IMPORTANT TOPICS

1. SPERMATOGENESIS AND
O0GENESIS
Spermatogenesis
Oogenesis
2n Spermatogonium Primordial
germ cell
Mitosis

2n 2n Primary spermatocyte Enters the gonad of female

and differentiates into
Meiosis I

(Zn (Ln Secondary spermatocyte Oogonium

(44+XX)
Meiosis I| Mitosis occurs
Zn (2n) Ln Spermatid (At birth, no more
Primary oocyte mitosis occurs and all
Spermiogenesis (44+XX) oogonia are replaced
by primary oocyte)
Spermatozoa Enter 1st meiotic division
(Sperm)
Arrested in prophase-in
Diplotene stage

Ist meiotic division is

Important Points completed after puberty, just
prior to ovulation releasing
Begins at puberty.
Spermatogenesis takes place in seminiferous
tubules
Time taken for spermatogenesis: 74 days Secondary First polar
(70-74 days). oocyte (22+X) body (22+X)
Spermiogenesis: Transformation of spermatids
2nd meiotic
to sperm. There is no mitosis or meiosis. division
Size of sperm: 50-60 um
Fertilizable life span: 48 -72 hours. Arrested in
Sperms attain Maturity: Proximal part of| metaphase
Epididymis The division is cowmpleted
Sperms attain Motility: Distal part of Epididymis at the time of fertilization
Time for spermiogenesis: 10-14 days
Time for capacitation: o-8 hours
Ovum 2nd polar
Site for capacitation: Female Reproductive (22+X) body (22+X)
tract-cervix
 Arora Hans
Gynecology by Dr Sakshi
Obstetrics and
One Touch OBSTETRICS
Time
intrauterine
Number of folliclo
1. Sth month of 6-7 million
ingportant Points of
Oogenesis
life (20 weeks) (maxm) 3. SIGNS IN PREGNANCY
intrauterine life
Oogenesis: Begins in arrested in: Diplotene 2. At Birth 1-2 million
Lst nmeiotic division is 4 lakhs-5 lakh Presumptive Probable signs Positive signs
stage of prophase 3 At Puberty signs
arrested in: Metaphase
2nd meiotic division is Time Table of
Events Amenorrhea Goodell's sign--so ftening of cervix
meiotic division completed at: Puberty Fetus seen on
1st completed at: Tine of |Time (ln weeks) (1st sign to become positive ultrasound
2nd meiotic division Event 6 weeks)
fertilization Germ cells reach genital @3 weeks
120-130 um (lt is the Nausea/ Hegar's sign-softening of uterine Hearing fetal
Size of mature ovum: vomiting isthmus. On Bimanual palpation, heart sounds
largest cell in the body).18-20 mm ridge 6 Weeks
yolk sac vaginal and abdominal fingers touch
.Size of mature follicle: Germ cells reach each other (see Image 1)
hours. Oogonia formed 4 weeks
Fertilizable life span of ova: 12-24 Chadwick's bluish discoloration of Palpation of
formed @ 12 weeks Fatigue
| Primary oocyte @ 14 weeks
vaginaa and vulva (Jacguemier's sign) fetal parts
Follicle formation begins by Urinary Osiander'ssign-lateral vaginal Fetal skelecton Image 1: Hegar's sign
e 22-24 weeks
It is completed by |frequency fornix pulsations seen on X-ray

Breast Palmer's rhythmic uterine

contractions
2. FERTILIZATION BASICS changes
Quickening Piskacek's-unegual growth of
uterus
fallopian tube
" Fertilization occurs: Ampulla of Positive pregnancy test
" Fertilization occurs on Day 14 of cycle Zygote
After 20-30hours
lncreased pigmentation

2-celled zygote Also Know

" 8-16 celled zygote is called Von Braun-Fernwald's sign Softening of fundus
4-celled zygote Softening of Mid part of isthmus
morula Landin sign
Zona pellucida prevents Easy flexibility of uterus over cervix
McDonald's sign
8-celled zygote (Surrounded by zona pellucida) Bleeding at time of implantation
polyspermy Hartman's sign/Placental sign
L6-celled zygote (Day 3 after fertilization) Quickening Perception of first fetal wnovement by mother
Primi = 16 weeks
Multi = 18 weeks
MCQ: Day 4: Morula enters uterine cavity
Morula enters uterine
Duration of pregnancy: The duration of pregnancy is 1O lunar months or 9 calendar months and 7 days
period. This is called as
cavity: Day 5: Zona pellucida lost (Zona hatching) or 280 days or 40 weeks, calculated from the first day of the last menstrual
(a) 3-4 days
gestational age.
Morula becomes blastocyst
(b) 4-5 days The entire duration of pregnancy is divided into three trimesters:
Day 6: lmplantation begins 1. First trimester: Till 13 weeks + 6 days
(c) S-6 days
(in form of blastocyst) |2. Second trimester: 14 weeks till 27 weeks +6 days
(d) 2-3 days 3. Thind trimester: 28-40 weeks
(Day 6 after fertilzation = Day 20 of cycle)
Ans: a (Not b)
Important Terminology
Implantation
" Site: Upper posterior wall of uterus <37 Weeks
Preterwm pregnancy
"Implantation window = Day 20 - Day 24 of cycle Early-term pregnancy 37-38 weeks +6days
" Implantation ends = Day 10-11 34-4O weeks + 6 days
after fertilization Full-term pregnancy
(Day 24-25 of cycle) 41-41 weeks + 6 days
Refer to Table 22 of obs for Events of Late-term pregnancy
early >42 weeks
pregnancy. Post-term preqnancy
 Arora Hans
Gynecologyby DrSakshi
One Touch
Obstetricsand
4. PREGNANCY DATING
OBSTETRICS
S.
A. Pregnancy
Dating for Natural Conception
Antenatal visits ANTENATAL CARE IN PREGNANCY
ldeal: Caloric Requirement
Till 28 weeks =
1/month
28-36 weeks =1 in 2weeks
Park = +350 kcal
trimester in all Recommended Weight
Gain in Pregnancy
|Ifcycle is Regular but
>36 weeks = 1/week National guidelines: (lmp.)
T1 = +70
In
normal BMI
11- 12.5 kq females
=

T2 = +230kcal/day
|If cycle is regular butthan WHO: 8 visits
Government of(minimum)
Regular 28-day cycle Cycle length is less than In females with low
cycle length is more 28 days, e.g., 25 days lndia: kcal/day females) = 12.5 - 18BMIkg(thin
28 days, e.g., 32 days 4 visits (minimum) +400 kcal/ day In females with BMI
ACOG/International
of Instituonly)
Medicine (For INI-CET te >30
(obese) = 7 kg (5-q kg)
T1 = o keal/day
T2 = +350
1. Calculate 2. Calculate T3 = +450 kcal/day
|Naegele's formula presumptive EDD presumptive EDD kcal/day
EDD = 1st day of LMP. using Naegele's using Naegele's
7 days + 9 months Formula Formula
2. 32-28 = 4 days 2. 28-25 = 3 daus
Note: If LMP is in
3. Now add 4 days to 3. Now subtract 3 from
February; first add presumptive EDD to
9months and then presumptive EDD to
7 days.
get actual EDD get actual EDD
In rest all cases ANTENATAL CARE IN
add 7 days first
and then 9 months
PREGNANCY
If cucles are
1. Iregular
2. Female conceived while on OCP
3. Female conceived during lactation
4. If fenmale is nSure about LMP
Folic Acid in Pregnancy
To prevent NTD = 400 mcq/ day;
Start 1 month before conception and
continue till 3 months after conception
Best method for dating of pregnancy To prevent recurrence of NTD = RDA in Pregnancy
4 mg/day; start 3 months before lodine (l,) req. = 250 mcg/day
is USG using crown rump langth conception or from the day a female Calcium req. = 100O0 mg/day
Not Naegele's Forwmula plans pregnancy and 3 months after Carbohydrate req. =175 g/day
conception
B. Pregnancy Dating for IVF Cycles To treat folic acid deficiency=1 mglday Protein req. = Nonpregnant =45 g/day
In diabetic patients who are pregnant = T1 = NIL (No additional requirement)
A For Fresih Cycle T2 = +1O 9
Rafer to Table 19 of obs for 400 mcg/day
To the date of oocute
retrieval +266 = EDD. Score ard Gravida and Parityobstetric In patients on antiepileptic =
T3 = +2O9
8. For Frozn Fat req. = 28 g/day
Cycle Before conception: 400 mcg/day
with D3 transfer: After conception: 4 mg/day
Date of DS transfer +263 To treat sickle cell anemia = 5 mglday Refer to Table 12 of obs for
= EDD. detailed Nutritional requirement in
C For Frozen
Cucle pregnancy and lactation
Witk Ds transter
Date ofDS transter
+261 = EDD
 One Touch

IN PREGNANCY
6. VACCINATION
OBSTETRICS
pregnant females 7. ANEUPLOIDY SCREENING
Viaceines which should be given to all
Tabhle L: Td vaccine FIRST TRIMESTER
Al pregnantfemales should be given: (A) Biochemical Test:
Td vaccine
Nutber of doses: 2
after a gap of 4 weeks DUAL TEST (11-13 SECOND TRIMESTER
(Tetanus
Tine: Lst dose at 1st AN Visit and 2nd dose "
PAPP-A ==l weeks): + (A)
Biochemical
Diphtheria) If preanant female was immunized in past3 years and had received 2 doses: then in " hCG
t(hchgh in Down TRIPLE TEST Test
booster aose is needed \hCa syndrome " Alpha-Fetoprotein =
Current pregnancy only one
Talapvaccine Tetanus toxoid - reduced Diphtheria toxoid + Acellular pertussis is also recommended "
Unconjugted Es =
(B) USG (11-13
weeks + 6 days): QUADRUPLE
lnhibin A= TEST:
during pregnancy. Nuchal translucency
be given between 27 and 36 weeks to all pregnant females to Indicates = = 23 mm
Aneuploidy
At least one Taap should ‘(KIhibin
protect nwborn from Pertussis. MIC = Down Increased
All pregnant females, regardless of trimester-during flu season (October to May) should Trisomysyndrome
18 (B) USG: Soft tisues
" Nuchal fold markers:
Infiuarza receive infiuenza vaccine. Trisomy 13 "Absent thickness zG mm
nasal bone
VRCCIna Tuner syndrome " Short femur/humerus
One dose IM or congenital heart disease "Sandal gap
" Duodenal atresia
Covid-19 This vaccine can be given in any trimester if pregnant female had not received earlier Case: If NT on USG (lmage 2) "Simian crease
Vaccine 23 mm and karyotype is
normal "Echogenic intracardiac focus
" Echogenic bowel
" Choroid plexus cyst
Table 2: Vaccines, exercise, intercourse and air travel in pregnancy Next step (Any 2 should be present)
Important Point
Vaccines to be given in special " Combined test = Biochemical
Vactines which are safe Vaccines which are absolutely Fetal Echo test + USG in T1
Circumstances contraindicated " Integrated test= T1 and T2 test
Al dead vaccines can be given: E.g., Yellow fever Integrated test includes:
Hepatits A Polio
Mumps SSereening PAPPA in T1 + USG for NT in
T2 + Quadruple test in T2
Measles test
Hepatts 3 Typhoid Rubella
FneunococcNs Smallpox ANEUPLOIDY SCREENING
Meningococcus Chicken pox Done in all pregnant females irrespective of age
Fabies
BCG
HPV vaccine
Noninvasive prenatal test e T screening is positive Karyotyping (Diagnostic test)
Secondary Tissue for karyotyping
Enercise in pregnancy screening test obtained by
Intercourse during pregnancy Air travel in pregnancy Cell free fetal DNA
Moderate cxeroise tor
150 T2
week is recommEnded duringmins/ Sexual activity is not C/l in ACOG recommends air Can be done anytime >10 weeks
pregncy pregnancy except in case of travel should not be done at Highest sensitivity 2qq% Amniocentesis
2. Threatened abortion Chorionic villus
236 wks of pregnancy sampling (16-18 weeks)
2. PTL (11-13 weeks) (lImage 4)
Heart asense 3. Placenta previa Negative Positive
(lmage 3)
Puimonaru disease 4. PROM |Karyotyping diagnostic test
patient
Sgnficant bleeding No further testing needed to reassure the

Pacenta pravia (mp PYQ's highest risk of aneuploidy.

which if present in isolation has
One single usG marker in T2 femur.
Rufur ta Table 10 of obs for |Nuchal skin fold thickness >short isolation has least riskof
aneuploidy:
GOt High risk pregnancy and Table 11 T2 which if present in
of obs for Color codes on antenatal card One single USG marker in
Choroid plexus cyst.
 One Touct
10

lnportant lnnages
OBSTETRICS
8. ANTENATAL INVESTIGATIONS

ANTENATAL INVESTIGATIONSs
Chorionic vili
At the First Visit
ABO, Rh typing USG in Pregnancy
Hb, Hematocrit (CBC) Dating/viability scan = 6-8 weeks
VDRL Nuchal Translucency scan = 11-13 weeks +
HBSAg 6 days
Rubella susceptibility screening Anomaly scan/Target scan/Booking scan:
NT 18-20 weeks
Urine routine and microscopy (Every trimester) Growth scan = 32-34 weeks
Image 3: Chorionic villi sampling HIV Testing
Inage 2: Nuchal translucency Chorionic villus sampling: Diabetes screening Important Points
(DIPSI test) done at Lst week and repeated " In all pregnant females, Tarqet scan should be
Nuchal translucency: Done >11 weeks between 24-28 weeks. done (28-22 weeks). It gives detailed anatomy
(Fluid filled area below neck) If done at <10 weeks Leads to If patient can afford: to look for qross congenital anomalies. If during
limbdefects
Fetel loss = 1% Oromandibula () TSH
(i) Aneuploidy screening
entirepregnancy only one USG has to be done it
should be level 2 scan, i.e., Anomaly scan
If fetal Echo is needed, it is done between
M/C complication of CVS =fetal loss At 35-37 Weeks 22 and 24 weeks
Mental Screening for Group B streptococci (Rectovaginal Estimation of Gestational Age by UsG
Low-set retardation swab)
Trimester |Parameter
" Repeat CBC = 24-28 weeks.
Ultrasound
Amniotic
Abundant
ear
-Epicanthal
folds and . GOl: Hb done at least 4 times in pregnancy T1 CRL
fluid USG in Pregnancy T2 BPD > HC
transducer neck skn flat facial T3 FL
Single palmar profile First trimester ultrasound done for:
Gestational age assessment
Fetus
crease -Protruding
tonque Viability of pregnancy CRL: Crown-rump length
Suspected ectopic BPD: Biparietal diameter
Congenital Suspected molar pregnancy FL: Femur length
heart de fects o Suspected twins and determination of Best parameter for estimation of gestational
(endocardial age-RL
cushion defect) Umbilical chorionicity AC is best for assessing qrowth of fetus, i.e., in
o For threatened abortion
hernia case of macrosomia and IUGR.
Intestinal o Nuchal translucency
CRL can be used till 13 weeks + 6 days, i.e.,
stenosis CRL <84 mm
(Duodenal Hypotonia Most accurate gestational age can be determined
atresia) by CRL between 7 and q weeks.
Predisposition CRL (mm) + 42 =Gage in days
to leukemia Smallest CRL Which can be measured = S mm
Gap between first and Mean sac diameter in mm + 3o = Gestational
second toes (sandal gap) age in days

Inage 4: Amniocentesis Image s: Down syndrome Refer to Table 13 of obs for Symphysiofundal height
Amniocentesis: Down syndrome (lmage 5):
Done = 16-18 wWeeks Babies have
Fetal loss = <0.5% 1. Short stature
2. Mental disability
3. Endocardial cushion defect (M/C Heart a
seen in down syndrome) > VSD > ASD
 Hans
Dr Sakshi Arora
and Gynecology by
One Touch Obstetrics
12 IMAGES
IMPORTANT USG
9.
OBSTETRICS
Uterus
SAG U

Double decidual
Sac SIgn
A
Image 8: Double Bleb siqn
lmage 7: Double decidual sac siqn A
mage b. lntradecidual sign Inner ring: Decidua capsularis;
Yolk sac and amnniotic sac are
1st sign of pregnancy the two blebs
USG indicatina intercikinl outer ring: Deciaua parietalis
implantation
TISO 2 MI 10

Images 11A and B: Omphalocele

Omphalocele
Herniation of abdominal contents in a sac Images 12A and B: Gastroschisis
Image 9: Anencephaly On USG = it has a smooth appearance Gastroschisis
Mickey mouse sign--triangular face It is a central defect Herniation of abdominal content without any sac
Frog eye sign-Bulging eye sign It is associated with chromosomal anomalies On USG it gives a cauliflower like appearance
. It should be followed by karyotyping It is to the left on right side of umbilicus
It is not associated with chromosomal anomalies

A
Refer to Table 20 of obs for important
points on Alpha fetoprotein

Image 1: Spina bifida

A. Banana sign-downward
of cerebellum
B Lemon
oTable 2s of obs sign-frontal bossing
for lmportant radiological signs in
displacement
Image 13: Duodenal atresia: Double bubble siqn
Seen in case of down syndrome
Duodenal atresia can lead to polyhydramnios in pregnancy
pregnancy
 Gynecology by Dr Sakshi Arora Hans
14 One Touch Obstetrics and

Portal sinus Umbilical vein

Unbilical vein Fetal stomach

AC

Vertebral body and ribs

Image 24: Abdominal circumference
Abdoinal circumference (AC) measurement on USG: AC should be measured in a plane where:
P= Portal sinus
U= Umbilical vein; and
S =Stomach are seen or Hockey stick sign is seen.
While measuring AC: Kidney and cord insertion should not be visible
Clinically: Fetal weight can be estimated using Johnson formula
On USG: Best method to estimate fetal weight is by combination of HC, AC, FL and BPD using
Hadlock's Fornnula and Shepard's Formula
Note: AC 235 cm: lndicates Macrosomia.
 OBSTETRICS 15

10. PLACENTAL HORMONES

PLACENTAL HORMONES

hCG hPL Progesterone Estrogen

Produced by Produced by Produced by Most specific in
syncytiotrophoblast syncytiotrophoblast corpus luteum till pregnancy = E3
C-subunit similar to Similar to GH and 6-7 weeks Most common in
LH, FSH, TSH prolactin After 8 weeks pregnancy = E2
Maintains the corpus Detected earliest produced by Placenta can
luteum of pregnancy at 3 weeks of placenta not synthesize
(Function similar to pregnancy Prepares the estrogen alone
LH) Maximu endometrium for unless it get
Doubling time of implantation precursors fromn
production is at
hCG: 48 hours 36 weeks Decreases fetus (fetal
hCG appears in Responsible for myometrial adrenals give
DHEA-S which is
maternal blood insulin resistance in contractillity
8-9 days after used by placenta
pregnancy to form estrogen).
fertilization, i.e., Day
22 of cycle, i.e.,
5-6days before
missed period.
Peaks at9-10weeks
Plateaus at
16-20 weeks. Then Refer to Table 21 of obs for conditions where hcG is increased and decreased
remains in blood at
low level throughout
pregnancy.
Images of Placental Anomalies (lmages 15A and B)

Image 15A: Fetal side of normal placenta
Forms 4/5 of placenta
Originates from chorion frondosum
Covered by fetal membranes
Cord is inserted at its centre
Image 15B: Maternal side of normal placenta
Forms 1/5 of placenta
Originates from decidua basalis
Dull, red in colour
Has polygonal areas called lobes
Each lobe is further divided into lobule or
cotyledons
Functional unit of placenta is cotyledons
 Arora Hans
Gynecoloay by Dr Sakshi
Obstetrics and
16 One Touch
lntervillous space: uteroplacental OBSTETRICS 17
PLACENTA IMPORTANT PoINTS
ln
Uteroplacental circulation is via
Uteroplacental circulation is circulaartitoenrybu)
spiral
Normal attachnment of placenta: Upper Uterine
Segments
Placenta if attached to lower uterine segment:
o
p-15
Uteroplacental
750 mL/min
circulation @termestablished
Placenta previa circulation
Best time to do ultrasound to detect placenta . In Villi-Fetoplacental
circulation
Fetoplacental
previa: T3
Formation of placenta is through chorionic villi p-17 circulation is via
established bu
o Fetoplacental
Primary villi: Formed by D13
Secondary villi: Formed by D16
Tertiary villi: Formed by D17
artery and umbilical vein umbilical lmage 18
Placenta Succenturiate
Image 19
Circumvallate Placenta

|Also know: Most common abnormal CTG finding

Placental Anomalies
Description
Cord attached to margin of
placenta
Placenta divided into 2 lobes
(equal) and connected by
blood vessels
Placenta divided into a small
lobe and abig lobe and
connected by blood vessels
Fetal side of placenta smaller
than maternal side and
separated by a valve like
thickening
Fetal side of placenta smaller
than material side and NO
valve like thickening seen
Cord ends a few Cms before
placenta, blood vessels loose
their felly and get attached to
placenta separately
Single Umbilical Artery (SUA) Vasa Previa
in vasa previa is: Variable deceleration due
to cord
the cord.
Called It is the M/Cvascular anomaly of It is an obstetrics emergency as fetal blood loss compression.
It is seen in 0.7-0.8% cases of single pregnancu ad occurs in vasa previa.
Battledore placenta
(lmage 16) S% of twin pregnancy. 3types of vasa previa cord/marginal
More common in diabetic patients, black patients Type 1 = A/W velamentous insertion of
Placenta with eclampsia, hydramnioS and oligohydramnioc insertion of cord (MIC)
epilepsy patients and in APH. bilobata/succenturiata
Bilobata Type 2 = A/w placenta
(lmage 17) Finding of a single umbilical artery is not Type 3 = Rarely A/W placenta previa
insiqnificant and is associated with:
Placenta Congenital malformations of the fetus seen in Antenatally diagnosed by = TVS + Doppler
Succenturiate 20-25% cases amongst which cardiovascular Management = Planned cesarean between 34 and
anomalies and renal anomalies are more 37 weeks.
(lmage 18)
common. If single umbilical artery is an If not diagnosed antenatally: Patient may present
Circumvallate time of labor when
isolated finding, chances of aneuploidy in fetuc as a case of APH; or at the
placenta are not increased but if SUA Is associated, membranes rupture or ARM is done ’ there is
proportion to
(lmage 19) with other major malformations-then Sudden fetal distress which is out of
changes of aneuploidy in the fetus are high blood loss. Image 20
Circummarginate and amniocentesis should be done. Management: Emergency cesarean section Velamentous insertion of cord
placenta M/C aneuploidy associated with SUATrisomy
(Trisomy 18).
Velamentous insertion SUA also causes increased chances of abortion,
of cord (lmage 20) prematurity, IUGR and perinatal mortality.

Image 16: Image 17

Battledore placenta = cord insertede margins Placenta Bilobata
 One Touch Obstetrics and Gynecology by Dr SakshiArora Hans

11. AMNIGTIC FLUID: SOURCE AND DISORDERS

Volume of amniotic fluid

Gestational age
10 weeks 30 mL
12 weeks SO ml
16 weeks 200 m
20 weeks 400 mL

34 weeks (32-34 weeks) 1,000 mL (Maximum)

At term/40weeks 800 mL (Volume decreases at term)
At >42 weeks 200 mL (Volume drastically decreases at and
beyond 42 weeks)
Main contributor
Gestational age
First trimester Ultrafiltrate of wmaternal plasma through the
placenta
12-2O weeks Fetal skin
>20 weeks Fetal urine

Color of Amniotic Fluid At Term: Straw Colored, May be Turbid

Seen in
Color
Green color (due to meconium: Presence of Fetal distress, Transverse lie/Breech.
Listeria infection
biliverdin)
Golden color (due to bilirubin) Rh incompatibility
Intrauterine demise of fetus
Tobacco juice/Brown
Saffron color, yellowish green Post-term pregnancy
Dark red colored Concealed hemorrhage (Abruptio placenta)
Amniotic Fluid Disorder/Abnormalities

Oligohydramnios Polyhydramnios
AFI: 224 Cm
AFl: <5 Cm
(Single largest vertical pocket = <2 cwm (SVP) SVP: >8 Cm
M/C cause of mild oligohydramnios = ldiopathic Mild Polghydramnios = ldiopathic
MICcause of severe oligohydramnios = Renal defect M/C cause of severe Polyhydramnios = aT detects
in fetus in fetus (Decrease swallowing) like:
Renalagenesis Esophageal atresia
Posterior urethal valve (on USG keyhole siqn Duodenal atresia (Note: In duodenal atresia on
seen-lmage 21) USG = double bubble sign seen-Image 13)
Cleft lip and palate
 Causes
D. Decreased C. Other
A.
B. Oligohydramnios
infection
TORCH Twin
twin to
Chromosomal Decreased Decreased
Uteroplacental placenta)
insuficiency IUGR (Small
PIH
evaluation
needed No which pregnancy
amniocentesis
Leaking Post
afterPROM-term inhibitor,
Drugs: fectsde
ACE Renal causes
Polyhydramnios Approach
oligo/
Mild
can volume urine transudation
transfusion
syndrome
to leadAnomaly:
of output:
Trisomy
Triploidy)
oligohydramnios case a to
(Polyhydramnios:
Karyotyping Amniotic
either
Seen of Triploidy across
polyhydramnios/oligohydramnios indomethacin
Next
step OLIGO/POLYHYDRAMNIOS
fluid placenta:
age
Difference (69
congenital
anomalies
scaAnomaly
Gross Target
scan
Moderate/severe on
polyhydramniosand oligo chr)
P/A
cerebral
artery)
middle(Peak of OBSTETRICS
Doppler
anemia
MCA of by 2. 1.
Polyhydramnios examination 3
Rule Rule
Next weeks lncreased C.
systolic out out D. tcauses
edOther
A.
Polyhydramnios
B.Transudation
Chromosomal Increased
PlacentomegalyD/t
doing fetal
PSV diabetes gestational aneia
Fetal 4.
Diabetes
pregnancy2. 1.
3. Twin
velocity Abdominal
defect
wall
Neural
defect
tube Diabetes
Rh-veTwins
Polyuria pregnancy
pregnancy
Rh-ve
Parvovirus
infection
B19
Thalassemia
D/t
Absent
transudation urine
of
anomaly: seen
2. 1. output:
Oligohydramnios
Rule in placenta:
across
ratio)
(S/D
insufficiency
placental
by Rule
umbilical from
Bartter
out out Trisomy
utero
PPROM fetal
syndrome
A
Doppler skin

19
 Sakshi Arora Hans
and Gynecology by Dr
20 One Touch Obstetrics OBSTETRICS 21

mp PYQ's
be used till 32 weeks) not
12, HEMATOLOGICAL CHANGES IN PREGNANCY
polyhydramnios is Indomethacin (To
arteriosus, hence should be
Drug which can treat premature closure of ductus
used beyond Increased Decreased Same in pregnancy
2. lndomethacin can cause
32 weeks of pregnancy Blood volume Hemodilution in pregnancy Bleeding time
Plasma olume (4O%) Hematocrit/packed cell volume Clotting time
3 Timing of delivery: IOL at 39 -40 weeks + 6 days
Mild-moderate polyhydramnios: RBC volume (20%) (RBC vol/plasma volume)
Severe polyhydramnios: 37 weeks Hb mass (g) Hb conc(g/dL)
Mild oliqohydramnios = 39 weeks + 6 days
Severe oligohydramnios = 36 - 37 weeks o Reticulocyte count
o Plasma protein mass (g) Plasma protein conc (g/dL)
Potters Syndrome Albumin
Globulin
Severe oligohydramnios due to kidney defects (Renal A:GRatio = N =L.7:1
agenesis/polycystic kidney) leading to Thyroid-binding globulin
Lung hypoplasia Sex hormone-binding Preg = 1:1
Typical flat facies globulin
Amniotic Band Syndrome o All clotting factors (Preg Factor 11, 13
is a hypercoagulable state)
The
PPROM leads to severe oligohydramnios. fetus
membranes wrap tightly around the S. fibrinogen Fibrinolytic activity
distal Image 21: Keyhole sign WBC count (15,000) ProteinC
causing constriction band and leadinq to
ProteinS
digit amputation and craniofacial abnormalities o Neutrophilia
Antithrombin
(lmage 22) ESR Inflammatory
CRP J markers Platelet count (Benign
Important Points to Remnember in gestational thrombocytopenia)
oligohydramnios Eosinopenia
"Moderate severe oligohydramnios is a high risk
pregnancy:
Size of spleen = ‘ by s0% in pregnancy
Size of pituitary = ‘ by 125-135% in pregnancy
Hence fetal monitoring is to be done from
32 weeks onwards BMR ‘ by 10-20%
1. NST weekly Image 22: Amniotic band syndrome/streeters
2. BPS weekly ANEMIA IN PREGNANCY
3. Doppler of umbilical vessels to wnonitor UPI syndrome 13.

M/C CTG finding in oligohydramnios variable Complication of oligohydramnios Pathological anemia

deceleration d/t cord compression Physiological anemia
Only indication for aminoinfusion is persistent Iron deficiency anemia is M/C pathological
variable deceleration on CTG T1 T2/T3 M/C cause of anemia in pregnancy cause of anemia in pregnancy
1. Pulmonary Organogenesis is Hb decreases but is never less than 11 g/dL Hb decreases to less than 11 g/dL
Complication of Polyhydramnios complete Normocytic normochromic anemia
1. Preterm labor hypoplasia (m/e) Microcytichypochromic anewmia
2. Limb Less space can
2 PPROM
amputation cause
3. Abruptio placenta CDC classification of anemia in pregnancy
4 Cord prolapse WHO classification of anemia in pregnancy
<33%
S. Malpresentation T1 = Hb <11 q/dL or Hematocrit
Limb deformities " Mild= Hb: 10-109 g/dL Hematocrit <32%
6 PPH Cord compression T2 = Hb <10.5 g/dL or
7 Subinvolution Moderate = Hb: 7-9.9 g/dL Hematocrit <33%
CTEV/clubfoot T3 = Hb <11 g/dL or
Fetal distress Severe = Hb: <7 q/dL
i.e.,
amniotl ICMR also defines very severe anemia,
Pass meconium in Hb <4 g/dL
fluid in lndia.Q
cause of maternal mortality
Anemia is the M/C indirect
Meconim aspiration
Syndrome
 22
Remember:
he
detected. should
tpregnancy
To is To DewormingInterventions:
hemoglobinometer
3.Digital Am:
2. 1. ANEMIA
given
prevent IFA
time treat To
Color Folic pill: prevent
be from Iron MUKT
when anemia acid Iron
anemia of IFA
started =pill
4th =
pill SOO 60 and anemia,
anemia =month BHARAT
= = mg folic
IFA IFA red mcg
from Not One
pill acid
is ofpill PROGRAM
pil to Touch
treat
Remember: Tab
Deworming Obstetrics
180
To Continue - At
Dose Dose Albendazole be Stop
Start4-month fetus) (ln When anemia
continued days preconception Start StoppiIFAl twice
Deworming
yeardone:
aTabGiven
of of IFA only Continue she and
lFA lFA
to throughoutin only plans
pregnancy tablet folic of IFA All Gynecology
pill pill
= be till pregnancy: folic
to to 400 done acid conception
post only pregnancy
pilreproductive
180 = period weekly fortification
6. 5.Food 4.
treat
prevent 1 acid Addessing Delayed
cord
mg
using: pregnancytablet/daytablet folic
days by
anemia once acid to400 Dr
anemia after decrease 400 Sakshi
in till mcg/day age
second other
= delivery or 3 mg females clamping Arora
2 =
for months isk of
pills/day 1 causes
pill/day trimester of albendazole Hans
at
NTD
least
in

stors
iron Done to
replenish
 23
OBSTETRICS

Management of Iron Deficiency Anemia in Pregnancy

Management of anemia in pregnancy in T2 and T5

Mild-moderate Severe anemia

L
Gestational age Hb <5 at any Hb = 5 -6.9
gestational age
<34 weeks >34 weeks
Oral iron Blood
(2 tabs/day) Parenteral iron tranfusion

Gestational age <34 weeks

+ Noncompliant/Intolerance >34 weeks

Check Hb after 3 weeks or 1 month

Blood tranfusion Parenteral
iron

Important PYQs
Management of Anemia in T1
Rate of increase of Hb after oral iron and
parenteral iron is same = lncrease in Hb is seen
after 3 weeks of starting iron and increase is
=0.7 g/dL/week Hb 25 g/dL
Calculation of parenteral Iron doses in mg = Use Hb <5 g/dL
Or Or
GANZONI formula No signs of
Signs of heart
2.4 x pregnancy weight of pt xHb deficit failure present heart failure
(14 - Pts Hb) + SO0 mg

(For replenishing storage) Blood transfusion Oral iron

Indications for blood transfusion in anemia. immediately immediately
(do not wait tilI
Unstable vitals (indicates hemorrhage) 14 weeks to start
Siqns of heart failure oral iron)
Thalassemia (Nestroft Test Positive)
Note: Parenteral iron is contraindicated in
- Hb <5 g/dL at any gestational age
pregnancy.
 Dr Sakshi Arora Hans
24 One Touch Obstetrics and Gynecology by

14. HEART DISEASES IN PREGNANCY

Ind
o. Chest X-ray:
Increased Decreased Remain same Mild cardiomegaly
border
o Straightening of left heart
2
1. Cardiac 1. Periplheral JVP
<3/6
7. Ejection systolicmurmur grade
vascular
output resistance
8. Continuous murmur (Mammary
murmur
d/t
In pregnant females lying supine (220 weeks
progesterone
- Left 4.
2. Stroke 2. Systolic BP
ventricular
volume
ejection
fraction Gravid uterus presses on lnferior vena cava Sy

3. Heart rate 3. Diastolic BP - Pulmonary

capillary Venous return decreases
wedge
pressure
4. Femoral Cardiac output decreases
Leading to hypotension in pregnant female &
VenouS
pressure fetal distress (lmage 23)
(from 8 to
24 mn Ha) Allpregnant females are advised to lie in las
lateral position
Normal Cardiac Markers in Pregnancy (Do not
indicate heart disease)
1. P/R increases (10-20 bpm)
2. BP decreases
3. JVP=N
4. S = S1 =loud + prominent split
S2 = Normal
S3 =easily heard in pregnancy
5. ECG = e Left axis deviation (15°) as heart is
pushed upward and outward and by the
diaphragm
" Mild ST depression Image 23: Supine hypotension syndrome
"Q wave in lead I/Ill
Note: 1st sign of developing supine hypotension: Mate
Tachycardia

Important PYQs
Cardiac output begins to increase by S weeks of pregnancy
In pregnancy maximum cardiac output seen at 28-32 weeks of pregnancy (30 Weeks)
Overall maximum cardiac output (Hence maximum chances of heart failure) seen in postpar
period >Second stage of labor >Late first stage of labor >28-32 weeks of pregnancy.
Cardiac output comes back to normal by =10 days after delivery hemorrhoids
and

Inareased emoral venous pressure leads to increased chances of varicose veins,

vulvar varicosities in pregnancy.
 X-ray-Marked 2.
edicators
|AnyHeart pregnancy syndrome
M/C At
Eisenmenger
syndrome HD
Tetralogy
fallots M/
of C Lesion: Second
Cause: stenosis
M/Lesion:
CMitralCause: M/C Most cardiomegaly4. 3. JVP 1.‘
stenosis
Mitral M/C prolapse
Mitral
valve M/C Symptoms Present
Murmur:
Presence S4 = S2
sounds:
Heart
Martan Severe
AS the Orthopnea
nocturnal
dyspnea Progressive
dyspnea
Dependant
edema
Hemoptysis
aneurysmn
If Aortic heart congenital Heartcommon Paroxysmal =
patient Diseases
maternal time time with cyanotic Atrial Rheumatic
Congenital Loud
disease of of
maximunm disease of of
syndrome
is heart Ejection + Heart
on where mortality
delivery death congenital valvularseptal in diastolic prominent
Warfarin where heartdisease heart inHeart
risk defect pregnancy systolic Disease
with or in murmur.
Cesarean
aorta is patients
within of HD HD disease indisease Disease
aortic seen maternal split
at in inpregnancy murmur in
the is with 1 pregnancypregnancy Pregnancy
root involved,
Section week of
time
dilatation whichEisenmengermortality 23/6
of of
delivery e.g.: is delivery
HD
Mandatory OBSTETRICS
in
or
within 8. 7. 6. Delivery S.
position4. Inducing 2. 1.
agent 3. Managenment 9. hypertension
8.Pulmonary 7. 6. S. 4. 3.category) 2. 1. Heart
oforceps
3rd 2ndanalgesia IV Dinoprostone
Epidural Relative
For withMisoprostol
Preferred
C/agent: patients
I: CervixCervixInduction Preferred defects
Fonten
Peripartum cms)(24 NYHASevereSevere LV
Coarctation Marfan
2 Oxytocin
Methylergometrine fluid EisenmengerPrimary
Secondary:
syndrome ejection disease
case
In stage stage pain left
weeks orduring is is surgery gradeaorticmitral
of of relief lateral not ripe: of - syndrome
of vacuum. Vaginalmode of of
of MS can labor- labor labor stenosis
fraction where
3/4 stenosis
delivery labor ripe:
Oxytocin HD cardiomyopathy
with aorta
qive be tilt
- of
used AMTSL - Foley delivery in with <30%.
diuretics - recumbent
relief):
Forcepsshould(Mandatory pain position
Semi Safedelivery
Labor residual (Valve(Valve
pregnancy
is Restrict
contraindicated catheter aortic
preferred
- be in defect area area
done cut to root
heart with <1
<1.5 is
short 1
mL/kg/hr cm?) C
dilatation
disease residual cm') (WHO
using

25
 SakshiArora Hans
One Touch Obstetrics and Gynecology by Dr

18. TERATOGENIC DRUGS

Drugs Teratogenicity
1. Alcohol (Image 25) Goa's = Growth Restriction
Famous = Abnormal facial Features (smooth philtrum
Thin vermilion border, small epicanthal folds)
Beer Abnanal brain development Microcephaly
2. Phenytoin Bar =Abnormal Behavioral development
Fetal hydantoin syndrome
)Midfacial hypoplasia
(i) Upturned Nose
(iin) Distal digital hypoplasia (Hypoplastic phalanges) +
3. ACE cardiac defects
Blocker in
4. Lithium
hibitors/Angiotensin Receptor Renal hypoplasia/Renal agenesis
Oligohydramnios in T2
Ebstein anomaly (lmage 26)
(Apical displacement of Tricuspid valve ’ Tricuspid
Regurgitation and Right atrial enlargement)
In neonates it can lead to Floppy infant syndrome,
5. Isotretinoin diabetes insipidus and hypoglycemia
6. Thalidomide Microtia/Anotia.
Phocomelia (Proximal limb amputation) (lmage 27)
7. Warfarin Stillbirth
DI SALA syndrome (lmage 28)
Chondrodysplasia
Stippled Epiphysis
Nasal hypoplasia
8. Methotrexate
CNS-Agenesis of corpus callosum
9. Tamoxifen Craniosynostosis: Cloverleaf skull
Leads to a number of defects in
Vaginal adenosis fetus similar to DFS:
Important PYQs
Craniofacial defects
After stopping tamoxifen, pregnancy Ambiguous genitalia
should be witheld for 3 months
Mother ’ Endowmetrial cancer
10. Misoprost Mobius syndrome
Note: Indomethacin if used in pregnancy can lead to
should never be used beyond 32 weeks of pregnancypremature closure of ductus
arteriosus. So
indomethacin
 OBSTETRICS 29

Low
NSal bride Epicanthal folds Also Know
Minor car
abnormalities Short Maximunm Permissible radiation during
lndistinct palpebral issures pregnancy-5 Rads
philtrum Flat midface X-Ray is contraindicated in Pregnancy
and short nose
Micrognathia
Thin upper lip
If during pregnancy X-ray is done accidentally
or deliberately then MTP is not recommended
lage 25. Fetal alcohol syndrome-facial features
Crux of heart

Normal Anterior PogterioyPBR

Medial
chordae Anterolateral
papillary muscle Crux of heart RA
Ebstein's LA
Anterior
right-sided

oster ARV
LV

Ebstein's RV
left-sided Rosterior
Anterior

Image 26: Ebstein anomaly =Apical displacement of tricuspid valve d/t lithium ingestion

B
lmage 27: Phocomelia: Distal limb Image 28: Warfarin embryopathy
amputation d/t thalidomide A= Depressed nasal bridge, B= Stippled epiphysis
qrowth Periods
Periods Definition Comment
1. Pre-embryonic period Day of fertilization till All-or-none law is followed
2 weeks after that Teratogenic exposure during this
period either leads to abortion
or fetus escapes any injury
2. Embryonic period 3 weeks to 8 weeks after fertilization Most teratogenic period
3. Fetal period 29 weeks after fertilization (Till delivery)
 Sakshi Arora Hans
One Touch Obstetrics and Gynecology by Dr
ANTIPHOSPHOLIPID ANTIBODY
14.

