. tv\.u!tiparit~
fl . Pl acehta praevia
iii. Unstable lie
••BBS: Obstetrics & Gynaecology
..,Ef01 "' 281
' iv. Cqntracted pelvis
v. Uterine anomaly
~
vi. Pelvic tumour
4. Management 2
i. Admit
ii. Ta½e informed consent
iii. Sent inves tigations and arrange blood
iv. Deliver by LSCS
OSPE for MBBS. Obstetrics & Gynaetology
282
Static§
Observed
Mrs.~ sented to the gynaecology clinic w ith offensive

vaginal discharge. On speculum examination there is typical
--
"Strawber(1'Cervix" and w et smear shows flagellated protozoan.
~-
Answer the questions of Role player. Examiner wil l only observe you
Instructions for the rol e player
You are a 25 years old air hostess, married to a commercial airline

pilot for the last 6 111onths. You have regul~r menstrua l cycle of 3-
5/ 28days.Your LMP is 15 days ago. You have noticed passage of
offensive vaginal discharge which initially was thin and scantv but
now is thick and copious.
Ask the following questions from the candidate
Ql : What has happened to me and why?
Q2: What coutd be the ot her problems which I may have if I don'I
get myself treated?
Q3: How w ill you manage my case?
KEY:-
•Professio nal attitude

•Eye contact
•Non medic aI jargon
1. SexuallY::transmitted disease caused bv an organ ·,sm ca lied
Trichomonas
-· - Vaginalis. Most probably th ro ugh your h usband
_
OS
(J!1f ror r,,1eeS: obstetrics & Gynaecologv 283
_ E~planation of other sympt?ms: 2

2
oy~ia, urethral pain, ircbing, lower-s-abdominal pain (J..()%)
and post coital bleeding. (10 - 50 %are asympt omatic)
- 2.5
3. Management
• Co']_ta<;,t t racing {most probably the husband, may need
hus_!>and's counseling for diagnosis or referral letter to
urologist).
• Con~act treatment (both pa rtne rs)
• Metronidazole Zgm o rally as a single dose or

Met ronidazole 400mg 8D for 5•7 days .
• Cure ra te - 95%
• Husband needs to be treated also
28~ OSPE tor MBBS; Obstetncs & G
vaae,01Dgy
Unobserved
Statio(i;)
Candidate's i nstru ction
Q. 1. What is the procedure shown in the above Photograph ?
Q . 2. What is Its indication s? Give any 4
Q. 3. What is its complicatfo ns?
KEY:-
1.W \LS_te roscope)

0.5
2, Indica tions
3'
I. Abnor mal uterine bleeding

11. Endomeuia I Ablation
'
Ill. In unexplained infertility, to evaluate the ute rine cavity ,and
cervix
IV. Hysteroscopic polypectomy or Myomectomy for submucous
figroid
V. lnl!;i) uterine adhesiofysis
Vt. For diagnosing and treating MQUerian anomalies like uterine
~@P.turn, bjcacDJJate 111enis 1eptaIe uterus div.isiOJl.. of a
ut~..rJne septum(hysteroscopic metroplas ty)
••ees-• Obstetric~ & Gynaecology
t)5Pf for .., 285
Sterilization; ttaosceO/.il:aJ.!y ~th the Essure contraceptive

VII- tuba l oc.clusion device
Removal of an intrauterine devi~e (IUD) und.e.Ldir_ect
VIII.
-
visualization _
complications 1.5
• Uterine perforat[gn
• Hyponetraemia
• Volume overload
• Cervical tra uma during dilatatio!1
.
OSPEfor MBBS: Obstetrics &Gvnaocotocv

