OBGYN – Mini OSCE Notes:

Partogram •Continuous record of the women in active labor

* Start using partogram when cervical dilation is 4 CM (active phase of labor)

* Dilation of cervix is marked with (X), and vaginal examination is done every 4 hours

* Descend of the head is marked with (o) / asses by abdominal palpation / Full engage : 0/5 ,, all of it in
pelvis

* Alert line: start at 4 cm, and should progress at expected rate (1 cm / hour)

* Action line: paraller to alert line, and 4 hours apart from it

* Fetal heart rate: every 30 min (in our university every 15 min)

* Amniotic fluid: record it at every vaginal exam ,, record it as follow :

(I : intact membrane / R : membrane rupture / C : clear fluid / M : muconiumstained / B : blood stained)

* Moulding: degree of compression on skull,, abnormal head shape that results from pressure on the
baby's head during childbirth ..
(0 : separated bones / 1 + : bones touching each other / 2+ : separated easily but overlapping /
+3:overlapping can’t be separated easily)

* Contractions: recorded every 30 min / count the # in 10 min + duration /

https://www.youtube.com/watch?v=hTh5MJFzgPY (4:30)
Uterine
inversion

- Uterine inversion Is treated with immediate manual replacement of the uterus by placing a
hand in the vagina and pushing along the axis of the vagina towards the cervix. Delay in
reduction of the prolapse can make uterine replacement more difficult as the uterus can become
edematous and the cervix can contract around the inverted uterus. If the placenta is still attached
to the uterus, as in this patient, it should not be removed (Choice D) until after the uterus is
replaced due to risk of massive hemorrhage.

- Uterine atony is commonly encountered after the

uterine replacement and subsequent placental removal. Uterotonics (eg, oxytocin, misoprostol)
(Choice B) cause uterine contraction and should be administered after uterine replacement to
prevent further hemorrhage and recurrence of the prolapse. As uterine relaxation is necessary for
uterine replacement, uterotonic administration prior to replacement may make uterine
replacement impossible to perform.
Instruments

OBSTETRIC FORCEPS

Definition. These are metal instruments used to provide traction, rotation, or both to the fetal head.
• Simpson: used for traction only. –( ST)
• Kielland: used for head rotation and traction. (K TR)
• Piper: used for the after-coming head of a vaginal breech baby. (P – Breach)
 * summarize the traction and rotation instruments?
- Traction : forceps (simpson for ROA &LOP &mental/ piper for Breach) // y (all presentation except
face)
- Rotation : killend (also used for traction)

* when to use forceps?

- fetal distress
- prolong 2nd stage
- materanal heart disease

* when to use vacum?

- fetal distress
- prolong 2nd stage
Preterm labor (<37w, contraction + dilation)
* MC cause? Spontaneous! (80%)

* Management? Always start by saying (admission, hydration + bed rest for the mom and monitor of the
baby) + DRUGS !! as:
tocolytic(B 2 agonist , Mg sulphate, CCB , Pg inhibitors) , Steroids , Antibiotics

Cervical The terms “cervical insufficiency” and “cervical incompetency” have been used to describe the
incompetence inability of the uterine cervix to retain a pregnancy to viability in the absence of contractions
or labor. A diagnosis was made in the past on the basis of a history of painless cervical dilation
after the first trimester with expulsion of a previable living fetus.

Recent studies using ultrasound to examine cervical length suggest that cervical function is
not an all-or-none phenomenon, but may be a continuous variable with a range of degrees of
competency that may be expressed differently in subsequent pregnancies.
Etiology. Causes may include trauma from rapid forceful cervical dilation associated with
second trimester abortion procedures, cervical laceration from rapid delivery, injury from
deep cervical conization, or congenital weakness from diethylstilbestrol (DES) exposure.

Diagnosis
• Studies show the benefit of elective cervical cerclage with a history of 1 or more
unexplained second-trimester pregnancy losses. The benefit of cervical cerclage placement
is unclear in the following situations: sonographic findings of a short cervix or
funneling, history of cervical surgery, DES exposure.
• Serial transvaginal ultrasound evaluations of the cervix after 16–20 weeks may be helpful.

Management
• Elective cerclage placement at 13–14 weeks’ gestation is appropriate after sonographic
demonstration for fetal normality.
• Emergency or urgent cerclage may be considered with sonographic evidence of cervical
insufficiency after ruling out labor and chorioamnionitis.

• Cerclage should be considered if cervical length is <25 mm by vaginal sonography

prior to 24 weeks and prior preterm birth at <34 weeks gestation.

• McDonald cerclage places a removable suture in the cervix. The benefit is that vaginal
delivery can be allowed to take place, avoiding a cesarean.
• Cerclage removal should take place at 36–37 weeks, after fetal lung maturity has taken
place but before the usual onset of spontaneous labor that could result in avulsion of
the suture.