Antiphospholipid Antibody Syndrome

Antibodies Diagnostic criteria: |Imp: PYQ

1. Lupus Anticoagulant (Name: Modified SAPPARO criteria/ M/C single cause of
2. Anticardiolipin Antibody SYDNEY criteria) recurrent abortio
(lgM, lgG) 1 Clinical + 1 Lab criteria for diagnosis APLA Syndrome
3. Anti B2 glycoprotein CLINICAL:
(lgM, lga) 1. 21 Episode of thrombosis (Arterial
Cause of abortion: It venous/small vessel)
inhibits trophoblast 2. 23 Fetal losses at <10 weeks.
function 3. 21 Fetal loss at >10 weeks
4. 21 Preterm delivery before
32 weeks due to severe preeclampsia
or uteroplacental insufficiency
LAB:
Any one of the 3 antibodies positive on
2 occasions at least 12 weeks apart
RECURRENT ABORTION Management
Conventional Definition = 3 consecutive APS without a thrombotic event and without
pregnancy Losses pregnancy loss - only low dose aspirin
DEFINITION BY ASRM APS with athrombotic event or with pregnancy
Ifthere is occurrence of two or more consecutive loss - Heparin and low dose aspirin
losses of recognized pregnancies by USG or HPE Intrapartum: stop anticoagulation
before 2o weeks start evaluating Postpartum: resume or start anticoagulation in 6
Four Established causes of RPL hours (after vaginal delivery) or 12 hours (after
cesarean section)
APLA Syndrome (single most common cause)
L6%
UTERINE STRUCTURAL ABNORMALITIES
congenital like septate uterus and acquired Q. How to Diagnose missed abortion on USG:
like cervical incompetence, fibroid, polyp 1. MSD 25 mm and No Embryo seen
Chromosomal abnormalities (Balanced 2. CRL >7 mm with no cardiac activity
translocation of chromosome) are responsible Such a missed abortion where no embryonic
for RPL in 4% cases structure is visualized is called AnembryoniC
Hypothyroidism pregnancy or blighted ovum
Note: Infections including syphilis and TORCH Management: Medical Abortion
infections do not cause RPL; they cause sporadic
losses
M/C groupcausing RPL =Endocrinopathies> uterine
Causes.
lnvestigation for RPL
Ultrasound uterus
APLA Antibodies
Parental karyotype
TSH
Investigation not done in RPL: TORCH test
 pregnant
Females
Vaginally: Non Transabdominally 2. Transvaginally CERCLAGE
CERVICAL
1.females
Pregnant
Females It
Pt Pt
onceiving Here can
cervix
S2.5
cm.
abortion H/O insufficiency.No
confirm dilatation
cervix
IOC: of
USGMears:
should should Delivery
completedsuture
family
herpregnancy pregnancy
showsUSG-Based
Diagnosis
cervical
lengthcervical >2Spontaneous
Diagnosis
History-
Based
The Ix: Benson
It cerclage
Wurms
Can cerclage)
Hefner (2 M/C =
Shirodkar
cerclage
applied) be
defective abortions
need cervix
LASH done One
Failed can be
be be done
TVS +
iveredadvised should done and
be McDonald INSUFFICIENCY
CERVICAL for
cervix should in second of dt
&Transvaginal done Durfee USG
LASH by pregnant second
be laparoscopically
also shortening
to is be to
done: length
present
of in
qive
byremoved
removed
duringcerclage suturesare
cerclage trimester trimester
arean procedure measure
a
cerclage
by females
gap pregnancy 20
cesarean of
surgically only (Purse
ection of applied;
called
also and
3 female
afterhas INSUFFICIENCY
CERVICAL
months section string non
and
pregnant
before before suture cervical
Nextlength
<2.5 Case Nextlength Case Next Case needNext CaseProgesterone
Important: steps 2. 1.
Next Management On
Cervical Shape TVS:
Length of
step: Pregnantstep:
step: 3: 2:forstep: 1:
4: of
Normal Note Relative 5.
Time(chorioamnionitis) Monofilament
Appliedstring
Purse
L.Nonabsorbable
on M/C IMP Pregnant PregnantPregnancy Cervical
shaped
’UShape Bleeding
contractions
Uterine . C/1:MaxmTime:sutures:
4. 3. 2.portiovaginalis Transcervical
Progesterone
cx TVS TVS) +
cerclage of
CurrentFetal s2.5 Cervical cervix
to Concepts on of cervix
of membranes 12-14
Ruptured Until Done: to
Progesterone cervical
’T remoe
demise/gross
C/: female female cm female insufficiency
cervix measure female (if =U =
pelvic cm cerclage
shaped Placenta indicated) S2.5
24wks McDonald
insufficiency shape
on stitch: (Not cerclage
with with has
infection wks cervical has cm,
(Not Cerclage cerclage) H/o
’YUSG NO H/Oone atH/O
congenital
previa
37
funneling of
as before + one12-14
shaped cerclage H/O
Progesterone length. two
it Weeks
dilates: T2 T2
12 Abortionbut T2
’v anomalies abortionabortion weeks(No
+ abortions
wks) OS
(suture:
shaped
 21. ABORTIONS
Definition of abortion as
Bleeding in carly pregnancy Pregnancy loss before 20 per WHO
Nonobstetric causes
Obstetric causes
1 Cervical erosion
pregnancy or before weight Weeke
of
1. lmplantation
bleeding/placental 2. Cervical polyp
SO0 gm
Note: vwt of fetus @20 wks fetus M
SIgn
2. Abortion
3. Fibroid polyp Wt of fetus @22 wks = ,=330
SOO gm
M

3. Ectopic pregnancy
4. Molar pregnancy
Also know
lportant one liners
2 most Imp risk factors for
M/C cause of TL and T2 spontaneous
Abortion:
(1) Previous H/O abortion
(2)lncreased maternal age
abortion
Best answer: Aneuploidy (50%) >
TRISOMY> MONOSOMY X(20%) > Most viable trisomy: Trisomy 21
TRISOMY (167) M/C outcome of trisomy 21: Aborti
M/Cuterine cause of T1 abortion or Most lethal trisomy: Trisomy 16
TL Recurrent abortion: Septate uterus M/Ctrisomy to cause abortion:
M/Cuterine cause of T2 abortion or Trisomy 16
T2 Recurrent abortion: Cervical M/Csingle specific aneuploidy to
incompetence cause abortion = Monosomy X (Tuer
M/Ccause of T1 RPL= APLA syndrome)
M/Ccause of T2 RPL = Cervical insufficiency
ABORTION

Types Management
Threatened abortion: Process of abortion
Approach begins but it is at astage from where it can
be reversed.
Mgt: Expectant management
H/O No H/O Inevitable abortion: Process of abortion canndt
Product of conception be reversed POC has not come out
Product of conception
cOmes out coming out Mgt: Enmergency suction evacuation-if bleedine
P/V: is heavy to prevent further blood loss and
Ylnternal oS anemia. Otherwise, conservative managemant
awaiting a spontaneous completed abortion
Incomplete abortion: POC start coming out
Close Open Close but process is incompete
open
Mgt: Emergency suction evacuation
Incomplete Complete lnevitable P/A Complete abortion: Entire POC come out
abortion abortion abortion spontaneously
Mgt: Conservative if an intrauterine
had been previously confirmed.
pregnancy serial
Otherwise, B-human chorionic
be an
gonadotropin (B-hcGa) titers shouldensure
Height of uterus Height of uterus obtained weekly until negative tomissed.
= POG = POG eetopic pregnancy has not been
Threatened abortion Missed abortion
 22. MEDICAL TERMINATION OF PREGNANCY
MTP Amendment 2022
MTP can be done till 24 weeks:
In case of contraceptive features: MTP done till 20 weeks
In severe congenital anomalies of fetus: No upper linit. If medical board permits
Medical board = Gynae + Pedia + Radiologist + Person from state
Single doctor opinion: Till 20 weeks
2 doctors opinion needed: 20-24 weeks
Qualification to do MTP Imp PYQs on MTP
For doing MTP till 12 weeks Females consent is needed for MTP
RMP who has assisted in 2s MTPs (at least s In minor/mentally retarded patients-Guardian
should be as primary surgeon). cOnsent needed
For doing MTP between 12-20 weeks Age proof-not needed
1. RMP with 6 months of house job in bs gynae or Marriage certificate-not needed
RMP With 1 year of experience in any hospital FIR report of rape-not needed
with all facilities All records of MTP should be maintained for
2. Diploma/degree/DNB in Obs and gynae S years

MTP

Period of Best method of MTP Medical abortion

gestation Gol = Until 7 weeks
<7 weeks Medical abortion WHO = Until q weeks
7-12 weeks Suction evacuation At <7 weeks 7-9 weeks
>12 weeks Abortion using D1 T. Mifepristone D1 T. Mifepristone 200
mesoprost 200 mg oral mg oral
(In patient)
D3 T. misoprost T. misoprost
400 mcg oral/buccal/p/v 8O0 mcg oral/buccal/p/v
D15 Ensure process is Ensure process IS
complete complete

A B

lmages 29A and B: MVA syringe and menstrual regulation syringe

Suction Evacuation
Done using Karman cannula
Number of Karman cannula corresponds to size
of uterus
Pressure generated = 6O0 mn of Hq
In areas where electricity is not available = MVA
is done.
Refer to Table 7 of obs for Methods of doing MTP.
Manual Vacuum Aspiration (lmage 24A)
Done using MVA Syringe (2 pinch valves)
Capacity of syringe = 60 mL
Pressure generated= 660 mm of Hg >600 mm
of Hg
Menstrual regulation syringe: (One pinch valve
or now no valve (lmage 29B)) SO m Syringe
 34

Resuscitatestep: Female CASEMIRENA>increased

Nextspotting, but
M/c Contraceptives:
Decrease Others: PID M/c: Maximum
occurs, risk:
Factors
Risk Ovarian
Abdominal Named
SiteCriteria other isthimus
pregnancy;
Heterotopic
pregnancy:
Surgical) of Least M/c
tubeectopic
TwinCornual M/c
FAST.
management
USG surgical
If of If DES
Cervicitis IVF
Cervical
Guarding on = if Smoking surgery
Tubal
Previous
ectopic
H/O
with Tubal Nontubal site:
common
Once as P/A: vitals thenfailure ectopic and
+ IUCD absolute pregnancy: Fallopian
aperitoneal Guarding P/A 6-8 one
diagnosis
sterilizationectopic cervical
and unstable, > of site: site:
examination weeks Studdiform
Spiegelberg Criteria
Palman,
Rubin
POP (Mgt is
Rigidity contraception risk Cesarean tube
and preg intrauterine, ectopic. Ovary
is amenorrhea, of
UPTve > = Ectopic (Ampulla)
One
nfirmed, Rigidity risk ectopic always
Ectopic
are
bleedingruptured scar Touch
not is in
present:present: pain 23.Obstetrics
then can
in PREGNANCY
ECTOPIC
be
dolmmediate PREGNANCY
ECTOPIC
surgery. seen Do abdomen, and
FAST Gynecology
on

Finding
P/V Localizing 2 1.
3. 2. by
signs3. Ruptured
Ectopic
Signs: 1. ToAmenorrhea
Symptoms Symptoms
abdomen TRIAD of Dr
POG.
than PID) in Cervical Most
less (Cervical
Uterus tenderness P/AShock suspect
peritonitis UrgeShoulder
Syncopal Sakshi
neal
etects
eding
Culdocentesis
Image30:
important:
is movement =
(‘PIR; to and Arora
soft motion Abdominal defecate ruptured
Tip
attack/orthostatic (6-10
bleeding Hans
and BP) pain
tenderness Adnexal
enlarged Ectopic
tenderness distension; weeks),
P/V
Guarding
Rigidity
mass pain
but is hypotension
size also D/t in
rebound
is seen lowe

M
 OBSTETRICS 35

Management of Ruptured Ectopic Algorithm for Diagnosis of Unruptured Ectopic

Always surgical
No role of conservative management or medical DO TVS
management
Route of surgery:
If vitals stable:
Laparoscopy/Laparotomy
If unstable vitals: Laparotomy G:Sac + Yolk sac seen Signs suspicious of
Surgery of choice: in tube Ectopic seen
Unilateral SALPINGECTOMY Next step e.g: Next step
Surgeries never done: for ruptured ectopic Empty
2. salpingo-oophorectomy uterus
Treatment of Ectopic B-hcG
2. Linear salpingostomy (Done for unruptured
Ectopic)
Value above critical level
Investigations done in Unruptured Ectopic (22000 I)
1. TVS:
Confirmed sign of Ectopic pregnancy: G:Sac +
YSac t cardiac activity seen in fallopian tube Yes No
Suspicion of Ectopic if:
Complex adnexal mass Next step Next step
Ring of fire on Doppler (lmage 31) Seen
Empty uterus on USG Treatment of Ectopic Repeat hCG after
48 hours
GSac without Yolk sac in tube.
2. Beta-hCG:
Critical value of hCG is that value of hCG above
which in all intrauterine pregnancies, G:Sac is hCG increases
visible inside uterus hCG increases hCG
TVS = 2000 /U by >66% but <33% decreases
TAS = 65O0 I/U
Viable slow rise Abortion
intrauterine
Other Important PYQS pregnancy Ectopic
I0C in Ectopic = TVS |pregnancy
Gold standard Ix: Laparoscopy
Investigation which may be done
TRV RT RONEYA
S: progesterone
Culdocentesis (ruptured ectopic)
Investigation never done:
Hysteroscopy
HSG
Colpotomy (drainage of pelvic absces)

Image 31: Complex adnexal mass and Ring of

Fire on Doppler
 Hans
36 Obstetricsand Gynecology by DrSakshi Arora
One Touch
Management of Unruptured Ectopic
Surgical managenment
Expectant management Medical management
medical
Least preferred Most preferred
management Done only if
cannot bedone or
fails management
Prerequisite for unruptured Ectopic Vitals = stable/unstable
BhCG = 2O0 IU and falling Prerequisites Can be done
No sac should be visible on Vitals of pt = stable Ruptured and unruptured Ect
USG Done only in = unruptured Ect If hCG 25000 IU
BhCG <5000 IU
If sac S0ze >4 Cm
Sac size on USG = <4 Cm
Family of pt = Not complete If family iscomplete
Should. Cardiac activity ispresent
Cardiac activity
preferably be absent.(If cardiac
activity is present: Chances
of failure med management
increase)

Details of Medical Management Details of Surgical Management

DOC = Methotrexate (MTX) Route = Laparoscopy
Dose = 5O mg/m² Surgery of choice if family is not complete = Linear
Route= /M salpingostomy
Remember: Surgery of choice if family is complete or if size
In Ectopic = The entire dose of MTK is given in sinale of sac 25 cm or in all cases of ruptured Ectopic
day. salpingectomy
It is called single dose therapy.
D1 = MTK injection D/D of Ectopic pregnancy
D4 =Measure BhCG 1. Abortion
D7 = Measure BhCG 2. Round ligament pain
There should be a fall of 215% between D4 and D7. M/C in second trimester (12-16 weeks)
If: Fall is <15% = Repeat MTX inj. M/Con riqht side
Total methotrexate can be given 3 times No bleeding
IfhCG value doesn't decrease even after Pain T's with
3doses of MTx-Do sugery
movement
Appendicitis
If b/w D4 - D7= hCG increases instead of decreasing o Migratory pain + fever
’ Do surgery USG =
o
Noncompressible structure >6
If value of hCG is T'ed on D3 then don't worry, it is
normal
management:
immediate appendectomymm
 OBSTETRICS 37

24. MOLAR PREGNANCY

Suspect molar pregnancy Partial mole Complete mole

If Q says: pregnant female
has c/o Bleeding in T1;
Hyperemesis
( High Bp + thyroid
storm). On P/A
examination. Ht of uterus
is more than POG, FHS =
not heard and on
ultrasound = snow storm
appeaance is seen
Karyotype: 69XXY " Vesicular Mole, H mole
" Dispermic 46XX (0%)
Some fetal tissue seen 46KX (102)
"Resembles incomplete " Monospermic
abortion on USG " No fetal tissue seen
PIH/Hyperemesis " Shows Snowstorm appearance
Thyrotoxicosis/Theca on USG (lmage 32)
lutein cysts absent " PIH/Hyperemesis/
" Ht of Uterus = POGor Thyrotoxicosis/Theca lutein
even less Cyst present
Ht of uterus > POG

BhCG levels are IOC: TVS

higher than normal Molar Pregnancy Gold standard: HPE
pregnancy

Management Signs and symptowns of developing GTN

" Suction Evacuation always
" IfQ says: Pt is >40 years and her
family is complete, then answer is
Hysterectomy
" After Suction evacuation
" Do sharp Curettage
Send tissue for HPE
Serial measurement of BhCG:
After 48 hours and then weekly
till undetectable and then monthly
for 6 months
Pregnancy isC/1 for 6 months
Contraceptive of choice = OCP
Prophylactic chemotherapy not
given
" Mgt of Theca lutein cyst
Not done
Thecyst resolves on its own
L.Persistent bleeding after evacuation of
H mole
2. Persistent Theca lutein cysts
3.Shock
4.Subinvolution of uterus
5.Metastasis signs
M/Csite of metastasis in GTN = lungs
2nd M/CSite: Vagina
Lab criteria for GTN
1.For 3 consecutive weeks = hCG level
increased >10%.
2. For 4 conseCutive weeks if hCG value
plateaus (within 107% of previous
value)
3.hCG detectable in blood even after G
months of evacuation
4. HPE report shows GTN

"H mnole is a beniqn disease of

trophoblast with malignant
potential
Gestational trophoblastic neoplasia
includes:
() Invasive mole
(i) Choriocarcinoma
(ii) PSTT - Placental site
Trophoblastic tumor
(iv) ETT- Epithelioid Trophoblastic
tumor
 Gne Dr Sakshi Arora Hans
Touch Obstetrics aand Gynecology by
GTN: Choriocarcinoma and Invasive Mole OBSTETRICS

MIC GTN after molar pregnancy invasive o 25. PLACENTA PREVIA

Choriocarcinoma M/C occurs after = Ma
pregnancy Bleeding in Late
M/C GTN after full term pregnancy: Placenta previa
choriocarcinoma delivery : (Placenta in lower uterine segment)
PSTT (Placental site thromboplastic Tumor) M/
occurs after = Full term delivery History older classification
WHO risk score for GTN Bleeding in T3: old Classification
o Painless
Grade I = Lateral previa
Low risk High risk Causeless
o Recurrent
Lower edge in the lower uterine segment
within 2 cm of internal Os
GTN develops after GTN develops after o Warning Henmorrhage present Grade ll = Marginal previa
age 32 Snowstorws apearance on X-ray seen in case Molar pregnancy full term pregnancy Imp: No pain in Abdomen Lower edge reaching uptil internal OS
of H mole Metastasis =lungs/ Metastasis = Brain/ Grade Ill = Partial previa
vagina Líver
P/A Exam " Placenta partially covers the cervi
hCG values <10 IU hCG 21O IU Grade v= Complete previalcentral previa
Ht of uterus = POG
Age of patient 240 yrs " Placenta completely covers the cervix
<40 yrs Uterus, Soft Relaxed Non Tender
Number of FHS = Heard
Number of metastasis 22 Fetal parts easily felt
Metastasis <4
Total score <o Total score 27 Malpresentation Transverse lie >
Breech common
P/V Exam and P/S Exam is C/I in
Management of GTN placenta previa
FIGO Stage 1: GTN Limited to uterus Investigation
Type 1 Type 2 Type 3 Type 4
Multi dose methotrexate + Folinic acid (alternate Screening lx = TAS
lage 3 Cannon ball appearance of chest X-ray in days) I0C: TVS
Image 35: Types of Pl. previa
choriocarcinoma (M/C appearance of lung metastasis FIGO Stage 2: GTN spreads to vagina-Do WHO
seen on chest X-ray) Scoring New Classification
If WHO score s6 =
Low Lying Placenta: Placental edge less than 2 cm from int OS (ld = Type 1)
Multi dose MTX + Folinic acid (alternate days)
Score >7 =
Placenta previa: Type 2; 3 &4 of older classification ie.,placental edge either reaching uptil
Multi agent chemotherapy the OS or covering it.

FIGO stage 3 = Metastasis to lungs |Imp Concepts

DO Scoring and T/t same as stage 2 USG is imp in placenta previa
1. To confirm diagnosis
FIGO stage 4 = Brain/Liver involved (No need for 2 To detect malpresentation
scoring)
3. To Rule out placenta accreta spectrum.
Multi agent chemotherapy
Best Time to do USG to Rule out previa: 32 weeks and 36 weeks.
Follow up in all cases of GTN with BhCG = For 1 year In patients of previa with previous H/Outerine surgery (LSCS) the villi may invade into
myometrium resulting in placenta accreta spectrum (PAS).
Multiagent chemotherapy used in GTN: The possibility of PAS should always be kept in mind in placenta previa patients.
4 ChestX-raySnowstorm appearance in E-Etoposide
Choriocarcinomna M-Methotrexate
A-Actinomycin D
C-Cyclophosphamide
|O-Oncovin
 thh fetal aqe not lung D and
putting ShortAnti
attaining Gestational
has
stable weeks
fetal
loss give
withouthemodynamically
Expectant
management seen hrs3o-37
wks (thra
trimester) blood for
elective of or 48 section
migration contraction
20 aim significant corticosteroids
weeks
pregnancy fortill
Hans at weeks Do the pregnancy
patient
cesarean
Arora USG bleeding <34 Admit
patient term
tocolytic
placental = with Noactive
bleeding
seendays. is Nofetal
distress
36 agebut uterine
maturity
Sakshi 2 =
levelT3 placenta with ContinuePt
risk Next
step:
Rh-ve do
at weeks Carry
+6 Indication
lung
maturity Gestational Give then
on in called then weeks occurred.
Dr
repeated presents at If In
by finding mother
Means: >34
Gynecology is & lying
This weeks 37 McAfee
and
previa
Incidental
is lowto Regimen
Johnson
USGseqment.
32 weeks
or exercise
and @ of
When (TVS)previa hours case after unstable and
STALLcalled
Obstetrics
PREVIA
an upper 36 wks weight
severeKnown
is = @ 20
UsG placenta z4 section occurred previa:was
previa
cases cesarean finding
in heavy
atAvoid for Persistent
bleeding/Active
bleeding
hemodynamically previa
TouchPLACENTA be repeat
intercourse
to
2: C/section
placenta
rinciple:
9O%
In qiven standing
medium cesarean placenta
Placentawill
Case
1: weeks lifting # Active
management CTG
One Case has placent
SO
Picenta be weeks
3 FMGE posterior
3G to AvoidAvoid by loss Immediate
distress/category positive
Avoid
OF Advise: TOP
of
resuscitation
ofpatient
MANAGEMENT
at
If Pt. blood
234 for variety of
variety
(mmediate age is
PYQs sign
= 2
Indications
Pt
in
laborSiqnificant
gestational
= posterior
In type
Management WORTHY
Important danger
Fetal Older
Means:
40
 OBSTETRICS

26. ABRUPTIO PLACENTA

History Types P/A Finding

Patient gives H/OTrauma or
Has High BP
4PAIN IN ABDOMEN
Bleeding P/V in T3
Blood dark red in color
Not recurrent
No warning hemorrhage
Abruption is premature separation of Ht of uterus>POG
normally situated placenta: Uterus is tensed
1. Revealed variety: Whatever bleeding tender and rigid
OcCurs = Comes out FHS = Not heard
2. Concealed type: Blood collects in uterus Fetal part: Not
behind placentagiving rise to couvelaire palpable
uterus (Bruised uterus) (lmage 3o)
3. Mixed type (M/c)

PAGE = Classification
GRADEO = Retrograde
BLEEDING IN LATE PREGNANCY: GRAD 1 = Pain + bleeding +
ABRUPTIO PLACENTA:
FHS (N)
GRAD 2 = Fetal distress seen
GRAD3= Fetal death
maternal shock ± DIC seen

Placental separation releases Thromboplastin P/V Examination

which initiates contraction + leads to DIC Not C/ in Abruptio but should be done after
ruling out previa
Investigation
TVS = Not diagnostic
Abruptio isa clinical diagnosis
On TVS =

1. See placenta in upper segment

2. Retroplacental clot
3. Jello sign: Shimmering of placenta
on maternal movement.

Image 36: Couvelaire uterus

Managewment
1. Abruptio + fetal distress/maternal condition unstable: Emergency C/section
2Abruptio + fetal death + mother unstable or DIC = Emergency C/section
3. Abruptio + fetal death + mother stable = 1OL for vag delivery
4. Abruptio + DIC: Correct DICf/b C/section
Aoruptio + No emerqency condition: If gestational age <34 weeks = Continue pregnancy
G. If gestational age >34 weeks = IOL f/b vaginal delivery.

Remember
Patient of abruptio may present as preterm labor
whenever in a patient of PTL > uterus is tensed and tender always rule out abruptio

For obstetric causes of DIC and investigations done in DIC = See Table 5 and o.
 Gynecology by Dr Sakshi Arora Hans
42
One Touch Obstetrics and
DIABETES IN PREGNANCY
27

Pregestational Diabetes
(Type non A diabetes)
Diabetic female conceives
Blood suqar levels raised Gestational Diabetes
from day 1 of pregnancy
Hyperglycemia is Fetotoxic (Pristella white = Type A diabetes)
Nondiabetic female conceives but
Leads to congenital
malfornation becomesdiabetic during pregnancy d',
Insulin Resistance
Doesn't resolve after delivery
Insulin Resistance is d/t HPL and
Diagnosis of Pregestational Increases as pregnancy advances
Diabetes Significant IR develops between
24 and 28 weeks of pregnancy
FBS = 126 mg/dL Gestational diabetes develops between
RBS >2O0mg/dL 24 and 28 weeks (organogenesis is
2-hour PP >20O mg/dL complete)
HbA1c 26.5 Doesn't lead to congenital malformati
Congenital Malformation
in Diabetes Type A diabetes can be
M/C system involved DIABETES IN PREGNANCY A, =Gestational diabetes
CVS > CNS controlled by diet
M/C congenital malformation A, =Gestational diabetes
controlled on insulin
VSD> NTD or OHA
Most specific = Sacral agenesis/Caudal
regression syndrome (lmage 37)
Diagnosis of Gestational Diabetes
In lndia: DIPSI guidelines are followed
Test = Lst antenatal visit + repeated e 24-28 wek
of pregnancy 5
Fasting = Not needed

Procedure:
Give 75g of glucose to patient mixed in 30O mL of wat
irrespective of previous meals
*(To be drunk in S minutes)
Result:
lmage 37: Caudal regression syndrome If 2-hour PP = <140 ma/dL = Repeat test at
24-28 weeks
M/C CVS anomaly If 2-hour PP = >140 wma/dL = Manage as aDM
VSD
If 2-hour PP= 200 m/dL = Manage as pregestatin
Most specific CVS anomaly (does not diabetes
resolve after delivery)
TGA
Important points:
M/CCVS Finding (reversible after delivery) Minimum time qap between 2 tests = 4 weeks
Weeks- !
HOCM If patient comes for first time after 28
test only once
 OBSTETRICS
Antenatal Care in Diabetic Patients 43

National Guidelines Metabolic Goals in Diabetes

1 For congenital (MNT or lnsulin)
malformation:
ln pregestational diabetes:
FBS <9S mg/dL
1-hour PP = <140 mg/dL
() Do HbA1c (Risk assessment tool.) 1-hour PP = <120 mg/dL
If HbA1c <6.5% = HbA1c <6
No risk
10% =
15-2O% risk Average capillary glucose <100 mg/dL
(ii) Screening of
Level 1 scan congenital malformation Medical Nutrition Therapy
(iii) 1OC: Level 2
Scan at 18-20scan/Target
weeks
Advised to all diabetic patients:
CHO = 40%
(iv) Fetal Echo: 22-24 weeks Fat = 4O% (Saturated Fat <10)
Protein = 20%
2. Target scan also done in GDM
patients as Target
scan is done in all pregnant females. Insulin
DOC for diabetes in pregnancy
3. In both GDM + Route =Subcutaneous
Pregestation diabetes M/Cused = Human premix insulin
28-30 weeks
Do 2 growth scans Vial = 40 IU/w
34-36 weeks Maximum times syringe can be used = 14
(To estimate Macrosimia and Amniotic fluid) Stored at 4°-8°C (in Fridge)

4. Number of antenatal visits:

(i) Wel Management of Gestational Diabetes
controlled GDM/No complications:
Routine antenatal visit Give medical nutrition therapy (Diet modification)
alone for 2 weeks.
(ii) Not well controlled GDM/Complication seen:
T, = Visit every 2 weeks
T, = Visit every week After 2 weeks
Check 2-hour
S. Urine R/mn and urine culture to be done in PP levels
each trimester as asymptomatic bacteriuria is
common in diabetic patients
Value <120 mg/dL Value z120 mg/dL
6. Begin fetal monitoring begin at (@) 32 weeks =
(i) DEMC: Daily
(iü) NST and BPS: Weekly MNT alone to be
continued MNT + Insulin
No need for: Umnbilical artery Doppler unless PIH
is present.
Obstetric Management Since lnsulin
Resistance increases |Initially:
Check 2-hour post
Gestational diabetes: during pregnancy
Well controlled on diet (Type A) Check = 2-hour PP prandial levels every
>39 weeks. levels
third day to adjust
Type A,:Well controlled on dose of lnsulin
drugs T, = every 2 weeks
Type A,: Not controlled on Insulin = 37 - T, =every week
38 weeks + 6 days
Pregestational well controlled >39 weeks
 44
teralNote:
M/C It
available (Flex Algorithm Shoulder
Dystocia
arm)
maneuver Remove
R=
R (Rubin EP= leads L= Maternal
Complications
Diabetesof Management
E H Turtle ItDelay
Sign:signdelivery
= the =Give is Malpresentation
future Risk o Polyhydramnios cause
Placentomegaly
PIH/polyhydramnios candidiasis OHA
diabetics.inIn give
eous = = an prolapse PROM
Cord Abruptio PPH
asymptomatic
can bacteruria, fed pregestationalMetabolic
Roll = EnterApply space thighs to Legs Call of PTL chances
case Aspirin When
are
nerve
JACQUEMIER Il
straightening For
for obstetric of in developing
maneuver/Woods
or
maneuver Liberal delivery ofdiabetic a
over suprapubic
hand fetal goals C/l
injured Al and Management Help of gestational of
nerve posterior in(To
patient4 abduct
Episiotomy; emergency. head of can infection pregnancy
inPregestational
prevent
in patient
maneuver)
during or shoulder diabetes pregestational
of pelvis cause
maneuver pressure McRobert
of diabetics: One
thigh them) of
on arm like PIH)
conceives:
cRobert cordscrew and
sacrum Shoulder = Touch
all Empty by in
(lmage (deliver (lmage
4 rotate Maneuver >1 IUGR.
and
patient If Fetal if Diabetes Obstetrics
limbs and diabetes patient Put
minute there -birth
still ted
Macrosomia
Shoulder
dystocia
aneuver 34) maneuver) 38)
the Dystocia hyperglycemia Fetal
posteriorshoulder increases bladder may ischances patient and
(Gaskin and refuses
after diabetic
have gestational Gynecology
on
- of
oligohydramnios abortion, Insulin lnsulin
vasculopathy: by
diabetes - (stop Dr
IUD, Metformin/glyburide OHA) Sakshi
McRobert
Image38:
age
are + Arora
mothers
Neonatal start
39:
Never same.
Respiratory
syndrome
Hyperviscosity hypoglycemia
distress
enterocolitis
Necrotizing
HypokalemiaNeonatal
Hypocalcemia Hans
retardation
Mental
Anemia
Polycythemia
Hypomagnesemia
Hyperbilirubinemia
All seen medical
our
in may
er maneuver babies benutrition
given
of
therapy
diabetic but
 OBSTETRICS 45
Iportant PYQs
. Fundal pressure is C/1 in shoulder
dystocia.9
Last step: Push the head of baby back into
M/Cfetal complication of shoulder dystocia:uterus followed by cesarean-ZAVANELLI maneuver
Erb's palsy (Brachial plexus injury)
M/C maternal complication of shoulder
dystocia: PPH.
For INICET
IADPSG
IADPSG/ADA criteria for gestational diabetes
Test done - between 24 and 28 weeks of Upper normalglucose level mg/dL
pregnancy FBS 92
8 hours of fasting needed
FBS taken
1 hour sample 180
Then 75 g of oral glucose mixed in water 2 hourssample 152
Blood levels checked after 1 hour and 2 hours
Total samples 3
If 21 value is abnormal then GDM is diagnosed
 Note
Pregnancy
vaccine
Rubella
WLONt aYter
If Rubella tnarcation
Rubella
pregnant
females MTPtor
Congenital
patient
occurs
TRIADthan
Congenital
Teratogenc
Rubella Most Sprramgcin To T/t:
then Blueberry
muffin
rashOthers
pulmonary
stenosis)
arteriosus
followed
patent
ductus
(M/C
Congenital Cataract
by SNHL Pyrimethamine
sultadiazine
prevent and
vaccine feces
laG FortranSmiSSion |H/O
MeatiCOning cating
conceives 2O if chorioretinitis
calcihication
Hydrocephalus Leads+ T Raw/urndercooked
severe
Most
MTP is tranSISSIOn
Maximuin
CI rubella
is (M/C) nfection
weeks known
is done Rubella vertical to:
IS for C/h defect
Heart Trad
TOXOPLASMA
not in in in is infection
occurs in
this month 1 al an L6
Sundrome
done pregnancy trarsnncssiOn (along aiforation
ofoccurs = contact
one wecks) intracerebral
less
with
with
IUGR) T, One
cat
(lmage
Touch
CICatricial
pneumOnitis
40) hepatitis,
eningoencephalitis
andNeonatehasdelivery 28.
delivery syndrome
Neonatal
infection Seen VZ
cicatricial
lesions
ZIgzag
Microcephaly, 12-20
weeks,
to
skin Teratogenic
cataract
syndrome: leads pd: exposed
given 96 If Pregnancy
Infections in Obstetrics
if congenital hours calcification H/O
mother and pregnant a Varicella
Zoster cause
periventricular
|Leads to Based
INFECTIONS
PREGNANCY IN
rash
skin or congenital
congenital
deafness M/C of viral
Syndrome M/C SNHL
S to
Microcephaly Chorioretinitis contact and
days2 limb VZIG CYTOMEGALOVIRUS
days VZ: On
gets varicella female History Gynecology
beforeHypoplasia should
Within with
after
be is Toddler of by
Patient Dr
Fetus:
Sakshi
Transplacental
transmission
occurs Receptor =
TIM-1borne
Female
Seizures
Clubfoot
Ttone
Limb of
Calcification Arora
Microcephaly Polyhydramnios
"Hydrops Mother:
fetalisFetus:
through Teratogen fetal
RBC PARVOVIRUS
Infectio
B19 gor H/O
teratogenicity
Parvovirus It
Anemia
Abortion
Mosquito Virus
Zika doesn't appearance)eck Hans
TAM-XL contact
(Slapped
children
disease)
(Fifth
teratogen
vector
borne
Only
Hofbauer
(lmage = lead
is with
Aedes cyto to
41) toxic school.
cells
to

Microcephaly neurogenesis
regulators
Inhibition of
Apoptosis

TLR3

receptor
AXL
Radial
cellsglial

brain
fetal
Developing
Cytotrophoblast
C
restriction ISGs Sygncytiotrophoblas
ZIKV

lmage
age
ISGs 40 OBSTETRICS

41: replication
ZIKV Varicella
ZIka HofbauErcall
Choriori acanta
viTls
Virus Trancple
B zoster

Protective
samrationViral Aadas
mosa
unity

DerS

Melanocyte

Keratinocyte

47
 Gynecology by Dr Sakshi Arora Hans
One Touch Obstetrics and
48
29.
OBSTETRICS 49

Suphilis in Pregnancy

Caused b Treponenma pallidum

pefinitions PREGNANCY-INDUCED HYPERTENSION (PIR)
Sexually transmitted Terminology
Definition
Primary syphilis Hypertension in pregnancy
Pregnant female 5P 214O/90 mm Ha on 2
IF BP >160/110 mm then occasions
4 hours apart
Localized do not wait for 4 hours to
Transplacental repeat BP. BP should be repeated in 15 minutes and
chancre
Seen more
In 1 and 2° spread Proteinuria antihypertensive started.
sypkilis Excretion of protein z30O ma (o.3 a) in 24 hours or
Secondary syphilis protein: creatinine ratio 2O.3 or urine dipstick 2+1
Fetus Siqns of End-organ demage Any 1 of the following:
o Platelet count <1 lakh
Systematic:
Early congenital syphilis condylomata lata Liver enzymes raised >2 times its N value.
o S:Creatinine z1.1 mg/dL
Anemia, NIHE, Macerated skin, o Pulmonary edema
Hepatosplenomegaly 1/3 o Visual symptoms/Headache
2/3
Tertiary syphilis . Chronic hypertension in pregnancy AHypertensive patient conceives, so increase in BP seen
Newborn Latent syphilis before 20 weeks without proteinuria and without end
organ damage.
Late congenital syphilis BP does not come back to normal even after 12 weeks of
|Symptoms = Absent Symptoms: Present delivery.
Diagnosed 2 years after birth: Physical indings = Absent Physical finding:
Gummas present
Pregnancy-induced hypertension A normotensive patient conceives but during pregnancy due
Hutchinson teeth (mulberry Nonspecific test = +ve
molars), saddle nose, malaise, Non specific test to placental pathology, BP increases. Increase is seen after
Treponema test +Ve
20 weeks of pregnancy. BP becomes normal within 12 weeks
Saber skin Treponema test:
Present +ve
of delivery.
Gestational hypertension PIH without proteinuria and end-organ damage. It's a
NIHE =Non immune hydrops fetalis |Management in Pregnancy: provisional diagnosis.
Benzathine penicillin 2.4 million units IM Preeclampsia PIH with either proteinuria or with signs of End -organ
damage.
Macrosomia (Image 42) Eclampsia Severe preeclampsia with new onset qeneralised tonic clonic
seizures or coma.
Definition = Weight of fetus 4 kq
Chronic HT with superimposed A female with chronic hypertension conceives, suddenly at
Risk Factors preeclampsia 20 weeks of qestation develops any of the following:
Post term pregnancy . BP becomes uncontrollable
Piabetic mother 2. New onset proteinuria
Male fetus 3. Siqns of end organ damnage
Maternal obesity
Mild PE Severe PE
Diagnosis BP >16o/110 wmm Hq
Abelominal circumference 235 Cm on USG. BP >140/9O mm Ha but <1GO/110
Siqns of End-organ damage present
Mode of Delivery No signs of End-organ dawmage OR

Vaginal delivery Siqns of impending eclampsia present

Ivnaqe 42: Macrosomia No signs of impending eclampsia
Jndication of C/section and severe PE
Not a criteria to differentiate between mild
l diabetie female if weight of fetus 24.5 kq or in
nondiabetic patient if weight of fetus is >5 ka. Proteinuria
etiet has acrosomic baby in this pregnancy and H/O cesarean section
coHtraiiaeation VBAC s a relative Oliguria
IUGR
 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans
Risk Factors for PIH Prevention of PIH Proven role
Exposure to Placenta for first time: Low dose aspirin
Primiqravida Calcium supplementation -if emale has
New paternity calcium low
Long interpregnancy interval Weight loss prior to pregnancy
Big placenta No Role of:
Twins Low salt diet Antioxidant
Diabetes Absolute bed rest Fish oil
Molar pregnancy
Hydrops fetalis Why PIH Occurs
H/O

Preeclampsia Extravillous cytotrophoblast (endovascular pus

Pregnancy is due to IVE. Trophoblast) fails to replace lining of matermal
Al disorder: APLAsyndrome spinal arteries in the myometum. Whereas
decidual part of spiral arteries, the linina
Patient detail: Obese female replaced. This is called incomplete trophoblasti
Age of female <18 years or 240years. invasion.

Markers in PIH
ACOG- recommends low dose aspirin
(75-150 malday) to be qiven to the Increase (Vasoconstrictors)
following females to prevent PIH Soluble fns-like tyrosine kinase (sFlt-1)
ALL = APLA syndrome Endoglin TNF-o
Hypertensive: H/O PIH in previous pregnancy Cytokines Thromboxane A2
Mothers = Multifetal pregnancy IL
Lipid peroxidase
Kin = H/O kidney disease lncreased sensitivity of vessels to angiotensin ll
Die = Diabetic patients Decrease (vasodilators)
Aspirin should be started at <16 weeks VEGF
(12-16 weeks) and stopped at 36 weeks. Placentalgrowth factor
Prostocyclin (2
NO
Angiotersinase activity

Management of PIH = Common Po ints

1. All patients with PIH Fetal Monitoring Definitive Management

should be admitted first Started @ 32 weeks
Proper History taken Termination of pregnancy by
Mild Severe lnduction of Labor
All Lab test done Mild PE = 37 weeks
DFMC Daily
Fundal examination
done NST Weekly Daily Severe PE = 34 weeks
To differentiate between mild BPS Weekly Impending
Eclampsia
and severe PlH USG for 3 weeks 2 weeks lmmediate
growth Eclampsia
HELLP
termination
Umbilical
syndrome
artery
Doppler
 51
OBSTETRICS
Alaorithn for Management Algorithm for Management of severe PE
(Mgt) of mild PE Treat as IPD
Treat as outpatient
Advise Check BP = 30 minutes
BPmeasurement twice daily Urine output = hourly
Fetal monitoring from 32 weeks Urine dipstick = 4 hourly
About signs of impending Mgso, to prevent To all patients give
eclampsia seizures Anti-HT+ MgsO,
NO role of: Give corticosteroid if pregnancy is
between 28 and 34 weeks.
Aspirin
Bed rest
Salt restriction Re-evaluate
Antihypertensive and Mgso,
Definitive Mgt: TOP at 37 weeks

Do immediate Continue
Signs and symptoms of Impending Terminate pregnancy
Edlampsia (IE) TOP without giving after 2nd dose pregnancy in
1. Severe headache 2nd dose of corticosteroid rest cases till
P =PROM/PTL 34 weeks
2. Visual disturbances In case of placental
3. Epigastric pain abruption R = Renal dysfunction
4. Clonus Impending eclampsia O = Oligohydramnios Then
Fetal distress terminate
HELLP syndromes M = Umb Art Doppler pregnancy
shows reverse diastolic
DIC
flow (30-32 weeks)
Pulmonary edema

Management of Eclampsia
1st step = Airway management or Raise bed rails
2nd step =MgSO, to treat seizures
3rd step =Antihypertensives (I/V)
Definitive Management = TOP inmmediately
Mode of delivery = Vaginal delivery
Remember
lIn all cases of PIH: Vaginal delivery is preferred.
Cesarean section is done for obstetric reason.
Anesthesia = Neuraxial > epidural
Important Points on MgsO4
DOC for prevention and treatment of seizures Check the following before giving
in PIH.
Centrally acting (blocks NMDA receptors)
Not Antihypertensive
Low therapeutic range: 4-7 mEq/L
Loading Dose
IM = 10g of so% MgsO, (1 ampoule = 2 mL =
1g MgSO), 5 gin each buttock.
IV = 4 qof 207% MgSO, @ 1 g/min (To prepare:
take 20 mL syringe, Add 4 ampoules of Mgso,
(i.e. 8 mL) + 12 mL normal saline)
No renal function test needed for loading dose.
Monitor patient's heart rate for giving IV dose.
Maintenance Dose
5g IM (S0%, solution) to be given 4 hourly till
24 hours after delivery or 24 hours after last seizure
whichever is later.
Maintenance Dose
1. Deep tendon reflexes (knee jerk) present.
2. Resp rate >12 breaths/min
3. Urine output >100 mL in 4 hours
 52
|Zuspan/Sibai
INI-CET) know
Also DOC
Methyldopa used:
NotNimodipine " Drugs lineIst
Maintenance (given Antihupertensives
Drugs in Note: LstSigns
infusion. Loading: Ketanserin
Nitroprusside
Nicardipine Verapamil
Nitroglycerin Nifedipine
Oral mg)30
for Vhydralazine VVlabe 824mEq/L Slurring
Diaphoresis
812speechof sign:
@15mEq/L
which MsO,
refractory used ard
over mEq/L Absent
4-69 as talol Syptoms
can in can
1520 regimen it
= is be (Maximum severe lead knee
Cardiac
paralysis
conduction
Cardiac
defect Resp
1-2 diluted hypertension: slow used: (Maximum = Pregnancy,
williams
26/ed. to jerk
minutes) for pre-eclampsia decreased of
acting arrest (10 One
g/hr, giving
in = MgS0,
220 mEq/L) Touch
in 100 variability
CTG on
Nitroprusside
MgsSO, ng) ToxicityObstetrics
100 mL
Hydralazine used:Not Drugs lineIst
mL I/V (lmp (only
Metoprolol Nifedipine
CCBMethyldopa Oral Oral Drugs
Orallabetalol
Hydrochlorothiazide
Propranolol and
I/V fuid which
for (Side at Gynecology
used
<20 can
effect= NICE
lndication
Antihypertensive
Pregnancy in
for
weeks; be
chronic quidelines: by
used:
cyanide Dr
never BP Sakshi
hypetension
z160/110
BP
poisoning) first Arora
215o/100
line) Hans
mm
Blocker
Diazoxide inhibitor
Angiotensin
Receptor ACE
mmHq
AbsolutelyC/I
Ha
 53
OBSTETRICS
30. HELLP SYNDROME AND LIVER DISORDERS IN PREGNANCY
HELLP Syndromne
Lab tests show a wnild elevation of bilirubin (>5)
Diagnostic findings are serum bile acids increased
Diagnosis 10- to 100-fold.
Hemolysis There is no adverse effect on maternal outcome,
Elevated liver enzymes but preterm births and stillbirths are increased.
Low platelet count
Recurrence rate is high in subsequent pregnancies.
Diagnostic Criteria - Tennessee Criteria Management
(all are required) Ursodeoxycholic acid is the treatment of choice.
Lemolysis- established by at least 2 of the Antenatal fetal testing should be initiated at
following: (1) peripheral smear with schistocytes,
2) serum bilirubin 21.2 mg/dL, (3) 32 weeks. Symptoms disappear after delivery.
low serum Induce labor at 37 weeks gestation.
habtoglobin or elevated LDH, (4) severe anemia
unrelated to blood loss. Acute Fatty Liver of Pregnancy
AST Or ALT 22 times upper limit of normal Acute fatty liver is the M/C cause of liver failure
Platelet count less than 100,OOo in pregnancy.
Management Usually occurs in the third trimester.
Prevalence is 1 in 15,0O0. Maternal mortality
Administer prophylactic MgsO, rate i 20%.
Treat severe hypertension It is caused by a disordered metabolism of fatty
Definitive management: Termination of acids by mitochondria in the fetus, due to deficiency
pregnancy (TOP) immediately. in the long-chain 3-hydroxyacylcoenzyme A
For pregnancies 34 weeks delivery after dehydrogenase (LCHAD) enzyme.
maternal stabilization
For pregnancies <34 weeks delivery done Clinical Features and Management
immediately after afirst dose of steroid without Symptom onset is gradual, with nonspecific
waiting for second dose. symptoms including nausea, vomiting. anorexia,
and epigastric pain in T,
Note: In 80% patients of HELLP syndrome: BP is Jaundice and fever wmay be seen in as many as
increased but in 20% patients BP may be normal. 70% of patients.
Hypertension, proteinuria, andedema can mimic
Liver Disease in Pregnancy preeclampsia.
This may progress to involvement of additional
Intrahepatic Cholestasis in Pregnancy systems, including acute renal failure,
It is stimulated by estrogen in genetically pancreatitis, hepatic encephalopathy, and coma.
predisposed wOmen in the second half of Laboratory findings include: moderate
pregnancy. Bile acids are incompletely cleared elevation of liver enzyme (e.g., ALT, AST, GGT),
by the liver and accumulate in the plasma. hyperbilirubinemia.
DIC may be seen.
Clinical Findings Hypoglycemia and increased serum ammonia
The most significant symptom is severe pruritus are unique laboratory abnormalities.
on the palms and soles of the feet-worse at Management: ntensive care unit stabilization
night-without any specific skin finding. with prompt delivery is indicated.
 lnage Umbilical
IF Umbilical
Normally
If(It Purpose.Done
45: S/D S/D
decreases
ge Normal ratioratio in
lmage Artery
LAAAA&AA circulation
S/D case
45 becomes 3 as
44: waveform
ed pregnancy
=ratio of
Absent Doppler
Uteroplacental PIH
y3= has
of in arnd One
lic diastolic a 31.
umbilical TOP umbilical
low (lmage Touch
advances) IUGR
is
flow done resistance.
flow 3sc insufticiency. DOPPLERObstetrics
artery for t5)
at vessel
37 prognostic
Doppler and
weeks is
<3. STUDIES
Gynecology
age Role IUGR
TOP in (Image45)
Management
(tpulsatility
index)
11-13 Note:
pregnancy.
predicts
disappears notch
Ifnotch 46).
Normally
The(mage EFW
estivnated
percenttile
If If o o IfTOP Management
Diastolic
IfTOP
46 diastolic oligohydramnios of pregnancy pregnancy IN by
Uterine USa UA NST
Steroids
Hospitalize UA
daily
CorticosteroidsNST
maturity =
for
weeks-predicts Uterine < if USG if Dr
rine Doppler Doppler pregnancy PREGNANCY
patient uterine percentile for = preqnancy for Sakshi
notch 1-2 of
ery 38
growth3 for is growth of
artery Artery talfe <33 Arora
-39 times
= <30-32
lung Reversed (Iage Absent
Flow
will artery =
persists =
weight 2-3 is 2-3 weeks is
ler develop
iswecks
37 betwecn =3 23344 Hans
early
Doppler Dopplerpresent maturity
daily
weeks
times/week times/week
Doppler
by weeks weeks Diastolic weeks
ing onset beyond is
PIH 22-24 =between 3O-32 wecks
done shows 36-37
olic preeclawmpsia 24 Flow
between weeks weeks diastolk a weeks wecks
3
and
notok t d
 Monochorionic
Monoamniotic Diamniotic.
Monochorionic disk): stage):
If(BLASTOCYST If
If (MORULA If
Monozygotic Twins
Types of
Time:
eks
CHIPHAGUS
HAGUS
14followed byLeast Monoamniotic
M/C 52
pelvis) COnjoined
10C PARAPHAGUS In division division division division Diamniotic
Dizygotic chances
pregnancy)
multifetalhistory
Hentifiable
DizygottwiCins Useful in
Rh
All eaidence Sex twins
2/23 of PSVMeasure
If21.5
=PSV IF Role
Monochorionic
and conjoined of
for variety ofova S
common
followed occurs occurs occurs fertilized
twin Polycythemia <O.8
MOM Middle
a
owing 34 stage):occurs ofof peak role
twins: Twins twins: varies negative
weeks IMPORTANT PYQS twins), in:
of twins at CHORIONICITY
twinung, risk can MOM
atbetween between systolie Cerebral
variety(Joined
conjoined Dichorionic Detecting
nicity (Joined by delivery >12 <72
(lmage Are from be by
monoamniotic by factors pregnancy, =
ORACOPHAGUS are same/different
use 2
hours sperms Anemia
velocity
cesarean days: always
of @ 9-12 4-8 47) ofusecountry Artery
monochorionic anemia
conjonea twins
lower should diamniotic HMG oflike
vertebral Conjoined days
= days Dichorionic clomiphene twin-twin (PS)of
section Maternal to
(30% fetus. Doppler
USG abdomen is be and country of and
between (embryonic fetus. of
(TVS)column) twin chances polycythemiaMCA
family, 32.
transfusion
OBSTETRICS
and (10%
of
TWINS
" Monozygotic twins
syndrome. of
Incidence
These into 2twins
No divides
Sex Single 1/3 of fetus.
Monochorionic,
monoamniotic identifiable
blood
Same
fingerprints
Diferent
karyotypetyping
SameSame
HLAgroup of
twins twins ova
Image constant
have
fertilized
Dichorionic,
diamniotic =
47: risk same
=
Types factors =
1 by
in single
of 2SO
twin
Monochorionic, sperm
pregnancy diamniotic