286
Unobserved Station lS
identify the organ an d name the different abnorma lities shown ln

picture
ii l! -
).:'
I
'
•
' :,, :r
i
l '•
l ;
KEY:-
Uterine anomalies. s
L Double uterus(didelphys), double ce_rvi><, double vagina
2. Uterine duplex bicorms
3. Bicornuate uterw, single cervix
4. Unicornuate uterus
5. Co~plete septated uterus
6. Subseptate , •ter.us
osPE for MBB5 Obstetrics & Gynaecology
287
Model
Paper Two
8PP '!.CIO
6"-rt (',-, i•~
aj-~~;, ~~3
"T_, b l<)( ~•r·"<rll 2~1
~v.~...,, 'l.%
~••-I<- \._!,,1 1.~6
€,v Ju•
1-<;.c.s _,..,...,,. '31ll
).il.t
p\, qbQ. .,-\,u.-.
~6
I '\ ',11 ),~
E.,.\vv<
C.('+ th,n,1 ~ "-\~1 \-..
t,....._..,., s,,.,..,'J 1
,,,'""
""1~••M ;•l
OSPE for MBBS. Obstetncs & Gynaecology 289
A 28 year old female with body mass index of more than 30,
presented in the OPD, with the complains of hirsut ism and
oligomenorrhoea.
Q. What is the diagnosis?
Q. What are the USG criteria for diagnosing the condition?
Q. What is the treatment options for such condition?
KEY:-
l.~ (0.5)
.
2. Jen or more periphera l cysts of sizes between 2 - 8 mm of
diameter (string of pearl's sign)
"'
3
Increased ovarian stromal volume t o >l 8cm ] (1.5)
3. For obesity ... w eight loss
For menstrual irregularities ----syclical progesterone or

combined OCP
Hirsutism and acne ---- anti-androgen along with OC~.

=
Cosmetic therapy such as waxing and bleaching or laser
removal of hairs
Infertility ---- ovulation induction ..
Hyper insulinaemia --- anti-diabetic drug like Metformin

(3)
290 OSPE for MBBS Obstetrics & G
Ynaec01ol\'
Unobserved Stati 0 11 l
Q l.What 1s meant by biophysical profile?
Q 2.What is its component.?
Q 3 Gjve 4 indications for its use
KEY :•
1. A biop hysical profile is a prenatal ultrasound evaluation of

feta l wellbeing. involving a scoring system. 1
2. Th~ biophysical profile /BPP) has 5 components: 4
ultrasound (US) assessments and a non stress test (NST). ✓
C
• The nonstress test (NST)(CTG) evaluates fetal heart rate

and re~ponse to fetal movemenl.
• The .!)PP (ult rasound) measures fetal heart rate, muscle
-
tone, movement, breathing, and the amoun t of amniotic
fluid.
3. Indications 2
• Hl(l)erthyroidism.
• Bleeding problems.
• Lupus anticoagulant. •
• Type 1 diabetes or gestational diabetes.
OSPE for NIBBS: Obstetrics & Gynaecology 291
• H_.!eq blood pressure (hypertension).

• ~lamps!~ •
• A small amount of amniotic fli 1id (oHgohydramnios)
-
or to~uch amniotic fluid (polyhyffr~r,io~).
• A multiple pregnancy (such as rwi~triplet0 ,
• A pregnanc't that has ~one b31~d due dat e,
be~een 40 and 42 w~el<s.
{),-.U..
~tic.• fu..id
c.:rc.,
TUWL
OSPE for MBBS: Obsterrrcs & Gy
292 "••coll>t,
Unobserved Sta1; 003
Candidates instructions
Answer the following q ue5lions
Q . l. What condition is shown In above figure ?
Q,2 What fetal diameter present in th is cond111on and wha t is its

measurement ? •· ·
.
Q.3. How will you diagnose it during Jabour? '
Q.4. How will you deliver baby in such condition ?'-:

KEY:-
l. Face presentation ,0,5

'
2. ~mento bregmati{),which measures 9,5cm, J
3. Olnos~d by palpating the nose,mouth and eyes o n~jnal
exa1111lnat10.ll 1.5
i. Va inaJ deliver if m"ento ant lor - --head de/ivered

by flexion
IJ, lSC If mento osterior---as futher extension of head

..
not possible
OSPE for M88S: 0bSU!lr1CS & Gynaecology 293
Unobserved Station V
Cand idate's instructions
A 36 year old P2 married for 8 year presented JP gynae OPD wit h

history of ~ever dysmenorrhea and dyspareunia. She has continuous
lower abdominal and pelvic pain. Her laparoscopy done, showed in
the picture.
Q.l. What is the diagnosis'
•
Q.2. What are the treatment options for her?
KEY:-
1. Endometriosis
2. Tailor the treatment accprdjQg IQ her age, symptoms,

"
e;tent of the diS';!!i.e and heL desire for future child
bearing,_
-== ,....
Medical Treatment:
. . ~
- ,.._ -
combined oral contraceptive ae.enls
oanzol/Gesulnone
•
OSPE for MBBS: Obstetrics & Gy
naeco1°1r
294
p~':P~t~g~s _
Gn~_onists
' _,,.--.~
~ tments.
Conserv~tiv~er.v:-
--< "
LaparoscopicalLy laser or diathermy of endnmetriotic

--===
lesions
Removal of endometriotic cysts
Definitive Sur~:
If disease progre~ve, total abdominal hysterectomy with

bilateral salpingo oopherectomy
rA r1 , tJ· 0
..
O~PE for MBBS: Obstetrics & Gvoaecology 295
Observed Statio~
Q. A 28 year old P, + 0 come to you with history of secondary

infertility for 5 year. on HSG She got bilateral tubal block~ge. Now
1
her tubal su rgery is planned. How will you take informed consent?
KEV:-
1. Introduction (0,5)
2. Explain allo.u.L the prep.aration a11.d procedure of

0
tubal surgery (1.5)
3. _E; glai~type of anesthesia given (1)
4, Discuss possible complications (anesthesia

complications, bleeding, injury to abdominal
viscera, and failure of procedure) (1)
5. Success rate following surgery depend upon the

age of the women, surgeon expertise, facilities
avai lable and the extend of tubal damage. (1)
osPE fo1 MB8S Obs1errics & G
vna"'
296
'I ,._ Statio~ 6

unobserved
Candidate's ins.truction
Q. 1. Whal is the pathology shown in the above figure?
Q, 2. How the pahenl can present with such condition?
Q. ~.How will you diagnose ihis pathofogy?
KEY:•
1($1vi!rlan1u"inru:l 1
2. Presenratton 2
r. May be asymptomatic
>
} If. Abdominal pain

'
11I. ~ b<:!g,minal distension
IV. '
~re~sl/.!e symptoms like nausea. yomiting,
urinary frequency etc
V. Menstrual disturbances
VI Hormonal effects
05PE tor MBBS Obst tr 1cs & Gynaecology 297
3. D1agRosls 2
By pelv1c-{xamjnationlf wnm,en s..exuallv

I.
-
active
IL
Ill. (Doppler USG¥
IV. Serum markers
"
OSPE for MBBS Obstetrics & G
298 Vn
Observed
An 18 year old G2Pl at 30 weeks of gestation presented 10 you In

the labour ward witt, history of labo ur pains since 6 hours. On
abdominal examination uterus corres ponds l o da tes, contracting
after every 3-4 minutes on specu lum exam ination cervical 05 3 till
dila ted fully effaced, memb rane i ntact.✓
Answer the examine.rs questions
1. What is the diagnosis?
2. What are lhe risk factors for pre term labour tell any 4
3. What are the mana ge ment options for preterm labour?
KEY:-
1. Preterm labour 1
2. Risk factors are 2
• Previous prete rm birth 20% risk
• Twin
• pregnancy
'
• Teen age pregnancy
• Ut!_rine anoma Iies

>
• Congenital anomalies;
• Cervical da d
.--= magc (cone biopsy, repeate
dilatation)
299
• Poor.,_ socio-economic status