and
then

it
55
 56

S. 4. 3.Markers
2.POSTpartum
1. INTRApartum Maternal
ANTEpartum Delivery
complication
Specific
Prognosis USGplacenta
Number Sex
On connectrons
Vascular
twins
ofbetween membrane
between
nnembrane
Thicknessoftwin
Number
Thickness
2
TwinDifferent 4
different layers
peak of
Dichorionicity Complications of
sex of of lauers
sign membrane
placentas
of
membranes
positive fetus of
Cesarean
delivery
subinvolution
Hemorrhage,
MalpresentationPreterm
labor
Gestational
polyhydramnios diabetes Anemia
APH,
Preeclampsia
between on of One
weeks38 GoodSame/Different
placenta
Twin fuse)
may 2 mm2
z2 USG DCDA
Twin placentas Touch
mm
peak
twins Pregnancy Obstetrics
+ve
(somnetimes
sign
and
(lmage
Gynecology
both
Complications Fetal SO)
Corjoined
entanglement 4. 3. 2. 1.
Cord twin ComplicationsCumulative Only
Dizygotic
M/Ctwins All TTTS-37 NO
weeks weeks
syndrome
present
IfTTTS
34 If
transfusion
Twin-twin Bad Same Deep
TSingleconnections mm
<2 2
MCDA
Selective TTTS Complications
(15% complications
IUGRTOPSTAPScases) sign by
complication fetal Dr
seen Sakshi
specific (Twin(Twin complication
risk (lmage
specific Arora
anemia
oligo of
to aneuploidywhich are of
51) Hans
monoamniotic poly to more Twin
polycythemia
Monochorionic of cesarean
section
between
32-34
weec
conjoined
entanglement
BytwinCord Bad Same
connectio. MCMA
sequence) is
twin sign TSingleSupertiCial
more Pregnancy in
monozygotic
pregnancy:
in
twin: DZ
sequencl
twin: twin
IUG tha
:
 57
oligohydramnios Polyhydramnios). no
or
48)
twins
(lmage
twins amorphous
staging (Anuria)
abnormal
of one/both
both (no acephalus
artery.
bladder
Quintero seen polycythemia A-554
Acardius
study or
not one umbilical
Congestive
heart
failure UsG, in acardius
Doppler
TTTS: Bladder
Hydrops
of 49). 49:
Oligohydramnios, Death (lmage
Polyhydramnios On other through
Image
Recipient
twin:
ComplicationsfailureHeart of to
twin: Renal
Donor failure Polycythemia 1: twin
Less
qrowth Staging
Thrombosis
seen.
2: 3: 4: 5: riseamorphous
Stage Stage
Stage
Stage
Stage
and
Anemia Oligohydramnios)twingiving
OBSTETRICS polyhydramnios acardiac
develop
oligohydramnios acardius
be Fetoscopic (TAPS)
twin
should other to may
TRANSFUSION
SYNDROME recepient
connection (TRAP) blood called
Monochorionic
diamniotic
twins (no
Sequence extremities
have and weeks: anemia acephalus
2 is
deoxygenated
have
will Followingoligohydrawnios from Perfusion it
on heart then
28 vascular
willtwin: depends AmniocentesisAnemia-Polycythemia
has lower Acardius
Until identifiable:
twin: twin Arterialhave
TTTS:
RECEPIENT with
polyhydramnios. the
(Mgt): twin
perfuses
TTTS One Rare
complication
not 48:
DONOR of polyhydramnios acardiac Image
of with ablation ofTTTS: does be
of Management Reversed
TWIN-TWIN
twin:
twins
MCDA
diagnosis
One tWin: Prognosis
weeks:
twin
twin may
twi Other
the
in 1present. laser>28 Variant part
Seen One Dne One
In
USG Twin Twin
 58
Important Risk Done
C/l Anesthesia GA
transverse= lInternal
ie Version
Indication Podalic Delivery
Twinsof
(Thick
= = delivered by
takes
breechdelivery If
done.first If
is Vaginal Placental
Note:
Image Previous in During Iage
Rupture first
branes =
0T = her twin twin
s2: Images vaginal
delivery: sO:
First hand of USG
Placenta cesareanuterus
second is is tissue
between twin cephalic breech
delivery: between
twins
showing
in inside
of Twins Ony rising
section extraction. twin, or
DCDA cephalic One
2 uterus, and possible twin
in
cords) anesthesia transverse Do the 1AMBIINPEAK Touch
patients second not peak
and holds form
give first if sign Obstetrics
second given twin lie of
(Thin the injection
or twin a =
Image transverse if peakDCDA
branes legs to twins and
twin is in
s3: mother cephalic Gynecology
and
methylergometrine
are
Placenta
Theoretically
pregnancy. Not
|Superfetation 2 fertilized
Can get 2 converts lie
etween ovaSuperfecundationova
monochorionic
followed
seen be
(vertex).
of released first No by
seenreleased Twin Dr
MCDA2 in twin
transverse by placental
cords) (i.e. human in peak
Sakshi
it inhuman at internal should after Image
till is 2 different monoamniotic sigtissue
n Arora
No
uterine
possibledifferent lie the s1:
(Image
podalic be absent
coming Hans
ranes to
delivered delivery USG
S4: cavity till cycles time breech.) or of
version. then Tin
Placenta 14-16 in of sign MCDA
between
is and
etween rated)
oblite same vaginallycesarean first
Breech
get positive
of (0bstetricia twin. twins
weeks fertilized cycle
MCMA
cords) is and sectio
and then
of for
mentation
Nutrient rest
5. 2. Bed 1. (0) PTB
() Previous Previous
PTB Prevention
PTB of
Long-term: ExtremeModerate
* (in) Kemember: Complications
Immediate PTB of Very Late WHO Late EarluACOG
pirical
Screening NoIr LengthPatient
She Cerebral
mortality
Increasedpalsy
infant lnfections
prematurity
Retinopathy of (Respiratory
IVH NEC RDS PTB
Cat e gories
patient
role
Hypoglycemia
Hypothermia PTB
preterm
preterm
days
has (Necrotizing PTB FPB -
of
does
singleton
following has
ofCervical 3234-56
role for cervix F
H/O F laborlabor
genital not 52-33
<28weeks
of
iotics iscerclage
PTB. enterocolitis) weeks 6/7 234-36 <34
pregnancy
inhave <2.5 distress
6/7weeks weeks
Yes
infectionpreventing H/O No
cm
is syndrome) weeks weeks
PTTB on done
US4. +6
PTB but only 33.
length Nothing No
allif
Progesterone
PRETERM
BIRTH
of 3
cervix of needs
following 1
Recommends
between PROM 7. S. 4. 3. 2. Factors
Risk
undergo AllACOGSmoking 8.
is to
short Length
Length females tncompetent OSShort
polyhydramnios
Uterine
ammonites,
vaginosis)
Bacterial Previous
InfectionUterine
abruption
Placental
be
conditions done
16
screening cervical
then
cervix
Short of of and with anomaly overdistention,
cervix
cervix (Asymptomatic H/O
only previous
are
Progesterone Progesterone
17-OHP
or Yes 24 length preterm
250
progesterone supposito pregnancy. with
to toweeks of like
fulfilled. mg predict
diagnose
TVS H/O septate(<25
Llm e.g.,birth
ry preterm bacteruria,
mm)
+
weekly PTL: for twins,(PTB)
Cervical daily PTL: uterus,
is
given. 2.5 cervical
10 2 birth
cmcm Chorio
cerclage
mcg should
length
 Indomethacin: as
32-34Recomimends
Tocolytics dose.
Till ACOG accelerates
first Dexamethasone: Corticosteroid
Role: ItBetamethasone: 6injections IOLNo
4.
Management 3. 2. 1. Conventional
it Chorioamnionitis
Corticosteroids C/injection
t: mg prophylaxis/screening
4 22 2Doseof tocolytics GBS 3. No 2. 1. Any Reqular Diagnosis PTL of
TocolyticMgsO,
Tocolytic leads 32 mg Corticosteroid ng/mL) (250
LengthLength
CervicalWith Uterine
weeks each, pregnant is
weeks each,
to anyone uterine reqular
acts
premature 22 if
of of = 24 of
dilatation
cervix contractions:
choice should
Indomethacin = hours of cervix definition
female Preterm
Labor
choice as Nifedipine
action of contraction uterine
tocolytic maturityfetal
lung hours for PTL
in not apart
is S2 the
in closure apart lung 234 between cm23 who
India: heart be begins following: 24 of contraction One
at maturity Cm preterm
used IM in contractions is
IM weeks TVS or having, and 34. Touch
Nifedipineq-10diseaseductus of
beyond after and3 2. dilatation
labor: accompanied Obstetrics
mEq/L = ESTABLISHED
PRETERM
LABOR
ATOSIBAN 48 cm
arteriosus. 32 in
hours +
weeks 20 of and
fetal mins cervix
of by Gynecology
fibronectin Or
or progressive
tive anomaly
5. Fetal 3. 1. Remember: a Indomethacin 2. lOLNo
Screening5.
GBS 4.
at
|A bsolute 4.Nifedipine
3. Drugs 1. Tocolytics Role
Tocolyticsof Management
Corticosteroid
3. 1.2. 28
4. 2. Tocolytic. MgsO, 5. least
aternal
mnionitis IUD PTL AtosibanB, pregnancy. of
Tocolytics
Tocolytics To protection Tocolytics
If contractions
by
C/t: of 234 agonist: used buy qestational protein 2. Dr
cm
dilatation Sakshi
fetus C/I time
tion
namic weeks Progesterone
for (Oxytocin as shouldshould on
Ritodrine (for of is
tocolytics
Terbutaline Tocolytics for in initial Arora
lsoxsuprinNoeusted 48
agematurity
lu ng
for PTL present 60
Corticosteroid
never be and
<32hours) mins presentation. Hans
of antagonist) used <34 effacement
rvixcm
23 prevents weeks: in
tability (only be cervicovaginal
given for Weeks
B, 48 Mgso,
PTL agonist afterhours to of
act cerviy
but for
34only secretig
n01 is used) weeks neuro
 Inprophyllaxis
2. Candidates
1. Theseantepartum. Note:
infection
onset
EarlNeonat
y e GBS üroup
o IF rest
GBS sepsis. All All vancomycin. neonatal DOC
sepsis.
early
Antibiotic weeks37 by CBS transmitted
30% aandhas diffuse
Presents
It as
is B/LweeksOccurs
birthof
Preterm
During4 labor GBS wOmen are GBS patient If mortality infection
leads
MembranesPPROMhours wOmen
- taking
Screening = sCreening in usually B
Screening GBS 2prophyllaxis V early pneumonia wIthin Streptococci
is for penicillin
prophylaxis
is in
labor prophyllaxis with categories withgiven allergic rectovaginal
Antibiotic rate
PTB vertically mother
ruptured is is a
was
positive. previous even done of few
she positive a
is to a. = Infection
not without of penicillin-’
given Given
has infectiononset
Late
218 done wil females
Prophylaxis swab in
GBS asOccurs
Presentweeks
birthafter
few
of to
fever be H/O intrapartum to all acquired
Hospital
meningitis GBS
hours and given screening. mother pregnant
between
babyurine in use neonatal
>100.4°F patient
culture. whom Clindamycin
if with to
and 36
prevent females,
has sepsis. OBSTETRICS
for GBS GBS not and
Chorioamnionitis
roleNo
of If chorioamnionitis
Management of doubt: in
If
tenderness
are
Although made
PolymicrobialA
oinfection
cesarean examination. Amniotic is 3. 2. 1. presumptive
Alongbranes IF
Corticosteroid
MgsO4 afebrileStop Antibiotics
Tocolytic metronidazole Add chancesC/section
of
preferred
delivery
Vaginal IOL Membranes not
sent beats/min) a
included Purulent (WBC
ologically)Maternal Fetal pregnantbased
antibiotics for maternalare with
presents
for is tachycardia on
done is Gram fluid count
postpartum
24 endometritis =
associated can features discharge any clinical
diagnosis
ampicillin in WBC woman
for obtained the up one with
hoursafter be
staining
chorioamnionitis ln tachycardia
obstetric sent diagnostic of to
count symptoms:
of
management of temperature
(fetal
patient with chorioamnionitis, from 15,00O the with of
+ for and from chorioamnionitis
gentamicin z15,0O0 following
reason: increased histopathological the heart ruptured
becomes amniocentesis
culture. criteria. is
and os seen
rate(239°C)
cells/cc. findings:
uterine physi z160 mem
they
is
61
 by Dr SakshI
Obstetrics and Gynecology OBSTETRICS
One Touch 62

PROM AND PPROM 37. RH NEGATIVE PREGNANCY

35.
PROM/PRROM
Rupture after 37 weeks
but Tests for Pathophysiology Management of Rh Nonimmunized Pregnancy
PROM: Membranes Per speculum examination shows pooling negative
berore the onset of
Labor amniotic fluid Mother is Rh
positive IF ICT is neqative at first antenatal visit
Membranes rupture before 37 weeks. - Amniotic fluid + Fetus is Rh
-PPROM: membranes. Nitrazine Test = Positive alkaline
C/O Ruptured Repeat ICT at 28 weeks
Lst stepTo do when pt examination Iitmus paper blue as it is Efetal blood enters maternal blood, Rh antigen
fluid shoue
Sterile per speculum contraindicated. Fern test positive, i.e., amniotic dry and 9 |infetal blood stimulates maternal immune system
Pervaginal Examination is fern like pattern when allowed to Still negative
under microscope.
Antibodiesformed against fetal Rh antigen: Give AntiD300 mcq (Antepartum Prophylaxis)
aGantibodies cross placenta Deliver34-40 weeks
Management PPROM (234 weeks) PPROM (<34 Weeks) JLeading to
PROM (37 weeks) Fetal Hemolysis After baby is born
Infection Fetal lung immaturity
lrfection .Fetal Anemia Do direct Coombs test (If DCT iS +Ve)
Man concern X
IOL only if Hyperbilirubinemia and Rh typing of baby (If baby is Rh +ve)
fetal distress Hepatosplenomegaly
chorioamnionitis,
placental abruption Placentomegaly Again give Anti D 300 mcg to mother: called
post-partum Prophylaxis
present
Corticosteroid X Alaorithm when Rh negative females visits Anti D
1st Antenatal Visit
X (Tocolytics are never v Antepartum Prophylaxis
Tocolytics X
given at >34 wks If husband is
t step: Check husband ABO/Rh.Rhve To Rh-ve pregnant female if ICT is -ve@ 28 weeks
X If qestational age Bh+ve = 50% chances fetus will be Dose: 300 mcg
MgSO, for <32 weeks
neuroprotection This becomes High risk pregnancy.
ruptured
Postpartum Prophylaxis
GBS prophulaxis Given only if membranes
has fever
Within 72 hours of delivery
218 hours or nnother (Maximum: till 28 days after delivery) if DCT is
Next
4hours negative and baby is Rh ve.

36. POST-TERM PREGNANCY Do Indirect Coombs Test Other lndications for Anti D
(@ 1st antenatal 2nd and 3rd trimester
Definitions 2. oligohydramnios leading to cord compression visit) 1st trimester
and Meconiun aspiration Syndrome To check for Rh Abortion Trauma
Post-Term: Preanancy which continues >42 weeks 3. Placental aging causing uteroplacental insufi antibodies Ectopic pregnancy APH
(2294 daus) from 1st day of LMP. Amniocentesis
Late Term: 41 +O weeks to 41 -6 weeks
ciency. Molar pregnancy
MTP ECV
Full Term: 39 +O weeks to 40+6 weeks On CTG Manual removal of
" Chorionic villus
Early Term: 37 +O weeks to 38 -6 weeks placenta
D/t cord compression variable deceleration can ICT +ve
sampling " Fetal death
M/Ccause of post-term: ldiopathic be seen
ICT - e Dose = 50 mcg
others Anencephaly. placental sulfatase deficiency, D/t UPl: Late deceleration seen
Dose = 300 mca
goung primi = 1,50O IU
More characteristic of post -term: Variable de
Important PYQs Rh isoimmunized
celeration Rh Nonimmunized except:
pregnancy
pregnancy IfQsays Anti D is given in all;
Only 4% females deliver on exact EDD Ans is cordocentesis
50% females deliver either 1 week before or Managenment
1 week after EDD Confirm dates (by T, USG)
Whenever a female comes with post-term ACOG Recommends: Induction of Labor in all
preanancy: 1st step is to reconfirm menstrual females with gestational age 41 weeks.
history BISHOP Scoring
Coplications Done before 1OL to assess the favorability of cervik
for labor.
4Macrosoia: Which leads to increased chances of
choulaer dustocia and cesarean section.
 lmportant
PYQs
fetomaternal 3O0 BETKE
Reagent: Testclamping
Test If in If InMode
donedelivery
ICT vaginal
done Rh Q Rh
mcg specifically
is
negative negative 235
of Deliver 3Weeks
Citric
of
-ve:
to
delivery Hematocrit
<3O% Cordocentesis anemia)
(Fetal
Hmg Anti calculate 21.5
MOM
Do pregnancy (PUBS)
and early says:
or D
pregnancy:
phosphate dose in stNextep cerebral
middle
arteryPeak If
15can umbilical
fromeitaken
blood
nFetal (2:16,
1:64)
L:32, ICT
cord Indirect Rh One
mL systolic 21:16
Titer
neutralize of = is
Earlynegative Next
step pregnancy +ve Touch
Anti
clamping Management
of Do Doppler
MCA
fetal buffer D: Coombs Intrauterine Weeks
<35 either
delayed cord transfusion velocity Obstetrics
KLEIHAUER
RBC 30 pregnancy is
clamping
test antibody
Measune
Critical titre calledeirst
mL of of
cord Rh and
of +ve "
anemia
absent)
"(Fetal Next
stepantenatal
Rh
DeliveryFetal
Repeat titer Gynecology
Isoimmunized
culture:seenNote: S1.5
MOM Isoimimunized
Hydrops
Fetalis " =
Nonimmune
chromosolmmuneSubcutaneous Pericardial
Ascites2.. 1.
effusion
Pleural
4. 3.Presence It Hematocrit
" 230% monitoring 1:16 visit
inedemna Deliver=
37-38 =MCA Repeat
is weeksFetal "
MCA
Repeat Delivery:
37-38
WeeksFetal by
Placentowmegaly
Hydrops an 37-38 or
Doppler (1:2,
1:4,
1:8)<1:16
Titer pregnancy@ Dr
HF: USG Doppler
monitoring
monitoring
of Titer pregnancy 28 Sakshi
mal
HF: Rh z2 Hb weeksbegin
but diagnosis and weeks,
diso effusion
indicates = every Arora
MIC
negative are i- @32 1-2
rder, hematocrit begin
1-2
32 4 such Hans
= not and weeks
CVS weekly weeks
parvovirus hydrops: weeks
weekly @
pregnancyincluded
Polyhydramnios
disease,
32
weekly weeks
infection in
diagnostil
are
 ANTEPARTUM FETALASSESSMEN
Components of NST
APregnant fesale at 54 weeks C/O decreased FHR = Norwal between 110-16o bpm
etal mOvEEnt
FHR variability:
FHRshows a variabilitu of S-25 bpm
Next step If FHR is fixed, it has bad prognosis
Sereening Test: Modified BPS (1st choice) FHR accelerations
increase by 210 beats/min
At <32 weeks: FHR should fetal movement
with
lasting for 10 seconds
Nonstress Test (2nd choice) increase bu 215 beats/min
Diagnostic Test: Biophysical scove. At 232 weeks: FHRshould movcment
s done in all high-risk pregnancies frowm lasting for 215 seconds with fetal
Note: NSTonward
32 weeks
Repeated weckly or twice weekly NST Result
Procedure Reactive NST Means in 20 minutes: presence of
22 accelerators
Paticnt liesin left lateral position: for 20 minutes and indicates fetal
Reactive NST is reassuring
Cetal heart rate is continuously monitored and well-being
ietal Heart accelerations are noted with respect is only 3/1,O00 in
to fetal movemcnts. In Reactive NST Fetal death
neXt wecks
in 2O minutes,
IfNST doesn't show 2 accelerations
more inutes. If in
thcn repeat NST for 20 accelerations it is
40 minutes: there are <2
called Nonreactive NST
NST has high false positive (ie., fetus non
eg, in
kupoxeic but test is Nonreactive NST,
case of fetal sleep, prematurity, drugs
It has low false negative result
"Nect step for nonreactive NST
-Biophysical score
Remember:
Biophysical score is a diagnostic test
Modified BPS is a screening test
Modified BPS has 2 components:
1. NST
lmage SSA: Nonstress test (NST)
2. Amniotic fluid index (AF)

Accelerations Accelerations

Fetal moVements
Fetal mOVEmEnts

lage SSB. NST strip showing

novement
FHR acceleration with fetal
 One Touch ObstetricS and

39. BIOPHYSICAL PROFILE (MANNING SCORE)

Done with help of USG and at least 15 seconds duration from onset
return associated with fetal movement.
Done Over 30 minutes
Fetal breathing movements: 2 points if one
5 Components more episodes of rhythmic breathing movements
>30seconds within a 30-minute observation pevi
T= Fetal Tone
Fetal tone: 2 points if one or more episodec
B= Fetal breathing extension of a fetal extremity or fetal spine
Meningitis = Gross body movement return to flexion. with
Always =Amniotic fluid volume (Single deepest pocket) Amniotic fluid volume: 2 points if a single deepr
vertical pocket 22 cm is present. The
Notorious = NST

Criteria for Biophysical Profile

dimension should be at least 1 cm. horizonta
Fetal movement: 2 points if three or more discre.
Nonstress test: 2 points if reactive, defined as at least body or imb movements within 30 minub
2 episodes of FHR accelerations of at least 15 bpm of observation. An episode of active continun
movement is counted as one moVement.

Score Management
10
or with AFV normal
Normal fetus: Repeat BPS weekly
10 10
Deliver
with normal AFV Equivocal <257 weeks:
10 -<37 weeks: Repeat test in 24 hours.
Deliver 36 weeks
Or with decreased AFV
10 10 (ln these cases, chronic asphyxia suspected)
4 Deliver >32 weeks.
Score
10

Score
2
or
Immediate delivery (certain of fetal asphyxia and
10 10 significant fetal acidemia)
Remember:
Anormal BPS: 8 or 10 is associated with normal pH of fetus
A score of O, 2, 4 is associated with fetal acidemia
A score of 6is equivocal
BPS can tell us about fetal outcome and to some extent fetal pH. Although ove rall sensitivity of BPS to
predict cord blood pH is low. (INI-CET June 2022)

40. AMNIOTICFLUID ASSESSMENT

Single deepest pocket (SDP) or maximum vertical Amniotic fluid index (AFI): The four-quadrant Af
pocket (MVP): This is the vertical dimension (in cm) assesses (in cm) the deepest vertical AF pocket ln
of the largest pocket of amniotic fluid not persistently each of the four quadrants of the uterus. The sumo
containing umbilical cord or fetal extremities. the AF pocket dimensions of each guadrant is knowh
It is most sensitive methode for amniotic fluid as the AFI.
assessment.
Oligohydramnios: <5 cm
Normal: 5-24 cm
oligohydramnios: depth <2 cm
Normal: depth >2 cm and <8 cn Polyhydramnios: 225 cm
Polyhydramnios: depth 28 cm
 41. RISK FACTORS IMPORTANT IN OBSTETRICS

PIH
Placenta previa
Primigravida ‘ Maternal age
New paternity "‘Maternal parity
Biaplacenta/tplacental tissue Big Placenta
. Molar pregnancy Twin pregnancy
Twin pregnancy " Succenturiate lobe
. Diabe tes
neqative pregnancy Defective endometrium
Autoinmune
Smoking
" Endometritis
" APLA Syndrome " H/O C-section/myomectomy
Kidney diseases " H/O IVF (TMaternal age, ‘Twins)
Personal history
Obesity
Extreme of age
(<18 years or 240years)
Pregnancy due to VE

PPH Abruptio Placentae

Maternal factors
Advanced maternal age Folic acid
Obesity Increased
deficiency
PIH
(
maternal age
" Previous H/O PPH and parity
Cigarette
Placental factors smoking and
" Placenta previa Thrombophilia
cocaine abuse
Placenta abruption Preeclanmpsialchronic
Placenta acceta hypertension
External
Intrapartum factors trama
" Precipitate labor rLeiomyoma
Prolonged labor Previous Twin
" GA abruption pregnancy
" Augmnented labor F Hydramnios
Instrumental delivery
" Chorioamnionitis Single umbilical
preterm rupture artery
Uterine factors of menbrance
" Uterine
Twin
overdistention<
Polyhydramnios
mage s6: Risk factors for
abruptio placentae
 42. MATERNAL PELVIS

Inlet Cavity Outlet

Lies at level of pelvic brim Lies at level of ischial spine Lies at level of ischial tuberositu
inlet = Imp diameters Cavity
AP diameter Two important planes:
True conjugate: distance between sacral Plane of greatest pelvic dimension:
promontory (SP) and upper border of Ant: Post surface of pubic symphysis
pubic synmphysis: 11 Cm Post- Junction of S2/S3
Obstetric conjugate- distance Lat - Obturator foramen
between SP and mid of pubic All diameters are 12 cmn
symphysis = 10-10.5 Cm It doesn't have any obstetric significance
Diagonal conjugate - distance between Plane of least pelvic dimension
SP and lower border of pubic Ant: lower border of pub symphysis
symphysis = 12 cm Post- Junction of S4/Ss
Transverse diamn = 13 Cm Laterally- Ischial spine
Oblique diam (Right and left) 12 cm Narrowest plane of pelvis
Oblique diameter is distance between AP diam- 11.5-12 cm
one side sacro iliac joint to other side Transverse diam: Interischial diameter/Bi
llio pectineal eminence spinus diam = 10 Cm
Midpelvis lies @level of plane of least
pelvic diversion

Qutlet Imp PYS

Ant = lower border of pubic symphysis " AP diam of inlet which can be
Post = Tip of sacrum clinically measured= Diagonal conjugate
Lateral = Ischial tuberosity "Critical obstetric conjugate
AP diam = 13 cm
That value of OC below which vaginal
Transverse diam = 11 cm delivery is not possible = 1O Cm
(Distance between 2 ischial " If diagonal conjugate is x cm:
tuberosities = Bituberous diam) Obstetric conjugate is x-2 cm
Posterior sagittal diam = 7 cm "Overall most imp diam for labor =
Interischial diam (IID)
"Angle of inclination = 55
"Sub pubic angle is:
Acute in male pelvis
Obtuse in female pelvis
Contracted Pelvis
If any of major diameters of pelvis is decreased by 1 Cm or if:
Obstetric conjugate <10 cm: It is contracted inlet
Interischial diam <8 cm: lt is called contracted midpelvis
Bituberous diam <8 cm: It is called contracted outlet
Mt of contracted pelvis: Always cesarean section
Naegele's pelvis = only one Ala is present, i.e., one Ala of sacral bone is
Robert pelvis = Both Ala are absent (lmage s8). absent (lmage 57).
 OBSTETRICS 6

lmage sT: Naegle's pelvis

Image s8: Robert pelvis
Caldwell Moloy Classification
Gynecoid Android Platypelloid
Diagraw of inlet Anthropoid
M/Ctype of pelvis 20% 25% Least common type
5O% (M/) of pelvis

Shape of inlet Transverse oval. Heart shaped Anteroposterior oval Flat bowl like pelvis
Transverse diameter TD > AD diameter TD > AP diameter
and AP diameter
AP diameter > TD TD >>> AP diameter

Ischial spine Prominent

Side walls Parallel and broad Convergent Parallel and narrow Divergent
Subpubic angle Obtuse Acute

lmage s9: Diagonal conjugate being measured

For some important one liners on pelvis: See Table 16.
 diameter Cm Cm. fontanelle. over
diameter
each) done
The
Cm
cm) 14 diameter: 3 prominence
to
is diameter (SOB)(11 diameter:
be diameter diameter equal
(11.5Cm.to diameter (SMB) anterior
14 has
diameter
of bregmatic (SMV) bita birth.
cm: diameter
Engaging (My bregmatic are
is section
which
diameter bregmatic Always
do
cesarean at Diamond/rhomboid (bony
transverse
9.5 -breqmatic
Submento Frontal vertical shaped.diameter
after
the
Mento-vertical fontanelles
Cm) cesarean diameter
Biparietal
arediam
Biparietal
1. Suboccipito 'bregma' to ocCiput
lamnbda'
diameters.diameter
transverse Submento months
(14 submentovertical/occipitofrontal
which
engaging Suboccupito q.5
cm.
Occipito or submento
9.5
C
11.5
Cm. AP
anterior
Triangular
shaped.
Anterior
fontanelle:
diameter Six as and Posterior
fontanelle: the
as occipital
bone).
SKULL
FETAL always
mentovertical Diameters
has known18lies
Transverse to
known
extended by
M/C Also
know:skull Sinciput
Ossifies close
oynecoOg
presentation,
mentovertical 2. 3. Also
head Fetal AlsoLies
Fully
flexed
head partially Head
isextended
than deflexed
isengagement the resistant
ana biaaer Seen
in is labor
overlap.
Obstetrics is Brow in Head of moulding:
separated. of
skull
alwaus or shave bones.
is in diameters.
are: posterior (with
the progress
fetaldianmeter
hence Cm not
anterior
loUch
are skull between nose of
the throughof do skull
of 8.5cm easily Slow
skull
diameter and Cm cm and
root of gradings
but of normally.
One Antero-posterior
diamcters AP of = 9.5 of
between
AP TD 7.5 8 subparietal betvween alteration
passing
skull the longestdiameter than
Transverse
Diameters = fontanelle root
lying Supraorbital
ridges) touchcanoverlapping
presentation, = =
order Biparietal labor. +
but seenmoulding
of Bitemporal and three
AP
fetal aiameters smaller Bimastoid Skull skull
Definition skull nose
and
chin
skull while bones
the during
fontanelle
fontanelle
AP
Dianneters longest
of secondlargest ascending
Super Fetal of anteriorof of are Overlap be
Skull Fixed
is head Grading-Therecan3 ’indicates
Diameters = Part Part
Alwaus Part
AP The Brow
the
= =
MissTina=
Pretty passage
It coming or CPD.
In So of Moulding 1: 2: 3: 1 2
is PartsPartVertex Moulding: GradeGradeGradeGrade
Grade
In it Brow
Face birth
fore
1. 2. 3.
 OBSTETRICS

44. TERMINOLOGY RELATED TO LABOR

LIE: Relationship between long axis of uterus and
long axIS of fetus Denominator part
Note: Before connecting on lie-always correct the Bony point of reference on the presentingpelvis.
destro rotation of uterus. which comes in relationship to the maternal
M/Clie: Longitudinal lie Denominator
Long axis of fetus and long axis of uterus coincide Presenting part
with each other. Vertex Occiput
Oblique lie: Long axis of fetus mnakes an angle with Breech Sacrum
long axIS of uterus. Brow
Frontal eminence/bone
Transverse lie: Fetal long axis and
are 90° to each
other maternal long axis Face Mentum (Chin)
Itis the M/C cause of cord prolapse.
Position
Mgt of transverse lie is always cesarean section Relationship of denominator to maternal pelvis.
whether baby is alive or dead
Presentation
Posterior
#is that part of fetus which lies at lower pole of Direct
uterus Occipito posterior
M/C presentation: Cephalic presentation Right occipito (6) (7) (8) Left occipito
The only normal presentation is cephalic posterior posterior
presentation
Rest all presentations are Malpresentation Right (s)
occipito
(1)
Left occipito
transverse transverse (M/C)
M/C Malpresentation: Breech Left
Presentation in Right
transverse lie: Shoulder
presentation (2)
Right occipito (4) Left occipito
Mgt of shoulder presentation or neglected anterior anterior (2nd M/C)
shoulder presentation is cesarean section (3)
Occipito anterior
Important PYQ's (3rd M/C)
M/C cause of cord prolapse: Transerse lie Anterior
M/C cause of hand prolapse: Transverse lie
(lmage 63) lmage 6O: Fetal positions
M/C pelvis a/w transverse lie: Platypelloid
pelvis From position 1-5, when delivery occurs it is called
normalvaginal delivery.
Presenting Part From position 6-8, vaginal delivery is called occipito -
posterior delivery.
The part of presentation which lies directly over
internal os and hence is the part felt first on PN Occipito posterior position is the most common
malposition.
examination. M/C position of fetus: LOT> LOA.
In cephalic presentation: Presenting part could be: M/Cposition during labor: LOT > LOA.
Vertex (M/C) = Seen in fully flexed and deflexed M/C occipito anterior position: LOA.
head.
5row =Seen in partially extended head. M/Coccipito posterior position: ROP.
Face = Seen in complete extension M/C position in normal vaginal delivery: LOT.
M/C position in breech: LSA (left sacroanterior).
brow always cesarean section is done M/C position in face: LMA (left mentoanterior)
In face: ln case of mento anterior: Vaginal delivery
is done
1n mento posterior: Cesarean section done
 portant imaqe-Based Questions

Image 62: Position: LOP

lmage 61: Position: ROA

occiput or posterior fontanelle (triangular fontanelle). If it f

To know position of fetus: Either notethen OP and if transverse then OT
anteriorly position is OA, if posterior is mother's right and vice versa
To know left and right: Always remember your left

lmage 63 Hand prolapse lmage 64: Compound presentation

In lmage 63 note lie istransverse lie: when hand comes out it is called as hand prolapse. Mgt is csar
section.
presentation
Image 64 is not hand prolapse as you can see, head of baby is down. It is called as compound
It is not managed by cesarean section. Mgt is by vaginal delivery.
 OBSTETRICS
451 LEOPOLD MANEUVER
Dont per abdominallu
Leopold Second Maneuver/Umbilical
Patients bladder should be
empty
Position Patient should be lying in Grip (Image 66)
witk knees flexed dorsal position Examiner hands are on Lateral side. Parallel to
umbilicus. Tells about: Position of fetus
Examiner should stand on right hand side.
For first three maneuver (1, 2, 3),examiner face Important Points
dhould face toward the face of patient. Fetal back: Felt like smooth, reqular, curved and
Ath maneuver: EXaminer faces toward the fegt
ofpatient. board like rigidity.
Limbs: Felt like small, multiple knob like
structures.
If back of fetus is on left side position is LOA
LOP/LOT.

lmage 65: Leopold first maneuver/fundal grip lmage &7: Leopold third maneuver/Pawlik grip
Leopold First Maneuver/Fundal Grip (lmage 65) Leopold Third Maneuver/ Pawlik Grip (lmage 67)
Examinar's hands: On Fundus on uterus Examiner's Hand: On the pelvic area
Tells about: (1) Lie of fe tus. (2) Presentation Tells About
of fetus.
lmportant points: Presentation
If fundal grip is empty: Transverse lie. Head has entered pelvis or not- ballotability
o If on fundal grip: Broad, inregular sort part
felt-not may breech is felt: Presentation is Important Points
cephalic. It is done while facing the patient using single hand
IF hard globular part is felt its means head is If a firm, globular, rounded structure is felt-it
felt and presentation is breech. is cephalic presentation
Head of baby is moved from side to side ’ if it
can be moved, i.e., it is ballotable which means
head has not entered the pelvis.

Leopold second maneuverlumbilical grip lmage 68: Leopold fourth

lateral grip maneuer/deep pelvic grip
74 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

Leopold Fourth Maneuver/Deep Pelvic Grip Important Points

(Image 68) To know head has entered the pelvis
Examiners hand on the pelvic area. Both hands are Fingers of both hands are brought
used and kept parallel to inguinal ligament.
It (1) Confirms finding of pawlik grip (2) Attitude
head.
If both hands converge: Below the head below
of fetus. head has not entered the pelvis.
If both hands diverge: Means head has er
the pelvis.

46. SOME IMPORTANT CONCEPTS

True Labor Pain vs False Labor Pain
True labor pains False labor pains
1. Uterine contraction
a Nature Regular rhythmic (On and off) Irregular, continuous
b. Progressive tlntensity, It is not progressive
‘Frequency,
1Contraction
2.. Cervical dilatation Leads to progressive dilatation Does not lead to dilation of cervw
3. Site of pain Lower abdomen + Radiating pain Localised to abdomen
to the thigh and back
4. Show Blood + mucus discharge seen Absent
5. Bag of membranes Felt Absent
6. Relieved by Not relieved by anything Relieved with sedation and enema

Note: Tachysystole can occur in spontaneous labor and

Oxytocin ’ Produces rhythmic and regular con
traction, and maintains polarity of the uterus ’
can be used in induction and augmentation.
Ergometrine on the other hand cannot be used
as it doesn't maintain the polarity and cuts off blood
supply to fetus.
Uterus Contractions
Beqin @ cornua of uterus and spread to entire uterus
at 2 cm/sec
Entire uterus is depolarized in 15 seconds
Adequate uterine contractions:
3 contractions in 10 minutes (Frequency).
Each contraction lasts for 45 seconds (Duration).
Generating a pressure of 65-7S mm Hg or
200-250 montevideo (M) units (lntensitu).
Tachysystole: 25 contractions in 10 minutes.
Hyperstimulation: Tachysystole Can cause
distress
with use of oxytocin or misop rost
On CTG: It appears as prolonged deceleration
Station of Fetal Head
It is described with respect to its position aboit
or below ischial spine
If fetal head is above ischial spine: Positive station
If e level of ischial spine = zero station
If below ischial spine: Negative station.
+2 means = 2 cm above ischial spine
-3 means = cm below
Important Landmark Ischial Spine
head
It is the site for internal rotation of fetal
Site for deep transverse arrest piercal
Site for giving pudendal block (ligament
sacrospinou
while giving pudendal block is
fetal ligament)
Origin of levator ani muscle
 OBSTETRICS

47. INDUCTION OF LABOR

Means initiating contraction in a uterus which lies auiescent. Before inducing labor-bishop score i5
done to assess the susceptibiltu of cervix for induction of labor.
Bishop Score

Mnemonic Parameter 2
>5 Cm
Delhi Dilatation of cervix Closed 1-2 Cm 3-4 Cm
Position of cervix Posterior Mid Anterior
Police
6O-7% 2807
Employed Effacewment of cervix 30% 40-5O%
Station of fetal head Above -2 -2 station -1,0 station Below ischial
Special spine
Commodities Consistency of cervix Firm Mediun Soft

Score <5 = Poor score: Ripening should be done before IOL

>6 = IOL can be done
>9 MaXm success of IOL

C/I for IOL

Modified Bishop Score
Contraindications of induction of labor:
Effacement of cervix is replaced by Severe CPD.
length of cervix (Measured by TVS) Contracted pelvis.
Transverse lie, Brow presentation,
Methods of Inducing Labor Face (mento posterior position).fetal
Mechanical Methods Fetal distress: Non assuring
heart rate.
30-50 mnL of
Foleys Catheter (Filled with infusion. Placenta previa
It best
NS) or extra amniotic saline Classical cesarean section
method for I0L in prevous cesarean pts Previous Hysterotomy.
Stripping of membranes PreviouS myomectomy.
Medical Method Active genital herpes infection.
given
Misoprost = PGE1 = Tab. 25 mcg
doses)
4 hourly P/V. (Maxm 6 Available in 2 forwms.
Dinoprostone = PGE2 =
hourly.
Cerviprinme gel: o.S mgigiven 6
Maxm doses = 4. (lmage 69)dinoprostone
Cervidil = slow release dinoprostone
formulation. Contains 10 mg (lmage 70)
placed in posterior vaginal fornix
Net Wt. 3.0 g

Droprostone Gel
Cerviprime 0.5 mg
lmage 70: Cervidil
lmage 69:Cerviprime gel
 48. CARDINAL MOVEMENTS OF LABOR

Cardinal movements Important points on Engagement

Every = Engagement Definition = When largest transverse diam of fetal
Decent = Descent crosses pelvic brain
Female = Flexion of fetal lead Time = Primi @ 38 wks
I= lnternal rotation (crowning occurs Multi e onset of labor
after this but it is not a cardinal
movement) How to know engagement has occurred
Employ = Extension (head of baby delivered) On P/A = s 2/5th of head palpable
Rises = Restitution On P/V= station : O or below it
Extremely = External They are now considered
Single movement If head of baby is unengaged @term in primi:
rotation
M/C =deflexed head/OP position
Late = Lateral flexion ’ body of baby is 2nd = CPD
delivered
3rd M/C = placenta previa

Imp points on cardinal movement: Engaging Diameter

M/C position of fetus during Labor: LOT
When head of fetus enters pelvis: Occiput is in
Transverse Anteroposterior diameter
diameter
transverse position
Sagittal suture is in transverse diameter of Always Biparieta Depends on degree of
diameter flexion of head
pelvis (9.5 cm). well flexed head
Descent occurs d/t uterine contraction (vertex presentation)
When head of fetus reaches the level of pelvic Suboccipitobregmatic
floor, occiput rotates by 2/8 of circle and diameter, 9.5 cm
lies directly behind pubic symphysis = this is Deflexed head:
internal rotation Occipito -frontal/
In vertex presentation, head of baby is born suboccipitofrontal
diameter.
by extension Partially extended head
In breech and face: head is born by flexion (Brow presentation)
After delivery of head = for delivery of shoulder mentovertical diameter.
= shoulders rotate internally by 1/8 of circle Fully extended head (Face
which is visible externally as external rotation presentation)
of head Submentobregmatic
Rest of body is delivered by lateral flexion diameter
 OBSTETRICS

49. NORMAL STAGESOF LABOR

Labor stage Definition Function Duration
stage 1--latent phase Begins: At Onset of regular uterine Prepares cervix for <20 hours in primipara
leads to effacement contractions dilation <14 hours in mnultipara
ofcervix) End: As per ACOG =5 cm
modified WHO criteria 4 cm
earlier WHO recommendation 3 cm
Stage 1active phase Begins: As per ACOG = @6 cm Rapid cervical dilation Primi = 1 cm/hr
of
leads to dilation modified WHO criteria = 5 cm Multi: 12 Cm/hr
cervix) earlier WHO criteria 4 cm
Ends: 1ocm (complete dilation)
Begins: 10 cm (complete) Delivery of the baby <3 hours in primipara
Stage 2
<2 hours in multipara
End: Delivery of baby Add 1 hour if epidural is
given
|Stage 3-Expulsion Delivery of placenta <30 minutes
Begins: Delivery of baby
End: Delivery of placenta
1-2 hours 1-2 hours
|Stage 4
Observation period after delivery of
placenta

Duration of Active Phase

Note:
Modified WHO partogram was based on earlier As per new WHO recommendations
recommendations of WHO where active phase Nulli Multi
began @ 4 cm Mean duration 4 hours 3hours
" Labor care guide (Next generation partogram) Should not 12 hours 10 hours
is based on modified WHO partogram, where exceed
active phase beqins @ 5 cm
As per ACOG: Active phase begins @ 6 cm Second Stage of Labor
Dilatation of cervix in active phase: Nulli Multi
O Earlier recommendation of WHO was minimal
dilatation of cervix inactive phase 1 cm/hr Avg duration 50 minutes 30 minutes
New WHO recommended = Dilatation could Maxm duration
as per WHO
3hours 2 hours
be <1 cm/hr
 Arora Hans
One Touch Obstetrics and Gynecology by Dr Sakshi

SO. ABNORMAL STAGE OFLABOR

Allthe abnormalities are stilldefined by earlier WHO recommendation
Abnormality Definition Mgt
1. Prolonged latent If latent phase 20 hours in primi Cause
phase >14 hours in multi Occipitopost position
Unfavorable cervix
Mgt
Therapeutic rest/sedation
C/section is never done
Protracted active phase If dilatation of cervix is Mgt : Do P/A and P/V examination
= slow progresS <1 cm/hr or descent of fetal
Rememnber dilatation head is <1 cm in primi or
<1 cmhr + moulding <2 cm in multigravida Hypotonic Normal
or caput indicates CPD contraction COntraction
P/V
If head is fixed =
30 mins OP
ARM > Oxytocin CPD
If head is mobile position
30 mins
Oxytocin ARM Wait and C/S
watch section

Arrest of active phase It is diagnosed if membranes Cesarean Section

are ruptured and cervical
dilatation has not changed
for >4 hours with adequate
uterine contraction or 26 hours
=if oxytocin is given with
inadequate uterine contraction
Second stage arrest Nulliparous: If second stage Mgt
>3 hours without epidural or In case of prolonged second stage
>4 hours with epidural If head of fetus above +2 station = cesarean
Multiparous: If second stage section
2 hours without epidural or Head of fetus is at or below+2 = forcep or
23 hours with epidural Vacuum

If Qsays:
Bandlring present-C/section
Bandl's ring indicates obstructed labor
If Q says: moulding/caput present with
second stage arrest:cesarean section
 51.OBSTRUCTED LABOR
Cinical features maternal Dehydration Augmentation of labor
haustion tachypnea, tachycardia
P/A: UUS is Thick, tender and tonically Augmentation wmeans accelerating the progress of
contracted labor
LUS = Thinned and stretched. A depression/ Indication: Protracted active phase after ruling
groove is felt between UUS and LUS called out occipito posterior position and CPD done
Bandl's ring 1. Methods: Artificial rupture of membrane
by kocher forceps (lmage 71)
Dn P/V: Hot and dry vagina 2. Oxytocin: Given at 6 mU/min. mU
Increased @ interval of 20-4O minutes by o
caput t+ or ttt
Moulding t+ or +t+
Hematuria +/ C/l of ARM
Mat = C/section immediately; 1. Maternal HIV infection
Do not give oxytocin 2. Active genital herpes infection
Complication: 3. IUD of fetus
4. Polyhydramnios
()Rupture of uterus
() WF Note: In Polyhydramnios = controlled rupture of
membranes is done

Mat of etal distress in labor

In first stage of labor : (Dilatation < 10cms)
Mat = cesarean section
In second stage of labor: (Dilatation is 10 cm)
Station of fetal head

Above At + 2 or
+2 below + 2

C/section Forceps of vacuum

Preferred :- Forceps
Image 71: Kocher forceps

In obs there are 2 rings:

Band's ring Constriction ring/Schroeder ring
Retraction ring Constriction ring
Due to obstructed labor Injudicious use of oxytocin leads to localised spasm
of uterus

Between UUS and LUS Can be seen any where

Seen in second stage of labor 1st or 2nd stage of labor
Felt and seen Felt P/V
p/A
A/W maternal dehydration and fetal distress Mother and fetus are normal
Relieved bu C/section Relieved by sedation if ring reappears then do a
lower vertical c-section
 careallowed.
recommended.
All
Comparison Pain
Bladder section
For C ORAL Late
I/V Ambulation
be ist
recommended 3
these Routine
Enema
pelvimetry
4. Routine2 1.Not C/Auscultate4FHS 3. 2. 1.
I is IfRecommended At
in Solid
Liquid fluidsgiven Routine
CTG pt
stage Routine Perform the
labor relief = intakelabor: is Do Note
recommendations function =G orally, having P/V
stopped can Vitals time
care = pt of
hours Early pelvic examinationLeopold
A should= Labor
besolids active of S2.
Pt of
Comparison
guide
Epidural/opiods/massage etc. = given pt
encouraged = should Labor: shaving admission
before 2
not lie bleeding WHO
hours maneuvers.
come in
Sx allowed,allowed
remain L/L
of before then RECOMMENDATIONS
Image under choice postion
hydratedclear P/N
Sx
supportive examination
72: should fluids
odified
be can

Ritgen
High auscultation
Low 2nd High Lowstage1st FHR Uterine
P/Temperature:
V hourly Maternal: pressure.
Fundal Notother Perineal FOR
ButMonitoring
During
Labor episiotomy
Routine
2 1.extended support
5. 4.Perineal
Massage
3. 2. 1. ToMgt
euver risk: risk:
stage
risk: risk: = if Recommended Head
Controlled Warm Prevent
everymembrane hand MANAGEMENT in
contractions-every 2nd
S 15 15 30 Pulse (Ritgen of compressperineal
minutes minutes 4 should
minutesminutes
Every fetus Stage
hourly and delivery
ruptured support should
maneuver)
4 BP @tear of
hourly perineumof Labor
= Recommended: OF
every first head
perineum
30 for
with LABOR
minutes hourly fluxed
many
one
(lmage
hand and
hours
72) and tha
’
 TMPORTANT POINTS RELATED
Important points related to third staqe of labor
Who recommends:
Active management of third
stage of labor (AMTSL)
. lt decreases the duration of
third stage
. Decreases blood loss
"Decreases chances of PPH
. AMTSL is the best method
to prevent PPH
Uterotonics
Recommended by WHO:
Oxytocin: 10IU I/M or in infusion
If oxytocin is not available
following can be given
1. Methyl ergometrine:
(methergine) O.2 mg /M
Never given I/V as it can lead
to hypertension
2. Syntometrine: Fixed dose
cOmbination of SU OKytocin and
O.5 mg methyl ergometrine
3. Carbeto cin - Synthetic
Oxytocin 100 mcg Slow IV
4. Misoprost PGE1
6O0mcg oral, sublingual or P/V
for AMTSL (40O-600 mcg)
WHO recommends misoprostol
distribution to pregnant
females to prevent PPH
Carboprost = PG F-2d
is used for management
of PPH and not AMTSL
TO THIRD STAGE OF LAOR
Steps in AMTSL
1. lnj. uterotonic within 1 minute of delivery
of baby or immediately after delivery of anterior
shoulder of baby (most imp step)
2. Delayed cord clamping (clamping cord in
1-3 mins of delivery)
traction
3. Delivery of placenta by controlled cord
(Modified (Brandt Andrews technique)
4. Intermittent assessment of uterine tone
(earlier: uterine massage) AMTSL
Note: Early cord camping is not a part of
Conditions of early cord clamping
(clamping cord within 1 minute of delivery)
1. Birth asphyxia needed
2. If neonatal resuscitation is
3. K/C/Ocongenital heart disease test is
4. If in RH negative female: Indirect coomb's
negative (nonisoimmunized pregnancy)
HIV +pregnant females (as per NACO guidelines)
but ACOG :Delayed cord clamping
In case of RH negative pregnancy: If indirect
Coombs test is positive, where maternal antibodies
are already formed against fetal Rh antigen, early
cord clamping is of no use: Delayed cord clamping
In preterm infants.
In COVID 19 + patients.
In macrosomic babies. Delayed cord clamping
In post term cases.
Allyou need to know on oxytocin
- Natural oxytocin is nonapeptide
Synthesized by para ventricular nucleus of
hypothalamus
- Stored in posterior pituitary =
T1/2 = 3-5 mins
-Can be given = /M or /V infusion
- Never given as l/V bolus as it leads to
hypotension/cardiac arrest
Infusion should be prepared in RL and not D-s%
as it can lead to water intoxication
- It is the Hormone responsible for milk ejection
Note: In all those conditions where
methylergometrine is C/1, oxytocin can be used
 Hans
One Touch Obstetrics and Gynecology by Dr Sakshi Arora
82