;;:.:
• ~making
>
• Drug abuse
<:...,
3. Managemen t options are

2
• Tocolysis
• Steroid cover
• Info rm neonata l unit.
• ln -ut ero t ransfer if neonatal serv ices not

sa tis factory
...,
.,
OSPE fo r MBBS: Obstetrlc, & G
. vn,e,o"CJ
300
Station 8
Unobserved
. '
- I
Q. 1. What is the procedure shown in the above pho tograph?
Q . 2. What are the contraindications to this procedu re? give any 4.
Q. 3. What are the risk of this procedure? give any 4 .
KEY:•
1
1. Externa l cephalic version
2
2. Contraindications
I. Placen ta praevia ✓
11. Oligo_hydramnios or po lyhydram~ios ✓

. ~
II I. H1stoi:y of ant epartum haemorrha2_e
. . • , .. ~,.,,eeWl11Y
IV. Prev,ous caesarean , s ~
sc~q n the uterus v'
OSPE tor MBBS Ohstetrn:;.s & Gynitecologv 301
V, Multiple gestation
·- ---------
VL Pre-ecla m ~ia o.r hyperte1J_sion
VII. C~hal_::.opeJvk disproportion
3. Risk of ECV 2
I. Placental abruption
-
II. Pre.mature manare ruptuflt of the
membranes
Ill. Cord accident
IV. Fi:>ta l b adycardia
V. Failed ECV
VI. Uterme rupture
OSPE for MBBS; Obn•tr·
' 't.l & Gy
observed Stati0its
A GJPl previous 2 caesarean sections

. admitted in labou r Ward ii
.. days of gestation for electtve LSCS.
38 2
Answer the questions asked by th e exami ner
1. How will you take informed co nse nt?
2. What complication she may have due t o caesarean sectioo
KEY:•
• lntrod uction
• Eye to eye contact 1
• Non medica l jargon
1. Ex~lain that as _she is previous 2 LSCS so will be

delivered by LS(:S. It is a major surgery, she need
proper preparation for it w ith '-~ hour'N 0 ,
arrangemem ~f 2 uni t of blood .Discuss type of /
ep idural or enera l anesthesia,
t hro mbo rophylaxis and
l
so discuss sterilization
l
2. Complications
• Anaesthesia complications
• Due to previous 2 LSCS adhesions, h~def~lJI

rn•~
adherent, thin lower uterine segment, d ~
OSPE for Ml>BS·· Ob SlettJc..s
. & Gynaecology 303
deliveri
" b.11 bY, placenta may be dh
11g ·- excessive
~
bleeding al1d uter· - a erent,

_ _ 1ne~ <_>nv _ • _
•
•u
-
Infection
Thromboembolism
'
OSPE tor MBBS: Obstetrics & Gyn~ecalol\'
304
Station 10
U11observed
Answer the followi ng questions
Q . 1. What is t he condition shown in picture ?
Q. 2. What are its clin ical features?
Q . 3. What are the complications of this co ndition?
KEY:-
1. tl2,cental abruptio~
2. Clinical featu res 2
~ Uteru s will be tense and tender
® FetaJ heart may be abnormal or absent

~ Tachycardia and hypotension out pf
proportion to vagina l bleed ing
rv. Coagulation disorders
-OSPE for MBBS: Obstetrics & Gynaecology
]05
3 Complicatio11s 2
1. 'lntra uterine fetal dea;\