54. DRUGS USED IN AMTSL PPH Carboprost: PGE2a Dinoprost/hemabate:

Available as injection:
Methylergometrine
Leads to tetanic contraction of uterus
Route: l/M
Absolute C/I
Can lead to hypertension Asthamatics
C/1: Pulmonary HT
T= After delivery of first twin Suspected amniotic fluid ewmbolism
O= Organic heart disease Relative C/l = Preeclampsia, renal
P= Preeclampsia disease disease,
E= Eclawmpsia Side effect = Diarrhea
R= Rh negative female Carboprost: Is best drug to manage PPH but is no
Relative C/t: HIV positive female on protease inhibitor used for AMTSL
Prostaglandins Carbetocin
Misoprost (PGE,) Synthetic oxytocin analogue octapeptide
Available as tablet T1/2 = 85-10Ominutes
Routes: Oral/sublingual/P/R or P/V Dose = 100 mcq slow /V
Never: I/V or l/M
Water and heat soluble Syntometrine
Side effect: Hyperthermia sU oxytocin + O.s mg methylergometrine highlå
T 1/2 = 20-4O minutes patient.
Not readily available, expensive

55. METHODS OF PLACENTAL SEPARATION

Schultz method Duncan's method

Blood clot Dull

maternal
side
Placenta
Blood
Shiny fetal
side

Images 73: Methods of placental separation

Placental separation begins from the center It begins from periphery
Blood collects behind the uterus and bleeding External bleeding begins with separation
is apparent only after complete separation of
placenta
Formation of retroplacental clot No retroplacental clot formed
Total blood loss is less Total blood loss is more
Shiny fetal side presents at vulva (s for Shiny, Dull maternal side presents at vulva (D for Dull
s for Schultz) D for Duncan
M/C (seen in 80% cases) Seen in 20% cases

Note: Separation of placenta is along parts of decidu (intermediate spongy layer of the decidua basalis)
 56. RETAINED PLACENTA
Placental Seperation
Signsof
Gush of blood per vaginally " Heiqht of the uterus increases sightly
Suprapubic bulge. Surest sign of placental seperation: Placenta felt
in
Lengthening of the cord (apparent and perma vagina
nent). 2nd best: Lengthening of the cord
Retained Placenta
Placenta does not deliver within 3o minutes of delivery of baby
If placenta is not expelling-it could be d/t

Placenta is separated Placenta attached to Placenta invades

from uterus but not uterus but doesn't myometrium
expelled as internal invade myometrium
OS closed
Placenta
accreta spectrum
TRAPPED placenta Oxytocin +
controlled cord
Signs of placental traction (CCT)
separation are present If at any point of time while
doing CCT Cord breaks
"Empty bladder Fails
" If uterus is relaxed Next step
give oxytocin Manual Manual removal
"If uterus is contracted and removal of placenta
lnt os closed: Manual removal of placenta
of placenta

Abbreviation: CCT, controlled cord traction

Fourth Stage of Labor
1-2 hours period after delivery of placenta
Monitor Following
Uterine tone = Every 15 minutes
Pulse, BP = Every 15 minutes
Voiding: wWithin 4 hours of vaginal delivery
Temp: lnitially every 4 hrly and then & hourly
Oral intake = after vaginal delivery is allowed after 2 hours
Watch for Complications
PPH
Vulval hematoma
Post partum collapse
Patient Experiences
Physiological chills in 4th stage
 behind
placentreflectine
(PAS)
1.appearance
line spectrum Doppler
placental
interface
white
basalis
decidua
representing
eatenarea on
ofPAS-showi
accreta vascularit
continuous
(PAS) lakes/moth serasa
Hypoechoic
USG:Placental Placenta
uterine Placenta
percreta
SPECTRUM
on 3.of
1.Placenta
accreta
Placenta
increte increased
PAS 75)
(lmage Disruption Hysterecto
my (decidua)
Myometrium 74:
Endometrium Image
75:
USG
bladder
of
Image
of Loss
Siqns Mgt:
ACCRETA Key
2. 3.
2.
to myometrium.
COmMOn cesarean forprior
cesarean structure of
Most
superficially
PLACENTA or either
factors meridian)
serosa. increases. PAS:
section.
pregnancy
of pelvic If
most number for
into to risk PAS
attachedattached cesarean bladder.
previa of
other markers
the infiltrate also important
and of
(multiples
presentthe serosa. chancesDoppler.
S7. is basalis risk previaPAS increta.
PASplacenta theany
percreta.
lt
are Villi layer e.g.as Endometrial
ablation Grade:
Placenta
accreta. as
past: to to to
villi Villi
Accreta: percreta: decidua in surgery
theimportant
factors:
risk of main of used
Nitebuch previa history Classification
placenta attached mom highercolor
attached
attached mom
this, lncreta: Etio
Pathogenesis in increases, of Placenta
Placenta these
are
present.
Types:
(lmage
74) myometrium. sectionMyomectomy two
factors
are
with
In DefectiveRisk
Factors prios
Placenta Curettage following
>2.5>2.5
be
Placenta Previous villivilliVilli will USG
Placenta Placenta
variety. Absent The
Cesarean
H/O sections Risk aresection. 2: 3: MarkersMSAFP
hCG
Grade 3a:3b:3c:
Grade There
Note:
PAS Figo The B 10C:
1. 2. 1. 2. 3. 4. If If
1. 2. 3.
 85
OBSTETRICS
S8.
PARTOGRAM
small
History Each big square represents = 1 hour and
Partogram was first given by Friedman & square =30 minutes
was
palled Friedman curve (lmage 76) 2 parallel lines are drawn =Alert line and action
e concept of alert line and action line was line-time duration between them is = 4 hours
qiven by Philpot and Castle
First WHO partogram was composite WHO Lower Part: Rep resents Maternal Condition
nartogram. Later it gave modified WHO In lower part uterine contractions are noted:
partogram and latest WHO has given: Labor Measured every 30 minutes by placing palm of
care guide contractions in
hand on fundus of uterus. Number of
10 minutes measured:
The manner
Modified WHO Partogram Each square rejpresents 1 contraction. duration of
in which each box is coloured represents
Based on following principle: contraction.
Latent phase = till 3cm
Duration of contraction:
Active phase = 4 - 10 cm
In active phase minimun dilatation is <20 s: *
1 cm/hr 20-40 s:
Based on this-Alert line is drawn >40 s:

Time duration between alert and action line = Following are noted in lower part along with
4hours contraction
Latent phase = Not represented 1. Oxytocin
Active phase = Represented 2. Drugs
Second stage of labor = Not represented 3. Pulse, BP, Temperature of mother
4. Urine output
Parts of Modified WHO Partogram (lmage 77) Following are not charted:
1. Respiratory rate
Upper Part 2. Oral input
Represents fetal condition 3. Oxygen saturation
In upper part:
FHR is represented by a circle Partograms
ofPhase
maximum
Normal FHR =110-160 bpm 10 Deceleration
FHR is plotted every 30 minutes phase
Each square is 30 minutes
|= lntact Cervical
dilatation
(cm) 8
A =Absent liquor
Status of amniotic C= Clear liquor
fluid is noted
B = Blood stained
stained
M = Meconium

Moulding if present is noted

Middle Part: Represents Cervicograph 2

On X axis: Time is representea Latent phase Aetive phase Secon

Stase
On Yaxis: Cervical dilatation representea
Cervical dilatation - represented by 'X 2 10 12 14

Descent of fetal head - represented by O' Tine (h)

Image 76: Friedman curve

 Hours
Hospital
number
Hans
Arora Ruptured
membranes
Sakshi
Dr
by
Para ActioD Partog
Gynecology
WHO
Gravida
admission
ofTime Modified
and
Obstetrics Alen
77:
Image
Touch
One Fetal
450 140
20090 180170100 heart
130
rate12010 00 90 80 Amniotic
fluid
molding HoursTime
8 7 2 1 Oxytocin
U/L drops/minDrugs
given
and
IV
fluids °C Protein
3 0
admission
ofDate of [Plot
O]
Descent
head Contractions
10
minutes
per 180170160150140130 120110 10090 B0 70 60 Temp Urine
Acetone
Volume
Sino
Cervix
(cm)
[Plot
X] Pulseand BP
Name
 3
BEYONDAcene
2H
Aet
tion s begims
STAGE
-SECOND pict fratation
2X P-PrteAt-
me pusthing
jag EXTENDS
stage
e enical hen
frst
TiggeredIn
secom
S
LASOUIR
active ndicale T-Tansse
in F
TAKEN
ACON P-Pestienor
AND
A-Antenior
ASSESSENT
A
Biood
THE B-
RECcORD-Meconium
GUIDE AND
DOCTORAClearN Guide
CARE ACTIVE
FIRST
STAGE OR C-
MDWIFE Intact
OBSTETRICS onset
Labr
-V-Varable
Care
LABOR SENIOR
THE
Labor
ALERT L-Late
WHO COLUMILE-Eaty
1Risk
factors 78:
ALERT Moble
MO-
Image
THE
CRITERIASupine
IN
SP-
me THE Umkngwn
MEETING
GUIDE
CAREU-Decined
OBSERVATION
LABOUR
160
2<110, 120
2<60, 140
2<80, D-
Ruptured
membranesDale ALERT
TimeHours
B
PT 2375P++
At 2.>5
>60
<20, 225h23h 25n 26n dropsimin)
(UL
Oxytocin NEW No
N SP 290 350 ANY
CIRCLE N-
INSTRUCTIONS:
N L
M A ON Yes
Campanion CcONTINUE
Y-
Pain
relef fuid
Oral
fuid Fetal
0eeraon
posilion
Mouiding
DiastolicC
SystolcBP
BP Temperature
Contracions
min
10perof
Duration
10
Contractions
9 3 7 6 5 5 3
ASSESSENT
PostureBaseline Amniofic Caput
4 2 1
A2Oreviations
FHRFHR Pulse Urine
Piot
X O)
Pot
Descent
Medicinefluids
V
Cervox INITIALS
SE
AlertColumn PLAN
PLEA
sUPPORTIVE
CARE WOMAN PROGRESS LABOUR MEDICATION MAKING DECISION SHARED
Seclion Section Section
5 Section
6 Section7
 88

6 5Parity
4 3 name
Section
age Pt2 Pt1 Section
Sections Where risk
LCG in females.) 2ndPlottingNo
Active
Latent LCGBased
At InLCG Inrecommendations WHO
New which
Principle* (mage78)Next
Time Time Time WHO
all all alert there
Thereprogress
no
is ofActive If
should stage
levels
shouldfemales phase: on mother is Generation
of of of 1 7 S 6 4 2 1 phase: based in
MeWoman
line
should this is
onsetonsetonset Note Shared Love= Smart
Beautiful 3 = =
of 202O
Pt of be no phase:
= LCG and on
labor and Begins Not
Medication details health LCG who used: need
active
labor in
of of of down begin validity gave
Care action babyBegins new Partogram:
redactivelabor decision LaborSupportive care
= be isrepresented was
are for
Care & careused: represented @@ next
of 5 made of fine-
S intervention thenare @s WHO One
labor progresS labor delivering line
making woman of cmcm alert
recomendations. cm. generation Touch
nes baby details phase<1 is
and Labor
Obstetrics
(especially action 59.
even if partogram Care
line. cm/hr. GUIDE
CARE and
GuideLABOR
low Gynecology

Pulse
Temperature BP
3Maternal
4 represents:
2 Section
1 Moulding
4 +++Caput 4. 3.Late 2. Alert
6.+++ S.deceleration deceleration
Amniotic
position
Fetal 4. FHR 1.
fluid3.FHR 2.
Section Mobile
SP MO=
posture Posture
For D=N=YesY=For P= reliefPain
OP= Section
C=
Urine
1.MouldingCaput
6. 5.
(OP/OT) Meconium
fetus FHR companum =
Cowmpanion
Oral by
post/Occipito Occiitpo = WOmen
Supine declines No
signs 3 2 Dr
<110 (alert
condition: of fluid of Sakshi
Arora
Hans
of LCG (alert LCG
+++ sectionor sign) pain
has: has:
or >160 sign)
Care blood relief Supportive
bpm 3
of transverse
position of include: and
women stained
oral
care
liquor fluid
 OBSTETRICS 89
Sactron 5: Represents progress of labor:
Uterine contractions
Also know
are noted in
Number of contraction section S In LCG second staqe is represented when cervical
occurring
along with the time for
in 10 minutes dilation is 10 cm then second stage begins. As
noted
which they occur is
per WHO =maximum duration of second stage in
Prime 3 hours, multi =2 hours
If number of contractions are <2 or 25 it is
alert figure Section 6 Following medications are noted:
If contractions OCCur for <20 seconds or 1 Oxytocin
>60 seconds it is an alert figqure
2 Medicine
LCG there is no alert and action line just time 3I/Vfluid
bound alert figures as follows:
Dilatation Time bound alert figure
5 Cm
6 hours
6 Cm S hours
7 Cm
3 hours
8 Cm 2.5 hours
9 Cm 2 hours
 resuscitation:
MaternalInitial definition:
Clinical
Perform odACOG deDefinition bloodloss
examination
P/V
Traumatic
PPH Normal
uterine vMassage
e uterus.
typing.charting.Place GiInsert
Arrange Excessive Bleeding Blofinition:
fallinA PPH:After
ofAfterNormal
ement Laceration/
propriate Hematoma Investigations Blood
Repair/ Perforwm Mgt
tone followed 10OO loss BloodceSarean
vaqinal
a Foley's 2 hematocrit
per associated 21000 loss
examination.
vaginalper for large of
bleeding loss
by
abdominal
per a mL PPH delivery
per
blood bore postpartum
period. 2100O 2500 section
’
catheter
crystalloids. mL
abdominal
Tranexamic
Uterotonics + vaginal and CBC, needing hypovolewmia.
>10% with mL mL
acid and IV OR irrespective
OR OR <1O00<500
confirm
atonic Ensure
entire
PPH placenta Reduced
uterine
Tone tone/ One
(3O its P/V examination blood Blood cannulae after after
expelled
beentoexamination with examination for between signs
membranes Atonic
PPHmassage examination ml Touch
min) maintainedonly blood nL 60.
products.grouping fluid and cesarean vaginal
(16 of Obstetrics
+ transfusion. admissionsymptoms type
massage input-output HEMORRHAGE
POSTPARTUM
followed or HEMORRHAGE
POSTPARTUM
have section.delivery.
of
and 14
delivery and
No). and
by Rh of Gynecolody
Drug 10-20
Tranexamic
usednotGiven
Carbetocin 2. 1. Dose acidCarboprost =this
for250 Oxytocin
Remember: Recommends:
If WHO
Oxytocin
Uterotonics Retained
T= tissue
Trauma
T=T=Causes M/C 12 M/Definition C
for a oxytocin 24 PYQ'ImSp
Dinoprostone
WHOfor case rectal
per
ACOG
oral/sublingual.Misoprost used Then
T= Secondary Primary
this within maximum 1 meg Throwmboplastin, Decreased cause:weeks cause: Hemorrhage. cause
M/C causeM/C
minutes g of
purpose added /M then- methylergometrine (Repeated
= PPH
3 Carboprost is 20= of PPH:
managing PGF-20 600-1O00 If =
unavailable used Retaineddelivery PPH:Atonic
hours @1 repeated of Misop
bleeding IU Tone -
(PGE,) to WHO
at 8 in 4TS Occurs shockof of
some mL/min
of 10o doses rost 2 SOO in Occurs PPH maternal
should
-4 mgt ie., of
placental
PPH hemorrhage is wil
recommends- uterus
mL every is mcg hourly) mL after
PpH.
after withindelivery
places not (maximum of bleeding
but of also not
(15-9o) be O. 2
= NS
PPH mortality
is NS oral/sublingual
used. not
(M/C) tissue 24
recommended controlled mg disorder hours hours
used infused be
= l/M in
of minuta2 useful. 800 but of ’India
mg) can deliven,
label ovo with
by Inh oy or mcg be
 OBS TE mies

Ato 1\1\ c PPH

/Res(.(sc,tate U,e P.,,t /ell\ t
L_ _ _ VI

t
[ c;:<!__nffrwi.. Ato"'ic r PH
- *
• Uterine lill\a s<;a_qe
lnj. tvane~awi.ic acid
j (
(

IJ tenne W\Wct;lqe. a' pev /\/HO ,s not_,_ _,)

a part of A M rc,L hu t ~as b~en st-i.:hed
W1.anageW1.ent
\__ --r to____ of PPH
[ _ IJ_~'2o!_onic dr1A8 s _
- _., ./ __,J

[3(eedi111.g is v\Ot covi.troUed
tf it fai(s: Bleeding coV\tiV\1Aes
CoMprr13.~S.i"lf\ s1,-<:, ·, e.
MI C IASed = 13 lyV\c/,\ S1At1Aves
(/WI.age 80)
Ot/,\evs
• CiuV1.S/,,\ella sut/Ave
• HayW1.aVt S1At/Ave
• Cho squave sutuve
If it fails-BfeediVlg COVltinues
Stepwise devasc1Alavi:zatioV1.
(suvgery ov by rndiology)
B(eediVlg COV\tmues
Med1an.ical coMpressio~ ·
TeW\porary W\et/,,\od =- B ·w.av, tAaf C.OW\p,ess ·o;,1
PerW\cu1.enr W\et/,,\od. - Bakr bo.((oov, ca~eter
(IW\o.ge 7 q)
fv1axiW\IAW\ co.po.city of Bo.kn ba1 oon
cat/tieter = soo W\L
Ot/tiers wJ,,.icJ,,. can be used
• SB esopl,,.a9eaf catZ,..etev
• CondoW\ catJ,,.etev
If bleedin9 stops: Bakri balloon catM ter-
sJ,,.01Afd be re/lV\.oved. after 1.-2 Z,..ow-·s
In stepwise devascl,(lari;!.a.tion. arteries wn.ich
are (igated:
1.-. Uterine artery
Site = As (.,(terine artery t1AYVlS
1Apwar-d.s in bvoad fi9aW\ent
2 Ovavian artery- a · as· owtoSiV\!, b ·av-ch
3. Ant evior d.ivisioV\ of interV\a.l iliac A a.~ 't
gives ovigiV\ t o v.tevine A)

✓ita(s of Vitals of
pa.tieV\t stab(e patient unstable
Ligate
AV\ter-ior- divisioV\ Fails Subtotal
of iVlter-Vlaf iliac J,,iystevectoW\y
figatiOVI.

• TAH/SiW\p/e hystuecto,..,,y = r-e Vv\ova{ of uterns

and cevvix
• subtotal 1,,.ystevecton,y rew,.ova/ of 0V1./y uterns
not cervix

IW\age 7q. Bakvi ba/looVt ca t J,,,.eter

 U71:: Touch Obstetrics and Gynecology by Dr Sakshi Arora Ham

\
'
:
'

;
;'
-~1111,1 p{11
Intact ofd
l.,(te,~i"'e iV1.cisioV1.
SIIV\a(le.,. V\ew iV1.cisioV\
Fov B-L!:jV\CM CAtev-iV\e J
coMpressioV\ SCAtlA r-e

IW\age 80 B /yV1.ch suti<V"e IW\age 81- Vulva/ heW\atoW\a

v"' HeMatoMa {(Mage 8 :1)

~:1-. POSTPARTUM ~~ ·
fv':/C site of pelvic heMatoMa. = vl,{lva.l heMa.toMa.
MIC artery iV1.vo(ved: Pl,{deV\dal A
AMniotic Flu.id EMboliswi
Suspect VtA(vo.( heMatoMo. if a <; o.~er defivery
prese.,,.ts with: It is a cliV\ical diagV\osis
1.. Sevev-e paiV1./pefvic pv-essw"e TiMe of occurren.ce: @ tiW\e of labor ov- witviin
2. Ur-iVtary r-eteV\tioV\ 30 W\iV\l,{tes of labor
3. SigV1.s of hypovo{eMia 2. phases:
witJ,.. V\.O exten'la{ b{eediV\g 1.st phase: Cardio + respiratory Faill,{re; patieY1.t
; OtE: F{u.ctu.aV\t teV\Se teVlder swe{{iV\g seeV\
has tBP/tHR/BreathiV1.9 difficulty
(I w..age 81.) 2.V\d phase: DIC
Mgt: CoV1.ser-va.tive Mgt with Diagn.ostic criteria:
AY1.a{gesics • UV\exp{aiV\ed shock with very less bleeding
Ice pa.ck • C{iV\ical OV\Set withiV\ 30 W\iV\l,{tes of labor
lndico.tioru of StArgica( M!Jt • Abrnpt cardio respiratory arr-est
• Severe paiV\ • Overt DIC
• Si.:z.e of heMatoMa. iV\creasiV\g • No Fever
• Shock Suspect AFE if Q says:
Surgico.( Mgt: I aV\d D of heMa.toW\a • UV\explaiV\ed shock aV\d br-eathiV\.g difficulty
• Ligate aV\y bleeder u.siV\g figl,{r-e of 8 Sl,{fore • Q says: UV\explaiV\ed shock with less b/eedir-9
• Close cavity of heW\atoW\a by W\attress Sl,{tl,{re or- /,{V\expfaiV\ed shock, bleediV\g aV\d DIC
PlA = Nor-W\al
P/V = NOY-W\O.I
• No coV\fir-W\ator-y test
• CaV\ fead to W\ater-V\a.{ W\orta( it!:J witl,,.iVl 30-
40 W\iV\u.tes
 D ; ru:it:AS of t4
, P
r
o uteri'M cav'ty
M ·sW\aVta9 d t
MantAa( r-epf a.ceW\ent Jolt\Yt rm.
+ rd sta9e of labor tt-ei-iVtiqu
'--- ~of t.(terw; _~
Do not try to reW\ove pfa.cet'\ta.
when. patitn. t 9oes iVtto
Fa.ifs: Qive i ~®rin ;~aV\ t:;.__
_.__.:.__..r
·.,'V\W\tdiate. s"'ock a~er deliver y arui OfJa.in a.tteW\p t W\a.nua.f repface W\en.t
, ,. c ~ is Vtetffo9e.Vtic of <AtertAs
..... t on t e d c; to Fa.ifs Sr.,w,gery doVte
AbdoM ina( = Hv!o'\. qto
HtMorr"'a.gic s"'ock W\et'1lor,l
~e~ , s a.It· HeW\orr"'agic tf co 'l5trictio V\ ,,. · a see I\ ----.

Ha<Aftail/\ suYger-y ,
5"'ock ~_-_-_-_-_-_-_--'____ ____,
=-_-__:__::. .___
-::_-_-_-_-_-__-_:,-
t - - - - - L . ._____

On PIA = A cup like depress ion

Note: Once repfa.ceW\.eVtt Outdat ed S..< es rrrv
is done 1.. O'suUivan.
fe(t below UW\bi(icu.s 1.. Stop toco(yti c '1l!:Jdrostatic
(fut'\dus is depress ed) 2. ReMove pf a.ceVtta. w..et'1lod
~ 0 '\ P/V = BleediV \9 + Qfobul ar 3. Sta.rt oxytocivt to 2. SpineU i s1,1.r9er!:J
preveVtt reinversioVl (vagiVta.( surger!: J)
wi.a.ss iVl va9iVta
4. ~ive aVttibiotics

1W\age 82A aV\d B: T~ese iW1.o.ges o.r-e giveV\ as spotter-~: A: Uter(V\e ivwer-sion. B. Pro/ap:;e (IV\ A = os V\Ot seeV\;
IV\ B = OS is seeV\) UtenV\e tV\verstoV\ ttV\d prolapse
1 1
• • ,., pr·olapse lCoYd/Fu.n.dic preser,.tation. j CoMpoun.d pr•s~~_!;~.
c.ord. i present anead of tne CoYd a"'d pr n
pr-esenttV\1 part but is above ar-e a(on9s1de each
intevna( os. above internal os
/
'

~
I
-
I

~
I (

j
I

t' )
I
I \
\ ,'
l
'-
'
Alqor-itnW\ for Mat-tageMet-tt of Cord Prof apse
Check where is cord presen.t

i
Cord (ie<: otAtside vaqina Cord (ies inside va9iV\a
A IM: To p(o.ce covd tV\<ide vagina
• MiV1.iwi.a.( J.,.o.nd(iV\9 of covd
l
Do not attewi.pt to p1At
• Use wet 9a1Aze cord inside 1Aterns
• Pface covd inside va9ina aVld
V\Ot 1A ttV1A5

Man1,4a( repositi0Vlin9 of cor-d

inside 1Aterns is not done

• Assess tJ,i.e di( ato.tioVt of cervix

• Li~ tJ,i.e presstAre Frowi. cord by
(1) Retro9rade fi((in9 of bladder wit"'-
soo IIV\L NS
(it) TreV1.de/enb1Ar9 position
(iii) l<.Vtee cJ.-..est positioVt
• Stop oxytociVt I FettAs a( ive

i
tf cervix is ftA( ly di fated Cervix is not ftA( ly dilated

+ +
• Do va9ina( def ivery tAnf ess • c;ive tocolyt ics
tfl..ere is traV1.Sverse (ie • Do C -section
tf fettAS is dead: prefer va9ina(
delivery unless there is traV1.Sverse lie
 I

...-o _ e e
ergo ~ ✓ag a d.e ✓e
• p,. ., . wi _at- be ed ar./w.ed o ate a
0

• A q e o wed o o.tera ~ 0
(Ro.t'\.9e = 45" - ~
✓O ✓eW1.e o a a Advantage of med 'olatero.l Ep s ·otOM!:J = [ ✓e
ade 3 pit- v- te...- t exter'ldS ·t CO.V1.V1.ot v- vo ✓e a ~ sp ,. e
iear- vwo v·n.q ~ S"Oo/. f tn r:kv-e:;' of
30.
Disadvo.nta.9es of Wt.ediolatera( ep ·s otoMy
exter-n.a( a.VI.a/ sphiV1.Cter "' b eed'viq
3b i ea . .- iV1.vo(viV\9 ~50% of th ckn.e=:s of • Muse es al"'e CIAt
exterV\al aV1.a( sphiV1.cter- • .... dyspa...-euVlia
3c iear- iV\vo(viV1.g iV1.ter-n.al aV1.a( ::.phiV1.Cter-. • Takes tiMe to heal
• arade 4: Tea r- ivwo(viV\g an.a( epitheliu.VV\ or- INi.ico.tioY\S for episiotoM!:J
rectal W\uco sa 1.. A~er coMiV\[j v-.ead. of br-eecl,,.

(Aro.de 3 aV\d. grnde 4 CoMp(ete perin.ea/ tear. 2 1V1.StrnMeV1.tal delive...-y

3 MacrosoMia
Mano.9ewient of pel"in.ea/ tear.
4. Shoulder- dystocia
:1.st o.nd 2nd. d.egr-ee pe...-iv.eal tea...- is ...-epaired. like
a~ episiotowiy.
Done in labor l"OOM urulel" LA
Seq1Aence: Vagina( W\ucosa ➔ Muscles -➔ skiV\.
Mano.geW\eV1.t of 3...-d. av.d. 4tv-. d.eg...-ee (coMplete
perinea/ tea...-)
Done in Oi under- epidural OV' ~A.
Stq1Aence: AV1.a( W\IACosa (iV\te...-r-(,(pted. sut(,(V"e).

l~terv-.a( O.V1.0.{ sphiV1.cte...- ( end to end. aV1.astoW\osis) IMage 24 Episiotot'Vl.!:J scissors

i EVl.d. to eVl.d.
Str-1.utlwes cut iV1. Med.(ol atera( episiotoVV1.y:
:1... Vo.9iN).{ skin
c-..... _
-1.ernal at'\tl spnil'\.Cter
Z aV\aStOW\OSiS (Mc)
OvedappiVlfj
techV1.iq1Ae
•
•
•
•
Levo.tor- o.V1.i (Pubococcy9eus -=- lleococcy9e1As)
Superficial trnV\.Sverse per·iV1.ii.
Deep t...-o.V1.sver-se per-iV\ii.
Bu(bospoV1.9ios1As.
1
~P0 rtar1.t poiV1.tS afte...- r-epai...- of coW1.plete per·iV\.ea( • PudeVl.d.a/ V1.erve o.Vl.d. vessels.
tear.
• Poste...-ior- vagiV1.a( wo.11.
• aive laxatives fo.,. 3 -4 d.ays. • SubcutaV1.eous tissue aV\.d skiV\.
• Si~le dose of o.V1.tibiotics to be giveV\ just p...-io...- ;z.. Muscles Y\Ot cut during episiotoMy:
to repair. • lscl-\iococc!:Jgeusl Cocc!:J9eus.
• ~rl.ar\Cy should be avoided fo...- 1- !:Jea...- ideo.ll!:J • lschiocaver-V1.0S(,(S.
&..ct at least for ~ VV\OVl.tt..5 o.fte...- ...-epai...-. • AV1.a( sphiV1.cter.
• h.tc.cre, these feMales co.VI. 1-\ave vaginal • Obturator- iV1.ter-V1.us
£.ry. 81At if tl-\e...-e is Wo ~;z. tiMeS iV1.jUY'!:J to
- - -~ 1- Sf'H'\'hCter, delive...-!:J sl,,.ou(d be b!:J C-sectioV1.. Note: Muscles attached iV1. VV1.idliV1.e or to per-iV\ea(
bod:1 are cut iV1. episiotoVVl.!:J
 Fae,
• OtV\OMiVlator. f.1entum
1ft: AMrotd p Iv, • M/C positioV1.. LMA (L.e~ W\tnto anteri
OP ,os,tiorl D Fl xtd nead • AbV1orW1a( attitude: ExteVlsioV\
Ot\ are M C iV1. Wlu.ltipavous • fv1/ c_ pelvis associated with face: Pfatyp
SM IV\ pr1W\1gra.vida fevv10,(es. pelvis
outooMe oF OP position • fv1/C cause: AV1.eV1.cep"1a(y
Occtpu.t rottAtts by 3 8 of civcfe aV1d becoWleS OA
Followed by vagiria( de(ivevy
Best Mtu,agement of OP position Wait o.Vld MIC position: Left OVt( y cesarean sectiori.
W\ell\to all\teviov. possible.
watcn.
Erigagirig diaW\eter: No WlecviaVtisw. of
In some cases: fncoW\plete forward votation:
Su.bW\ell\tobvegW\atic (o.bov.
Occurs by 1../8 of circle.
(q,5 CW\). rf patie11tt pv-eseVtts
Results ii'\ Deep trnV1svu-se arrest
Vagi11tal de( rvevy is i11t eady fabov: \tlait
• Level: lschia( spi1'1.e all\d watc/,,. fov- face
possible.
• MfC ii'\ AVtdvoid pelvis
Fovceps co.Vt be o.pplied to votate artd beco1t11.e
• Best Mgt: Cesaveo.Vt sectiort MA.
Head is de(iveved by
Ra.rely: OP positioY\ W\ay U.Y\devgo postev,ov W\OVeW\e11tt of f(exioll\. Fovceps ov vacuu!N\ a.re
rot~t!'ol'\ resu.ltiY\9 ir. direct occipito posteviov- V\.Ot ap:olred.
pos t1ov. (DOP).
MIC seen in AVttl-tropoid pelvis De(ivevy occuvs by f(exio11t oV\l!:} iVt bveec/,,. and face
pveseVttatioV\.
In An.thropoid pelvis mgt ·s face to pubis de(ivev-y
In a.n.y other pelvis: Cesav-eaV\ sectioVl
Q sa.ys: MIC cav.se of DOP or- persisteY1.t occipito
posterior position: AVltl-tropoid pelvis BROW
En.ga.9iY19 diaWl i"'- OP; OF or SOF diaWletev- • Erigagirig diaW\: /v1eV1.tovertico.( diaw.eter
(:1-4 cw.)
TrarlSVerse Lie DerioW\iY1.ator-: Fvo11tto.( bo11tes
Lie: Tr-aVlSVU-Se
• Mgt: Ceso.veaVl sectioVl
Presenta.tioY\: Sr,ouldev
Denowdnator-: Acv-oWliOVt process Dof'\ot Cof'\fuse
MIC positioY\: Dovso-aVttev-iov
• Face_ to pubes delivery occurs iVl: Anthropoid. ·
MIC ca.u.se: Pr-eW\atuvity Pelvis
MIC ca.use at term: PlaceVtta previa • Face presento.tio11t is seeVl iVl: Pio.type/ loid pelvis. !
Most o~eVl fet1,1.s witl,,. tv-o.Vlsvev-se fie spoV1.taVteously
rotates duviV\.g preg11taV1.C!j aV1.d becoWles cepvia(ic/
breeck
Exawiination:
• OVt PlA ExaWliVlatioVl iVI OP positioVl
Height of uterns is less tJ,,.aVt pev-iod of gestatioV\.
o SubuWlbi(ica( flattenin9
Leopold maneuver-: FuVtda( gv-ip aV1d deep pelvic
o Feta( fiw.bs ewe towards uWlbilicv.s
grip are eWlpty.
o Fetctf back is towards wwth.ers f{aVtk
Highest chartces of covd pv-olapse av-e witJ,,.
trartsverse lie. ° FHS tire best heard in wi.otJ,,.ev-s f(avik area.
Mgt of trartsver-se lie: fVI aV1.teV1.ata( pd: L3~ weeks:
Exterrtal cephalic versioVt.
Mgt of trartsverse lie iVt. labor: C sectioVt.
~),:
 _ ,.,,,.,.,, ,c11v, Ta OV\
of breech. P
of

CA Jr., Jr. ) /l.1 I

No
in.vest19atioh ,.,, breech
Cit to vaq
eel-\ Head of ba b~ 1s exteV\ded ,t 15· Called as 4 usa sho<Ald show
ra,1,r-breech (It is aV\ iV\dicatioV\ Fov cesav-eaV\) ( .L) F-v-ank bv-eech ;, C
(2) We 19ht of bab11 - 2 4 q
(3) Head should vvJt be e e
( 4) No O.V\OW\.o.ly cal,{5 V\£j ab .,, -
s. Facility
Fov- eVV\ev-9ev-.cy ceso.v-eo. sec+-
obstetv-iciav-. st,,.ou 1d be pr-ese t
Types of Breech

Flexed Breech Fro.n.k Breech Kn.ee presen.tation. Footi~ presen.tat on.

i-l"p Flexed Hip flexed Hip ext en ded Hip exten.ded
KYl.ee Flexed knee flexed knee flexed knee exten.ded
PIV: Hee( + Buttocks + P/V: Buttocks+ Cienita{ia P/V: KVtees fe lt P/V- Feet s ~e c.
aeY1.ita/ia + Ana{ OpeniV\9 + AV\o.l OpeV\iV\9
Mic in wi.u{t19v-avida Least CV\O.V\ces of cord Ct,,.ances of co vd pv-o lapse Ma x iVVtuW\ cJ,,.an.ces - ~

pvolapse. iVtcv-eased cord t?rolapse. H - ,.re r

/\//IC in pviVV\i9rnvida C -section is done C-sect"on

MIC var-iety of Bv-eeck Fran.k Breech. Ma.n.a.9eMen.t of Breech

UC var-iety of Bveeck CoW1.p{ete Bv-eeck
~ver-al/ MaxiVV\uVV\ ct,,.aVtce of covd pvo{apse: Tv-aVtsvev-se
Ire > FootliV\9 bveect,,. > knee pv-eseVttatioVt.
In. O.Vlten.ata{ period: ExterV\a{ Cepr.a{ic vers ·en.
If ECV fails ov is C/1:
Best w.an.agel'V\en.t: Cesarean sectioVt at 3 q IA; e_ -0
We co.Vt do va9iVla{ de livery in. breech. ~{l{{ed as AS!. ~"te.:l
Br-eech delivery .
 Are any of fo((owin9 preSe
Y\t
1-. Ski(/ed obstetriciaY\
\fl ly I 2. Fae ifity for cesareaV\ sectioV\
3. PediatriciaV\

+ i
No Yes
..
C/ Secti
I
oV1.I14• - - - - _ _ ,
Sti(/ 1
If patieV\t opts
ReCOW\VV\end for vafjiVtO.f
C/ sectioV\ delivery

If: 1-. Avoid AR M

•
• Slow pv-o9iress of labor- 2. Avoid assistiV\g r'({
• NoV\ ireassiwiV\9 FHR W\aternaf efforts have
deliveired ti(( rAMbit:c:.is
3. If W\aterV1.a( effor
ts are
C/sectioV\ t,(Vl.ab(e to def iver fetiA5
Ap ply W\aY\euver
Part
de ·very of buttocks
Fo r Ma ne «v er
aroiV1. tiractioV\ (IW\age 8 5)
For- de/ ver-y of extew:1.ed leg
s iV1. fraVtk breech PiV1.aird W\aV1.etAveir ( IW\a9e
51\oulder 8 6)
- - ~ - - - - ~ ~ ~ ~ -L
_1_v_s~et_'_s _W\_a_l'_e
l. _u_v_e_r_(_IW\
_ a_g_e_8_7_)_ _ _ _ _ _ _~
Delivery_!!_Faf ter Cowu·Y\9
Head iY\ Breech
• Head is the last par-t to be
delivered iV\ breech
• Mic cause of death iV\ breech
: /V1.tracraV\ial HeW\oirrhage
• Head is borV\ by W\OVeW\eV1.t
of = FlexioV\
• Mostly bv-eech is dorso aV1
.ter-ior: IV\ dorso aV1.terior br
o BurV\ Marst,,.a/1 Tec eec h W\ett,,.ods of de /ivert1
hV1.ique (IW\a9e 8 8) of fetal /tlead are
o Matar FlexioV\ aV1.d Shoulde
r TractioV1. (Mat..<riceau - SW
o Pipeir's forcep (IW
\age qo ) \el/ie -Veit techV1.ique) (IW\a9
e 8 q)
• In. case of dorso posterio
r bv-eech: Pr-ague W\O.V\etAver
used
 le. '->

,
I

m m \
RI
IWlage 85: c;r-oiV\ tr-actioV\
l1Ma9e 8 ~- PiV\ar-d W1.aV1.euver-
aroin Traction.: Used Fo r- delivery of buttocks tV\
ast of flexed bv-eeck Pinard W\al'l.e1Aver: Fov d.elivevy of exteVlded le9s iY\ :

<
bveeck \
PiV1.avd.
ReW\eMher: p
Popliteal Fossa

d for- deliver-y of sh.ou/der-s

/W\age 87 : L "'"'veset's W\aV\euvev- use
 l) • TOL ch Ob tetnc-. t1nd Gyn cology by Dr 5akshi Arora Hans

tw,.age 8 8. BunA tvlav-sha/1 techVtiqCAe

" br£uh: Let t J,e bab!:J haV\g b!:J its OWV\ weiglAt. For- de liver-!:J of Head Hold feet of bab~ o.Ni. take : :c1 ,,,
- -. ers abdoW\en..

lw.age 8q tvlalav- FlexiOVt aVtd snou ldev- trnctioV\

Mau.ricea u- SMeftie - Veit wian.euver-, Also ca{/ed as Ma/ar- flexioV\ O.V\d shoulder- traction. Tlt--..e one. hmd ·1,s·.1.
vagiVta -put 2 fi¥1.ger-s oVle OV\ each c'1teek of bab!:J O.V\d 2 fiV\ger-s of ot"'-er- hand on bab!-J'S s1'\0 , t der tmd r<'-1 1
flexioV\ witVi sl,\01,1.(der- t r-a ctioV\ is dov,.e.
----------
(

/VV1age qo Piper-'s For-cep (LoVtg Fov-ceps witn s/idiVtg lock ; oVtlf:J Fov-ceps with a pev-iVteal
cuv-ve or- it has a v-ever-sed pelvic cuv-ve)
 , -- -

b,tbt/ 1· 1 ot ~t i tr r • In F j,,. n. qat,...-

i
'r lwt. cl l,; u.V1.d
~V\
• f-Jfl ~
( W\al '4 / I
VV\q J A ,f ( I I ,
t • ltiotdd h rinv- d ('('.
clF'fl
fr'\
W\0n1tonV\q
\ • ,;1 ~iot V\et:dfd toco lytic
s ave used • I( Fetal distr -e,,. lhrn dyca r-d r.t
~ l ~TL1 uta/1V1.e 0.2 5 W\,9 s/ c) rr,
tltie prnceduv-e
0 Stop the pvocedl.,(Y'e
~·h IV\ SiV\9letoV1. pve9V\O.V\C!j 0 Rev evt the bab1::, :o '"-e V\0Y-IN\O. p,:,::.. - _,
.;il'\SVeY'Se Ire iV\ SiV\9/etoV\ pve9V\O.V\C!j 0 IW\W\ediate cesav-ea · sect OV\

ra. If ECV successful iVl 1-st o.tte W\p t.

Wa. ·t for
spon.tttl'\eous labo r (Do V1.ot iV\duce';
If ECV fails: It caV\ be Y'etried on. an.o ther
day , c e.
W\OVe tiMe .
If 2V\d atte Mpt is successful: tn.d.uce labo
r with
oxytocin. drip .
IF 2V\d atte Mpt Fails: Sch edu le an.
elec tive
co.eso.reo.l'\ at 3 q wee ks.
Pruequisities and coritrain.dication.s for ECV

8Hwn:ma11·lm.___________~_,_·_
_ -·~ ,
;:;t od of 9estati0Vt z3~ wee ks: usua lly doV\e at
37 weeks (Less ci,\aV1.ces of v-evev-sioV1.). Ol19ot-.ydvaMV1.1os

-qiwr sv-.ou/d be o.dequo.te aVtd /VleW\bv-o.V1.es si,\ould Rup tuve d VV1.eVV1.bvaV1.es

oe ,ntact.
~aribe doV1.e iV\ eo.v-fy (o.bov- (/ateV1.t pt-.ase) if Acti ve pha se of labov.
tW\bran.es ar-e iVttact.
5 r1.9/etoV1.
e pve9VtaV1.cy. TwiV1./Multifeta/ pve9V1.aV\.C!:j.
r
Fetal hear t rnte s"'o u(d be V\.OV"W\al OV\. AbV1.ovMal fetal ht:-art .--ate
CT{;. OV\ CTCi.
No coV1.tvaiV1.dico.tioV1. for- va9iV1.al de/ivev-y. Plo.ceV1.to. pvev ia/ cov, tvac ted pelv ,s.
Ute rns/ fetu s gvoss/y O.V\O~t'\C1{N1S

Relative c . . .
• PIH o~tva1V1.d1cat1V\.S of ECV:

• Het:1rt d.
• llJqR ,seo.se iV1. W\othev-

PreVfOl{S
·
LSC S.
 67. I

ff ca e.i S n1Aso1da( Heart Rate (IW1.a9e a1-

ov

prngnos·s.
FHR by 1.5 bpW\ x 1-5 secoV1.ds is dece(ar-ation.
ast t · 2 w..iV1.1Ates.
~ts or 2-:l.O W\iVltAtes - its a pr-olo~ed deceleration seen n :::J ers+-
c;xytoc ·wW\ ·sopirost (f W\a9e q 5).
c;r ~UJ W\intAtes tiien its not a decefera.tion bu.t a cl-tan.9e n as

Types of Deceleration.

t
l. E

t nne OY\tra t10Y\

H e It\ ,de

It l
p • d H'"S w "th n 30 seconds
2.. Late deulerat o,i (lwi.ag, 'I ) or uttrit\( contracticY\
Oc ur-s o u , , • Indicates cord co..,,,pr-ess Of'\
0Mtt or d,p IV\ FH I a(t r n et • No fixed t~e(C1.tioV1.s"1ip with
contraction and_ d,p end a( 0 after uterine i1terine contn:tctioV\
contracton subs,dts
Severe variable dece(eratioV\-
o Sttn in UPI
Dece(er-ation reacl-tiV1.9 a vi.adir
0
Most obvious typt or dtctftrat,o.,, W\ore ti-.aV\. 00 b/M below the
base!iV1.e aV1.d {astiV1.9 {0V1.9er
ti-.aV\ 00 secs.
 OBS Tt.1R CS

'Wt.age q:;i: Early deceleratioVt

fW1.a.9e q3 Late decelera.tioy,.

,fO

~
= = Prof1m9ul. i:Lecete.rSJ.tion :.~
,o UC

\fvt~r,,r QO -ri/
~--:--1•1--~~~......-z..■•-----
jQ

lP.
u
w •~
~
·~
lO

+fJ ~
fg
j,tJ

f1Ma.9e q 5: Pr-o/oy,.9ed dece /eratioy,.

/Wt.age q4: Vav-iable decelarntioV1.

Norwial CTCi: (Category j.. CTCi) Cate9ory 3 CTQ

FHR = 1.1-0-1.20 bpw-.
Vario.bifity = 5-25 bpw-.
Acceleration = +/ -
Early deceleration = +/ -
Late deceleration - rtt
v.ar,o.. ble deceleration. -
'.1-. SiV1.uso idal t,..eart rate patterV\
2 . AbseV1.t vav-iablility witi,.. aV\y of followiV1.9
(i) PersisteV1.t bra.dycaY-dia
(ii) PersisteV1.t /ate deceleration.
( iii) Pev-sisten.t vav-iab/e dec/ara.tiol'I-
rtt Man.a9eW\en.t of Cate9or-y 3 CTa
IV\ utero resuscitatioV\ + EMe.Y-_geV\cy cesareaV\
sectioV\
Steps For il'I- utero r-~~uscitatiol'l-
'.1-. Le~ lateral posrt10V1.

2 . 02 by Mask
_ stop oxytociV\
3
 L) f' TouLli Obstctr11 c; and t ync>colotJY by Dr Saksh1 Aror~ Han~- -

.,. Kerr- ,n.cisioV\.

\I)(
dWI 111(
,, l~(ttll'\
I ower '-1'.qW\erit cesarea"' sect~,
) H c V\. Cf IOI'\

as at,9c1"s 1rtc1sio"'- Rr k of r1Apt Arf.. O 2 o a7

1

\ (
In
.....
I 'YI
t ( t ~, r ►\ next prcgV\.~I\C 1}
)
,rH/0 W\l,dt,ple 1ow trail'" 1err, ,. r,
cesarea""' sect,o""' that'\ o q 1.. • • ,,

- ~ K f'\i9 incision/De lee if'-cisiof'-

Remember
tf classical cesar-eo.n is done once tt,,.en 1,r s:,(~'J~ea~,
.,_L'Vv ersegMeV\.t pregVto.Vtcies ~ cesareo.v- has :o be do(\.e 1:_ 3~ --l

weeks. Tt,,.eve is V\O role ot tv a 1 of labor-. ~

L'csiAr-etu, sectio"' but witt,,.
\.trt'ca( 11'\cisio"'
• fvlostly iVt LSCS ➔ Verv mc,sioYl is 9 ·ve.-i
• t<voVtiVtg iVtcisioVt 1s g veV\ iVtcase of con..str·~!':
Ct'.,u'\ces of rupture = :1- - 7%
V'iV\g.