.. ::: z:;:.
II. ~aterna~ shoe~

-< -
(w} Disseminated intravascular coa
0 ~
G Postpartum haemorrhage
(Y\el.euJri\
--'I ~ t &
J)-,RY
OSPE for MBBS·· ObSletncs &
G'lllift
Label the diagram
>~~
~ 3
!
KEY:-
Marks 5
1. uter.us
......
I
\
...
2. Fallopian tube
3. Cervix
4. Vagina
S. 0_11ary
-
OSPE for MBBS; Obstetric$ & Gynaecology
307
Observed r ~~
A 24 year primigravida presented to you with history of 6 weeks
gestational ameoaccbea and bleeding vagioally sioce , day. Her
urine for pregnancy t ests is +y,;, She has severe lower abdominal
pain since 2 hours. On examination her abdomen is tender and on
pe lvic examination ce rvical excitation +ve .Her B.P is 100/60 with
thready pulse.
Q.1. What is the most likely diagnosis?
Q.2. How you will co nfirm the diagnosis?
Q.3. How you will manage the patient?
KEY:-
1. Ectopic pregnancy 1
2. By ultrasonography pre fera blY (TVS\ and serum

BH!=G quantitative (low for gestatiaoal aee) 2
3
3. Admit her
:'' the c;,ituation
· P rPgacning --- -
a. Consul her and reIat1v
Take informed consent
Arrange blood
OSPE for MBBS: Obstetrics & GYna
908
Sali:>in ectomy (removal of the tube and G
salpingostomy (openin of the
Gestational sac only) via laparoscopy or laparotomy
OSPE for MBSS: Ob>telncs & Gynaecology
309
-•
Q.1 Identify the object It 1s used for what purpose?
Q 2. Wh,ch dr ug IS used in ll ?
Q 3 Give 3 indications for its use.
Q 4 Give 3 contraindications for Its use.
KEY:-
1. Epidural catheter and Touhy / Epidual needle set used for

epidural analgesia / anesthesia 1
2. Bupivacaine 1
3. Indications 1.5
• For effective pain relief d11ciog l;1bgur
• Pcolaoped lahqur
• Maternal hyRertensive disorders
OSPE for MBBS : Obstetr·
310 •cs & Gy
naec
Multiple gestation
•
• certain maternal medical co nq_itions
• Where there is high risk of operative interventions
4. Contraindications
1.s
• Coagulation disorders
• Local
. or systemic sepsis
• Hypovolaemia
-
• Local deformity of spine
• Lack of trained staff
0SPE for MBBS: Obstetrics & Gynaecology
311
Observed
Station 14
20 year old primigravida presented to you in the outdoor at 12
weeks of gestation while taking history you come to know that she
-
is smoker and use to smoke 1..Q:15 ci~rette per day how you will
counsel her regarding smoking.
KEY :-
1. Introduction
0.5
2. Eye to eye co ntact
0.5
3. Polite and use non med ica l jargon

0.5
4. Advise to stop smok ing during preg nancy

' 1
5. Explain that smoking is associated with 2.5
t i. Increase Becio 9t 91roortalit_jl, ✓
I U.,G R,,,I
[ ii
iii . Lo;v 9irth_weight ✓
iv. Antepartum Haemorrhage

'
V. Later Leukaemia in chi ld hood
OSPE for Me:,s: Obstetrics & Gy"••tol°"
312
Unobserved Station 1S
· ns
Answer t he following quest10
Q. 1. What is stfown in the diagram? •

Q. 2. It is used for what purpose? 1
Q. 3. What Important features of labour are noted on .11 ?· Tell anv

four
QSPE for MBBS. Ooste1r1cs & Gynaecology
313
KEV:•
1. Pa rtogra m
2. It is used to make the graphic record of the labour which

show th e progress of labour
-
3. Features noted are
i. Patient prof,le
11. Patient viral signs
iii Feral heart rate
fv Uterine contracuons (strength, duration

and intensity)
v Descen t of fetal head
vi Dilatation of the cervix
..
VII. Colour of the liquor
viii . Drugs and 1/V fluid
OSPE for MBBS: Obsietrics & Gynaecolot,
314
APPENDIX
Arm prola pse
p ...__.......
E11isiotomy scissors
Brow presentat ion
OSPE for M885: Obstettks & Gynaecology
315
Breech delivery
Cord clamp
Vaginal pessaries
Pie l ring pessary pie 2 hodge pessary
Fetal scalp electrode
()SPE for M88S· Obstetr c, & Gynaecolor,
316
,. . . .
Syntocinon
°"' ~
Injection syntoci non
_..
ili.l •
0
Sonicade for fetal heart sound
\\
•
/,
oSl'E for M88S. Ob>terrlcs & Gynae~ology
317
Twin pregnancy
Suction evacuation
,.
Hirsutism + polycystic ovaries
I
Molar pregnancy
l ess. KiSI<. 'i