Also Know
1
3AC = Va9iri.a! birth after cesar-eaVt) • Level of AV1.algesia for- Epidur-al aV\.a 9es·a. = -:.:
- c,_AC = T,ial of labor after- cesareaVt) • Level of AV\.esthesia iVt cesat"eo.n = T4
• ideal position for- cesar-eaV\. supiV\.e w ·t ·. :!.s= ~-:
Cl for VBAC or TOLAC
later-al tilt of table or pf ace a wed9t ... tu!'
• ;;y-·ar c 1assicaf cesav-ean sectioVt
V'igt,,.t t,,.ip.
• Dr ar- - sriaped cesareaVt sectioVt Ideal tiw-.e gap between cesar-eal'\ aru:l 1£\:
• ~,.. or !J.ttrine v-t.Apnwe •
pvegV1.aV1.Cfd = :1- 8 w-.oVttbts.
• ..... ;Me b rt1,, fvliVtiW\uW\ gap betweeVt cesareaV\ aNi r.e~:
• ~/0 h~sterotow-.y/W1fiOWtectow,.y (coW\p lete •
pregVtaV\.Cfj = 6 W\OV\tV\S.
t °Ci<r\.e.SS~ Elective cesarea11t sectioV\. tor- noV\ Mea =
•
reasoVtS is dorte @ 3 q weeks
R£ a.t ·ve C/1
• Mo~l"~sowJa iv, preseV'lt pregVtaV\Cfi Indications for aeneral Anesthesia in. Obs
• f/.o. p.--esev-tot.-of', ·n pr-eseV1.t pr-egV1.0.V1.Cfj
Severe fetal distr-ess
:1-.
2. LSCS iVt patieV\.tS witJ,,. J,,.eart d:seo.se
ACOCt RecoWtwi.en.ds
5 /Vttrnco.r-diac sJ,,.1,mt
• -ro._1- C cov, be doV'le IV\. pr-eviot.AS H/O LSCS
ce~Meo" :-eltioV1. H HOC/vl
• TO._/- C: au. be dorte iVt previous kroV1.i9 iV1.cisioVt E EjectioVt frnctioVt <35'7o
( ... /-, P PulW\oVtar-y HT
• Ill\ b_r-eecV1- ✓ersiovi. co.Vt be atteW\pted witbt 3. For- bt"eecbt extractioV\.
pvev,ous LSC5. 4. fvlaV\ua/ r-ew,.oval of place~HeY1.t.
• TWt/1\S ti/\ presev-.t pregVta.VtCfi is V1.ot a el l for- TOLAC.
5. fvlal-'\t.Aa( replacew.el'\t of uterus '""' in\ usioi\
Indications for- Classical Cesar-ean Section 6. UV\COV\tro/lable psycriicttr-ic per-SOV\.

WneV\. access to lower- segWleV\.t is difficuIt, tfJ ,

severely contracted pelvic
• Cancer cervix
• Lower uterine segWleV\.t adbtered to bladder
• PfaceV\.ta previa with blood
• Lower se9Wlent V\.Ot forW\ed-
o PreterWl cesareaV\.
o Cesarean sectioV\.
 a.,-e appl,e d +t,,.
o cervix ,., 10 CIM

\ of Feta 1 head .l..

4
st s I< V\OWV\ a c aq I pa
~ ,. vorabl pos,t10V1. aV1.d st~t,o"' /vll)t/,,.e"' i t-~lv ve
lo
fu'ly dilated PreseV1.tatioV1. vVher·e r,erar ,o i-.o. I ~ r

,.. , , s., b rnptu r-ed aV1.d head sho ,J b Cl rro.V\Sverse Ire

u 1u e rotated 0
Brow
= s Shou Id b e coV1.tr-actiV1..9
Ep 5iotoW\y should be 9iveV1. ° Face- W1eV1.topostenor
:.. ~J CPD/pelvis sho1Ald be adeq1Aate PYQs
s o Forceps Application. 1. Vo.cuuM co.Nl.ot be used 1n.
o t et Forceps Applico.tion. o Pretev-W\ d.eliver-y
..,ad. is OV\ per-iV1.euW\ o After coW\1V1.g Head ·V\ breeci-.
• s.:a p visible at iV1.tr-oifo.s. o Face for W1eV1.to AV1.terior
• Sr<ull OV\ pelvic Floor- /Vt fetal distress: VacuuW\ ·s Not pr-efer ~e.:i.
.2.. Vo.ct.ct.cW\ is applied at flex,on point (1Ma9e q ~
• Sa9 'tta/ sufo.r-e iV1. AP diaWleter-. to CM postev-ior- to AV1.ter-,.or foV\ta 1- ~
- :.e 0Y1./y Forceps used as outlet for-ces is Wr igley's 3 CM aVtterior to post FoV1.ta.V1.e e
, -~ep (IW\age 1.04 ) . 3 /1'1. 9el'l.eral fetal coW1.plications are more with
2.. Low Forceps Application. vacuuM il'I. coMparison to forcep.
, Applied wneV\. head is at +.2. ov- below +.2.. StatioVt 4. Matev-Vtal COW\pl,-co.t;OV\S a.re w,.ore w'th o ·ce,;
1:7:A t not yet r-eacned pelvic Floov-. tV\O.V\ VO.CUUW\.
5. Fetal coMplications More with vacuuM
Ad.vanto.9es oF Vac«uM over- Forceps
o tott,,. Vtev-ve palsy
✓ac u.u. W\
caV\. v-otate head of fetus. o St,,.ouldev- dystocia
2 VacuuW\ caV\. be applied wheVt cev-vix ~to CVV\ o Cept,,.a.(ot,,.eW\a.toVV\a.
d.i ated. o Sub9a.lea.l ¥\eVV1.orrt,,.a.9e
Advanto.9e oF Forceps over Vact,U.tW\ o RetiVta.l iVtjw"y
to. Fetal coMplications More with forceps:
==c reeps CO.VI. be 1.Ased:
o Facio.I V\ev-ve palsy
• Pr-eterW\ de/ivev-y o Bra.ct,,.ial plexus ihjury
• Alter coW\iV1.g head of bv-eecV\ o CorV1.eal iV1.jury
• Face-VV\eV1.to AV\.tev-iov- 7. /1'1.itio.l pressure 9eY\ero.ted iY\ V(lCULOV\ = 0.2. k.9/
• Fetal distv-ess (pv-efev-r-ed ovev- vacuuW\) CW\2

Ma.XW\ -=k9/cmz.
08
8. Tractiol'I. force applied in forceps·
PriMi = W\ax11HUM 20 k9
Multi = M,l>slv\\U~\ l-3 k9 - ~ -

3 CW\

'----~---------
IVV1.a9e q~ ; FlexioV\ poiV\t
 On e To uc h Ob ste tri cs an
d Gy ne co log y by Dr Saks
hi Arora Ha n 1

Alf (ayeY-S of ute r-u s Y-uptu

\ S~ M pto W \: v-ed
.M• other Shock = HypoteVtsioV\ aV\d
Ta.chyco.v-dia.
I Tachycar-dia. Prnfuse b(eediV\9
PY-ofuse heW\atuY-io.
•• Va9inal bleeding
\ HeVV\atu.ria
P A = Sup.,-a Pubic teV\der-ness ++ No utev-iV\e COV\tv-actioV\ fel
Uterine COV\tra.ctioV\ ++ t
FHS = IY\itially tachyca Fetal pa rts felt superficia
v-dia ((y
La te r bradyca.,-dia A gap Fett OV\ utev-us
P IV = Fetal statioV\ FHS = Not heav-d
felt
Loss of statioV\ of feta( he
M ,u ,a9 eM en t = lvvwv\ed ad
iate cesav-eaV\ sectioV\
Maten".a( ResuscitatioV\ +
Exp(ov-atov-y Laparotow,,
(ReW\ove p(aceV\ta a.Vtd ba
Note: Free fluid is abseV\t by O.V\d .,-epair <Aterus) "
in pev-itoV\eu.W\.
Fv-ee ftuid pv-ese/1\.t iVt peY-ito
ll\.eU W\.
Fo r r-adiological sigV\S of
IUD-Refev- to Table 8.
 11:D

• y
• /( r It tlACj IA .,-

• Active TB i/f\[ect,oVt
• B~·IAce((osis
• HSV
• Ebola viv-us
• HTL VI, II
• Vav-icel(a :zostev- 1v- fectioV\ (witv.iV1. 5 days pv- or- to
----------------------d~e(~1v~e~ v-y aV\d 2 days a~ev- det,vev-y)

Note:
• II'\ /V1.dia: HIV is V\Ot o. Cl/ to bv-eo.stfeediV\ .
9
• 1f feW\.a/e has to.keV\ Arr fov- 2 weeks , she c,.,.,.Vt bv-eas tfee d IV\ . .
. TB 1V\fectioV\.

,-able 4: Postpartum blues., depressioJI\ ttJl\d s cl-tosis

~
MIC - (70-80%) 1-.0"lo 0.1.%

Develops: 2 weeks-1...2 W\OV'lt"1s 2-3 days

Seel'\ = 2-4 days postpav-tu IN\ PostpartulN\ (vanab(e)
PostpartulN\
(Resolves withiV\ :1.0 days)
Symptowis: lvritable AtteV'ltioV\ deficit
Mild iVtSOW\Vlio. Phobia CoV\fusioV1.
Irritable AV\Xiety Clouded seV\sov-hH'V\
Fo.ti9ue SyVV1.ptoVV1.S wov-SeV\ iV\ eveV'liV'lg
lr1.creased cv-yiV\.9
IT/t: AV\tidepv-essaV\t AV1.tipsyci-iotic O.Ytd
AV1.tidepv-essaV'lts
Not Tit

Tab(e ~= Lab investigation in DIC

To.hie s: Obstetric causes of DIC
• AbrtAptio placeV1.ta (Most coW\W\OV\ cause) •
• Elevated D diV1.Vlev-
• IUD of fetus
• E{evated fibv-iV\. degv-adatimt products
• AMI\V\iotic fluid eW\bo(iSW\
• Dec v-eased fibv-iV1.ogeVt
• Septic slt\ock/o.bortioV1.
1
Sev,we PE/HELLP S!JV1.dV-oW\e
 Orie Touch ObstetrKs dnd GynE'cology by Dr Saksh1 Arora Hans

~r i.Jt ,g /VITP able W CiOI: Hi9h risk pre9r.o.ncy

f' ,1 ~l/0 L (',....
First tritvtester Sacor.d tY'iM&Sttr
T-jf 1H
• .. ti
H/0 'yrlew11 c 1tlne.'r;
f'I C t 1..19/ Mr11V\ 4 Age <20 year-) or- ,,.35 yeors
l .xtr ,1 aW\niotic ~- PIH
etl--\acv-idine
,, lntv-a -aVV\niotic h /V1a{pveseV1.tat10V\
saline 7. Low fy1V\g placeV1.ta
o Oxytocin
8. 5: AV\eMia (Hb <7)
• Di(atation aV1.d
Evawation q_ RJ,,. V\egative
• HysterntoVV\y
:1-0. CiestatioV1. Diabetes

T. e 8 : Radioi'ogica( signs of IUD

:1-:1-. Hypotl,,.yvoid
:1-2. HIV +ve/SypJ,,.i(is
l.st s"gn. = Robert Pv-eseV1.ce of gas ivi. gv-eat vessels
s'gn
Table :1..:1..: Co(or codes on. an.ten.a.ta( card
Spalding sign. OvedappiV1.g of crnvi.ia( boV1.eS of
fetus Cireen. Fen-,.a{e witl,,. V\0 v-isk detected
Ba t sign. Hypev-ff exioV1. ov- hyperexteV1.sioV\ Red Fen-,.a{es with J,,.(91,,. v-isk
of spiVte
Blue Fen-,.a{es witl,,. PIH
Deu.e(>s Halo s19n. /Vtcv-eased pevicv-aVlial fat
Ye{low Fen-,.a{es witl,,. con-,.ov-bid coV1.ditiov-. -
Diabetes/Thy void
Tab e q; Locn.ia.

• Sheddi¥19 of decidua a~ev delivev-y

• A ✓er-age duv-atioVt of Lochia = 24-3h days
• Seq1Aen.ce of Locn.ia
Locl,,iia Rubia
-1-
Loc/,,.ia ser-osa (24 days)
J,
LocV1ia alba (~10 days)
 o.-ia( requireh!\.e OB~ TE r,
nt rn p 11I[ S
t'e9 hGtl'\cu
::, tt"'-d I
• Gtctat,ot\

- (kcal/ day)
t I'"!:} L !Cci
,.,jtr,,
100
0
2700 /'
,,I

~~
a!:1) 4s
+q 5
. , ,_ d ~y) 1.30 2:2
:1.. 75
, '.;; day) 2 q W1.9/ da.~ 200 J
40 w...9/d.o.y
,l, (V1.c9/ da !:1) 1.S0
2 I
250
280
v\ ( W\9/ day) 1.000
:1..000 1..200
t A ( w.cgl da.!:1) 840 qoo q50
·e :W\c9/day) 220 570 330
(Tablet 500 W\CB)

Tritvtestey ~o 1<.9 awa

mJ~~ llS1'J~ )
kcal/day
:(' triMester 70 85

.230 .280
2 triWtester
3qo 470
3 tr;iwi.ester
3~5
3:1-0
._ vero.ge of 2N1 and 3rd triWle.ster

Sr,, t~e overage of ca (one · ke m

· tVtta · tY\e
'- pvegV\.aV'-C!:J ,s· sa,'d to be +350 kcal.

Table 13 · SyWlphysiofun.dal height (5FH)

1
~l," "ice 9u ideli vces (;2.00 g), 5y w,p/'ly5 iofu"da I V<eig/'lt shou Id be ",. "" red ;,, aII p " , t
eeV1. 24 aV1.d 3~ weeks of gestatiovi.
s~.,.pk~siofuy,.J.a/ V<ei9/'lt correspov,ds to 9estatio"al age '" weeks (row, ;u, io 36 wee,\., _,f 9 <t ,fr '

s~Wi.ph
• Y51.ofu.nda( height is viot W\easuved tV\
. :
1
• tri:u,.sverse (ie.
I'\

, Overd'
k ,stended utevus.
l"lown case of fibv-oid.
 .ind < ,yr coitifJY by Dr :,c1ksh1 Arord Han
'l l 1 llb I 1

perwd of able 1 r. Qt/,,.ev IW\povto.V\t PYQ'""

, W\ .rtrf/",t l(iV' ( nt Wt,iqnt q
I
1
l e we,qht qo.iV1. iV1. pvegV\ancy iv-.c..-e«'"P
• I/ { { I~ l, t' I
o11\a(I for qesta.tioJl\al age fet1As
• fl.lu!t,Fetaf pveqY1c.mClJ
[ 1 1abetic po.titvtfc;
fvlnr we1r1ht qaiY' raj/\ lead to
•
. • f /H
• F- afyl-lycfrawu'\/OS
• C'oY1.cca(c.i. v~n tt~ of ,~bvupt 10 • fvlacnYoW\ia
• /viola,-- pr JV\O.ncy • Failed IOL.
• fvlacn.,sol'V\ia • C/sectiovi.
BMR
CoJl\ditioY\S where height of 1Ater<As < period of
gestatioJI\: Water 1o.5 frtev
• w rv~,9 dates ReteJl\.tion
• IU4R Th.eve is Na+ and J<,_ v-e~~r.t,
• lntr-a uter·1Vle deat/,,. of Fetus IV\ pve9V1.0.V\C':j but f'Ja a,vi. : .
r

coV1.CeV1.tva.tioV\ decv-eases d.J•

• PIH
ivi.cveased water vetevitioV\
• O{i9ol,,.ydr-aW\nios
• PRO/vi Table j.6: Pelvis
lmportartt Tables Related to Mater.,,al Physiology fWtpov-taV\t OV\e (iV1.ev-s
~·f
:r,
Table 1-4: RespivatOV'!:J changes ReW\eWtber the followiV1.9 poiV\tS OY\ pelvis (Mos:
Re.-vte.-vtber-
the questioVlS a.v-e asked ovi theW\).
• NorWta( FeWta(e pelvis-CiyV1.ecoid pelvis:.
2 TraV\Sverse diaW\etev chest iV1.cv-ea.ses by • Ma.le type pefvis-AV1.drn id pefvisQ_
2 CW\
• Most COW\W\OV\ type of pelvis - CiyV1.eco d pe
4 Dia.pvwa9W\ is pushed up b!:J 4 CW\. • Least coW\W\OVt type of pelvis-Platy-cie :
pefvisQ.
h Circu.Wtference of chest iVlcr-eases b!:J
6 CW\. • The 0V1.l!:J pelvis with AP diaw-.e!er ""'~r~ rh.
tv-aV1.svev-se diaWteter-AV1.t l-wopo1d pe(vtS".
Su.bcosta( iV1.creases fv-oW\ 1o8° to 1-03° • Face to pubes delivery is 'V\OSt cownv,o" ·
Parawieters which iJI\Crease iJI\. pregMJI\C!:J AV1.thropoid pelvisQ.
• Div-ect occipitoposteriov position is l'\'\.15:"
I see( c; IV\spirntory capacity coW\W\OV\ iVl AV1.thr-opoid pe(visQ.
TV Tidal vo(uMe • Pev-sisteV1.t occipitopostevior pos t OV\ is WID>-
CoW\W\ovi iVl AV1.droid pefvisQ.
fvlo Vic fvliV1.ute ventifatiovi • Deep transverse arrest/NoV1.YOtat·o!I\ . IDY5toc11·
Parawieters which reMain u.JI\ChaJl\.ged is W\OSt COW\W\On in Android pe,v:s~.
• Broad f(at pelvis-P(atype((oid pelvisa. F
I RV lnspiratov-y reserve vo(uW\e • Travisvev-se diaWteter is W\uch w\Ore tJ,,.aY'l A
R Respiratory rate diaWteter-P(a.typelloid pe(visQ. ..
V Vita( capacity
• En9a9ew-.eV1.t by exa99er-ated po 5t eriot
asyV1.clitiSW\ occurs tV\ P(at!:Jpelloid pelvis~- t t'
Rest of paraMeters decYease • Super subparieta( iV1.stead of biparietal d1aW'e e
ey,.9a.9es tV\ P(atype{f oid pefvisQ_
 V\

•
•
- SkiVt •
~--SutL<re •
-----4afea •
PeriostelA VV\ Tit
Bone
Duva VV\atev- l
Table 1.q. 4ravida and Part
It is a ver-y iwi.portanr; concept.

e q8 Cepha(ohewi.atowi.o. Ciravida
.,,. 7 Swe.UiVl.fJS on Feta{ l,,.ead

CQf111.t succedan.e«M
Parity DeVtott-s p e
CoUection of blood just have rta
be( ow tl,,.e per-iosteuW\. viab ·ty
per-·osteuw..
Hta.d s There are various wa~s w, •
Cause; Due to tr-auW1.atic cav-. be det,oted.
t fey o. (oy-,9 0

V'i.Str-tAW1.eV1.ta defiver-!:J.
r.e pos,60¥1.. 1-. Ci.P,, w-.ethod: It is th s
4ravida and Parity 1re
above. For exaMpft
Doesn't pit on appfyiV\9
piressur-e. Case :i..: If a feMal
an.d has a ch,fd
r s the SCAfoye Caviv\Ot cvoss ti-i.e StAtlwe (Ci btcause th s c;
lines. aV\d P because s
which we ,,t beyo
b,rti-. aNi Not pr-e<:eV\t at birth Case .2.: If the s
~l'Pl4R w,tl\ ·~ few appeav-s few_ /,\01-H"S o.Ft~r 4 ~ear child b <t
brtk birtt,.. O.V\d d1S(J.PP 1 ar 11" then. she v. ,ti b
Few days pre9•,an y w .,t
Frot tusociated witl,,. Note c;,~1 n
4ct~res 0 f Cav1 be asc;ocia.l ed wi th pt<t'
bo~. LcndedyiVl9 fract1.,o'ec; o( 1AV\dP.rf111Y\a Jl'\llV\ I

boV\e . Clise 3· V11•a e w'd,

pt v u h r S w eks ,s
Q&sociated witt,.. Associated with JaLw, l, {i f (<4 h\t' she has
becovv\t' p ·1.H1St' her l.:.t pregnancy
C1.1p went l1eyon the period cf \ frtb1(1t~ It will be
Ltt SI.( • {" l 5 counted a.s :l only, 1rresptctive of the t\L<W\ber of
CpD (ce ccedan.eL<IM + sfo w pv-o9iress of (ab ov- ,vH ,cc1 e
Pho.lope/vie dispiro poirtioVt). chilclrr.n delivered
 L1rie Tm.ch Ob t trio ,rnd Gynecolo-JY by Dr Sakshi Arora Hans
I Table h.Cu: ClrV\ico.l
.2.l
I
IW\p.•CO.tlO~\'; r,f
. ti
~ Method· ,,, clrvi.•c~/ prl'.l.ctrc ,t •-; W\O.v..datonJ VV\easureW1eV\.t or "1.Cu
_ r _.-, pat'•ty by .2 d,4its. tY\e f·r t _oV\e (h)
•• L e,-.ts t"\uW\h r of v."o.ble yweqwtV\Crl' O.V\d
Increased hC'4 va/1.AeS
•cv\tl O,\ (c) n,(atL<; wrtk V\UVl-':b . . - of ~bu• t10V\
c,; v do. t'"c.:Wla n~ , v..,e a, xpf cA1~, ,,,{ l ,u-/1 t c 'I t- bc,v 0
Case 4· , f'V"l '\dV\ ft VV\,llt I,,. I(, H/0 tw•< c"1rld
of \ i i 1h>t tioV\ CV\C 1 LO week' aV\d (
1
e<f(),t1ov\/,d • ft"';(}W\lj ') Dl"'tt'.)

k ~ t ol t h, hi<,ttll y will l1e rrophob/(A<,trc d,sea'e l)r., NV\ '; j I ', e

L- - <.... , s ~LlVV\ 1,9 pt·e9V\m,t fov 4ti,\ tiVV\e • UV\der estiW1ated

1. , :;]V\ih\CY weV\t beyoV\d the peviod. of 9estatioV1.al a9e
\, i , t!j as sJ,,.e /,\as a c/,\i(d of 4 yeavs.

2 .::. '\ .,.W\ber of abortioV'-S wv-.ich av-e 2. • Ev-yttwoblastosis

feta/is as it is
3
~ P .. ~ethod: IV\ soVV\e ceV\tev-s pav-ity is associated witl,,. fetal
~ cted by 4 V\uW\ber-s. heVV\olytic aV1.eVV\1a
p

l
Critical titre of nCa:
• Tl,,.e titv-e of hC<'.:; at which 9estatioV"lal sac sho,, d ,,
visible OV\ TVS iV\ case of iV\trautev-iV\e pre9V\tU~.
N().VV\bev- = 2000 IU. .
\i,AV\,'l.beF I\JuW\ber- of N().VV\bev- 1
• Tl,,.e titv-e of hC<'.:; at wl,,.icJ,,,. 9estatioV"lal sac sho,1 :/. '?
Preter-W\ of of
a-= -er-W\ chi(d.veV\ visible OV\ TAS rV\ case of iVttVO.().teriM pre.9na,,..:.
preqvi.an.cies defivev-y abortioV\
above at = (0500 IUIL. .
1 37-?..2 (28-3(0)
pv-eseVlt
"'eeks, Table 2.2.: EveV\.tS of early pv-egVta.V\.C!:j
- ot is why t/,\(s is also called. c; pT+P+A+L VV\etJ,,,.od..

A:..';O know:
• A :ev."-a 'e who has i,\ev- fir-st pv-e9V\aV1.cy at tJ,,,.e a9e Ov()./atioV"l Day o
1, oc 30 or More is caUed. Elderly priVV\i9v-avid.a.
Fev-tilizatioV'- Day o
• /- pregnaV\t WOVV\O.V\. with previo().S histov-y of
( ,:, '.JY b:'rlYIS or- VV\OV-e is called. l;ro.V\d. VV\().(tipav-a.
EV\.tY-aV\.ce of w,.orn/a iV\. Day 4
().tev-iVte cavity
Table w : ,t. :pr1a fetoprnteiVt
IVV\p. ZoV\.a hat chiV\.g Day 5
fv1ate.l'Y\Lll Serw1V\ AFP is tested. betweeVt 1-5 aV1.d. Fov-VV\atioV\. of Bla.stocyst
:i..owuk5
IVV\p IaV1..tati0V\ D.:t:~ c--
It is ra ised 1V\. M aV\y coV\.ditioVts iV"lclud.iV1.9:
• NTD hCQ appeav-s iV\. blo od. Day S
• AbdoW1.1V\al wall defect )' s
• Multi fetal pvegV\aV\cy t,..CCi v-escue of cov-pus '",t.:.,

• Cystic i..ygvow,.a I(). t eu VV\

Awi. the list is a loV\9 ont. So Rtl-'V\tW\bev coV\ditioV\.5
where AFP is decreased in:
Diabetic = Diabetes VV\ellitis
a = '4estational Trophoblo.stic disease
0 = Over estiW\ated 9estatioV1.al a9e obesity
A = Abortiovi.
T = TrisoMy 21. or 1. 8
 ) s t-TR1cs
p tAj l{).lt\C~

,'\ L d_ K{l

::Lst USCi s19n of pr-l"qnaV\c ech'?ir r,vv1 (J,...r: 51 ·

"JVI. 'V\ -:-uba: ectop c
-, ' 4

. d" y
ec duo.I sac It Ill\ /Cate 'Vl.t
d "d ., ra, "1111-
- ec1 LAa. par-ier~r, · p.,-egvv;,.nr,j IVl V\f v- v-,'v,,q ,s ti e.r d'Aa "apsulans ~Vl.d c,utev- r-1V1q
It bfeb sign It il!\dica.tes iV1.tr-,.,,,t .
Sa.c. "'"" enV\e pv-egV\O.V\cy
OYl.e bleb IS rov yo lk sac aV\d. ott,,.ev .
for- aWi.o'\IOt c
bdtt sign US4 siqll\ seell\ Ill\ D .
bet ween Wl.eW1.b.,.,.,,,.es rcnonoV\k
. pv-eaV\aV\cies. ,_
'"'" F
0 tWtV\S. ;:,; (dlt· pv-ece
· VI.Ce Of CnOV'IOV'! TC t S'.::.<e ,

sr9n US4 sign seen ill\ Wl.onoc"'-o .

nonrc
. .
twrV\S

ott sign Fv-ol!\ta.{ bossil!\9 seen in spiV\a. bifida

al'\IAl'\l! sign Abv-.or-W\a.{ a.V1.tev-iov- cuvva.tuv- O f
tion. SeeVt in spil!\a. b •[!• -1 e cevebel/uw,. d/t associated Arn.old cl,\iar-i w,.a(fovVV1a. -
rrrua.

be over leaf skutf Seen in cr-aV1.iOS!jl!\OStosis.

cy
...ab'e 24: Basics of pla.ceVtta.
be
cy Fetal side of placenta. for-Med by = Chov-ioV1. FuVtdosuw,.
Maternal side of placenta for-Med by = Decidua Basa/is
PriMary villi = For-W\ed by D=1-3 ( 0V1.(H trophoblastic she(I)

Secondary vi((i = For-W\ed. by D=1-~ (Has W\esoderW\al cove)

Tertiary villi = For-W\ed. by D:1- 7 (Has fetal capiltav-!:J)

Volutvie of blood in villi = (Feta.I blood) = 350 W\L

VoluMe of blood in inter- villi space = (Matev-vi.al blood) = :1-so V'AL

VoluMe of pfacenta @ terM = soo W\L

Weight oF placenta @ ter-M = soo 9W\S
R4tio of weign.t of placenta: Fetus = J..:b
,0 . ht of fetus = :1- 7 weeks
Q at wn.icn. weign.t of pla.cen.ta. = we,9

'
l
I
~aternat spiral A's open in tV5 on. = 01.- 5
7
establisJ,,.ed by = 01.-
I
~ place.,,tal circulation __--- _ soo-750 W\t../V"AiV\
<---va. 1lAe -
i:; establisited by = 01-~
etor,t4ce.,,ta( circulation. C::::::::: va/1Ae =400 bfoo tfV\low-
Fetal wd..lW\d @terW\ =:1-:z.s
- ·-__:_ __ w,.Ukg
__::___ _ _ _ _ _ __,

---------------
 , , I I ,'

z ■ g
Ma~o scissors IIM 10,2. Doyt irtt

100 ~ebuJ,ac.cM scissors IMa 03 OvuM fora s

IM• 04 Wrigley's Forceps

(OtAtlat Forceps s~ort forcsps wit"' Er\glis"'- lock)
- :------~-~~~~=~~~-~-~~~-~-----,
O Kie{/aV\d Forceps = LoV\9 Forceps wit/ti sf idiV\9 lock. tt is a r-ota.tioV'lal forceps V\Ot tAsed tJ.,ese days

i PeripartuM Ca.rdioM~opa.th~
-1,;aleh-;;; t,,.eart failure iVt last VV\OVtth of pre9VtaV\cy
v. tkiV'l 5 W\OV\ths of delivery
Ct:tn. lead to < PreterVV\ labor
PyeloV\ephritis
oiagMstic criteria
l- No 1deV\tifiab(e cause of Heart failure
Risk F-actors = < Sickle cell aV\.eVV1.ia
Diabetes iVl pre_gVtaV\.C!::)
2 No H/0 Heart disease prior to this
MIC UTI in. pre9n.an.cy = cystitis
3. 0V\ ect,,.o = LVEF <45% MIC or9t:tn.isW\ = E. coli
Etiology
• /v1ultifacton·a1 3 . M9t oF Acute Pyelorlephritis
• Viral 1vtfect10V\.
Acute pyelon.eplwitis:
• AbMr-Wtal IIMVV\UV\.e respoVtse
Nulliparous feMales
MIC i / YouV1.9 fe1Male
IOC =Echo-::::-- LVEF <45%
~SecoV\d half of pre9VtaVtcy
~ Leh veVttricular d1(atatioV\ PatieV\t pre-e with
Prognosis
l.. Fever with chills
SO% FeW1.ales will have V\.OrVV1.a( (eh veVttricle fuV\ctio.V\.
2. PaiVt IV\ lu1Mbar area
b~ '- VVIOV\ths (IV\ such feVV1.ales recur-r-eVtce rate IV\
rttxt heVtce pr-e9V\aVtcy = 20%) .
..g
feVV\ales with persisteVtt LV dysfuVtctioV\ =
Ir\
l..Hospitalize
~~rto./ity r-ate is s -1.0% aVtd VV\uch hi9her recur-r-eVtce 2. IV\vest19atioV1.: Blo~d culture ]
e heVl.ce pre9V\aVtcy is Cl I. UnV\e culture Repeat IV\
2., Asu~pt t· . . CBC 24 l,,.rs
" o~a ,c Ba.cternw,a. Electrolytes
lJrj~r .
• !J tract IV\fectioVt without aV\.y syVV1.pto1MS
Cr'lterj 3. IV fluids = UriVle output ~5O1MUl,,.r
fi .
Midst "' or du;t9"'-osis 4. IV AVltibiotics =
, 2. rel'-lW\ c/eaV\ catch saVV1.ple of uriV\e: AVV1.picil/ IV\+ CieVltalMiCiV\.
~:~eclAtive satMples: s. wt,,.eV\. pt is afebrile
1~ Ct.1thbt.tcterit:t of saMe species/tML. Switct,,. to oral AVltibiotic aV\.d COV\.tiVlue for 7 -1.0
eterized fe1Males= days
"'Sit SQW\p/e ~100 bact/lML ro. wt,,.eV\. pt is afebrile x 24 hrs = dischar,ge the
patieVlt
t tit
 Gynecology by Dr SakshiArora Hans
One Touch Obstetrics and
116
C Section
4.Group
GBSB:Prophylaxis not preferred
It ispostpartum in chorioamnionitis as it
To prevent neonatal sepsis. Should be given to endometriosis.
is done = add
For obstetrie reasonit
metronidazole and \eads
intrapartum
guidelines:
cesarean
Antibiotics tillpt is afebrile for 24
hours contine
Indication as per lnternational
Screening positive females.
streptococci 6. Fetal Lung Maturity Test
B
Pregnant female with group Amniocentesis in third
bacteriuria in present pregnancy. Done by doing
has a child who was On amniotic fluid
following
If the preqnant female streptococci causing 1. Lecithi/sphingomyelin
tests are performed trimeste
ratio (L/S Ratio) MIC
r
infected with group B
neonatal sepsis. done Test
with
Unlnown Group B streptococci statushours. If L/S Ratio 22 = lungs mature
>1O04°F x 4
1 Intrapartum fever ðS Ratio <2 = lungs not mature
2. Allcases of preterm labor. Phosphatidylglycerol
of membranes 2.
3. Preterm premature rupture Present in A:f = lungs mature
(Rom<37 wecks.)
membranes Present in A:f = lungs not mature
4. Prennature rupture of labor) 3. Lamellar body count
(Rom >/= 37 weeks but before onset of Packets of surfactarts in A:f
for 218 hours.
DOC: Penicillin G. <15 K = lungs Not mature
dose and
Dose: 5 million units as loading delivery. >50 K = lungs mature
2.5 million units every 4 hourly up till 4. Nile blue sulphate test fluid.
Alternative: Ampicillin (M/C used in lndia): Initially Nile blue dye added to amniotic
24Vand 1 g IV 4th hourly up till delivery. Mature cells appear orange color
and
Allergic to penicillin-Cefazolin: Initially 2 g IV
1g8th hourly. If z50% cells are orange in color it means lungs arz
Resistant cases: Vancomycin. mature

5. Chorioamnionitis
Bedside test: Shake test/Bubble test/clement test -
outdated
Infection from ccrvix and vagina reach uterus
Polymicrobial infection 7. Fetal Hematopoiesis
Presumptive Diagnosis Time Main hemoglobin
Chorioamnionitis is a clinical diagnosis made when a Site
pregnant female with ruptured membrane has Yolk sac 1st site Gower 1, Gower 2
emperature
Te 259°Con 2 1 occasion Portland
38C on 2 occasion within
3Ominutes + any 1 of following Liver 6 weeks onwards HbF (
1. FHR 2160 bpm Bone marrow 24th week HbA (a,8)
2. Mat WBC COurt 21Sk
3. Purulent discharge from os Fetal RBCs are bigger in size and have a shorter lt
compared to adult RBC
Not a criteria Maternal Tachycardia and uterus span (90 days) as
tenderness (secn in chorioamnionitis but not
diagnosticcriteria) At birth:
Mgt = Total Hb 16-18 g/dL
1. 1OL Fetal Hb 70-8O%
2. Vaginal delivery preferred Adult Hb (HbA) 20%
3. Antibiotic = Amnpicillin +gentamicin HbA, S-10%
No Role Note: 6-12 months after birth, HbF is L-2% This
Expectant management change is mediated by glucOCorticoids and irreverstbi
Corticosteroids and tocolytic
 OBSTETRICS 11

piierences between
HbF and HbA
HbA Ii. ln newborns having bloody vomitting, stool
HbF
Hashigheraffinity or active bleeding from nasogastric tube to
Has less affinity for differentiate whether blood is of neonate
due to
foroxygen of2, 3 oxygen due to higher origin or he/she has Swallowed maternal
less binding binding of 2, 3 blood during delivery.
diphosphoglycera
and
diphosphoglyce rate In Kleihauer- Betke test, reagent is citric aciad
Resistant to acid Sensitive to acid and phosphate buffer. This test is used to quantitate
alkali alkali the number of fetal cells present in maternal
Lesscarbonic More carbonic cirulation in Rh-negative females. Once the amount
anhydrase enzyme anhydrase enzyme of fetomaternal hemorrhage is determined, dose of
Anti D can be calculated appropriately.
Clinical Correlation
limportantOne lincrs
(HbF) is rresistant to acid and alkali. Qualitative test: Singers Alkali Denaturation test
Ftal hemoglobin
the basis of two very important tests - (Apt test)
t forms
SingersAlkali Quantitative test: Kleihauer-Betke test
penaturation test (also called Apt- Downey test or Test which differentiates fetal blood from maternal
blood: singers Akali Denaturation test
sinply Apt test) and Kleihauer-Betke test. Test which differentiates fetal RBC from maternal
n Singers Alkali denaturation test, reagent RCB: KIeihauer-Betke test.
Used is NaOH or KOH and is used for differentiating
Maternal blood from fetal blood.
i. ln case of vasa previa to differentiate it from
placenta previa
GYNE
 primary division
arrested
is prophase.
under Main
hormone
releasedMain
released by maintained
hormone
life. division. of initiated
luteinized
follicle:
granulosa
by
cells: granulosa
by
cells
lUto starts by
Estrogen
and
of ProgesteroneProgesterone.
in changes stage is surge
begins meiotic
oocyte is
(Mitosis) Estrogen Estrogen.
surge
diplotene
1st
meiotic
Oogenesis LH LH
Oogonia 1st
Primary PYQS
Concept oocytegoing |Inhibin
A
in k/a
released
IMPORTANT
TOPICS Proliferates
uterine
Meiosis
1completed (CL)
Luteum
Corpus
luteum
Corpus
endometrium and
74.
MENSTRUAL
CYCLE Estrogen LH
Surge Formed secretes
Ovulation
oocyte
Estrogen
2°
isReleased. cels get
to
release toEnzyme:
converted
Estrogen
Androgens.
hours
Ant:
Pituitary
onPrimordial
follicle
Acts
Granulosa
cells
From theca and
the
Estrogen
is enter
Androgens
on
LH
+Ve
48 cells
FSH of
x helpAromatase)
granulosa
pg
on
Acts
ofCycle 200 (with Mainly
=
Progestrone
Menstrual
Flowchart Dominant
Follicle
which
FSH FSH cells releases:
Progesterone
All
follicles
undergo
FolPrilimclordi
e and
acells
laranulosa atresia
except
One
known
as
(K/a)
COntinues
to
grow and
Luteinizes
them:
before
ovulation.
At Progesterone
TFSH
00Cyte
Primary
bysurrounded lnhibin
B on on Folliclelow
qranulosa
Luteinizedconcentration
feedback feedback
cells
theca
on QndLH
-ve -ve Acts
 22
" |PYQs
PYQS
Day
menstruation
phase/secretoryDay
phase/proliferative vary Hormone
follicularas In weeks. 5 CL12-16
Life Life hCa.
Hormone Test
Minimum Maximum
cycle of FSH-ve = LH
Progesterone FSH LH
Progesterone MaximumHormone
8
a is days
of span for =
but
of menstrual span -ve =+Ve =
ovulation essential days
ovulation +ve after
ovulation= second which of FSH
which progesterone feedback feedback
CL of feedback feedback growthwhich
(Novak @ ovulation at
phase cycle
initiates to in CL and high
= half maintains done low maintains
length pregnancy is LH and
= maintain Pg concentration concentration: One
14 is ofFirst nonpregnant seen (Day
130) on: level
seen activity
of days fixedcycle ovarian CL
Touch
cycle
-14 half CL Day on: 22
to pregnancy = =
prior called of 10-12 in 22Day of ofLH. Obstetrics
14phaseandcan cyclecycle pregnancy on
of 22 cycle) CL
days females = is
to as is = weeks. cycle
FSH of Day seen and
TIlI = cycle
next luteal called
22 on Gynecology
=
2. 1.
Progesterone
10-12
hoursTime
32-36 Time
14-24
hours
peak:Time Estrogen Progesterone
decreases: Corpus decreases
Hence LH Wil It by
menstruation
andVasoconstriction
-ve F,-alpha
Dysmenorrhea.(PGF,0) ocCurs supports
have Dr
durationdurationduration E Endometrium
isSupport
hours peak feedback
fresh luteum Sakshi
and
a at
(24-36 cycle Inhibin negative
endometrium
betweenbetweenbetween to (CL) High Arora
14-24 on
begins. FSH Hans
LH A OCCurS degenerates feedback
Concentration
hours) LH
LH Estrogen
LH\Surge i
hours decrease:
is
peak surge 10-12peakI
I LH lost
hours
released
causing on
prostaglandin
= =
and and peak FSH LH
and is
ovulatiOn:ovulation: Ovulation i
and increases lost
LH
 NSAD
nagement
(Mg) " dysmenorrheaPrimary " " .
suprapubic
childbirth
marriage, Pain Painis Due Hematocolpos.
Hematometra,
Public
Breast LH to and
Cryptomenorrhea
OnThere Patient
)eOCP dysmenorrhea
beginsPain Spasmodic menstruation
hiddenie.
to and P/Rsometimes but Pt
decreases decreases and = is CRYPTOMENORRHEA
has C/0
centralized release examination:
2°FSH an C/0 Cyclical
Patient
abdomen
axillarysexual obstruction
= cyclical 1° Yes
le wnenses
with N
1° amenorrhea
hours
onwithin72 of urinary C/o
PaFax amenorrhea,
its and characteristics
hair pain 75.
own Uterus
in = to
retention. in
normal outflow PATIENT
after justor
is Pain
palpable pain
physical = Is in
before tract. she
is in Amenorrhea
normal Abdomen C/0
area abdomen a
Leading case
activity GYNECOLOGY
menseS CYCLICAL
of
1°
nagement dysmenorrhea
Secondary Cryptomnenorrhea
3. 2.Causes ofovulation
1.MITTELSCHMERZPain
d/t Pain
Treat
cause localized
progressively
the increases Pain isever
Pain Adenomyosis PIetDc,.
dysmenorrhea
PainCongestive Transverse
Vaginal
lmperforate
Due PAIN
o These in
after
occurs to o Ifo o
mentioned
Mid
some imperforate
hymen. absent: If Hymen.
bulging If Ifatresia
in
Hymen cycle IN
onset Hymen nocanvaginal
much pelvic a vaginal Hymen ABDOMEN
case differentiated
Transverse and No
of
periodspathology,
before
itappears
of Coughappears septum
should
cryptomnenorrhea opening: (M/C)
DYSMENORRHEA Pain@
menstruation
menses vaginal
coughandimpulse
benormal on
M/C: tensed
Vaginal the
taken local
time
Endometriosis
and septum is:
examination.
aslmperforate
bluish
atresia
nothinga of
remains
case
and
of is is
 124

tic On (lmage
phase)
Endometrial
Shows: (lmage
108).nuclei
siqn Biopsylntermediate
Epithelial
Vaginal
Cells |SecretoryPhase
USG: FerningCannot Cervical
progesterone
Becomes mucus D/t
thick, Proliferative
Phase
of On
different
Endometrial
white (lmage Biopsy
113) Showspyknotic
nuclei
Epithelial
(Eosinophilic
cells)-pink mucus:
Vaginalcycle On Cervical
Subnuclear and EstrogenD/t
ntThick ovulation USq microscope:
stretched-Spinnbarkeit Thin
watery
ElasticcanProfuse,
be
distinct is be line =
cells: lost
stretched = Simple,
rium 114) (lmage
Endometrium
but levels
vacuoles boundaries Basophilic onscanty
it D predominate
(lmage Ferning
ge is 110) Tubular Superficial
Cells:
cells
seen 18
(Tack)
One
(Although of
2). with in predominate cells cycle in glands
Pseudostratification colorin seen 76. Touch
early the
terior with on
form
thinof with Day Obstetrics
secretory it's with PHASES
small
first Menstrual
Cycle nucleie 107) 8
of and
Phases of
OF
Gynecology
2. cervical
1.
Different
MENSTRUAL
Application
appearance/SAWTOOTH Secretory
Phase
Late OvulationSecondEndometrum Phase
Late
PYQ USG:On
Best USGin: (If Proliferative
Cervical
method in To
casesknow Highly Subnuclear Occurs
1st Ans Q by
mucus secretions sign best Says: Dr
characteristics =
mucus
ofwhether of d/t Sakshi
infertility Endometrial
coiled BiopsyOn of Ans: Late Triple
contraception are ovulation LH
vacuolation appears CYCLE
glands Proliferative
@time Arora
characteristics used them in Surge layered
ovulation
triple Hans
(Test-done of called on of
appearance (lmage ovulation
Endometrium
seenon
in EB, (lmage Endometrial layered Phase
Billings occurred vaginal CORKSCREW
used 114)
115). ((mage
on
method as Dor cells seen
natural 21) Biopsu:
not and with 111)
 lmage
Superficial
cells 107: lmage106:
limage
Vaginal
1O8: 77.
ep Ferning
cervical of
diate ithelial IMPORTANT

(ntermediatecell cells:
cells Superficial
mucuS IMAGES

cells GYNECOLOGY

RELATED

lmage
Image TO
white110:
111: MENSTRUAL
lmage
ENDOMETRIUM line USG
ilaminar representing of 1O9:
proliferative
Parabasal
CYCLE
pearance
endometriumphase
cells

showing
on
USG
thin
125
126 One Touch Obstetrics and Gynecology by Dr SakshiArora Hans

1. Subnuclear
vacuol ation
is earliest
sign of
ovulation
On EB
2.. Seen at
D17 of
cycle

Image 112: USG in secretory phase (mage 114: Endometrial biopsy in early secretory phar
Showing thick endometrium with poste rior acoustic
enhancement

Nuclei are e
differentlevelsa
Apseudostratification
Image 115: Endometrial biopsy in late secretory phas3
Image 113: Endometrial biopsy in proliferative phase
Showing cork screw appearance of gland
Also Know

Maturation Index: It is the number of Parabasal| ntermediate

cells. superficialcells counted per 10O vaginda
Represented by 3 numbers a/b/c
a = Parabasal cells b =
Intermediate cells c= Superficial cells.
ln preoperative phase maturation lndex: o:30:70
In secretory phase maturation Index:
O:70:30
At menopause = 100:0:O
Sample should be taken from Lateral wall of vagina.
 portant points on estrogen GYNECOLOGY 12
Natural estrogen:
lmportant parts on
Natural Progesterone:progesterone
E1 = ESTERONE:
menopauSal femalesM/C Estrogen in
C21 steroid
E2 = ESTRADIOL:
reproductive age M/C estrogen in Synthetic progesterone:
androgenic side effects C19 steroid: Hence lt has
E3 = ESTRIOL: Most specific Least androgenic side
third generation effects are seen with
pregnancy.
Sourceof estrogen
estrogen in progesterone, e.g., Desogestrel,
Norgestimate Gestodene
Granulosa cells 4th generation progesterone is Antiandrogenic, e.g.,
Corpus luteum Cyproterone acetate actions of
Androgens Aromatase enzyme itProgesterone downregulatesprogesterone
is antiproliferative. Estrogen receptors so
Adipose tissue
Potency = E2 > E1 > E3. ’estrogen Continuousof endometrium
thinning use progesterone
of or OCP can cause
Ratio of E1:E2 = 1:2 Increases
No
BBT slightly
Obese females and PCOS = E1: E2 = 2:1 effect on clotting factors. So
Natural estrogen is a Ci8 steroid COntraceptive
H/O thrombosis
progesterone
can be used in females with
previous
Estrogen upregulates Progeste rone receptors Acts on pregnant uteruS and grows it
that is why
endometriumprogesterone
can act Smooth muscle relaxant
primed by Estrogenonly on Progesterone J HDL and LDL
Acts on uterus @puberty and grows it
That is why in females with decreased
estrogen e.g., Turner syndrome, uterus is
hypoplastic or infantile
Increases bone mass
Responsible for closure of
Increases clotting Factors epiphysis
(0CP and HRT are
C/l in patients with H/O thrombosis)
At puberty: Leads to breast development
Estrogen is cardioprotective
It ‘ HDL and LDL
Important points on FSH and LH lmportant points on HMG
FSH and LH related by
anterior pituitary HMG (Human menopausal Gonadotropin)
FSH 9= Acts on granulosa cells: It is synthetic LH and FSH derived
from urine of
Releases Estrogen and menopausal females.
inhibinB Use = To bring about ovulation induction.
Follicular qrowth As a2nd-line drug in females with PCOS
-o= Acts on SERTOLI cells: (1st line = Letrozole and Clomiphene)
Releases inhibin As a first-line drug in patients
LH F=Acts on luteinized granulosa cells: As a first -line drug in patientsundergoing IVE.
with Pituitary
Ablation
Progesterone
Acts on theca cells: Androgens Chances of multifetal pregnancy: 3O%
-Þ F Leydig cells = Testosterone Letrozole has Maximum chances of OHSS
Estr200ogen palways inhibits
it
X 48 hours
LH and FSH except when
then it increases LH
PrHioghgesconc.terone: decreases
=
In low Conc. increases LH and FSH;
LH and decreases FSH
 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

Receptors Synthetic GnRH Analogs

Examples: Leuprolide, Goserelin, Buserelin
Membrane bound Orally inactive
receptors: Given as subcutaneous (s/c) injection
1. GnRH
2. LH
1. If given in a pulsatile manner
3. FSH
It increases LH, FSH and estrogen
Used for:
Delayed puberty
Intranuclear: Kallmann syndrome
Estrogen Anovulation
o Sexual infantilism
2. If given in continuous manner
Intracytoplasmic: It decreases LH, FSH and estrogen (ater
1. Progeste rone initial flare).
2. Androgen
(To act they go Used for hyperestrogenic conditon
inside nucleus) Precocious puberty
Fibroid
Endometriosis
T1/2 o ER positive breast cancer
Used for excessive androgenic conditon
Hormone/Drug T1/2 o Hirsutism
GnRH 3-4 minutes
Prostate cancer
Drawback
Oxytocin 3-4 minutes
LH 20 minutes It decreases estrogen hence leads to hot flashes and
osteoporosis so:
FSH 3-4 minutes Add-back therapy given in the form of
Letrozole 48 hours
(Norethindrone).
Synthetic GnRH Antogonist
Synthetic GnRH Example: Cetrorelix, Elagolix
Natural GnRH: Released in a pulsatile manner by Advantages:
paraventricular nuclei of hypothalamus Orally active
It is a decapeptide No initial flare
GnRH acts on anterior pituitary: To release LH and Disadvantage:
FSH Expensive
" Ifpulse frequency is low Uses:
M=FSH released Same as those of GnRH analog in continuous mannel
"If pulse frequency is high Norethindrone
M= LH released
It is a first with some
generation progesterone
estrogenic effect
 78. COLOGY

HYPERESTROGENIC CONDITIONS
129

Risk Factors
Ingyne, are: Nulliparity
Obese females are
Precocious puberty to connected
(Androgens adipose
Endometriosis tissue,
Estrogens with help of
Fibroid Aromatase)
Early menarche
Endometrial cancer Late menopause
Ovarian cancer
Protective Factors
Multiparity
Pregnancy
Physical exercise
Smoking (inhibits aromatase
enzyme).
HYPERESTROGENIC
CONDITIONS
|Drugs for T/t of SERM (Selective Estrogen Receptor Modulator) Drugs
|hyperestrogenicconditions
Have estrogen effect on some tissues and antagonist effect
|2. Progesterone: As it has On others:
antiproliferative effect and 1. Clomiphene: Used for ovulation induction
downregulates estrogen M/C side effect: Hot flashes
receptors. Others: Vaginal dryness
2. Letrozole: Aromatase
Doesn't cause: Endometrial cancer
inhibitor.
3. Danazol: Drawback is it 2. Raloxifene: Used for osteoporosis
leads to Hirsutismn (has Side effect: Hot flashes and vaginal dryness
Doesn't cause: Endometrial cancer
androgenic side effects)
4. Continuous GnRH: DOC 3. Tamoxifen: Used for breast cancer management.
Can cause Endometrial cancer, vaginal dryness.
It decreases LH, FSH and dryness.
estrogen 4. Ospenmifene: SERM used for treating vaginal
treat
5. Bazedoxifene + Estrogen combination: To
osteoporosis and hot flashes.
6. Ormeloxifene active component of contraceptive
centchroman.

Ovulatory Cycles
Cycle
Normal Characteristics of Menstrual d/t progesterone
Ovulatory cycles areassociated
withdrawal
dysmenorrhea.
with
regular and may be indirect evidence
Frequency: 24-38 days. that female is
Dysmenorrhea is an
Cycle to Cycle Variation: 2-20 days having ovulatory cycles
(New proposal: FIGO = 7-9 days) Anovulatory Cycles
|Duration of flow: 4.5-8 aays estrogen breakthrough
Volume of blood: 20-8O mL Anovulatory cycles are d/tirregular and painless.
bleeding. They are heavy,
 " "
Ifblood
bleeding).
(Heavy lossdays.for>8
Hypomenorrhea
Menorrhagia bleeding
Hypomenorrhea If
cycles. quency
Polymenorrhea
If Oligomenorrhea
days.>38 quency
days.<24
menstrual Any
blood cycle
deviation
for is to
is loss cycle cycle
>80
(Prolonged <4.5
(Light <20
mL: bleeding). variation is
(Shortened
days.
(Infrequent(Frequent AUB.from
it One
called
also is m: normal
bleeding): is 79. Touch
It >20 cycles) cycles)
bleeding)
is characteristic
days: ABNORMAL
BLEEDING
UTERINEObstetrics
menorrhagia If
bleeding also = Cycle =
Irregualr Cycle
caliea and
=
fre- fre-
is If of Gynecology
page.
next inshould Serum
done. beIf ferritin 3.
5. 4. Investigations
2. 1. N 1 ELeiomyoma o ML =
P
Causes
suspecting
Indications in
USG= TSH
Coagulopathy
= = C
= =PolypA
Complete
count
perimenopausal = = = =
adolescent
blood UPT latrogenic Not
EndometrialOvulatory
Malignancy/Hyperplasia Adenomyosis by
IF
otherwise of Dr
Should
pregnancy AUB Sakshi
coagulopathy
for
females be (d/t
in dysfunction
endometrial AUB causes Arora
done or classified
OCP/IUCD)
adolescent is Hans
(puberty in suspected
then all (Earlier
biopsy AUB
coagulation female
menorrhagia) in
patients called
are reproductivel
discussed DUB)
pro except
 Key
ometrial
icknessET= C in
O anycells OnIn AUB nm.>12 ln Diabetes o Eg.
ET Or>11mm
r IFIn thickness
managenmentEndometrial USG,
. reproductive
Tamoxifen
therapy endomet
ET post Pap case USG Post
of unresponsive Hypertension PCOS facctomorpsilaafoirlnhave of
females
>4bleeding Indications ReprEndome
oaucntdiviceationtsriafolr
unknown
menopausal smear of
menopausal =
ET
m metropathia AUBriskand <40
but >4
menopausal Age
+ age years
fluid on
shows mnm to
significance for femnale if
on Females
USG=
female females, EB medical who
is carcinoma
seen atypical
hemorrhagica in Gold IOC
post (ET) Biopsy
doesn't EB Standard =
(AGCUS) Endometrial
glandular is
done ENDOMETRIAL
PATHOLOGYFOR
have
if = GYNECOLOGY
Fractional
sampling/Biopsy

" " curettage

management
medical
despite
atypia
endometrial If In If If
case EB EB
EB Indications
Primenopausal
femalesIn
endometrial,
Hyperplasia
Atypicalreport
report Hysteroscopy
Curettageand +
but report of Fractional
Indicationfor Hysteroscopy seen
irrespective
(Note: <45 All
cervical primenopausal
years;
patient says: shows: still
Even
hyperplasia is
do FOGSI
for
stenosis.
lnsufficient
normal of
endometrial ifEndometrial
continues USG
on
<40
USG: females
(EH) or findings
sample years)
to Fibroid
Biopsy.
without EB (FIGO Biopsy
bleed, says
is
131
 Gynecology by Dr Sakshi Arora Hans
132 One Touch Obstetrics and

Managment Options in AUB

Procedures
Hormonal Dilatation and curettage (t
Nonhornmonal Drugs
Tranexamic acid OCPs is not done is Case of puberty
Progesterone menorrhagia)
IUCD-MIRENA Endometrial Ablation (done
Orally only if family is complete)
[medroxyprogesterone Hysterectomy
acetate] (MPA)
Can be given continuously
or cyclical (12-14 days)

Endometrial Ablation
Concept for Medical Mgt of AUB
Surgical destruction of uterine lining up to
If on USG ET is thick: It indicates endometrium 4-6 mm deep.
is primed with Estrogen = So, both OCP and Done by: Nonresectable methods: E.g. cryosurgery,
progesterone can be given to control bleeding. Hydrothermal ablation
IfET is thin on USG: It indicates endometrium is Called 2nd generation method and not done
not prinmed by estrogen and hence progesterone under hysteroscopic guidance (So no risk of
alone is not used. Because progesterone cannot fluid overload)
act on uterus which is not primed by estrogen Resectable methods: E.q., Rollerball, Laser, TCRE
so OCP is given or V Estrogen followed by (Transcervical resection of endometrium), Wire
progesterone is given.
Loop
MetropathiaHemorrhagica Called 1st generation method and done
Seen in perimenopausal females
under hysteroscopic guidance (Risk of fluid
of overload)
Female complains of: Amenorrhea C/: For endometrial ablation
2-3 months f/b excessive bleeding
Whenever a perimenopausal female c/o AUB Pregnancy.
Suspected Endometrial hyperplasia,
Do Endometrial Biopsy Endometrial cancer,
On HPE: Swiss cheese pattern is seen Active pelvic infection
IUCD in uterus.
Risk of malignancy = 1%
Management: Progeste rone therapy
 GYNECOLOGY 13
80. ENDOMETRIAL HYPERPLASIA

Endometrial hyperplasia

Patient C/O: Types Management of EH without Atypia

Excessive bleeding (AUB)
p/t: Excessive estrogen
(unopposed estrogen)
TVS
1st Ix =
OC = Endometrial sampling
Gold Standard = Fractional
curettage and hyste roscopy
Simple and complex
Endometrial Hyperplasia
without atypia: Risk of
malignancy =1-3%
Simple and complex
ndometrial hyperplasia
with atypia: Risk of
malignancy = 8-30%
Done with progesterone
MIRENAor Oral MPA or oral
Megestrol (Continuous or
cyclical for 12-14 days)
Repeat EB every 3-6 months
for 1 year.
If bleeding persists or if EH
persists on EB
JNext step
Fractional curettage and
hysteroscopy

Managewment of EH with Atypia Endometrial Sampling

Whenever report cones as EH with atypia on OPD procedure
Can be done as:
endometrial Biopsy
Next step: Fractional curettage and hysteroscopy L. Endometrial Biopsy
(To rule out coexisting endometrial cancer) 2. Endometrial aspiration cytology
Best Mgt: Hysterectomy Done Using
If patient refuses hysterectomy: give Megestrol Karman cannula in lndia
(Progesterone)
Repeat EB every 3-6 months for 2 years Pipelle and Vabra aspiration = Outside India
atypia persists
" If bleeding persists or EH with
Next step
Hysterectomy
 Type 1 months
afterTamoxifen
PYQ:2Nulliparity
useT=N= U= Diabetes
A = DL= Family HFactors
familial/hereditary =Risk
Endometrial
50-60
years
Age: andestrogen Mutation
genePTEN in
Adenocarcinoma
grade I,2 80%
= ObesityO=as
hyperplasia Seenexcessive prognosis
Relatedto KRASQnd A/W Good tumor
(TM)]cellAtypical
Unopposed Late =
Pregnancy Hypertension
in menopause
obese
EH
tamoxifen
stopping estrogen
Q's
should and
Type 2 [PCOS, Early
Endometrial
atrophy. Seen gene
thin inRelatedNottomutation
andestrogen
excessive A/W in
Adenocarcinoma
Cancer,grade 20%
G-70
years
Age: females ps3prognosisBadPapillary
tumor
Serous be
avoided HRT, menarche 81.
3,
Clear granulosa
Endometrial
Cancer
Cell for ENDOMETRIAL
CANCER

l(M/C
causeof |Papillary
|M/CSerous|HTM |Corpus
ypertension
|M/C diabetic
syndrome
Cowden Endometrial
Hereditary
Cancer
syndrome
Lynch ll M/C Most M/C Most Important
of Points
Screening: also Mutation:
ISBest BRCA1
agepelvic patients: D/t MLH1, Cancer
MSH2 Other 2nd Colon Endometrial
M/C specific
cause age
completed complain: malignant Type
(To lead =
amination method mutation M/=C cancer of cancer
use Ovarian of Sth-7th
Do toand cancer: endometrial
Gatekeeper
genefor complain:
India:
PMB in
Endometrial
outAnnual Endometrial
TAH BRCA2 associated PMB:irregular cancer +
by to in type: syndromne:Obese
ovarian Endometrial decade
prevent
at + cancer
PTEN Endometrial
fron least BSO Post Clear
are +
endometrial qene bleeding cancer:
chances
with cancer high then d
cancer) 30 4O when cancer qene menopausal
Cancer
cerviy) (60
Cancer
mutation Adenocarcinoma Cell . female If
toyears on
lynch years)
= atrophu) Carcinowma
Childbearing
35 chr. (Type PTEN
biopsy of syndrome
years in bleediv
age thes = 10 1)
Can
 31
Protocol for Endometrial Cancer
Sugical
staging Surgery in Endometrial Cancer
ln stage 1 is: TAH + BSO
MRI
r cancer involves cervix or structures below cervik:
For exawmple,
Followedby Stage 2 and 3: Wertheim Hysterectomy (Modified
Surgery for Tumor Radical Hysterectony)
2
Stage 4: Debulking surgery
LN dissection
specimen for HPE
Send
5 Histopathologist tells stage of cancer
ABased on stage, do Postoperative management.
5
Node Dissection in Endometrial Cancer Postoperative Therapy
Lymph
offTTM<2Cm and involves <50% of myometrium:TOc is: Radiotherapy (in all stages)
Nosize
LNdissection Except Adenocarcinoma grade 1 and grade
2 and

fsizeofTM >2 Cmand involves <50% of myometriunm: stage 1a: No postoperative therapy= Chemotherapy
Pelvic LN dissection In stage3and 4 of adenocarcinoma
par aortic LN dissection+ Radiotherapy
(Cisplatin+ Paclitaxel)
all cases: Pelvic and
ln Rest Adenocarcinoma grade 3,
Note: If Question says: Therapy is given
stage 1A what postoperative in grade 1 and 2
Answer is Radiotherapy. (only
postoperative Therapy given)
withstage 1A = No

Grading of endometrial cancercancer

EndometrialCancer Grade 1 = Well
differentiated
RGO Staging of differentiated cancer
Grade 2 = Moderately
differentiated cancer
to the uterus.
Stage 1: Cancer is limited Grade3 =Poorly
involved.
As5O%myometrium involved. cancer endometrium
Role of MRI in myometrium,
6:250% myometrium Done to assess
involvement of

stroma and glands are involved. LUS and cervix

of spreed of
endometrial
Stage 2: Cervix route
Most common spreed
the cervik. cancer = Direct hematogenous involvement
Stage 3: Cancer spreads beyondserosa or
adnexa. Most common site of
A: Cancer inyolves either the parametrium. lungs
B:Cancer involves the vagina or
CLymph node involvement.
C: Pelvic lymph nodes involved.
involved.
Para-aortic lymph nodes
Stage 4: Metastasis.
either bladder or bowel.
A: superficial
B: Regional
Distant
metastasis to
metastasis or
involvement of
inguinal lymph node.
 82. IMPORTANT NEXT STEPS

CASE 1: Patient C/O AUB and Endometrial Biopsy done

Hyperplasia without atypia Endometrial Hyperplasia

with atypia
Next step Next step

Progesterone Fractional curettage and

Hysteroscopy
CASE 2: Patient with Endometrial Hyperplasia and on progesterone continues to bleed

Endometrial Hyperplasia Endometrial Hyperplasia

without atypia with atypia
Next step Next step
Fractional curettage (FC) Hysterectomy
and Hysteroscopy

CASE 3: Patient C/OPostmenopausal bleeding

Next step
TVS

ET <4 mm ET 24 mm

Next step Next step

Tranexamic acid Endometrial biopsy

If patient (pt) continues to bleed

FC and Hysteroscopy
 GYNECOLOGY 137

CASE 4: Female complains of

postcoital bleeding (PCB)
Next step
Per speculum examination

Clinically abnormal cervix: Normal cervix but persistent

NORMAL barrel-shaped
Friable cervix post coital bleeding or
coexisting intermenstrual
Thick indurated cervix bleeding
Next step Irregular mass
|Next step
Next step
Pap siwnear
TVS t EB

Abnormal result Colposcopy

As Rarely endometrial
pathology may present as
Next step PCB
 tal
thrombosi thrombosis
given
cancer (HRT)
cream decreasing
disene
syndrome Vaginal
(ubricant
of cervical
risk
heart LH
=
ncreased
ESH
245
IU
(if
and
cancer
cancer CAD
E1 cells drugs
2
Teriparatid
and
Genitourinary and of (PTH
analogue)
Teriparatide
rank = by
coronary present) endometrialflashesriskof -parabasal
females
flashes cancer risk act
endometrial
absent present to except
decrease
increase Bisphosphonate
e.g. osteoporosis
of
Hans of (<IU) uterus hot (STEAR) (binds menopausal
Tibolone
Hot decreased
=
Estrogen
decreased
InhibinB
= breast decreases
= chances is is to cancer
colorectal cells osteoclast
Arora symptom:
vaginitis HRTuterus
decreased uterus Osteoporosis
alendronate Denosumab
lead not not + Strontium
Bazedoxifene
Raloxifene
Osteoporosis to with to epithelial
Sakshi 'E' HRT notlead doesdoes ligand)
Symptoms Increased Only lead
if females
Senile Diagnosis Given if = HRT in
MENOPAUSE
M/C Given HRT HRTHRT mgton
in
Dr = Can E+P= Does
Can estrogen
vaqinal
by AMH HRT: PYQS acting
osteoblast.
There
are:
Gynecology MENOPAUSE Phytoestrogen
" . " Gabapentin
Isoflavone
flash
Hot SSRI,
e.g-»
fluoxetine
Estrogen used
common
common
resorption
by Strontium
1st
HRT
line All
drugs
and there do Perioddays
83.
Obstetrics years So
primary for
T/t Most
Most
when years cancer: 27 SERMOthers
are transition: 2ndline Note:
<4O length
Touch seen calledat
(now >55
Menopause
there
Menopause endometrial
menopause.
diaqnosis; = cycle and females
post-menopausal
intake
One years menopausePerimenopause/menopausal surge
months perimenopause
(ntermenstrual symptomdecreasedsweat Recommended:
Vasomotor Calcium
51 menopause
insufficiency):
of LH
Clinical biopsybefore
endometrial IU/day
PYQs of = years Late
ImportantWorldwide
chances
menopause:
late
to night
amenorrhea STRAW
staging menopause Recommended
Corresponds
years D/t
Occurs called lD
Menopause:47 Premature of mg800
ptsincreased sign:
in estrogen
Ovarian 4-5 Staging
flash
Hot Seen
= Also 1200
=
Age:India all
1st D
is In of Vit
in =
138
 BID) Danazol OCP
+
Antiandrogen
increased ng confirmed
Androgen-secreting
2200
mg Females OVarian
tumOr
Alternatives:
Topical
Eflornithine
For
G
months
generation (50-100 GnRHHirsutismn: Testosterone and >800CAH
LIf
relief
no in
Add:
Antiandrogens Increased
Alopecia
Continuous onset
Ketoconazole
4th
relief
No choice)Flutamide
Finasteride
to
Hirsutism
lead Late
Management
of
Hirsutisnm or
or of test
diagnostic
Do
Brd (15t resort:canMgt Testosterone
normal
Spironolactone which C/O
(with
progesterone) Last congenital test
Stimulatio
ACTH
with
Finasteride
OCP
Drug Minoxidil (CAH)
hyperplasia
adrenallevels
progesterone
17-0H CAH
HIRSUTISM ng step
Next
OPD testosterone
Serum <200
DOC: Note: onset
gyne Next
step onset 200-8OO
" but late
terminal
coarse
pattern =
(28
hirsutism)
to
cones
late
Increased Suspectingng.
84. or <70
d/t PCOS
male girl =
Severe
fewmale fema
in young test
Screening
hair
arowth
= a androgens. in
-gallwey
Ferriman
Scoring:
alopecia
chest 215 of
Virilization:
Score A
CASE: level
Masculinization out
Hirsutism, mass
chin,
ruled
andr
lijps,and Clitvoice
ofpresenceatrophy
excessive Breast oofDeepening
romegalmuscle
yscore
Prader
Score:
Increased
ldiopathic
hirsutism
isutisnmUpper acne Normal
Hirsutism <200 CAH
of
Eg:
ludes ncludes: onset
Norm
Latee Note:
 to mellitus
Abnormal
lipidprofile:
LDLt -Dyslipidemia
-chances
of‘ leads
and
HDLL heart
disease
In
future
can
lead
to future
diabetes
PCOs
androgen
as In
tooin
increased Androgenism
of adrenal
A
Acanthosis
Nigricans
N Syndrome
Hans PCOSamount
SYNDROME)
(STEIN-LEVENTHAL c/o
may
Pt
Menometrorrhagia
iS 1:3
1:1 R
Resistance
Hyper 1lnsulin
by also females
obese
In levels
Androgen
* LH =
severity
but increased
also LH=
Arora produced
Some -Pcos: N LH HA
is (1)
=
E1 = : 50-80%)
DHEAS FSH
FSH :
Sakshi Note: analogues
Aromatase
inhibitors of
FSH
Normally manifestationneck,
velvety
is nigricans:
- insulin
ofresistance
pts * =
in Pcos in of
Dr (seen -D
smooth
arknape
by etc.
armpit
Gynecology SYNDROME)
(STEIN-LEVENTHAL
PCOS ovary resistance Acanthosis
Clinical in
androgen
Excessive skin
problem
Main secreted
is(AMH
by tLH
dlt
is and
partial
by follicles)
antral -
production ‘AMH
conceives, have AbN years OGTT
OGTT
and abortion
ofrisk with-Insulin
resistance:
also = of
Obstetrics patient
GTT
SHBG pts 2 pt
all qmevery
gm
androgen pt -hour 75 PCOS 75
PCOS In PCOS:- yearly
affect
toxic
(Follicular infertilityluteum PCOS
done
Touch arrested
folliclesandrogens) corpus
No pregesterone
No 2 In
Excessive of ovulation
No If is Do
ofGrowth
One 85. dyslipidemia
C/O
Pt to
Adds
or
(pt)
C/O oligomenorrhea
Patient
amenorrhea
Hirsutism androgen
more
produce
to
Stimulates
cells
theca
USG
on
Ovary
polycystic
Morphology
ababnormalitiec
NECOLOGY 141

nrasea

Androgens(increased but <200 ng) Rotterdam

To
criteria
of themake provisional
a diagnosis of PCOS: Any 2
DHEAS
1.
should be present:
lncreased androgen
Hyperandrogenemia levels
=
nsulinresistance
2.
or hirsutism
Obese= E1 Ovulatory dysfunction manifested as:
prereased
Oligomenorrhea or amenorrhea
3. Polycystic ovaries on USG = z12 follicles of
Progesterone 2-9 Mm in size in one or both ovaries or
HDL volume of ovary z10 cC
SHBG(sex hormone binding globulin) With Rotterdam provisional diagnosis of PCOS is
Normal
made. It should be diferentiated from late onset
CAH to come to confirmatory diagnosis.
SH
Prolactin Note. Awmerican and European society have revised
Progesterone challenge test is positive in PCOs. criteria from 12 follicles to 20 follicles

Notadiagnostic criteria for PCOs

Obesity Remember: In pts of PCOs ovaries can be normal
Necklace appearance on USG on USG
LH:FSH ratio
Menometrorrhagia
Insulin resistance

Long-term consequences of PCOS/anovulation

Coronary artery disease " Nonalcoholic steatohepatitis
Dyslipidemnia Metabolic X syndrome
Endometrial cancer Sleep apnea syndrome
Ovarian cancer (+/-) Anxiety and depression
Diabetes mellitus

Management
St step: Lifestule mnodification in all cases of PCOS
nfert
DOC i=litLetrozole
y: > Clomiphene citrate
Ma line =HMG or Laparoscopic ovarian drilling
Ast resort: Pulsatile
Menstrual irreaularty:GnRH
DOC = 0CPS
Insulin resistance = DOC= Metformin
Hirsutism = DOC = OCPs burnt so that theca cells are destroyed and androgen

deLacpreaarsoessc. opic
ovary is
ovarian drillina: Strona of
and OHSS
AdRotDievs:aandtvaagnetage = Norisk of multfetal pregnancy
= Risk of ovarian failure
of PCOs: Progesterone should belong to third or fourth generation
whnenever OCP is used in a patient
 42

Tenderness Adnexa
Adnexal
mass
+nt Examination:
P/V
Normal
Uterus Examination menstruation
metaplasia
coelomic For accepted
For Sampsontheory: CNSf/bLeast General
M/Spleen
C cOmmon M/C Parts
P/A ligament)
Retroverted
Nontender
corrected)
manuallyFixedenlargedNot Examination: distant
umbilicus: site:
(Means: Theory Ovary>
may sites uterosacral
Halban
Right be like (Endometrioma)
(chocolate
present. cyst) Retrovision of
inplantation/Retrograde
lung:
Image Theory
ligament One
lanoff
116: Touch
cannot of
colate lymphatic
theory > Obstetrics
Broad
POD >
86.
be of
Occurrence
Ectopicof
ENDOMETRIOSIS
cyst endometrial
tissue spread and
on
ENDOMETRIOSIS
Gynecology
USG
If cyclical
Bleeding
hydrothorax Specific 3rd 2nd Least Age:
pelvic M/C RuleNote:Symptoms
present
M/C M/C out
Reproductive by
symptom
pain common: If
Standard:
Gold
Laparoscopy
HPE I0C: Whenever hematuria,
symptoms endometriosis Dr
Next
step then not is symptom:
symptom: > mullerian Sakshi
o
endometriosis) TVS
Absence
Endometriosis 116) A
USG Done
ruleout (lmage it a
dyspareunia) =
(although chief Prepubertal/Pubertal Arora
It It chocolate is = Pain age
is to Patient menorrhagiacatamenialAdnexal malformation
has Infertility Hans
rule complain vicarious (2° occurs(25-35
ound cyst a of
Chocolate
Cyst dysmenorrhea
chronic >
internal
echoes. chocolate cyst out it mass
with is C/0 menstruation, in
glass other
pneumothorax pubertal years)
may diagnostic
not for in
omogeneous Dysmenorrhea
endometriosis (Chocolate
rencl cyst disorders
be age
seen femle
doesnt
Cuch
on
 GYNECOLOGY 14

Dysmenorrhea in Endometriosis Management (Mgt) of Infertility

Mgtof
is minimal/Mild.
Ifpain OCP
1st ine =
(pt) wants to conceive: NSAID
Ifpatient Progesterone
Dnd line =
Mirena or
Moderate/severe
Oral progesterone Minimal/mild disease disease
3rd line = continuOus GnRH analogue or
GnRH Antagonist
If all 3fails: Laparoscopy Treat like Adhesions
Pain is Moderate/severe unexplained + nt

1st line = GnRH continuous or infertility

GnRH Antagonist
If it fails: Laparoscopy VE
Clomiphene
Laparoscopy is both diagnostic and therapeutic
Note: Other Drugs which can be used: IUI
1. Letrozole
l Fails
2. Danazol ’ side effect-hirsutism IVF
Drug which can be theoretically used: But not
approved by FDA: Mifepristone (leads to endometrial
atrophy). Mgt of Endometrioma (Imnage 117)
Laparoscopy in Endometriosis It cannot be
managed medically
It is lOC in endometriosis.
Indication:
Pains not relieved by medical management
Pt doesn't desire
For management of chocolate cyst Pt desires pregnancy
Uses:
pregnancy
" Diagnostic: On Laparoscopy following are seen:
o Chocolate cyst (lmage 117) Conservative mgt
Red lesion (lmage 119)
Gunshot appearance (lmage 118)
Peritoneal defect (lmage 120)
Asymptomatic Symptomatic or
Therapeutic and s0ze <5 cm SIze >5 cm
Take sample for HPE
Tostage the disease
Follow-up Laparoscopic
Steps: cystectomy
Adhesiolysis
Fulguration of implants Endometrioma cannot be managed medically.
Presacral neurectomy
aparoscopic uterosacral nerve ablation (LUNA)
follow
Severe disease means presence of any of pelvC
Adhesions 2. Chocolate cyst 3. Distorted
Anatomy
management fails to control
pain in endometriosis, then last resort is: Hysterectomy
If
Laparoscopic
(Prevents formation of new implants)
 Arora Hans
14 One Touch Obstetrics and Gynecology by Dr Sakshi

Laparoscopic Appearance of Endometriosis

(mage 117: Chocolate cyst Image 119: Red lesion-indicating newly formed lesinu

Uterus Right broad ligament

Peritoneal
pocket
Cul-de -sac
Right
uterosacral
ligament

lmage 120: Peritoneal defect called

lmage 118: Gunshot appearance/powder ALLEN master syndromne
burn appearance (lndicating old lesion)
Important Concepts
1. If bleeding is most prominent complain in reproductive age female: Think of fibroid
2. If pt C/O heavy menstrual bleeding + 2° dysmenorrhea = Think of adenomyosis
3. If pt C/O intermenstrual bleeding/irregular bleeding Think of Polyps.
4. If pt C/ODysmenorrhea + Dyspareunia + Adnexal mass: Think of Endometriosis
 GY
145
lnportant General Points 87.
Smooth muscle tumor FIBROID
FIGO
Arises from myometrium
Derivedfirom single
Classification of Fibroid
6 MC Fibroid: Intraural monocyte -Monoclonal in oriqin
Sizeof, Fibroid remains
DCP has
no effect on
Fibroid isan estrogen a
unchanged
size of in
Fibroidpregnancy
Submucous
fibroid: >50%
tumor.
and progesterone although
dependent in myometrium
<50% in cavity
AlsoKnow Type 2
Degeneration of Fibroid
Red Occurs in
second half of Type 1
abdomen,pregnancy
e
Pt ClO pain in Type o Submucous
is an aseptic, condition nausea, vomiting fibroid: <50%
blood vessels suppling fibroid
d/t
thrombosis in Submucous
fibroid: in myometrium
x= WBC ‘ >50% cavity
Totally inside
ESR ‘ cavity
M¡t-conservative
No antibiotics Image 121: Types of fibroid
No TOP, NO myomectomy Note: Type o and type 1 submucous fibroid can be
removed hysteroscopically and not type 2.
Management of Fibroid

Management of Fibroid
C/O

Heavy menstrual bleeding Pressure tnfertility

symptoms

Intramural Medical mgt M/Cseen in

Submucous Or with drugs
Fibroid Subserosal Fibroid which decrease Submucous
size of Fibroid Fibroid

Medical GnRH Treat like

management analogs HMB
Type o Type 2 Continuously
Or Or 1st line drugs
Type 1 If size >5 Cm
Fails
2nd line drugs
Hysteroscopic
myomectomy
Laparoscopic
myomectomy Fails UAE = Uterine artery embolization
UAE HmB = Heavy menstrual bleeding
Fails
HIFU High-intensity focused
= Magnetic
Hysterecto my ultrasound or MRg FUS ultrasound
Or resonance guided focused
MRgFUS
OR
HIFU
 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

Sequence for medical management Uterine Artery

First-line drugs: Decrease bleeding but do not Done radiographically via femoral arteru
decrease the size of fibroid
1. Tranexamic acid The contralateral uterine Ais emnbolised
2. OCP
gel foam or polyvinyl alcohol. uslng
Done in females who donot desire
3. Progeste rone
Second-line drugs: Decrease bleeding and decrease
pregnancy
Contraindication: PID malignant fibroid desire fu
futurel
the size of fibroid
future pregnancy
Since fibroid is on estrogen and progesterone Relative contraindication menopause
dependent tumor: To decrease the size of fibroid.
A: Drugs which estrogen IE fibroid is
associated with right sided pleura
Progesterone effusion and ascites it is called as Pseudo-Mel
Letrozole syndrome.
Danazol Most common fibroid to undergo malignancu:
GnRH Submucous fibroid
B: Drugs which J progesterone Most common ibroid causing infertility ori
Mifepristone Recurrent Abortion: Submucous fibroid
Ulipristal (It is a selective progesterone recept Fibroid can undergo calcification: Which can
or modulator drug) appear as POPCORN calcification
Note: Out of all drugs-the one approved by FDA
is: GnRH

Myomectomy
Surgical removal of fibroid only
Done in females who desire pregnancy
Symptomatic relief seen in 80% cases.
In 10-25% cases, subsequent surgery needed
Hysteroscopic myomectomy done in Type o
and Type 1 fibroid if size is less than 5 cm.
In rest all: Laparoscopic
Before doing myomectomy myomectomy
is done.
check pts.
Hb
Semen analysis of partner
E Biopsy
 ptirentialDiagnosis
Fibroid
Polyp Adenomyosis
Reproductive age (endometrium inmation)
(25-35 years) Any age >40 years
Nulliparous females With increasing age, (4th-5th decade)
chances of polyp increase Multiparous female
N/CcOmplain Heavy wmenstrual bleeding In premenopausal/ M/C = HMB
Reproductive age: 2nd M/C = 2°
lntermenstrual bleeding dysmenorrhea
Irregular bleeding Usually pt C/O both
Dther
2° dysmenorrhea In postmenopausal female:
Infertility
Pelvic pressure symptoms Postmenopausal
bleeding
PIAExamination Uterus is enlarged and
irregualr and may reach
up to 20 weeks' pregnancy
SIZe

Gross appearance Fibroid has awhorled Mucosal outgrowth Symmetrically

appearance, white in color Fleshy, red in color enlarged uterus
and is Surrounded by a Has asmooth surface = globular uterus
pseudocapsule cut surface shows
and hangs from a multiple hemorrhages
Blood vessels suppying narrow base in uterine
(lmage 124)
fibroid are present in cavity (lmage 123)
pseudocapsule
Cut surgace: irregular/
uneven and arises from
broad base (lmage 122)
Normal in size Size of uterus:
PAV examination Enlarged 10-12 weeks
Anteverted
uterus: Irregular pregnant size
Nontender Uterine tenderness
present (Halban sign)

No adnexal mass
Adnexa: Adnexal tenderness
may be present
USG = 1st IX MRI
10C sign Junctional zone
USG
For submucous fibroid: On USG: Feeder vessel 212 mm in thickness
sonography seen (lmage 126)
Saline infusion I0C: Hysteroscopy
(lmage 125) Management:
Endometrial Polyp:
Removed by Hysteroscopic
polypectomy
Cervical polyp: Removed
polypectomy
with ahelp of
hook
 by Dr Sakshi Arora Hans
148 One Touch Obstetrics and Gynecology
AND ADENOMYOSIs
88. IMPORTANT IMAGES OF FIBROID, POLYP

DATE
SPECINEN

Image 123: Specimen of polyp

lmage 122: Cut Surface of fibroid Red fleshy mass
Showing whorled appearance

Isages 124A and B: A. Adenomyosis gross showing uniformly enlarged uterus

B. Cut surface showing multiple haemorrhages

Chs

lwsage 125: USG of fibroid Showing echogenicity same as vesselsign

myometrium and arising from broad base Image 126: USG of polyp: Showing feeding
 GYNECOLOGY
149

lmage 127: USG image of adenomyosis: Image 128: USG showing myometrial cyst in
Venetian blind appearance adenomyosis

Leiomyoma Adenomyosis
Asymimetric enlargqement of uterus Symmetric enlargement/globular uterus
Nontender uterus Tender uterus C/a Halban sign
Uterus is firm Soft uterus

Menorrhagia is chief complaint Menorrhagia with dysmenorrhea is chief

presentation
Uterus can qrow to huge size even up to 20 weeks Uterus usually does not grow beyond 12 weeks size
pregnant uterus sIze

diagnosis is by histologic
The only definitivesurgically
USG Appearances of Adenomyosis confirmation of the excised tissue.
includes the
1. Asymmetrical myometrial thickness. Management: Medical treatment
intrauterine system,
levonorgest (LNG)-releasingmenstrual
2 Myometrial cyst (blood collection in myometrium) which may decrease heavy
bleeding.
is the
(lmage 128).
of blood). Surgery in the form of hysterectomy
D. Myometriual island (large collection treatment of choice.
4. Venetian blind appearance (Image 127)
S. Irregular junctional zone.
junctional zone.
6. Increased vascularity of
Adenomyosis
Diagnosis and Management of diffusely
shows
USG or MRI imaging
uterus with cystic areas
Symmetrically enlarged
myometrial wall.
found within the
 Gynecology by Dr Sakshi Arora Hans
50
One Touch Obstetrics and

GYNECOLOGICAL PROCEDURES-PAP SMEAR

89.
Procedure
Conventional method:
Pap smear is acytological test-1st
specimen is taken from
Transformation
zOne (lmage 13O) with the help of
Ayres spatula (wooden) and spread on
glass slide.
2nd specimen taken from Endocervix
with the help of Endocervical brush
(Rotated in one direction 360) and
rolled on same glass slide.
ln liquid based method: A single cervical
brush is used to take sawple fromn TZ and
endocervix sample. The brush isput directly
into the fixative

Images 12 9A to C: (A)Ayres spatula;

(B) Endocervical brush; (C) Cervical brush
PAP SMEAR

ACOG recommends: It is a Most Sensitive Test = HPV Absolute C/l None

Screening test for Cancer
cervix.
Age: 21 years.
Repeated: 3 years
Till female is 3O years.
Then HPV DNA test and
pap smear done together till
65 years for every S years.
DNA Test Relative C/l
Most Specific Test = Pap Active bleeding
Smea
Do not do P/V examination
before Pap smear.
Best Time to do Pap
Periovulatory phase
Fixative for conventional Bethesda Report
method 95% ethyl alcohol t Satisfactory conventional Pap
S% ether
Smear:
Fixative for liquid cytology = 8000 to 1200O squamous cells/
methanol 10 HPF + 10-12 endocervical
Do not air dry slide cells

Satisfactory Liquid Pap:

SOOO squamous cells/10 HPF
Columnar epithelium 10-12 endovervical cells
Stratified squamous
epithelium
Old squamo
columnar junction New squamo
Endocervical canal
columnar junction
Transformation zone

lmage 130: Image of

transformation zone
For lmportant Pap smear images of infection see page 210
 Pap
smear
GYNECOLOGY 151

sCreening test.
sC Based on its
s
onlya
report-No T/t is done.
Pap Swmear Report
ASC US (Atypical squamous cells of Next Step
significance) unknown <25 years: Repeat pap smear after 1 year
>25 years: HPV-DNA testing
2. LSIL (LoW squamous Intra epithelial lesion)
25 years: Repeat pap smear after 6 wmonth-1 year
>25 years: Colposcopy
3. HSIL (High squamous Intra epithelial lesion)
Colposcopy irrespective of age (Colpo -biopsy) +
4 ASCH (Atypical squamous cells where HSIL
Endocervical curettage
cannot be ruled Out) Colposcopy irrespective of age + Endocervical
curettage
5. ACGCUS(Atypical glandular cells of unknown 1. Endometrial Biopsy
significance) 4

2. Colposcopy
3. Endocervical curettage

90. COLPOSCOPY AND CONE BIOPSY

Colposcopy
Colposcope is a magnifying instrument.
Magnification: 30 times.
Focal length: 30.
" OPD procedure.
Can visualize exocerviX.
Canot visualize endocervix
Before colposcopy: UPT is performed if indicated.
Take Biopsy
1 From rough areas.
Imaqe 131: Aceto white area on colposcope
From white areas after applying acetic acid
(Aceto white areas) (lmage 151) Cone Biopsy
From abnormal blood vessels Sampleincludes:
o Reticular blood vessels Endocervix
0 Mosaic blood vessels Ectocervix
0 Punctate blood vessels TZ
with GREEN
are seen
Abnormal
FILTER.
blood vessels OT procedure
Anesthesia needed
CIN 2
The report of colposcopy comes as CIN 1, labor.
or CIN 3 Risk factor for preterm
method and Indications
is a diaqnostic curetteage is positive.
Colbasedposcopy
o biopsy
its report, treatment is done 1. If endocervical
2. If adenocarcinoma in situ
is suspected.
If Tz is not visible and lesion
extends to cervix.
If there is a discrepancy in pap smear and
4.
colposcopy report.
 Arora Hans
Obstetrics and
Gynecology by Dr Sakshi
152 One Touch
91. CONTRAINDICATIONS
Risk Factors
|CIN 1: Dysplasia limited to less than 1. HPV
1/3rd of cervical thickness
2. Early coitarche (<18 years)
CIN 2: Dysplasia involving 1/3rd 3. Early age of 1st pregnancy
2/3rd cervical thickness
(<20 years)
CIN 3: Dysplasia involving >2/3rd of 4. Multiple partners
cervical thickness
5. Multiparity
Ca in situ: Dysplasia involving entire 6. HIV
thickness but overlying membrane
intact 7. Low socioecOnomic status
Invasive Cancer cervix: Dysplasia 8. Smoking
involves entire thickness and overlying 9. OCP (risk is reversible)
membrane broken. No role of Familial inheritants
No role of Early menarche
late menopause.

A new marker P 16 testing tells

CIN is high grade or low grade CIN
P 16present =CIN 2, CIN 3
|P 16 absent = CIN 1

Diagnosis Management of CIN

1. Colposcopy =gives report as CIN and not Pap CIN 1: Follow up for 2 years. If CIN 1 doesnt in
Smear. 2 years resolve: cryoablation
2. Management is done only after diagnosis is CIN 2: ln all age groups and for all parity
confirmed by colposcopy. LLETZ or LEEP is treatment of
CIN 3: choice

Cryoablation LEEP/LLETZ (IMAGE 132) (EXCISIONAL T/T)

OPD procedure OPD procedure.
Co/N,O is passed e very low temperature, No anaesthesia required.
leading to crystallization of intracellular water. Current is passed into wire.
It destroys cervical epithelium 5-7 mm distal Cut and coagulate at same time.
to probe.
Patient C/O persistent watery discharge. Short procedure: 10 minutes.
No bleeding. No admission needed.
No tissue is available for HPE Minimal bleeding.
Criteria for Cryoablation (as per WHO) TiSsue removed upto a depth of 10mm: Sent for
HPE.
Endocervical curettage should be negative.
CIN should be limited to 2 quadrant of cervix.
Not used for treating:
CIN 3
Female with HIV with CIN.
After any previous therapy
|Hysterectomy is not done for managing CIN.
CIN 1 = 80% cases regress, <1% progress
CIN 2 = 5% progress lmage 132: Wired loop used for LEEP
CIN 3 = 20% progress
 GYNECOLOGY 15

dsDNAVIirus Low Risk Subtypes

Epitheliotropic-for completion
cycle, HPV HPV and 11 = lead to qenital warts.
of life 6
reguiresintact squamous epithelium.
eads to changes in High Risk Subtypes
HPV epithelium
Koilocytosis(Corresponds to CIN 1) cell K/a HPV 16, 18, 31, 33, 45, 52, 58 lead
Koilocytes are superficial/Inter (Image 133), cervix and other cancers. to cancer

withlarge
nuclei and halo around itmoderate cells
AUclei withresinoidHPV Vaccines
.Viral Proteins
= needed for viral replication Vaccine Valent Effective Protects
Eland E2 against from
Knocks out Ps3 gene needed for
E6= Cervarix Bivalent HPV 1G Cancer
out
E7 = Knocks malignant and 18 cervix
Retroblastoma gene transformation
L1 capsid protein = Used for making HPV Gardasil Quadrivalent HPV 6, 11, Genital
Vaccines 16 and 18 warts +
Cancer
HPV cervix
Cancer caused by
Gardasil 9 Nonavalent HPV 6, 6 cancers
females: + genital
Cancer cervik (Available 11, 16,
and MC 18, 31, warts
Vaginal cancer used) 33, 45, 52
Valval cancer and 5
Males:
Oral Cancer Prepared from L1 capsid protein
Penis cancer Age group = 9-26 years
Anal Cancer High risk indvidual = can be given in age 27-45 years
ldeal age = 11-12 years
WHO's age recommendation
9-14 years = 1 or 2 doses
15-2O years =1 or 2 doses
>21 years = 2 doses (at6 months interva)
HIV +ve = 3 doses
No need: For HPV DNA testing before qiving
vaccine
Can be given: Tosexually active femnales also
c/l in: Pregnancy
M/C side effect: Syncope
After vaccination: Donot stop screening
India's First Cancer Cervix vaccine
CERVAVAC
Quadrivalent vaccine (HPV 6, 11, 16, 18)
Pune
Image 133: Koilocytosis Prepared in Serum lnstitute of lndia,
 Dr SakshiArora Hans
s4 One Touch Obstetrics and Gynecology by

92. CANCER CERVIX

Cancer Cervix Important Points

WHO Screening for Cancer Cervix
Age to Start: 3O years (30-49 years)
Age to Stop: S0 years
See And Treat Approach: HPV DNA test
done >VIA
See, Triage and Treat Approach: It is better
than see
and treat approach.
As per this: - HPV DNA test + VIA
are used as
screening methods
If HPV DNA is -ve = It is repeated
General population = 5-10 years
Repeated
HIV +ve = 3-5 years
If VIA is -ve = Repeated = 3 years
If HPVDNA is +ve and VIA is -ve: Repeat HPV after H = Hypogastric LN
3 years (ln see, Triage and Treat approach).
Staging of Cancer Cervix
M/C type of cancer cervix: Squamous cell
2nd M/C type of cancer cervix: Cancor
M/C site for cancer cervix: Adenocarcinomy
Transformation
M/Csite for adenocarcinoma: Endo cervix
M/C symptom: Irregular bleeding
Most specific symptom: Post coital bleeding
M/C cause of death in cancer cervix: Renal
failur
M/C age for cancer cervix: 35-39 years and
60-65 years (Median age = sO years)
M/C route of spread in cancer cervix:
spread Lymphati
Lymphatic Drainage of Cervix
O = Obturator
P =Paracervical/Parenteral
E =External lliac LN
Sentinel LN of Cancer Cervix: Paracervical LN
Cx doesn't drain into: Superficial inguinal LN.

Stage Deseription Management

Stage lA: 1: Cancer is limited to cervix.
IA, Extension to corpus is disregarded.
A: Micro invasive (<5 mm deep)
A,: <3 mm deep. Surgery is the preferred
A,: 3-4 mm deep. option, except if size of
tumor is >4 Cm.
Stage 1B: Macro invasive (25 mm deep).
IB, Size of Tumor <2 cm.
IB, Size of Tumor 2 Cm.
Size of Tumor 24 cm. Chemo radiation.

Stage l: Cancer spreads to upper 2/3rd of vagina.

IIA: Parametrium not involved.
Size of Tumor <4 cm.
Size of Tumor >4 Cm.
Surgery
’ Chemoradiation.

IB: Parametrium involved. ’ Chemoradiation.

Contd
 GYNECOLOGY 15
Stage
Stage
IlI: Description
Cancer involved lower Management
1/3rd of vaqina.
Pelvic side wall not
Pelvic side wall involved.
MIA:
IB:

IC:
Hydronephrosis.
Lymph involved/Hydroureter/
nodes involved.
Chemoradiation.

Pelvic lymph nodes.