.7/ 1.Qu..,,._ r~~
~ Co.,,plutc.. ~ l .,_, .
Pelvic endometriosis
'
ass:Obstet rics & Gynaecology 3JO
()SPf tor M
-
Out let forceps
_,)'[aparoscopy
.,.
Types of pelvis
A u ynae coid pelvis B Anthropoid pelvis
C Android pelvis D Platypeffoid pelvis
320 OSPE for M88S· Obstet
• ncs&Gy
~~r
Delivery of after coming head of breech by forceps
Ectopic pregnancy

Alia Bashir - Gyn - Obs Ospe

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•

Chapter-1: OSPE as an Examination Tool 01

Chapter-2: How to approach at different stations 13

Chapter-3: How to attempt OSPE 19

Chapter-4: OSPE circuit with keys 25

<vPractice session one with keys

Chapter-5: Model Papers 287

BSO Bilateral salpingo oopherectomy

PMS Premenstrua l syndrome

TITS Twin twin t ransfusion syndrome

Total written part = 150 marks

Obj ectives of OSPE

In year 2008, ma1or SubIecl1ve Components o f Practical/ Clinical/

It is designed to expose the candidates to .a greater number of

OSPE has made the exam

Format of the OSPE

Features of the OSPE station s

• Stations are short.

The marking syst em

Types of OSPE Stations

uno bserved/Static Stations

1. What are the 3 types of breech presentations shown in the

2 What 1s the 1nc1dence of breech at term?

3. What.are the pre -requisites for vaginal breech delivery? Give 3.

2 8 o f all t erm pregnancies present as bre ech (0.5) •

~- The presenta tion sho uld be either extended or flexed breec

No fetopelvic di$pr□ poctjon . ✓

Fetal weigh t less than 3500g . /

No evidence of tw oer extensiop of.thP. fetaLhead. ✓

F~ abnor111al11ies have been ru led out. ./

Q. 1 . What is this diagram showing?

2, (Explain about t he di<Pas§) tha t she needs to be

3 Treatrnen1 opt ions

• GnRH analogues, Mirena, (~evonorgestril releasing

Answer t he questions asked by the examiner.

2. (8!st~ry;:G:xamin~tion)including ~ Q.,eral physical/ apdomjnal

@aterni> Investigations --FBC. blood grouping, cross match and

~nvestigations---<;ni USG for fetal well being

Then manage according lo the type of placenta praev,a

Possible Topics for OSPE Stations

• Clinical skills/interpretation of lab results

• Managemenr/ trea1ment plans

• CTG trace, Pa rtogram

• )( rays, Movie rlips e tc

"The curriculum tells the staff what to

The OSPE tells the students what to learn!"

1. communication/ Counseling Skills {Examiner/Role Player)

At this station, candidate should keep certain t hings in her mind to

• Introduction/put patient at ease

• Appropriate eye con tact/listen attentively

• Avoid technical language (medical jargon)

• Establish rappQLt with patient (role-player/examiner)

• Follow verbal/non-verbal clues

• Use diagrams/drawings if appropriate

• Adgguate explanation of intended course of action

• Introduce you c..~lf

Ewress ceeret at the poor outcome, report or bad news

Acknowledge anger. fear. and sorro~ wh ere appropriate

• Try 19 identify the problem, like I realize t his must be

• An swer the questions in P21ite. la.Y.man language. Do not

• B~ sympathet ic to the patient but do not overact by

• Have a set of prepare d st atement tha t can be applied to all

o I am very sorry about your loss