MC, Para aortic lymph nodes.
StageIV: Metastasis:
VA: Regional metastasis: Bladder/bowel. Palliative care:
IVB: Distant metastasis or superficial inquinal lymph
node involvement. Chemoradiatron.
Management of Cancer Cervix Trachelecto my is done only if size of Tm <2 cm
If female becomes pregnant after trachelectomy =
Basic Principles Delivery by C-section.
Surgery: Investigations for cancer cervix
Can be done in early stages of cancer cervix till
Lab: CBC, urinalysis, KFT, LFT
stage lla, Radiology: Chest X-ray, IVP, CT, PET Scan, MRI
Cannot be done if size of tumor 4 cm.
Surgery is TOC for stage lA,, IA,, IB,, IB,, llA,. Procedural: Cystoscopy and proctoscopy
Most Imp prognostic marker in cancer cervix is
Cannot be done: IB, and llA,: stage > LN involvement.

Remember: Cancer cervix rarely spreads to ovaries Chemo Radiation (Radiation Therapy)
hence when hysterectomy is done in young females Can be done in all stages.
for cancer cervix oophorectomy is not done
Preferred T/t from stage lla, to stage IV and for
Surgery + LN dissection done for: IB,
Side effect = Ovarian failure and vaginal fibroses
A Surgery for older females Before RT, cisplatin is given to increase the
O Stage LA, = Type 1 Hyst = TAH +
BSO sensitivity to RT: cisplatin is Radiosensitizer.
No LN dissection (Alternative s fluoro uracil.
o Stage IA, to stage llA,= Hysterectomy Radiotherapy Types
Type 2 or 3
+ Pelvic and Para aortic Brachy the rapy Tele therapy
LN dissection
Intracavitary therapy External
beam RT
B. Surgery for young females (EBRT)
dissection)
Stage IA, = Conization (No LN Iridium 192 Cesium
Radical trachelectomy Isotope
Stage 1A, = aortic
Order Done after teletherapy Done 1st
+ pelvic and para (To shrink
Stage IB, = LN dissection Tm size)
and
Type 3 Hyst + Pelvis Inside body at point A: Outside body
Stage
Para
IB,, IlA, =
Aortic lymph node
dissection Source of
radiation 2 cm above and
lateral
to ext OS
Kadical Trachelectomy parametrium High dose: 212 Gy/hr SO Gy
Dose
Removal of cervix with entire Low dose: <2 Gy/hr
Uterus is stitched to vagina
Cervical cerclage is done
 Gynecology by Dr SakshiArora Hans
56 One Touch Obstetrics and
q3. HYSTEROSCOPY

Distension Media
Basics Electrolyte Deficient Medin
Position of patient =Lithotomy Electrolyte Rich Media
Can be used with both
For pain relief Can be used with
Bipolar instrument only Bipolar and Monopolar
IV sedation + analgesia instruments
Distension media
Can lead to uterine
1. CO, (only for diagnostic Can lead to uterine perforation
purpose) perforation
2. Electrolyte rich media Stop procedure when Water intoxication Can
occur: (Patient C/O
NS/RL there is a fluid deficit of
3. Electrolyte deficient media 2.5 L = Nausea, vomiting,
1.5% glycine, 3% sorbitol
headache)
S% mannitol Except mannitol all
Concept
Pressure inside uterus Fluid deficit = Amount of electrolyte deficient
fluid given - Amount of media are HypooSmolar,
Normal= 75-8O mm of Hq so hyponatremia
fluid which comes out
Maximum =15O mm of Hq can occur: (delirium,
confusion)
Stop procedure@luid
deficit of 1 L.

HYSTEROSCOPY
It is best to visualize and treat pathology
inside the uterus
Uterine cavity is a potential cavity.
Hence to visualize inside the cavity
distension media is used

Uterine
cavity

Polyp

Intracavitary
lmage 134: Hysteroscopic view of fibroid
Image 135: Hysteroscopic view of polyp
Fibroid appears pale in color
Has abroad base Polyp appears Beefy red in color
Has a narrow base
Has surface vessels present
Has no Surface vessels
 GYNECOLOGY 157

94. ASHERMAN SYNDROME

Problem = lntrauterine adhesions and
endometrium defective
Cause=
EXcessive uterine curettage
Highest Risk:= Postpartum period
o MTPD
o Genital TB
o Schistosomiasis
M/C symptom group: Menstrual irregularities.
lnfertility
M/CSymptom =
|(nfertility >2° amenorrhea >Hypomenorrhea
Others
Dysmenorrhea
Recurrent pregnancy loss
1st investigation = TVS
Better investigation =Saline infusion sonography Image 137: HSG of Asherman syndrome
Sereening test = Hyste rosalpingography - on HSG
o Multiple filling defects Diagnostic = Hysteroscopy (lmage 138)
Filling defects have irregular outline Management:
(lmage 137) 1. Hysteroscopic adhesiolysis
o Moth-eaten appearance
Note: In contrast to this, in case of polyp of fibroid uterus
defect is seen 2. Place a foleys catheter inside
=On HSG a single smooth filling
(mage 136)
progesterone for 3 months
3. Give Estrogen and
(Togrow endometrium)

fibroid/polyp
Image 136: HSG of

appearance of
Image 138: Hysteroscopic syndrome
Adhesions in Asherman
 Hans
and Gynecology by Dr Sakshi Arora
158 One Touch Obstetrics
95. HYSTEROSALPINGOGRAPHY

C/I =
Procedure
1. Pregnancy
lodinated water soluble dye is passed into
wilkinson
uterine
cannula 2. Active genital TB Infection
Leech
cavity with the help of 3. Active PID.
followed by serialX-rays.
Dye: Urografin
Instrunent used
Leech wWilkinson cannula (lmage 139)
Done on = D7-D1o of cycle (i.e. preovulatory phase) Right tube
Left tube
Uterus

Spill of Spill of
dye dye

Image 140: Normal HSG

Image 139: Leech Wilkinson cannula

Uses of HSG

Mullerian Malformations In case of Genital TB: It is IOC: For Tubal Filling Defect Seen
are seen as coincidental (After T/t if HSG patency
| findings on HSG If filling defect is
Smooth: Fibroid/
is done:) Typical
appearances seen Tubal block seen polyp
1. Beaded appearance (lmage 136)
of Tube (lmage 141) If filling defects
2. Golf stick appearance are multiple
(lmage 143) and have
3. Cotton wool moth-eaten
appearance appearance:
(Image 144) Asherman
4. Lead pipe appearance syndrome
(mage 142) (lmage 137)
S. B/L cornual block
6. Tobacco pouch like
appearance
7. Asherman syndrome:
Multiple filling defects
(lmage 137)
 GYNECOLOGY
96. GENITAL TB

Image 141: HSG of Genital TB Image 142: HSG of Genital TB

Beaded appearance of tube Lead pipe appearance of tube

lmage 143: HSG of Genital TB lmage 144: HSG of Genital TB

Golf stick appearance of tube Cotton wool appearance of tube

Important Points
M/C: Genital TB is a secondary infection. M/Cpelvic finding in Genital TB = Normal
M/C primary site for infection =Lungs followed 2nd M/Cpelvic finding in Genital TB = Adnexal
Tenderness
by lymph nodes
M/C route of spread = Hematogenous M/Cpelvic finding in adolescent gives in Genital
TB = B/L Adnexal mass
MVCsite = Fallopian Tube (Ampulla) IOC =Endometrial biopsy in premenstrual phase.
From FT ’ spreads to endometrium and T/t for Genital TB = ATT x6 months
Ovary by direct spread T/t for infertility in Gential TB = VE
Least Common site =Vagina and vulva.
M/C Symptom =lnfertility Genital TB can lead to B/L cornual block on HSG
M/C Polymenorrhea but M/C cause of B/L cornual block on HSG is
menstrualamenorrhea
secondary
irregularity seen physiological spasm.
 160

Bacterial
Vaginosis Trichomonas
Vaginitis
Leukorrhea/Physiologial
Discharge
Discharge:
Alteration Partner
replaced Pregnant B/D T/t pH
Gold I0C (lmage On Discharge
146) Other o
protozoa)
Organism No
Odorless
Colourless
profuse/scanty (white)
Could be
Colorless
smelling
Foul A/W Frothy,
of P/S smellingFoul itching
standard
culture
x= = =
discharge
Saline
Nonpregnant7
Dyspareunia/dysuria
complaints =
examination
bytreatment days pruritus (No
Image in = Yellowish -
Gardnerella, Metronidazole microscopy Trichomonas foul
vaginal =
145: >4.5 smell)
= =
Given = discharge One
Clue Metronidazole Strawberry
Mycoplasma,flora. = Touch
cell
except
as Motility vaginalis
it
Doderlein is in Obstetrics
on seen vagina
T1 so0 (Flagellated
etc. STD.
VAGINITIS97. and
bacilli mg
Gynecology
Candidiasis
symptoms Topical Standard
Partner
Pregnant- Gold
T/t-culture pH discharge
IOC Other n Organism:
likeCandida Partner
Pregnant
albicans. Criteria B/D T/t (lmage
Gold145). IOC:odor Whiff pH
MaiDischarge: by
= of x = Saline seen
itching
of No Dr
Saline complaint
Nonpregnant discharge standard
7 test
discharge
complaints T/t days
forNonpregnant Sakshi
Image T/Azole:
t
Oral Curdy diagnosing (Positive =
= microscopy
Metronidazole= = microscopy
Not Add Arora
146: Miconazole = >4.5
Not <4.5 = Gram
Azoles =
Pruritus white needed. test) 10% Hans
Strawberry givenFluconazole = Splash
BV staining = -’ KOH
are discharge/cottage
’
or Metronidazole
= but Clue
unless not Hyphae dysuria
clotrimazole Amsels to
vagina given avoid Nugent cells
150 discharge,
partner seen
seen criteria in
mg T1500 score
shows used stat cheese fishy
chlamydia|M/in|have Cogwheel
CAdhesions ITZ SiUSGgnson mg
symptomatic
partner Chlamydia
TreatAzithromycin pocfor IUcauseCDMIC
(limage
Hydrosalpinx
Wai Adhesions in
cavityAdhesions
st147)Beadsperitoneal inside
tube 2/m DOCfor OR causeMIC causof
Mc
PIeD: 2rd CauseM/C of
Violin HUGH
Cefixime T.
Doxycycline Actinomyces M/C
between
are sign on Gonorrhea
single = Gonorrhea
acute of
string of Cause:
sign string 100
CURTIS
formed (Image 2 PID PID PID:
800
dose g
mgsingle in Chlamydia
in
>
(lwmageappearance OR Polymicrobial
appearance
Gonorrhea Syndrome 149) mg lnj BD virgin
148) singleCeftriaxone days x dose
7 users:female:
>
Goorrhea
(lmage liver dose
Genital
LaparoscopyPIDin SOO
150) and be investigation
standard
Specimen ScoreScoring adnexa
directly
Laparoscopy
tubes,
With Gold
anterior GYNECOLOGY
done: 98.
for can PID
can BOER PID
abdomen conception be
be
collected MIESEL visualized Additional Minimum
Criteria CDC
Criteria following:Lower
Criteria
Specific
which TVS/MRI Raised WBC
CRPabundant
Mucopurulent
ESR discharge
Microscopy tenderness
Adnexal
Uterine
tenderness
Cervical
motion
Fevertenderness
can Laparoscopy
Endometrial
Biopsy LabRaised criteria
abdominal
Test
mass GAINESVILLE
staging
StageStage for
Consequences
Long-Term StageabscessStage StagingPIDof of for
Chronic
pelvic
Recurrent Infertility
(M/C)
pain Ectopic
PIDpregnancy
Hydrosalpinx chlamydia/ discharge: pain
Diaqnosis
4: 3: 2: 1:
Ruptured Peritonitis No with
Tubo
Peritonitis any
Gonorrhea Shows of
ovarian
Tubo present of PID

ovarian mass/
161
 Dr Sakshi Arora Hans
162 One Touch Obstetrics and Gynecology by

Dilated fallopiasabe withy

pearls on stagsgn

lnage 147: Beads on string appearance lmage 148: Cogwheel sign

lenage 149: Waist sign lmage 150: Violin string adhesions,

Fitz Hugh Curtis syndrome

99. SYNDROMIC MANAGEMENT

1. Vaginal discharge 2. Urethritis
GREEN KIT KIT NO. 2 3. Anorectal discharge
T. fluconazole 15O mg 4. Serotal pain syndrome
T. Secnidazole 2 gm
Partner treatment not done.
3. Lower Abdomen Pain Syndrome (PID)
If pt C/0 Lower abdomen pain with ang
2. CERVICAL discharge
To differentiate between vaginal
following.
Uterine tenderness
cervical discharge ’ do a Perspeculumdischarge and
examination. Adnexal tenderness
If on Perspeculum Examination ’ Cervical erosion/ Cervical motion tenderness
cervical ulcer/mucopurulent cervical discharge are She is given Kit No. 6
seen ’ Kit-for cervical discharge given, i.e.: YELLOW KIT/KIT NO. 6
GREY KIT/KIT NO. 1
T. Cefixime 400 mg OD x 1 day T. Doxycycline 10Omg BDx 14 days
T Metronidazole 400 mg BD x 14
T. Azithromycin 1 g OD stat days
T. Cefixime 400 mg OD x 1
Other uses of Grey Kit day
1. Used for partner t/t for PID Partner treatment in this case is done with grey
 GYNECOLOGY
100. MULLERIAN MALFORMATIONS
mportant PYQs
Mullerian
uterus.
Anomaly: Septate > Bicornuate 7. Maxm
associated with renal anamalies
2. MIC clinical features: Recurrent Abortion mullerian agenesis > unicornuate uterus
Infertility a/w: Septate uterus 8. Surgery for septate uterus:
23. resection of septum Hysteroscopic
otcome: Arcuate uterus > didelphus 9. Indications for surgery: Recurrent
uterus Abortion
10. Surqery for bicornuate uterus: StrauSman
worst reproductive outcome: Unicornuate
uterus metroplasty
11. Surgery for didelphys uterus: Unification
Uncommon lie in Didelphys: =Transverse lie
Surgery
Malpresentations seen in
Congenital Malformation Gynae complication with mullerian mnalformation
Infertility
Outflow tract obstruction > hematometra
Endometriosis
Dysmenorrhea
TRANSVERSE lie BREECH
Septate uterus Uterus didelphys > Obstetric complication With mullerian malformation
Subseptate uterus Bicornuate uterus Recurrent pregnancy loss (RR)
Bicornuate uterus Preterm labor
Malpresentation
M/C complication: RPL
vstigations for: Mullerian malformation
1st Investigation = TVS or ASG Specific complain in unicornuate uterus
00= 3D USG Unilateral dysmenorrhea
Gold standard investigation: MRI Ectopicpregnancy
Last Resort Laporoscopy + Hyste roscop9 Ectopic Ovary
U/L Renal anomalies

Rlevant Ewmbryology
2. Major part of female genital tract is derived from Müllerian duct.
2
3 Müllerian duct: Invagination of coelomic epithelium (at 6 weeks).
Each MD gives rise to that side FT, half of uterus, half of cervix and upper half of vagina.
At
10
S Fusio weeks: Right and left MD approach in midline and fuse with each to form a septa.
20 begins
6 At in below upward direction.
D. Weeks: The septa dissolves (from below upwards). Asingle uterine cavity is now formed.
Last step: Fundus of uterus becomes dome shaped.
Yagippernal development:
part = Müllerian duct
rtF Sinovaainal bulb of urogenital sinus
 Hans
64 One Touch Obstetrics and Gynecology by Dr Sakshi Arora

Mullerian Malformations
Comment
CLASS HSG Image
Both MD Absent
Class t: Mullerian agenesis Ovary present as it
genital ridge arises from
Class ll: Unicornuate uterus Single MD
Single fallopian tube
On HSG
Single FT
Half of uterus
Half of cervix and
Half of upper vagina
Banana shaped uterus
(lmage 151)

Image 1S1: Unicornuate uterus

Class Ill Uterus Didelphys Both MD are present but fail

to fuse. Hence 2 vagina seen
It is the only condition where
2 vagina are present
Hence on HSG 2 Leech
Wilkinson Cannula used
(lmage 152)

Image 1s2: Uterus didelphys

Class IV: BicornuateUterus MD Start fusing but fusion is

(Grossly = fundus of uterus incomplete.
is divided into There are two uterine horns
2 parts) and single vagina.
Cervix could be one or tw0
1. If there is single cervix -
Unicollis
2. If 2 cervix = Bicollis

Image 153: HSG of bicornuate Uterus

Angle between uterine horns: obtuse
Distance between horns 24 cm
 GYNECOLOGY
LASS
HSG Iwmage
Comment
Septate Uterus
ClassV of uterus
Grosy= funduS Both MD fuse
&notdivided) Septa is formed
But Septa fails to resolve
There are 2 uterine horns and
single vagina
1. On HSG: It is difficult
to differentiate between
septateand bicornuate
uterus
2. To differentiate between
them fundus of uterus
should be visible
In bicornuate: Fundus is
divided
In septate: It is not divided
Note: Fundus of uterus fused Image 154: Septate uterus
inseptate uterus. Angle between uterine horns: Acute
Distance between horns <4 cm
Class VI: Arcuate uterus Flat topped uterus or there is
slightly dipped fundus
Best reproductive outcome

Image 155: Arcuate uterus

Class VIl: ln utero expoSure M/C malignancy a/w DES:

Clear cell cancer of cervix and
|to Diethylstilbestrol (DES) vagina
M/C uterine malformation
a/w DES: Hypoplastic uterus
Most specific uterine
malformation a/w DES:
T shaped uterus
DES exposure does not lead
to renal anomalies in female
fetuses.
 by Dr Sakshi Arora Hans
Obstetrics and Gynecology
166 One Touch MALES
DEVELOPMENT IN
101. NORMAL SEXUAL

DEVELOPMENT IN MALES
NORMAL SEXUAL
* SRY region is present On
distal end of short
chromosome is present = SRY region is
present chromoso me arm ofy
Y * In males SRY gene activatec
SOX-9 gene for testis
Testis |(6-7 weeks) formation
Gonad
(Develop from genital ridge)
Testis has

LEYDIG CELLS
SERTOLI CELLS

* Appear by 6-7 weeks Appear by 7-8 weeks

* Lies
* Express SRY gene outside blood
testis barrier
Testosterone @ 8 weeks
Mullerian Inhibin B
Inhibiting substance
released (AMH)
-ve feedback With
Promote -ve feedback
On FSH
growth of on GnRH and help of s
Regression of MD reductase
Wolffian duct LH
Abdominal Scrotal descent
gets
COnverted
descent of of testis
Remnants of to
testes
MD in males
1. Prostatic utricle Male internal genital Dihydro
2. Appendix of testis organs Testosterone
S= Sewminal vesicles (T and DHT act
E= Epididymis through same
receptors)
E = Ejaculatory duct
D= Vas deferens
Masculanization of
external genitalia

Also Know
Lst feature of developing testis on
Descent of testis occurs with help ofUSG: Presence of testicular cords.
1st stimnulus for Leydig cells to Gubernaculum
release testosterone =(Processus vaginalis)
Mullerian duct isparamesonephric duct and hCG
Wolffian duct is mesonephric duct
 102.
GYNECOLOGY
NORMAL SEXUAL
NORMAL SEXUAL DEVELOPMENT IN FEMALES
DEVELOPMENT IN FEMALES
YchromoSOme is * Absence of Y chroosome
absent (SRY reqion
absent) determines the presence of
Ovary
But for proper development
Gonads: Ovaries of ovary both X chromosomes
are needed
* D/t absence of SRY region in
females: WnTY4, RSPO1 and
No sertoli cells DAX1 genes get activated
No Leydig cells leading to ovary formation.
No MIS/AMH
No Testosterone

MD grows and leads to

development of:
Fallopian tube Wolffian duct No DHT
Uterus regresses
Cervix Remnants of
WD in females: No masculanization of
Upper vagina
Epoophoron external genitalia
Paroophoron
Gartners Duct
External genitalia look
female like

Note:
Oraries develop from genital ridge
Lower vagina develops from = Sinovaginal bulb of urogenital sinus
Upper vagina and lower vagina fuse to form a transverse septa which resolves by 20 weeks of
ghancy. If it does not resolve it results in transverse vaginal septum
Ovary is
hormonallyhave natural tendency to form female external genitalia in absence of any hormone
External genitalia
silent in lU life
ants of WD are present in leaves of broad ligament.
168 Gynecology by Dr Sakshi Arora Hans
One Touch Obstetrics and
EXTERNAL GENITALIA
103. DEVELOPMENT OF
External genitalia develop from same Qmalaam in both males and females.
testosterone/DHTis present: Male external genitalia formed
rtestosterone/DHT is absent: Female external genitalia formed
Testosterone +nt/XY Testosterone -nt/XX
Genital tubercle Penis Uterus

Labioscrotal swelling Scrotum Labia majora

Genital fold/urethral fold Penile urethra Labia minora
Testosterone XY individuals XX individuals
Absent
Female ext genitalia Female ext genitalia
Present in N levels In XX individuals
Male ext genitalia
Testosterone is neverwithpresent
ovary: in
Such levels that male ext
formed genital
Present but low levels Ambiguous genitalia Ambiguous genitalia
Ambiguous Genitalia
Includes Clitoromegaly, LabioSCrotal fusion, Micropenis, etc.
M/Ccause of ambiguous genitalia in XX individuals: Congenital adrenal
" M/C cause of ambiguous genitalia in XY individuals: hyperplasia.
Androgen
1st step to do when achild is born with ambiguous genitalia = insensitivity syndrome.
I0C is = Karyotyping. Thorough physical examination

Hermaphroditism

True
Hermaphrodite Pseudo Herma
phrodite

Individual with Female Male

both ovaries and Pseudo Hermaphrodite
testis present means Gonods: ovary
Ext Genitalia = Male
M/C cause = CAH
Pseudo Hermaphrodite
means Gonads: Testis
Ext Genitalia = Female
M/Ccause = Partial Androgen
Insensitivity Syndrome
 104. GYNECOLOGY 16
External FEMALE EXTERNAL
gmale
Genitalia
i's the area of the
=
Vulva (lmage 156) GENITALIA
comprising the Homologous Glands
perineumminora,
Valva
pubis, labia majora and
mons of vagina and urethra
qpening and the Male Female
Thelabia majora
are areas of
skin with Cowper's gland Bartholin gland/Greater
fat
pads which bound the
the labia minora vagina. Medialunderlying
to these vestibular gland
are
Posteriorly where labia Prostate gland
Glands of Littre Skene/paraurethral glands
Posterior commissure majora meet is: Glands in labia minora
Posteriorly where labia and majora
Fourchette inora meet is: Vulval and Vaginal
,Anteriorlylabia minora come
Cyst
together to form M/C cyst: Inclusion cyst
the prepuce of the clitoris & frenulum of clitoris.
On each side of the introitus are the ducts of Bartholin cyst: Located in vestibule at junction of
Ant
qreater vestibular glands known as the 2/3rd and posterior 1/3rd (lmage 157).
glands. Bartholin's Gartner cyst: Located an anterior wall of vagina
dhe vulval blood supply comes from the pudendal Paraurethral cyst: Located
artery and lymphatic aranage is through the adjacent to urethra
inguinal lymph nodes. The nerve Supply co mes Management of Bartholin Cyst
mostly from the pudendal nerve and pelvic 1. For
plexus. symptomatic Bartholin cyst/abscess: Incision
and drainage.
2. For asymptomatic Bartholin cyst:
Vestibule: Area of vulva bounded bu (a) For size <3 cm: Conservative management.
Anteriorly: Clitoris (b) For size 23 cm: Incision and drainagqe.
Laterally: Labia minora If incision and drainage is done for a total
Posteriorly: Fourchette of 3 times, then the next step would be
marsupialization.
Bartholin glands originate from urogenital sinus Biopsy of the cyst wall should be done in cases of:
1. If aqe is >4O years or
2. Post menopausal or
3. Solid mass or a solid mass fixed to a structure.
Inthese patients, Bartholin cancer should be suspected.
Mons

Clitoris Labium majus

Skene's gland Labium minus
opening Urethra
Vaginal opening Hymen
Bartholin's gland
Perineum opening

Anus

Image 156: Vulva

 by Dr SakshiArora Hans
70 One Touch Obstetrics and Gynecology
105. PUBERTY

Precocious Puberty
Important PYQs Puberty occurs at <8 years in
Puberty age in = 10.5 years
Puberty Age in o: 11.5 years
<9 years in males.
More common in females
females or
Sequence of puberty in Most common cause is ldiopathic
females = Growth spurt DOC =continuous GnRH
(First sign) Breast Precocious menstruation Occurs at
Budding (Thelarche, first
visible sign) ’ Pubarche
Delayed Puberty = If puberty (does nl <10years
occur by 13 years in females or by 14
(appearance of pubicand in males years|
axillary hair) ’ peak Height More common in males.
velocity ’ menarche
(12.5 years) Most common cause = Constitutional
Sequence in males: Testicular delay other cause is Kallmann syndrome
DOC = Pulsatile GnRH
enlargement (First sign)
’ Penile enlargement ’
Pubarche ’ peak Ht velocity Central Precocious Puberty
For breast development in It is due to premature activation of
females, Estrogen is needed HPO axis.
For pubic hair and axillary Mostly idiopathic but in 10% cases it could
hair development Androgen
is needed.
PUBERTY
be due to brain tumour (Hamartoma)
‘ LH, ‘ FSH, ‘ estrogen
Always isosexual.
TANNER Staging Peripheral precocious puberty
5 stages for breast and pubic Due to exogenous production of
hair development. estrogen (lsosexual) or Androgen
Stage 1 & 2: Early stages of (Heterosexual)
Causes = Granulosa cell Tm
development
Stage 4 & 5: Fully formed Isosexual: Hypothyroidism, McCune -
breast and pubic hair. Albright syndrome
Breast budding means: Tanner Heterosexual: CAH, Androgen secreting
stage 2 Ovarian tumor.
Hair on Mons Pubis means: ‘ estrogen, LH, FSH
Tanner stage 3. Management: Treat the cause.
Ix done in all cases of precocious puberty
1. Bone age evaluation
2. LH, FSH, estrogen estimation
3. MRI skull
4. TSH levels.
S. USG
Ix done only in heterosexual precocious
puberty = DHEAS, testosterone, 170H
Bartholin progesterone
gland cyst
|MeCune-Albright syndrome
Cafe au lait spots
Polyostotic fibrous dysplasia
Image 157: Bartholin gland cyst Precocious puberty
 GYNECOLOGY
106.
DISORDER OF SEX
Probem with gonads DEVELOPMENT:
Problem with
46XX INDIVIDUALS
Ovotestis Internal genitalia Problemn with external genitalia
2 SeXreVersal Mullerian agenesis Ambiguous genitalia seen in
congenital adrenal hyperplasia
AoTESTIS(re hermaphroditisna)
46XX sex reversal complete sex reversal
Karyotype= 46 XX (M/C) 46XY
Gonads. =
Both ovary and
testes are
(Sometimes) Problem SRY gene is activated On
each side or both on both sides
present (one chromoSo me
On Gonads as SRY qene is present: Testes develop
Ontheside where ovary is present: Mullerian duct o Sertoli cells - Normal ’ secretes AMH
develops ’ Female lnternal genitalia develop hormone ’ MD regresses.
side where Testis is present: wolffian duct o
On the
develops, male internal genitalia develop Leydig cells: Namal ’ secretes testosterone in
adequate amount ’ WD develops
Since Hormone: Testosterone is present (but it " lnternal genitalia organ = Male internal
not adequate) leading to masculanization of genitalia organs
external genitalia External genitalia organ = Male Ext genitalia
birth
Taken as = Male child@ organs
3/4th of them develop gynecomastia Taken as male child
1/4th of them menstruate Secondary sexual characteristics of males
develop
These individuals in later life complain of:
Because for proper
Infertility: both testosterone
spermatogenesis tooccur
and Y chromoso me must be present
Cryptorchidism
Short stature

Clinical Features
Congenital Adrenal Hyperplasia genitalia.
individual is born with ambiguousaldosterone,
qenitalia in fewmales 46 XX
CAH is M/C cause of ambiquous It is life threatening, as d/t decreased
Hydroxylase has hyponatremia (Low BP), hyperkalemia
M/C enzyme deficiency = 21a Hydroxylase
Childmetabolic
and acidosis
2nd enzyme deficiency = 11ß decreased cortisol there is Hypoglycemia
Due to
deficiency Baby's BP is decreased
PetDecreased
hophysiolocortisol,
gy Decreased
corticosterone,

decreased aldosterone feedback on with

negative 46 XX individual
Since cortisol is decreased; If in
CAH ’
ACTH is lost ambiguous genitalia with
of decreased
ACTH increased BP is increased instead
Then enzyme
’hydroxylase deficiency is 11B
Androgens increased (Here deoxycortisone
BP)
levels are Ted, child has high
 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

Congenital adrenal hyperplasia

Diagnosis Enzyme deficiency causing Mat of CAH

Screening test ambiguous genitalia in 46XY DOC: Corticosteroid
17 (OH) progesterone individuals (as it will ACTH)
<200 ng:- Rules out CAH 17u Hydroxylase
> 800ng: Confirwms CAH DOC in P= if she
17-20 lyase has CAHa
200-800 ng:
Do diagnostic test Hydrocortisone
Enzyme deficiency causing (as it doesn't cross
iLe., ACTH stimulation test
ambiguous genitalia in both placenta)
DOCin with
XX and XY individuals
"3 BHSD suspected fetus
with CAH:
"P450 Oxidoreductase Dexamethasone
deficiency (P450 OR (as it cross -placenta)
P4SO Oxido Reductase deficiency deficiency) When a newborn with
Newly diagnosed form of CAH XX is born with CAH
P450 is an electron donor for Leads to skeletal T/t is
many enzymes abnormalities like
1. Hydrocortisone
:It affects both males and craniosynostosis and 2. Fludrocortisone
females
Hence it leads to ambiguous Antley Bixler syndrome also 3. NaCl

genitalia in both male and female " Aromatase deficiency 4. Reconstruction

fetuses surgery for genitalia

Cholesterol Mineralocorticolds
P450scc Glucocorticoids
StAR Protein Sex Hormones

Dehydroepiandrosterone sulfate
27a-hydroxylase
Pregnenolone +17-0H
17,20 Lyase 17ß-HSD
pregnenolone Dehydroepi.
androsterone
’ Androstenediol

3p-HSD17a-hydroxylase 3B-HSD 3B-HSD 3B-HSD

17, 20 Lyase 17B-HSD
Progesterone 17-OH + Androstenedione +Testosterone
progesterone
21-Hydroxylase Aromatase
21-Hydroxylase Aromatase

Deoxycorticosterone 11-Deoxycortisol Estrone 17B-HSD+Estradiol

118-Hydroxylase 118-Oxidase
Corticosterone Cortisol
18-Hydroxylase
18-0H corticosterone
18-0xidase

Aldosterone

Image 158: Flowchart for adrenal hormone production

 GYNECOLOGY
L07. 46XY DSD
46XY DSD
A With exactly female
looking external genitalia B. With ambiguous
1. Complete
syndromne androgen insensitivity genitalia
2. Swyer syndrome L. Partial androgen
3.5 areductase insensitivitysyndrome
deficiency (testosterone
and not converted to ’
DHT)
2. CAH dlt
4. LH receptor defect - 17-20lyase
- 17 a hydroxylase
Imp PYQ's
-3 BHSD
- M/C cause of
ambiquous
qenitalia in XY genotype - -P45O oxido
Partial androgen insensitivity reductase deficiency
syndrome 3. Ovotestis (46 X)
.Ifan individual who is
phenotypically
female presents with inguinal Causes of ambiguous
hernia = suspect undescended genitalia in XX includes
testis and XY karyotype 1. CAH due to
" All individuals with XY -21 alpha hydroxylase
karyotype and exactly female deficiency
External genitalia : - 11 beta hydroxylase
Present as a case of primary deficiency
amenorrhea and have - P450 or deficiency
undescended testis (inguinal 2.. Ovotestis 46 XX
hernia) 3. Aromatase deficiency
4. Maternal exposure to
Undescended testis
" Have high risk of malignancy
androgenic drugs
5. Maternal overproduction
" MIC = Gonadoblastoma of androgen e.g.,: (in
M/Cmalignancy :- dysgerminoma luteoma and theca lutein
In all cases of undescended testis ’
gonadectomy should be done cyst)
 One Touch Obstetrics and Gynecology by Dr SakshiArora Hans

108. WORKUP OF A CASE OF AMBIGUOUS GENITALIA

When a newborn is born with ambiguous genitalia

1st step Best investigation/IOC

Physical examination Karyotyping/FISH technique

|Ifgonads are palpable If gonads are not palpable

46 XY karyotype 46 XX karyotype
Suspected Suspected
* Probably = CAH
* It is a life threatening condition :
Testosterone
so send investigations but
DHT do not wait for report
AMH to initiate T/t
LH
FSH
l7 " Karyotype/FISH
Pelvic USG " 17 OH progesterone
"Sr. electrolytes
l, = (nvestigations
DHT = Dihydrotestoste rone
AMH = Anti mullerian
hormone
 GYNECOLOGY
KARYOTYPE WITHAS EXACTLY
PRESENTING PRIMARY FEMALE LOOKING GENITALIA AND
Rgince Complete AIS
46XY
AMENORRHE SWYERS Sndronz
Undescended testis 46XY

Srtnl
celr
Individuals &areDHTinsenstive
Testosterone to
Undescended dusanetic testis
Testes are dysgenetic
Normal ’secrete MIS
:. MD Regresses
Ldgcel Dysgenetic: NO MS MD grows
Normal
but these
’
s2Crete testosteroe Dusgcnetic: no
Individuals are testosterone so
to it resistant WD regreSSZS
C SEnital organs :WD regresses
None
Absent Fenale int qenital organs
Btgenital organs Present
Resistant to DHT SO Female Ext No
genital organs seen tastosterone
Female Ext qenitalia setn
Atpuberty
Testosterone gets cOnverted to No
Testosterone
Bect (development of breast is estrogen No estrogen
Estrogern dependent) Present; fully developed Tarner Absent
stage 4, S
Abie and axillary hair (d/t Absent as these individuals are Absent
drogen) resistant to anarogens
Increased (D/t resistance to lncreased (NO testostzrone)
testosterone
PSH Normal (D/t nhibin secreted
by sertoli cells) lncreased (NO rhibin)
Management
Let Gonadectomy after breast Iumediate Gonadectonn
individuals be females development is complete
Estrogen for 1 uear for
(26-18 yrs of age) breast development i/e E -
Estrogen Replacemnent Preplacement (as uters s
therapy present)
Progesterone not needed as
there is no uterus
Vaginoplasty

Partial
Arndrogen Insensitivity Syndrome At puberty: Pt C/O prinary
Testosterone iS converted toamenonrhea
Androgendisorder
Recessive lnsensitivity syndrome. is an Xlinked estrotn SoL
breast development = corresponds
stage 4 or s (well develope)
to Tarntr
CompleteTestisAIS:(undescended)
Gonads:
Here also: Pubic hair and aillary Hair: Slight an
corresponds to tarner stage or 2
Internal d/tgenital organs: Male: WD grows
slExternal
ightly genital organs
partial insensitivity to androgen
= Female External
Management
Imnediate gonadectomy Estrogen replaceent
genitalia with SOme masculanization Therapy +vaginoplasty (No neea to add Prgesteron)
appeari
They n
areg as ambiguous genitalia
taken as female child at birth
 Hans
76 One Touch Obstetrics and Gynecology by Dr SakshiArora

Make a Diagnosis
Diagnosis
Condition
A girl presents with primary amenorrhea, has Swyers syndrome (46XY)
uterus
inquinal hernia. On P/R examination:
present. No Breast development. No axillary and
Pubic hair
A girl presents with primary amenorrhea, Complete AS
has ingquinal hernia, uterus is absent. Breast (46 XY)
development corresponds to Tanner stages 5,
pubic hair corresponds to Tanner stage 1.
agenesis (Both MD absent, 46 XX
A girl presents with primary amenorrhea, uterus Mullerian
is absent. Both breast & pubic hair well developed
insensitivity syndrome
A girl presents with primary amenorrhea, has Partial androgen
inguinal hernia, uterus absent. Clitoromegaly
present, breast corresponds to Tanner stage s
pubic hair corresponds to Tanner stage 1

110. PRIMARY AMENORRHEA

Definition:
All cases of primary amenorrhea can be broadlu
divided into two categories:
Absence of menstruation by 15 years of age in
a female with breast budding or by 13 years in Primaru amnenorrhea with uterus absent
absence of breast. OR Mullerian agenesis (46 XX)
Absence of menstruation within 3 years of Androgen insensitivity syndrome (46 XY)
thelarche or
Absence of menstruation in a female by 14 years Primary amenorrhea with uterus present
with signs of hirsutism, excessive exercise or
Cryptomenorrhea (46 XX)
excessive eating. Kallman syndrome (46 XX)
Remember Turner syndrome (45 XO)
Swyers syndrome (46 XY)
Overall India
M/Ccause of Gonadal Mullerian agenesiS
1° amenorrhea dysgenesis
(Turner > Workup in a Case of Primary Amenorrhea
Swyer)
2nd M/C cause Mullerian Gonadal dysgenesis Breast
agenesis (Swyer > Turner 1. Physical
examination
Syndrome) Ext: genitalia
Should be done in
2. UPT all cases of primary
Causes: Organ wise amenorrhea
1. Hypothalamus Kallman syndrome (46 XX) To know:
3. USG uterus is present
2. Pituitary Craniopharyngioma or absent
3. Ovary Gonadal dysgenesis
Turner syndrome (45 XO) 4. FESH
Swyers syndrome (46 XY)
4. Uterus Mullerian agenesis (46 XX) Best investigation: Karyotyping
AIS (46 XY)
 Management LH
Testosterone somites
cervical
FSH Hemivertebrae,
Can Anomalies:
Skeletalkidney
sAapedproblems
ASSoci
Ranal: ated Abic organsBt
they development
srASt genital genital t
ionads
&
have
Renal axillary
kyotype
agenesis/horse organs
biological
hair
111.
child
shoe
PRIMARY

withVFYes N N
Normal genitalia
Female
ext (normal)
Ovaries Mullerian
agenesis
as
AMENORRHEA
Time:
marriage
vaginoplasty
Mclndoe difficulties
technique
Veichetti
Laparoscopic
Technique: coital
Vaginoplasty
orpatients
have as association
Hauser
Rokitansky,
(Mayer
Nsyndrome skeletal
X-ray)
KusterMRKH & (TannerNormal
breast Normal
estrogen
develop ovary
Normalso so vagina) MD (Best
upper int between way XX
46
ovaries
K/a Renal
female
levels skeletal
surrogacy
done (Tanner organs
absent:
Just GYNECOLOGY
syndrome) anomalies
are stage
anomalies them
before normal stage (FT,
Absent
differentiate to
4, uterus, is
or (:. 4, 5) karyotyping) WITH
or 5) female
after DolVP)
(Do
MURCS
cervix
UTERUS
No
Increased High X
Tanner testosterone) testis
Tauner Female Undescended
No XY
46
Syndrome
insensitivity
androgen
Complete
therapy
need (16-18)
mullerian
agenesis)
Estrogen Gonadectomy
development
Vaginoplastycomplete
(same after
is Let
as breast int
as ABSEN
them compared stage stage ext genital
to
add (No gentilia
placenment be 1, 4
& organs
2
uterus
geste 9 to S
fenale
(resistant
so
rone)
no levels
to
 Arora Hans
One Touch Obstetrics and Gynecology by Dr Sakshi

UTERUS PRESENT
112. PRIMARY AMENORRHEA WITH
FSH: Increased
1. Cryptomennorhea LH: lncreased
Karyotype: 46XX Estrogen: Decreased
Gonad: Ovary (N) Stature: Short (due to mutation in SHOX gene)
Internal genital organ: Females; uterus present Other Features (Image 159)
External genital organ: Females Low posterior Hairline
Problem:
Shield shaped chest
M/C Imperforate Hymen (no opening in Hymen Widely spaced nipples
through which menstrual blood cannot come out)
Transverse vaginal septa Heart diseases: Bicuspid aortic valve, coarctation
of aorta
Pt C/o:
Primary amenorrhea with cyclical pain in Cubitus valgus
abdomen. Mgt:
Pt may C/O urinary retention.
Estrogen alone X 1yr (for breast development
followed by E and progesterone
On P/R: Uterus present and enlarged (Hematometra). Growth hormone before age of 8 years
On L/E: Tensed blue bulging Hymen. Streak gonads of tuner are not malignant and
Mgt: Cruciate incision on Hymen. should not be removed
LH and FSH: Normal
3. Swyer's Syndrome
2. Turner Syndrome (Image 154)
Karyotype: 46XY
Karyotype: 45X0
Gonad = Streak ovary Gonad: Dysgenetic testis (No testosterone, NO MIS)
Estrogen = Less
Internal genital organs: Female Internal organs but
uterus is hypoplastic
Streak ovaries are not malignant External genital organs: Female external genital
Internal genital organs: Female internal organs but organs
uterus is Hypoplastic (as E is less) Breast: Absent
External genital organs: Female ext genital Pubic hair and Axillary Hair: Scanty
Breast: Absent (as E is less) FSH: Increased
Pubic hair and axillary hair: Scanty (as androgen is LH: lncreased
produced less by ovary)
Short stature
Characteristic facial features
Low hairline Fold of skin
Coarctation of aorta q9% of cases
Shield-shaped chest
Poor breast development aborted
Widely spaced nipples Cubitus valgus
Streak ovaries Gonads streak
Shortened metacarpal (underdeveloped 1 in 2,500 or
Small finger gonadal structures) 1 in 2,OO0
nails No menstruation liveborn females

Brown spots
(nevi)

Image 159: Turner syndrome

 amenorrhea
estigations
SCondaryVestigated.NOrmally.
Aso: Definition
Absence 5.
prolactin
Estrogen FSH
LH, TSH UPT
S a decreased and
Primary S.Drinary uterusand absent.
andpresent. and Make a GonaOvard:y
Females female Primary Primaryuterus
Primary
with problem:
short
normal
KATYoSyndrome
of Diagnosis
ty4p6eX:KaX l maenlopment Norourm: al
who amenorrhea
amenorrhea amenorrhea
Hypothalamic te
ImmediaDecreased
menstruation FSH stature
amenorrhea amenorrhea followed for 1
to having stature
be was aonadectomy
and year
done and
previously
<9 uterus
and failure:
cycles/year
in for with wrthuterus with
with
all uterus
present.
decreased
ncreasedincreased normal normal leading t
AMENORRHEA
females menstruating SECONDARY
90 113.
days present. Estrogen
by
present.
should E
with (3 LH FSH
to +
months) LH, LH LH P.
& for
be & & FSH & GnRH.
GYNECOLOGY
FSH LH breast
FSH

syndrome
Kallman syndrome
(45X0)
Swyer Turner Müllerian Pulsatile
(46XX) Cryptomenorrhea Stature:
GnRH Tlt:
Normal LowLH,Breast: as
ExternalInternal
Uterus OvaryPituitary
HypothalamusOrgan PregnancyM/CCauses
= Other FSH: Pubic estrogen
Chronic
anemia
ThyroidLactation
Hyperprolactinemia
Chronic
disease
kidneydisorders syndrome Features:
hair/AxillaryAbsent
agenesis genital genital
is
decreased
lorgan:
(as
erman
drome PCOS
syndrome Bulimia
SheehanAnorexia, Cause (46XY) Hyposmia/Anosmia, organ:
PrimaryProlactinoma Stress, (46 E
hair: is
XX) lesS) Female
Excessive Female
ovarian Scanty
but
nsuficiency exercise, (as uterus
color androgen is
hypoplastic
blindness
(PO) is
)
17
30 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

Workup of a Case of Secondary Amenorrhea

Measure FSH and estrogen levels

FSH increased 251U FSH = low to

Estrogen decreased normal (uptil 10)

Hypergonadotropic Do progeste rone

hypogonadism challenge test
Give MPA 10 mg BD
Suggestive of for 5 days and stop
premature menopause
Or POl
Bleeding present Bleeding absent
= Test +Ve = Test -Ve

Check
PCOC/anovulation
estrogen levels

Estrogen normal Estrogen decreased

Asherman syndrome MRI

Empty sella Space occupy lesion Normal

Sheehan syndrome Prolactinoma Hypothalamic

cause

Differential Diagnosis of 1° and 2° Amenorrhea based on FSH levels

FSH ‘(2 25 IU) FSH

FSH = N
Estrogen decreased decreased

Problemn = ovary Problenm uterus Problem = Hypothalamus/

Primary Amenorrhea
" Turner syndrome (45 xo)
" Swyer syndrome (46 xy)
Secondary Amenorrhea
"Premature menopause/POl
pituitary
Primary Amenorrhea Primary Amenorrhea
" Mullerian agenesis (46xX) " Kallmann syndrome
" Androgen insensitivity (+ Anosmia)
syndrome (46 xy)
Secondary Amenornhea Secondary Amenorrhea
" Asherman syndrome " Pregnancy
"Sheehan's syndrome
" Prolactinoma
 DROLACTIN DISORDERS:
pplactinoma

Prolactin:<20-25

is
iprolactin
N
ng
mildly elevated
PROLACTI
SheehanNOMA/ SHEEHAN
Syndrome
SYNDROME

Necrosis of Anterior pituitary gland dlt excessive

Repeata 2nd sample blood loss after delivery
poTSHevels GH decreases (1st hormone to decreased)
+fbothTSHand prolactin are LH and FSH
increased =always decrease
yeatTSHfirst ACTH decreases
prolactinisincreased Prolactin decreases
fonly
DoMRIbrain TSH levels are last to decrease.
Prolactinoma Clinical Features
Meroadenoma = <1 Cm Failure to lactate
Macroadenoma =>1 Cm Secondary amenorrhea (persistent)
Mild fatique and anorexia
Symptom of prolactinoma Loss of sexual and axillary hair
N/CAmenorrheafollowed by
infertility Hypothyroidism
Other Symptoms: Galactorrhea, delayed puberty
(D/t J GnRH) M/C Symptom: Failure to Lactate followed by 2°
amenorrhea
Symptoms specific of
girrounding structures)
macroadenoma (invade On MRI: Empty sella turcica
Bitemporal hemianopsia Pituitary Apoplexy
. Cavernous sinus syndrome Acute ischemic infarction/ Hemorrhage of pituitary
1 Headache gland (or undiagnosed adenoma)
One of precipitating factors for pituitary apoplexy
is PPH.
Mgt
Others could be Hypertension/Diabetes/SCA/
Acute stock
All hormnones formed by pituitary decrease
It is a life threatening condition
Conservative mgt Medical mgt Patient presents with:
(Follow-up with MRI DOC: Cabergoline > Headache of sudden onset
and serial prolactin bromocriptine
bvels) every 1-2 years (ndications: Visual disturbances
Asymptomatic Symptomatic +

microadenoma microadenoma
Shock (d/t ACTH deficiency)
Pregnancy
Lactation
Any
macroadenoma +

Hypoglycemia
Female C/O
Pituitary.
infertility (DOC = Management: Of both Sheehanandandlater thyroid
Indication for surgery Bromocriptine) Apoplexy is first corticosteroid and growth
After 4 months of hormones, sex steroid, vasopressin
|tnediprolactin
cal management hormone.

sill high. levels are Indications of surgery:

Progressive visual loss
1. Cranial nerve involvement
Only Condition where pregnant or lactating 2. Loss of consciousness
temale is medically
appear treated is if visual symptoms 3.
 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

115. FEMALE INFERTILITY ANOVULATION

Infertility: lnability to conceive Basic lnvestigation
after 1 year of unprotected To be done in all couples
intercourse who complain of infertility
Investigation for 1. Semen analysis
Infertility should begin 2. Sr. progesterone levels on
" Infemales <35 years: day 21 (test for anovulation)
After 1 year of unprotected 3. HSG (test for tubal patency)
intercourse
" In fewmales 35 years after 6 months
" In fewales 4O years after 3 months

Infertility

Causes Female infertility causes

" Female infertility:
40-55% of infertility
"Male infertility = Ovarian Tubal Uterine Cervical and
20-40% cases of Causes Causes Causes unexplained
infertility. causes

" Unexplained = 10%

Class I: Endometriosis Submucosal In cervi:
Hypogonadotropic PID fibroid " Cervicitis
Hypogonadism Salpingitis Endometrial " Presence of
e.g., Kallmann
polyp Antisperm
syndrome " Asherman Antibodies
syndrome
Class Il: " DES exposure
Normogonadotropic " Mullerian
Normogonadism malformations
e.g., PCOs

Class Il:
Hypergonadotropic
Hypogonadism
e.g., POl (Primary
ovarian insufficiency)
Class IV:
Increased prolactin
 GYNECOLOGY
Anovulation
D21-
-D22 of cycle (as on D21 Maximum
2oneOn
prgesterone
is present) Signs of ovulation on follicular monitoring:
Srprogesterone levels (Easiest and best test)
Size of follicle suddenly decreases.
Cervical mucus study 2. Fluid in pouch of Douglas.
Vaginalepithelial study 3. Trilaminar appearance of endometrium on
s Basal
bodytemperature USG.
4 Endometrial biopsy

6 Follicular monitoring: TVS from D10 of cycle

5

to see follicle. Every day follicle grows by

1-2 mwday till it reaches: 18-20 mm.

Female infertility
Anovulation

T/T of anovulation Clomiphene Letrozole

"Overall DOC in Action Peripherally
Centrally acting
anovulation: SERM acting drug
Clomiphene citrate which inhibits
"DOC for anovulation aromatase
in PCOS: Letrozole T2 Few weeks 48 hours
DOC for anovulation in It decreases It increases
pituitary ablation = HMG Estrogen and FSH
" DOCfor anovulation in ‘ FSH
Kallman syndrome = Startinq dose 50 mg 2.5 mg
pulsatile Maxm dose 150 Wmg 7.5 mg
GNRH Given between
D2-D5 on any day for 5 days
PYQ'S " Rate of ovulation
1. Prepequiste for ‘ (20%) 11 (27%)
" Chances of live birth
clomiphene: " Chances of pregnancy
Hypothalamic pit axis S-8% 3-7%
s/b normal (FsH= N) "Chances of twinning " Hot flashes " Headache
2. " M/Cside effect
Ovulation trigger = hCG
D. Inj. hCGas ovulation
- Ovarian cyst
-Dryness of vagina
Hot flashes
(less common)
trigger is not mandatary Note: If visual Earlier studies
in all pts of disturbances occur showed it is
clomiphene while pt is on teratogenic
clomiphene - it but now studies
should be stopped have shown it
immediately is not
" lt is not teratogenic
teratogenic
184 One Touch Obstetrics and Gynecology by Dr SakshiArora Hans

116. OVARIAN HYPERSTIMULATION SYNDROME

Risk Factors
|Imp concepts Pathophysiology
latrogenic complication Uinj HMG Young
M/C drug: HMG Multiple follicles grow PCOS
(If E2 22 500 pg) Thin female
L/C drug: Clomiphene
Not seen with: Letrozole Increased follicles
Early OHSS: develops within 9 Inj hCa given lncreased antral follicle Count
days of Inj hCG ‘ AMH (>3)
Late OHSS: develops >9 days All follicles rupture ‘ E, (225O0 pg)
after Inj hCa Pregnancy
Triger: lnj hCG VEGF released hCG for luteal phase support
*‘ Capillary permeability
leading to Symptoms and T/t
Hemoconcentration
Thrombosis
Abdominal pain, nausea, vomitina
MILD disease = T/t
Collection of fluid in
3rd space (Ascites,
Analgesics
pulmonary edema) Avoid strenuous activity &lntercourse
Admission not needed
Moderate-severe disease
Admit the patient
IV fluid
Heparin for thromboprophyllaxis
Image 160: USG in OHSS In pregnancy: Always admit the pationt
Also know Prevention of OHSS:
ldeally Inj hog should be given Monitor follicles, E, Levels
1. E2 = S00-1500 pg/m Withhold hcg if E, >2 500
2. >3 follicles Cabergoline decreases VEGF
3. Size of follicles >17 mm in diameter If risk of OHSS is present ’ delay
E2 released by each follicle is200 pg embryo transfer so that pregnancy
doesn't occur.

117. FEMALE INFERTILITY - POI

POI - Primary Ovarian Insufficiency

Tests for Ovarian Reserve Mgt

1. S: FSH: Day 3 FSH levels are measured. Levels are * (nfertility in these cases is treated by
increased in POI. IVF with donor eggs
2. S: Inhibin:
Levels decreased in POI Indication for Doing Test for Ovartan
3. S: Estrogen: J Reserve
4. S: Antimullerian hormone: (can be measured on any day).
Normal= 1 to 3.5 ng/mnL 1. Age of female 235 years
If value is <1 ng/mL = Borderline 2. H/O premature menopausl
If value is <O.5 ng/mL =lndicates POI family
5. Antral follicle count: Done with TVS 3. Personal H/O surgery or RT
4. Case of unexplained infertility
If <10follicles seen in both ovaries: Indicates POI.
 118. GYNECOLOGY
FEMALE
OC:
Tubalcauses lead to tubal block
HSG
GoldStandard
INFERTILITY: TUBAL CAUSE
LaparoscopicChromopertubation
(methylene blue or
LAparoscopeisinserted in
indigo carmine) is passed into
abdominal cavity to see the uterus
free spillage of dye.

Bilateral Cornual Block (Image 161)

ause = Physiological spasm
M/Ccase =
M/C
M/CPathological cause = Genital TB
Nextstep
Hysteroscopic cannulation (pass a guidewire
under hysteroscopic guidance) followed by
laparoscopic chromopertubation.
n most of cases: there is spasm/mucosal
which is relieved. plug
fblock persists
Best mgt: IVE

Image 161: HSG with bilateral cornual block

Bilateral Distal Block (Image 162)

Noxt step: Laparoscopic chromopertubation +
Hysteroscopy
FB/L mild block: Fimbrioplasty
FB/L severe block: IVF
Hydrosal pinx is seen: Before IVE 0S done; do
alpingectomy as fluid present in Hydrosalpinx is Riqht Uterine
Fetotoxic. hydrosalpinx Cavity Uterine
cavity
Image 162: HSG with BIL Distal block

Note:
Ip concepts Presence of hydrosalpinx wmeans disease is severe
Mgt of unilateral tubal block of any kind: is like
nexplained infertility. iie., clomiphene +(UI
 Gynecology by DrSakshi Arora Hans
86 One Touch Obstetrics and
119. MALE INFERTILITY

Note: In new semen analysis

* Semen Analysis Total sp count and normalforms remain
Done after an abstinence of 2-7
Sample should reach lab within 1
days
hour Terminology for abnormal semen analysis unchanged
Analysis is done on liquefied semen 1. Aspermia: Absent semen
Liquefaction time = 30minutes 2. Oligospermia: Sperm concentration
criteria
WHO semen analysis gives minimum <15 million/mL (as per now criteria
needed for conception (Not average values) <16 milion/mL)
New
3. Severe oligospermia: Sperm concentration
Semen analysis Older <5 million/m
|values values
parameter 4. Azoospermia: No sperm in semen
1.5 mL 1.4 mL
Semen volume (mL) 5. Teratospermia: Abnormal sperm morpholoau
Total sperm no (million/ 39 39 6. Asthenospermia: Decreased sperm motility
ejaculate 7. Necrozoospermia: Increased non viable sperm
40% 42%
Total motility %: Most Imp parameter of semen analysis:
Progressive motility 7% 32% 30%
Sperm wmorphology > Motility > concentration
Nonprogressive motility % 1% 1% If on semen analysis: Report is Azoospermia
22% 20% JNext step
Immotile sperm Repeat semen analysis after 1 month.
58% 54%
Vitality M/Ccause of male infertility: Testicular cause
Normal forms/Morphology 43 4% M/C reversible cause of male infertility :
Varicocele.

Azoospermia could be:

Pretesticular Testicular Post testicular Azo ospermia
(obstructive)
Defect in Hypothalamus/Pituitary Test Sperm pathway
LH/FSH Decreased Increased Normal

Testosterone Decreased Decreased Normal

Causes Kallman syndrome Klinefelter syndrome TB, Cystic fibrosis,

Hypothyroidism Mumps orchitis, Miners, Congenital B/L absence of
vas deferens, varicocele
Increased Prolactin heat expoSure
Mgt Tlt the cause Surgical extraction of Surgical correction
sperm from testis by TESE
followed by lCSI

Also Know In varicocele -On semen analysis-OATS seen

Azoospemia is seen in Oligospermia +Asthenospermia + Teratosperm
1. Klinefelter syndrome (These findings also seen in chronic smoker)
2. Cystic fibiosis If Azoosprmia is confirmed twice on sem
analysis-next step is etimation of FSH leves
Asthenospermia is seen in
1. Kartageners syndrome
2. Varicocele
 120.
ALGORITHM FOR OBSTRUCTIVE
Azoospermia present with LH,
FSH, AZOOSPERMA
Testosterone Normal (Refer image 163)
=

LOW semen volume, Decreased

Fructose
Semen volume =
Normal + Fructose present
Semen has cOme from prostate and
hulbourethral gland. Means SV has given its contribution
to semen

Seminal vesicle has not poured its

secretion (SV secretion Contain Obstruction is in epididynis or vas

fructose) deferens

Seen in: SCROTAL USG

2. Congenital B/L absence of sV
seen in cystic Fibrosis (Chk: CFTR SV =seminal vessicle
Mutation)
2. Obstruction in ejaculatory duct: -
Do transrectal USG
lmportant PYQ's
Major contributor to semen:- Seminal vesicle f/b
prostrate f/b Bulbourethral gland.
If SV dilated Seminal fluid = adds to volume of semen +
SVare normal makes it alkaline + adds fructose
= Obstruction
in Ejaculatory Prostatic secretions are acidic.
duct Retrograde Bulbo urethral gland gives secretions only
@ time of intercourse
ejaculation

Klinefelter Syndrome
enotype =47XXY
henotype = Tall men
long legs Seminal
9ynecomastia
estis = vesicle
Have Small and
Prostate

riskHypoplastic gland Vas deferens

increased
Breast cancer of Ejaculatory
1NonExtra Hodgki
gonadalns lympnowma
germ cell
Epididymis
duct

Q= Autoimmune
decreased disease Tm Testis
te span decreased
Note:. To measure size of testis: - Prader
orchidometer Image 163: Male reproductive system
to show sperm pathway
 DrSakshi Arora Hans
One Touch Obstetrics and Gynecolooy by
123. ART PROCEDURES
IU-Intrauterine Insenination Indications:
1. Tubal bleck
Prerequisite = At least 10 illion spervn 2. Mullerian agenesis (IVE surrogacy)
Decreased ovarian reserve(VE with
OPD procedure
Processed centriuged sperms (O4-06 nL) Olgaspermia in males with sperm cone a
donor egg)
Aelp of Ut
are inserted in uterine cavity with S-10 million m
catheter. Cannot be done for:
Indications: 1. Azoospermia
1. Female-cervical factor infertility 2. Asthenospermia
2. Unexplaned infertility (clomiphene citrate + lU) 3, Severe oligespernia
3. Males with ejaculatory problem (Hypospadias, Intracytoplasmic Sperm Injection ICSt
Epispadias)
4. Oligosperia with Sperm conc. 30-15 Procedure: Same as VF
milliornL Except: In cach oocyte a single sperm is injected.
Indications of ICSt:
IVE-Invitro Fertilisation
Azoospermia (after sperms are surgical
extracted from testis).
To female partner Give HmG injection so that
they hyperovulate. Asthenospermia
From D,. do follicular monitoring Severe oligospermia (sp conc <s milliov'mL)
When follicle is 17 mn and 3 follicles Remember: Azoospermia means absence of sperms
in scmen, not in testis.
Give injection hcg (ovulation trigger) be surgically extracted from testis by:
After 32-36 hours - Do egg retrieval under Sperms can
USG guidance. TESE: Testicular sperm extraction
Theoocyte picked are incubated with sperms = " TESA: Testicular sperm
aspiration
For each oocyte F
50,000 to 1 lakh sperm Maleproblem Management
o Temperature =37°C IUl (Sperns taken
Retro grade ejaculation from rine sample)
o0, = S-20
o Tie = 12-18 hours.
eimbryo Premature ejaculation SSRI
After fertilization occurs, on Day 3 (cleavage is
transfer) or Day s (Blastocyst) embryo transfer Ejaculatory problem= IU
done 2 cm below fundus. Hypospadias
Success Rate = 20-30% Erectile dystunction Sildenafil
Prerequisite = At least S nillion sp/m
 GYNECOLOGY
122. PROLAPSE
Supportsof Uterus
Ligaments which support uterus:- PYQ'S
() CARDINAL Ligament/Transverse 1. of
First step for prolapse: Retroversion
uterus
cervical ligament/Mckenrodt 2. Fixed retroverted uterus seen in
ligament
(i) Pubocervical ligament Endometriosis
(i1) Uterosacral ligament 3. Liganment which keeps uterus
in Anteverted position Round
Together K/a TRIRADIATE ligament. ligament.
Muscles which support uterus:- 4. Ligament which prevents retro
2 version = uterosacral
() Levator ani muscle
(Most Imp S. Ligament which is secondary
support)
support =Round ligament
i) Superficial and deep transverse 6. Ligament which doesn't support
perinell muscle
uterus: Broad ligament
(ii) Bulbospongiosus
Mechanical support
Angle of anteversion = 90° (b/w cervix
and vagina)
Angle of anteflexion = 120° (b/w uterus
and cervix)

PROLAPSE

Vaginal De Lancey Support

Decubitus Ulcer
Cause: Venous congestion
|with
Management:
AcriflavinePacking
(antiseptic) and glycerine.
Classification of
Prolapse:
POP-Q Classification
LEVEL 1
Risk Factors Supports upper 1/3rd of vagina
Supporting structures:
Elderly menopausal Uterosacral ligament
females
Birth trauma
Cardinal ligament
Defect leads to
Multigravida Apical prolapse
Instrumental delivery Vault prolapse
Elongation of cervix
Enterocele
LEVEL 2
Best method to prevent
Support middle 1/3rd of vagina
Prolapse:
Perineal Exercise/
Supporting structures:
Arcus Tendinous fascia

Reference point: - Hymer Kegels exercise Defect leads to

Cystocele
Rectocele
LEVEL3
Support lower 1/3rd of vagina
Supporting structures:
Perineal body and muscles attached
to it.
Defect leads to
Urethrocele
Laxed perineum
 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Harns

To prevent vault prolapse after

Vaginal Prolapse
Anterior Vaginal Wall
Upper 2/3rd =Cystocele
Uterosacral suspension is
Management of Vault Prolapse
done
prophylHyasctteirecaltolmyy
Management:- Anterior colporraphy Vaginal surgery
Lower 1/3rd = Urethrocele 1. Uterosacral suspension (both
Management:- Anterior colporraphy therapautic)
2. Sacrospinous Fixation
prophyllactic
Posterior Vaginal Wall 3. Lefort colpocleisis
Upper 1/3rd = Enterocele Abdominal surgery:
Management:- McCall culdoplasty Sacral colpopexy (Difficult to perform but
Middle 1/3rd = Rectocele restults). gives best
Lower 1/3rd = Laxed peureum M/C done is: uterosacral suspension
Management:- Posterior colpoperineorrhaphy Remember: Colposuspension is a surgery for SUl and
not vault prolapse.
VAULT Prolapse
Prolapse of vaginal stump after Hysterectomy

Management of Uterine Prolapse

(Depends on age and parity of female)
(Done for second degree and third degree prolapse)
Condition Management
1. Uterocervical Prolapse in Repr age females who SLING Surgery/colpopexy
need future child bearing Best Result: Shirodkar sling surgery
Least complication: Purandare sling surgery
2. Prolapse in Repr age female who do not need FOTHER GILL surgery/Manchester surgery
future child bearing. (2 steps =1st = cervical amputation, 2nd =
plication of cardinal ligament)
3. Prolapse in menopausal female/female who has Vaginal Hysterectomy
completed childbearing (If there is third degree uterine prolapse
+ cystocele and rectocele = Do = Vaginal
Hysterectomy +Anterior colporraphy and
Posterior colpoperineorraphy = Together called
WARD MAYO Hysterectomy
4. Prolapse in = 60-65 years with some C/1 to Leforts colpocleisis
Surgery (Diabetes/tBP)
Prolapse in female z 65 years with
5. comorbidities Pessary (Should be changed every 3 months)
or prolapse in pregnant/
postpartum female

Stress Urinary Incontinence Best Surgery for SUI: whert

Bursch colposuspension (Abdominal surgery
ligament)
intraabdominal proximal urethra is suspended to coopers
Involuntary escape of urine when
pressure is increased as in sneezing. coughIng and M/C performed surgery:
TOT (Tension Free Transobturator Tape)
laughing.
Cause: (Tension Free Vaginal Tape) midurethra
M/C = 75-80% = Bladder neck
descent Both are day care vaginal surgery where
defect is suspended.
2nd M/C = 20-25% = Intrinsic sphincter
 JLOGY
UteroVaginal Fistula 123. URINARY FISTULA
Fstula between ureter and vagina
Vaginal Fistula
Fstalabetween bladder and vagina
UrethroVaginal Fistula
Fstulabetween urrethra and vagina

Complain
complains of continuOus Type of Fistula
dribbling of
from vagina and has normal bladder urine
too. emptying Ureterovaginal Fistula
2. Pcomplains of continuous dribbling of urine
from vagina but doesn't have normal bladder Vesicovaginal Fistula
emptying.
9doesn't have continuous dribbling of urine
3.
from vagina but when she sits forurination. Urethrovaginal Fistula
urine comes fromn vagina and urethra.
PYQ:
M/C site of ureteric injury: 2 cm lateral to internal os ka water under bridge
2nd M/C site: Pelvic brim
Maximum risk of ureteric injury: Wertheims Hysterectomy
WC ureteric injury seen with = Simple Hysterectomy (TAH))
Vesicovaginal Fistula Methylene Blue 3 Swab Test
" M/C urinary fistula Observation Fistula
" M/Ccause in developed countries is TAH
M/C cause in developing countries = Obstructed 2. Jpper most cotton swab Ureterovaginal
labor wet with urine but not Fistula
blue.
10C =Cystoscopy
Time of repair = lmmediate 2.. Middle and lowermost Vesicovaginal
cotton Swab wet and blue Fistula
TeChnique = CHASSAR MOIR Technique/ LATZKO in color.
technique
Post op Instruction 3. Only lowermost cotton Urethro vaginal
Swab wet and blue in Fistula
o Continuous bladder drainage x 2 weeks color.
o Antibiotics x 2 weeks intercourse
exan, No
NO P/S, No P/V
x 3 months-6 months
No pregnancy x 1 year.
ligaments
lImport ant Order of clamping
Concept:and Mackenrodts ligawment
1stvagi
= nUterosacral
al Hysterectomy
nd =
Brd = Uterine artery
tube/Round ligament and
ovarian
Falcompl
Mgament
The order loispiareversed
nex in Abdominal Hysterectomy
192 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

124. VULVAL CANCER

General Points " IB: Size of Tn >2 cm or depth of

M/C type: squamous cell carcinoma Stage 2: Tm involves lower 1/3 of invasion
2nd M/c: Melanoma
1/3rd of vagina or lower 1/3rd of anus.
Stage 3 and Stage 4: Lymph nodes involved
urethra, lower
Age group: 50-70 years
M/esymptom: Pruritis Management of Vulval Cancer
M/C site: Labia Majora > Labia Minora Stage 1 and stage 2
Squamous cell CA has two varieties: Surgery: For Tm excision + LN dissection.
(1) Warty/Basaloid Type:
o 55-60 years Stage 3 and stage 4: Chemoradiation
o Good prognosis
o Unifocal Surgery for Tumor excision:
(2) Keratinizing Variety: Stage 1A: Wide local excision or simple partial
vulvectomy
o65-70 years Stage 1B and Stage ll: Radical Vulvectomy
o Bad prognosis
o Multifocal
Lymph Node Dissection
Risk Factors
HPV infection (16, 18)
If LN are clinically palpable
’ lnguino Femoral LN dissection
Smoking If LN are not palpable
VIN
Lichen sclerosis
ps3 mutation
Pagets disease
LD of Vulva Stage 1A Other stages
Sentinel LN:
Superficial inguinal Lymph node No LN dissection Inguino Femoral
LN dissection
Deep inguinal LN/ Femoral LN
Pelvic LN are not involved in vulva cancer
Structures which lie within 2 cm of midline their
lymphatics cross on either side.
Lymphatic drainage of clitoris: U/L Inguino Femoral B/L Ingiuno Femoral
Glans of clitoris drains into deep ingunalLN.lymph LN dissection: Only if dissection:
nodes ’ LN of cloquet or Rosen muller Size = <2 cm
Body and crura of clitoris drain into superficial If any of criteria for
inguinal lymph nodes and then into deep inguinal Tm should be >2 cm U/L are not met.
lymph nodes. away from midline
lmportant Stages Local extension should
Stage 1 and stage 2 be absent
Lymph nodes not involved
Stage 1: Only vulva involved
IA:- Size of Tm s2 cm and depth of invasion
 125. IMPORTANT TABLES
pH of vagina @different ages
Table25:
Age
pH
Beforepuberty
Alkaline (6-8)
Atpuberty Changes from alkaline to acidic
Reproductive age
Acidic (3.5-4.5)
Pregnancy Acidic (4)
Menstruation
Alkaline (6-8)
After menopause Alkaline (6-8)
Important Concept
Vagina has inhabitant bacteria called
Doderlein Bacili (Lacto bacill) which converts glycogen present
in vaginal epithelium to Lactic acid
Doderlein bacilli =Appear @puberty and disappear ater menopause.
For acidic pH both Doderlein bacilli and estrogen are needed.
Table 26: Cervix: Corpus Ratio
Remember
Cervix is longer than uterus (corpus) before puberty.

Age group Cervix: Corpus ratio

At birth 1:1

Before puberty 2:1

At puberty 1:2

Reproductive age 1:3 or : 4

1:1 (as both organs atrophy)

Menopause
lable 27: Contents of blood
ligament
One tube Fallopian tube
Two ligawments Round ligament
ovarian ligament
TWo arteries Uterine artery
Ovarian artery
Iwo nerve plexus Uterovaginal plexus
Ovarian plexus
ree embruoloaical remnants Epoophoron
Paraoophron
Gartner's duct
 Dr SakshiArora Hans
One Touch Obstetrics and Gynecology by
Table 28: Fallopian tube
Ampulla
From medial to lateral parts of FT are:
lnterstitial part > isthmus> ampulla > Isthmus
infundibulum
Narrowest and shortest interstitial/intramural
parts
Widest and longest part: Ampulla
M/C site for ectopic pregnancy =Ampulla
M/C site for genital TB pregnancy = Ampulla Infundibulum
M/Csite for tubal abortion = Isthmus
M/Csite for tubal repture = Isthwmus Fimbriae
M/Csite for tubectomy = Isthmus
Ectopicpregnancy ends earliest in = Isthmus
Ectopic pregnancy lasts for longest period of Image 164: Parts of fallopian tube
time intramural part

Table 29: Muscles attached to period body-1o muscles are attached to perineal body
Category Muscles
TWo unrepaired Fibres of longitudinal muscle coat of anal canal
Fibres from external anal sphincter
Four paired Bulbospongiosus
Superficial transverse perineeii
Deep transverse perineeii
Levater ani

Table 3O: Emergency Contraception

Drug Dose Comment

1. Levonorgestrel 0.75 mg stat and after 12 hours M/C used

O.75 mg or 1.5 mg single dose Plan B of emergency
contraception
2. Ethinyl estradiol (5O mcg) 2 tab stat and 2 tab after 12 hours
and norgestral (0.25 mg)
3. Copper IUCD Inserted within 5 days after Most effective method
unprotected sex. Not suitable for rape victims
4. Centchroman 2 tablets (60 mg) to be taken
twice at an interval of 12 hours
(within 24 hours of intercourse)
5. Ulipristal 30 mg within 72 hours Most effective horwmonal EC.
6. Mifepristone 10-50 mg single dose

Drugs not used as Emergency Contraception

1. Progesterone only pill
2. Mirena
3. Misoprostol
 liners on
GYNECOLOGY 19
mportantone Emergency Contraceptive
Emergency contraceptive is most effective if used
Maximum use till = 5 days within 72 hours
Mechanismof action: - Delay
ovulation (Not anovulation) followed by inhibitsimplantation)
31; Mechanism of action of some important
Table
Contraceptive
contraceptive
Main mechanism Others
OCP's (E+P) Anovulation (FSH >>> LH) Thicker cervical mucus
Thinning of Endometriu
2 POP Make cervical mucus thick
4 Prog implant/prog Anovulation Make cervical wmucus thick
injection/cerazette
(POP in lndia)
4 Cu IUCD Prevents fertilization (Copper released induces Inhibits implantation
an inflammatory reaction)
5. MIRENA Prevents implantation
6 Centchroman Makes endometrium out of phase and Inhibits
implantation
Table 32: OCP's
OCP's

OCP's and cancers Noncontraceptive uses of OCP's

1. Irregular cycles = OCP is DOC
Increases 2. Todecrease blood loss in fibroids,
1. Hepatic adenomas endometriosis, AUB
2. Breast cancer in 3. DOC for primary dysmenorrhea and
perimenopausal females endometriosis
3. Cancer cervix (Reversible 4. HRT
risk) 5. DOC for Hirsutism, acne and
Decreases hyperandrogenism
6. To manage premenstrual syndrome
1. Endometrial cancer (DOC for PMS = SSRI = Fluoxetine)
2. Ovarian cancer 7. Progesterone in OCP's makes cervical
3. Ovarian cyst mucus thick decreases chances of PID,
4. Benigqn breast disease STD and Ectopic pregnancy
S Colorectal cancer
M/C PID with OCP use - Chlamydia
No effect M/C Vaginitis with OCP use = Candida
Liver cancer
 Arora Hans
96 One Touch Obstetrics and Gynecology by Dr Sakshi
OCPs
Table 33: Absolute contraindication of

WHO Category 4:
loans during May.
Mnemonic Banks have various schemes to provide home
Banks: Known/suspected case of breast cancer.
Have: Uncontrolled hypertension: severe (160/11o)
nonsmoker, of any
(Medicaly controlled hypertension, in a female who is ange: Notta CA
for OCPs).
Various Undiagnosed vaginal bleeding.
Schemes: Smoker2 35 years of age.
To: Known or suspectedin case of thromboemnbolism or family history of idiopathic
thromboembolism parent or sibling or Wo CVA/MI, or conditions predisposina to
it (Risk factor for thromboemnbolism, e.g., malignancy, lupuS anticoagulant present
prolonged immobility due to trauma or surgery ’ absolute contraindication).
Provide: Pregnancy or Woperipartum cardiomyopathy.
Home: Severe hypercholesteremia, hypertriglyceridemia
Loans: Presently impaired liver function/ liver cancer/acute or chronic cholestatic liver disent#
During: Diabetes with vasculopathy
May: Migrane with Aura.
OCP: Also C/l in breast feeding and post partum females (<21 days)]
Table 34: LARC methods Table 36: IUCD Generations

Long Acting Reversible Contraceptives IUCD: Generations

1. lnjection: DMPA 1st generation Inert like Lippes Loop

2. lmplants 2nd generation Contain Cu - e.g., Cu T 38OA
(lmage L65); multi load 375
3. IUCD (lmage 166)
Table 35: DMPA lnjection 3rd generation Contains progesterone MIRENA
(lmage 167); Progestasert
Included in NFP by name of: - ANTARA (Outdated)
Dose = 150 mg
I/M
Repeated every 3 months
Window period = 4 weeks
Method of Action: (Anovulation)
Advantages
Decreases seizure frequency
Decreases sickling in SCA
Disadvantages
Delayed return of fertility
Decreased bone mineral density
Leads to irregular bleeding
lmage 165: CuT 380A
 GYNECOLOGY

lmage 166: Multiload 375

Image 167: Mirena
Table 37: lmportant IUCD
Important IUCD's
1. Cu T 380A: T shaped device
PARAGUARD Has copper wire on vertical stem and horizontal arms (:. A)
(mage 165) Surface area of copper wire: 38O mm² (:. Number = 38O)
Small ball which prevents perforation
Releases 5O mcg of copper/day
It can release Cu up to 12 years but approved life span is 10 years.
2. Multiload 375 Not T shaped and no copper on arms.
(lmage 166) Arms are bent and have spurs on arms which lessens expulsion
Nylon thread present
Life span: S years
3. MIRENA/LNG
IUCD
Not copper containing
Contains progesterone = Levonorgestrel s2 mg.
(lmage 177) Mirena releases 20 mcg per day (.:. called as LNG-20 also.)
Releases LNGfor 7 years but approved for life span of 5 year.
Table 38: Comparison of CuT 38o and Mirena
Mirena
CuT 380
Acts by preventing fertilization Acts by preventing implantation
Releases 20 mcg of LNG per day
Releases 50 mcg of Cu per day
M/C side effect is bleeding It helps in reducing bleeding so in pts of AUB it is used
Makes cervical mucus thick and decreases PID

iIncreased
risk of infection (PID) @ time of
nCauses
sertionEct incase failure occurs"
Chances of Ectopic pregnancy more if failure occurs
pregnancy Cannot be used as an emergency contraceptive.
Can be used as emergency contraceptive
98 One louch Obitetick and Gynecalogy by Dr Sakah Aroa Hant
Table 34:Absolute cowntraivdieations ef UCD
Abselute eontvahdieations of UeD
A Undignased vaginal bleeding
2. Diterted uterine cavity (Pbrveid/Endenetril ea/Cervieal eancer/Congevtal Anonaies of u
3 Curent PID
4 Suspected pregnancy
Only for Cu T wilson disease
Only for Mirena: H/OBreast cancer

" HO Eetopie pregnaney and H/O PIDsnot a cAfor luCD ivsertion

M/C PID with use of IUCD: Aetinonyces
Tìme of insertion of Cu T
o Postplacental insertion within 10 mnutes of delvery
o Post partum insertion: After 10minutes but within 48 hos of delivery.
nterval insertion Sx weeks after delivery.

Table 4O: Contraceptives ineluded in National Family Table 41: lmportant PYQ'%
Planning Programme
lportant PYQ'S
3. Male NIRODH
condom Natural methods Rhythmmethod (Calendar
inelude method)
2. Mala N/ Composition of Mala N and Mala Cyelobeads/TIRUMALA
Mala D Dare Same: (used by neducated
EE =3O meg + O.15 mg LNG females)
mala N- free of cost Cervical nucus - Biling
Mala D-Subsidised rate method
Lactational amenorrhea
3 ANTARA Dmpa injection 1so mg Basal body teperaturt
4 CHHAYA Also k/a: Barrier methods Male condom (included in
Centchroman include NEP) (Iage 168)
Active ingredient: Female eondom(FC-2
ORMILOXIFENE distributed bu NACO to
Developed by SQPQl LKO. sex workers)
MOA:- Makes endometrium Diaphragm (lmage 170)
out of phase and inhibits (Can be sed till 1 year
implantation. by wasking and drying)
Dosage = 30mq twice a week Today sponge (lnaN 17) an
for first threemonths and then (g nonoNgnol )
ties fr
weekly be used wnultiple
24 hours
5. Cu T38O
Permanent Tubectowy
Multiload methods of Husteroscopie essre
375 contraception Vasectog
7. pillEzy Emergency pillcontaining 1.S mg
pill levonotgestrel
 Faailure rate of GYNECOLOGY 19
abe
42:
Tpeofcontraception
contraception 2. DMPA: Leads to osteoporosis
Lactationof 6 months Failure rate (%) Breastfeeding = give 4 weeks
roitusinterruptus O.5-1.5 Non breastfeeding = Day 1
25 3. IUCD:
piaphragnm 4-6
ntrauterine devices Postplacental = Within 10 mins of delivery
O-3
Postpartum = till 48 hours of delivery
Progesterone only minipill 2-3 Interval = After 6 weeks
Condom 10-14 4. Emergency contraception: After 4 weeks
Combinedpill O.1 s. Tubecto my
Vasectomy O.15 Laparoscopic tubal ligation is C/I in post
Tabal ligation O.4 partum period
Mini laparotomy (Modified pomeroy
technique)
able 43: Postpartum contraceptive use Post partum: Till 1 week
Interval: After G weeks
Rule of 3:
When to start contraception in a IMPORTANT IMAGES OF CONTRACEPTIVES
Postpartum female
Unrolled

Rolled
Not breastfeeding/ Exclusively
Partially breast breastfeeding
feeding

3 weeks 3 months

List of contraceptives which can be given from

Day 1 of Delivery: lmage 168: Male condom
Condoms
Centchroman
Progesterone only pills
Progesterone implants
Other Contraceptives and tie at which they
can be given
1. 0CP's
Decrease breast milk in breast feeding females
RCreased
and
risk of thrombosis in breast feeding
non-breast feeding females
Nonbrldeally:eaststart:feedi2nweeks
Can >3 g: weeks
ExclCanusivelstart:
y breastfeeding:
>6
Image 169: Female condom
weeks
ldeally: 6months
 by Dr Sakshi Arora Hans
00 One Touch Obstetrics and Gynecology

White beads:
Brown beads pregnancy is most likzl
pregnancy is very urlikely
Dark Brown beads tells you

rubberMovabirieng
if your cycle is shorter than
26 days
Red bead: first dau
of your period

Inage 17o: Diaphragm lnnage 173: Cyclobeads Tirumale

roDAY 0

Extended Extended Extended

tip tip with (2) tip with (2)
Silastic ring Silastic ring
Iage 272: Today sponge lnage 174: Laparoscopic ring application

Fallopian tube

Uterus
Fimbria

Image 172: Implanon tmage 175: Pomeroy technique

 Image 77: Essure: Coiled device which is put in
intersectral part of Tube via Hysteroscop
Leads to tubal blockage
lmage 176: Nonscalpel-Vasectomy Blockage is not immediate-back up contraceptive needed
for 3 months.
Table 44: Risk factors and protective factors related to
ovarian cancer
Proven risk factors Controversial risk factors
EXcessive estrogen Early menarche PCOS
Late menopause HRT
Obesity
Endometriosis
ExCessive ovulation Nulliparity Infertility and ovulation inducing drugs
(Theory of incessant ovulation)
Genetic syndrome Lynch syndrome
BRCA 1
BRCA 2
Exposure to carcinogens Asbestos Talc
Smoking (mucinous adenocarcinoma)
Protective Factors of Ovarian Cancer
Related to estrogen Related to ovulation Certain surgeries
Physical exercise Anovulation : multiparity Hysterecto my
OCP (most important) Tubal ligation
Breastfeeding Salpingectomy
Table 45: WHO classification of types of ovarian cancer
Epithelial oVarian tumor
M/C = q0%
Germ cell tumor Sex cord stromal tumor Metastatic tumor
M/C = Teratoma Estrogen secreting: Krukenberg tumor
M/C = Serous Benign = mature Granulosa cell tumor
Mucinous tumortumor cystic teratoma Androgen secreting
Brenner tumor Malignant immature Sertoli cell

Endomet
Clear all rcarcinoma
ioid tumor Teratoma
Dysgerminoma
Yolk sac Tm
Leydig cell
- Hilus cell Tm
Stromal Tm
Embryonal cancer Fibroma
Choriocarcinoma Thecoma
Fibrothecoma
 by Dr Sakshl
One Touch Obstetrics and Gynecology
2
Table so: Ovarian Tm and tumor markere
Table 46: Epithelial ovarian tumor
Tumor Tm marker
M/C variety of ovarian Tm
M/C is : Serous Tm Epithelial Tn CA125
Age - 6O years Mucinous Tm Ca9-q
Mostly - Bilateral Dysgerminoma Main = LDH
Prognosis - Worst as they present with Others =hcg/PLAP
nonspecific symptoms Never produce =EP
HPE - Psammoma body Main = aFP
Yolk sac Tm
(endodermal sinus Others = LDH
Table 47: Pseudomyxoma peritonei Tm) a antitrypsin
MIC cause Appendix cancer Never produce =hca
Other causes - Mucinous ovarian Tm, MucOcele of Embryonal cancer AFP, hcg
|appendix Choriocarcinomas heg
Prognosis - Bad dlt high recurrence rate
Granulosa cell Tm Inhibin B AMH
Table 48: Imp PYQS on epithelial tumnors
Mutation a/w:
Table s1: Meig syndrome and pseudomeig
syndrome
Low grade Tm: Kras, PTEN.
High grade Tim: p53. Meig syndrome: Any 1 of following Ovarian Tn:
* M/C ovarian Tn associated with endometriosis Fibroma
Best answer: Clear cell Tm Thecoma
2nd best answer: Endometrioid Tn Brenner Tm
* M/C ovarian Tm associated with endometrial Granulosa cell Tm
cancer Along with ascites and right side pleural effusion.
Endometrioid Tm Pseudo meig syndrome: Ascites and right side
Granulosa cell Tim (Do EB in all case)
pleural effusion seen with any other condition.
e.g., fibroid, mucinous tumnor of ovary
Tm marker: CA125

Table 4q: Important PYQ's on germn cell Tim Table s2: HPE finding of ovarian tumor

M/C age - 10-30 years Ovarian Tm HPE finding

Mostly - Unilateral Epithelial tumors Psammoma body
Prognosis Good as it is detected at early age Hilus cell Tm REINKE crystal
M/C GCT Dermoid cyst (mature teratoma) Brenner's Tm Walthard cell nest with
M/C malignant GCT Immature teratoma coffee bean nuclei
GCT with best prognosis Dysgerminoma Clear cell tumor Hobnail nuclei
GCT with worst prognosis Yolk sac Tm
GCT With rapid progression (presents as acute Dermoid cyst Rokitansky
abdomen) Yolk Sac Tm protuberance
Only ovarian Tm which is radiosensitive Dysgerminoma Nest of cells separated
Dysgerminoma by fibrous septa
M/C ovarian Tm in dysgenetic gonads Yolk sac Tm Schiller duval body
Gonadoblasto ma
M/C ovarian cancer in dysgenetic gonads - Granulosa cell Twm Call Exner body
Cancer - Dysgerminona Krukenberg Tm Signet ring cell
GCT which is 1O0% unilateral - Yolk sac Tm
 Steps ofsurgical
GYNECOLOGY 203
staging in ovarian cancer
Midlineincision
present: send
fascites sawmple for cytology
Ifno ascites: saline cyto logy
nspection and palpation of all abdominal organs
s Random peritoneal biopsies
+ BSO
5 TAH
lnfracolic omentecto my (not biopsy)
Pelicand paraaortic LN dissection
7
B. Closure

oble 54: Management of ovarian cancer

De TAH + BSO for staging purpose followed by chemotherapy (6 cycles of
paclitaxel + cisplatin) in all
epithelial tumors except stage 1A and stage 1B.
In germ cell Tms: U/L salpingo -ophorectomy + chemotherapy (BEP) in all stages except dysgerminoma
stage 1.
In sex cord Tm: If it happens in young females =U/L salpingo-oophorectomy, older females =TAH +
BSO +Chemotherapy (BEP) is given only in stage 3 and 4.

Table 55: Differences between benign and malignant adnexal mass

Benign Maliqnant
U/L usually * B/L
Cystic consistency Usually solid consistency
Pain and tenderness may be present * Absent
USG: >10 cm
U/L B/L
Anechoic Variable echogenicity
Unilocular Septa
No solid component Increased vascularity present
No ascites Ascites present
No enlarged LN Enlarged LN
Matted LN
204 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

126. IMPORTANT IMAGES OF OVARIAN TUMORS

lnagc 178: Dermoid cust with teeth and hair lmage 179: USG of dermoid cyst showing rokitansku
protuberance

Dermoid cyst: Mature cystic Teratoma.
M/c ovarian Tm in Reproductive age female
M/c ovarian Tmn in pregnancy
Mostly unilateral - B/L in 10% cases
It has components from all 3 germ layers
(lmage 178) -
M/c is Ectodermal.
Mostly benign but risk of malignancy = 0.2-2%
M/C site of malignancy = Rokitansky Tuberance
M/e malignancy =Squamous cellcarcinoma.
On USG:
o Tip of lceberg sign
o Dot-dash appearance
Rokitansky protuberance (lmage 179)
Management = AS chances of torsion are high: do
cystectomy

(nage 18O: Dysgerminowma gross specimen

Image 181: HPE of dysqerminoma
Dysgerminoma Solid
2nd most cowmmon of GCT
Usually U/L but it is B/L in Lobulated
(lt is GCT with highest risk15-20% females
of bilaterality:
Tan in color
dysgerminoma)
It is the we ovarian cancer HPE (Imnage 181)
indysgenetic gonad
Only Tm which i radiosensitive Nest of cells separated by fibrous
The septa is infiltrated by septa
Grossly (mage 18o) lymphocytes
Fleshy
 GYNECOLOGY
Image 182: Schiller duval body
Granulosa cell Tumor
Gene defect = FOX L2 gene
Can be seen at any age
Estrogen producing tumor
At puberty: Fewmale can present as precocious
puberty
In Reproductive age-pt presents as AUB
Menopausal female -presents as PMB
D/t increased estrogen-Increased risk of
endometrialcancer .:. do endometrial sampling
On HPE: Call Exner Body (lmage 183) many follicle
like structures-crowded cells with acidophilic mate
rial filled in lumen and coffee bean nuclei seen.

Yolk Sac T/Endodermal Sinus Tumor

Most malignant GCT.
Most rapidly progressing tumor
Can present as Acute abdomen
GCT With worst progress
100% unilateral
HPE
Schiller duval body = glomeruloid bodies
(lmage 182). You can see a central capillary
Surrounded by Tumor cells. The tumor cells are
Surrounded by an cystic space
Image 184: Krukenberg Tm

lmage 183: Call exner body lmage 185: Signet ring cells

KRUKENBERG TM
Metastatic Tim of ovary
M/C primary cancer r is = Cancer of pyloric end
It is mobile
Shape of ovary is retained (lmage 184)
reaoomach which via retrograde lymphatics Capsule remains intact.
reaches ovary On HPE- signet ring cells seen ie cells filled
BiLeads
lateralto (807)
Symmetrical enlargement of ovary
with mucin and nuclei pushed to periphery
(lmage 185)
Has awaxy consistency
 Sakshi Arora Hans
6 One Touch Obstetrics and Gynecology by Dr

127. IMPORTANT NEXT STEPS

features of malignancy
Case 1: Ovarian cysts seen on USG: without any

Managenment of ovarian cyst (No features of malignancu)

Note:
Percentage of ovarian Extremes of age
mass to undergo Reproductive age group
malignant transformation:
Postmenopausal: 30%
5-7 cm >7 Cm
Premenopausal: 7% Cyst size:
3-5 Cm Follow up Surgery
CA 125 levels are not of with serial (D/t High chances
Wait and
much use in reproductive USG of torsion or
watch
age group: as it is Raised rupture)
in anumber of benign
conditions (Fibroid, PID,
Cervical TB)
Significant only if very Postmenopausal Prepubertal
high 220o IU.
Next step Next step
CA 125 > 35 IU If any raised:
AFP, heG, LDH

Surgery Surgery after

after further investigations
investigations

Case 2: Ovarian cyst in pregnancy

Ovarian cyst in pregnancy

Symptomatic cyst Asymptomatic cyst

Removal of cyst 1st trimester 2nd trimester

irrespective of Wait and watch If USG shows features
gestational age (as mostly it is a of malignancy Or
corpus luteal cyst) Size of> 10 Cm

Surgery
Note:
M/C benign tumor/cyst in pregnancy: Dermoid cyst.
M/C to undergo torsion: Dermoid cyst (mature cystic teratoma)
M/C tiwme for torsion: End of Lst trimester or during puerperium.
M/C ovarian cancer during pregnancy: Dysgerminoma
 GYNECOLOGY
female has
BRCA1/BRCA2 mutation/lynch syndrome:
BRCAgene 1, mutation has
maximu risk of
gene 2, mutation has 15% risk of ovarian = cancer 407%
BRCA ovarian cancer
Best method to prevent ovarian and
endometrial cancers in these patients
TAH + BSO when family is complete (By
40 years)
Case 4: Afemale has 1st degree elative with hereditary ovarian cancer/BRCA-1 mutation. (seen@ SO yrs

LNext step
Annual screening = TVS + CA 125 (from 35-40 years)
(As these females will have increased risk of ovarian cancer)

Cse 5:Afemale has 1st degree relative with sporadic ovarian cancer and dies at 65 years
JNext step
Reassure the patient, no screening needed
Case 6: A female on OCP's: Misses her pill:

" Take wmissed pill asap

1 pillmissed " Resume schedule
No backup needed Failure rate
Perfect use-O%
Typical use-8%

2 pills missed " Week1 or week 2: Take 2 pills daily

for 2 days and finish the pack. Backup
for 7 days
" Week 3: Start new pack. Use backup
immediately for 7 days (same should be
done if3 pills are missed at any time)
 Arora Hans
One Touch Obstetrics and Gynecology by Dr Sakshi
Case 7: ln case of missing thread
Cause:
Thread coiled
Patient has conceived (size of uterus increased)
Perforation of uterus
IUCD expelled
First step to do is transvaginal scan:
+ Thread is + Serial abdominal X-ray:
not visible as IUCD is radio opaque

Not preferred as first investigation as then are

chances of patient being pregnant
+ Thread is visible (mostly):
Coiled thread

Continue lUCD Remove IUCD

Under hysteroscopy by Shirodkar hook/

grasper/artery forceps

Perforation

IUCD in peritoneal cavity IUCD in uterus partly and

partly in peritoneal cavity

Laparoscopic/Laparotomy Hysteroscopy + Laparoscopy

(as per the adhesions present)

Case 8: lIn case of IUCD with pregnancy

Pregnancy with IUCD in situ

Patient wishes to Patient does not wish

continue pregnancy to continue pregnancy

Thread is visible Thread is not visible Remove IUCD

Remove IUCD
(preferred method)
Continue pregnancy MTP
with IUCD in situ. IUCD
is not teratogenic. But it
has increased chances of
infection/Abortion/PROM/
IUGR/preterm labor
 128. GYNECOLOGY
IMPORTANT INSTRUMENTS IN GYNAE 209

lmage 186: Sims' speculum

Image 189: Uterine sound

-0
Image 190: Myoma screw
lmage 187: Cusco's speculum

clamp
lmage 191: Myoma
curette
Iwage 188: Blunt and sharp
 One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

129. IMPORTANT PAP SMEAR IMAGES OF INFECTIONS

Epithelel cfls

Clue cel
lmage 192: Lactobacillus (Normal)
age 14s Bacterial vaginosis
Clue cells
Vaginal epithelial cells that have bacterie
adherent to their surfaces
Absence of lactobacillus

Leptothik

Image 193: Leptothrix

Long version of lactobacillus
May have trichomonas infection
Called as spaghetti and meat ballappearance

lmage 196: Actinomyctes

Cotton wool appearance
Common in IUCD users

lmage 144: Herpes simplex virus

Multinucleate intermediate squamous cell
Moulding of nuclei
Margination - big infusion in center, normal
chromatins pushed to periphery
Pink color intranuclei Cowdry type vial inclusions
 GYNECOLOGY 211

lmage 198: Candida

Image 197: Tadpole cells yeast
Small, uniform, round buddingidentifying small
Orange
color cell
carcinoma Liquid based cytology for
well differentiated squamous cell candida epithelial
Note:Size ofspore is smaller than nuclei of
cells