• Shirodkar cerclage utilizes a submucosal placement of the suture that is buried

beneath the mucosa and left in place. Cesarean delivery is performed at term.
Vaginal
discharge

Bacterial vaginosis: Clue cell / GRAY discharge / NO ITCHING

Candida: Vulvar excoriations / Vulvar Erythema & swelling / Thick Whitish vaginal discharge
PET =
preclampsia

* Physical Exam : Hyper-reflexia& clonus, papilledema(Abnormal ophthalamic exam) and RUQ

tenderness
Hypertensive mom love nefidipine = Hydralizne, Methyldopa , Labetalol, Nifidinpine,
* Management? Control BP / Mg sulphate/ delivary

* Investigations ? KFT / LFT /CBC / urine dipstick

* (Severe preeclampsia is BP ≥160/110 mmHg with proteinurea+2 by or ≥2gm/24 hour’s urine

collection) + SIGNS AND SYMPTOMS
* (Mild preeclampsia is the one where BP is ≥140/90 mmHg proteinurea+1 by urine or a total protein
level of ≥300mg/24 hour’s urine collection)
Abortion •Abortion (induced) , miscarriage (spontaneous) .. before 24 weeks

* 15% of Dx pregnancies
* Most btw 8 and 12 weeks of pregnancy.

* Threatened abortion:
-Hx: early GA / Pain mild or none / Bleeding
-PE : general is good / closed cervix / uterus is correct in size
-US : show fetal heart acitivity [essential in dx]-Management : no admission ! / Reassurance / advice to
decrease activity + decrease intercourcecause semen contain PG !! Relax cervix / Bhcg+ Progestrone to
stabilize pregnancy / Anti D if Rh–mother , indirect coomb–and husband is +/ ANC as high risk
•Inevitable +Incomplete :
-Hx: heavy vaginal bleeding [ with no products on conception in inevitable // with products of
conception in incomplete ] / severe PAIN
‫ بينما بالحمل المهاجر االلم يحدث قبل النزف‬.. ‫مهم جدا !! األلم يحدث بعد النزف‬
-PE : poor general / dilating cervical / uterus small for date in incomplete , normal in inevitable /
contractions
-US : fetal heart may or may not be there [ not essential in dx]
-Management : labs (CBC , blood grouping ,cross match) / Resuscitation (large IV canulas, fluids)/
Oxytoxic drugs (ergometrine+ oxytocin) / E&C

•Complete abortion :
-Hx: Heavy vaginal bleeding then stopped ! / pain stopped
-PE : closed cervix (everything happened before she came to u) / uterus is SGA -US : empty or RPOC
(retained products of conception)
-Management : E&C (If there is RPOC)

•Missed abortion : Most of missed abortions are diagnosed accidentally during routine U/S in early
pregnancy
-Hx: episodes of mild vaginal bleeding , regression of early pregnancy S&S
-US : diagnosed if two ultrasound (T/V (transvaginal) or T/A (transabdominal)) at least 7days apart
showed an embryo of >7 weeks gestation (CRL > 6mm in diameter and gestational sac > 20 mm in
diameter) with no evidence of heart activity [[ due to the probability of wrong dating ]]
-Management : labs (CBC , blood grouping , cross matching , platelets count) / Conservative
(spontaneous expulsion , worst , due to increase DIC) / D&C [ 1st trimester only ] / medical [Best ,
misoprestol which is PGE1 analog , 1stand 2ndtrimester , SE : N,V,fever

•Septic abortion : incomplete abortion which complicated by infection of the uterine

-Hx: heavy bleeding + pain + pyrexia , tachycardia , pelvic tenderness , purulent vaginal discharge
MC MO : Mixed infection , E.coli+ anarobes(Bacteroides)
-Types : mild [inflimited to decidua] ,moderate [myometrium] ,severe [pelvis + shock + DIC]
-Management : labs / cervical swab (not vaginal) / coagulation profile / AB : cephalo4th,
metronidazole/surgical evacuation (12 h after AB)

•Complication of abortion : Hemorrhage / related to surgery : perforation , cervical tear , infection /

Rh isoimmuni/ pyshcological trauma

•Post abortion management :-support-Anti D-Contraception : immediately -wait 3 months [ regulate

cycle + give folic acid ]-no evidence that sexual intercourcemay cause it in 1sttrimester

•Recurrent abortion : 1% incidence -Is defined as 3 or more consecutive spontaneous abortions-Primary

: All pregnancies have ended in loss / secondary One pregnancy or more has proceeded to viability(>24
weeksgestation) with all others ending in loss
-Causes : chromosomal / anatomical / medical (Hx, PE , Management depend on them)
Ovarian
masses
Molar
pregnancy

Molar,PE : Fundal height large for gestational age

Molar ,S&S : Early vaginal bleeding with vesicles, hyperemesis gravidarum
Umbilical - umbilical cord descends alongside or beyond the fetal presenting part
Cord Prolapse
*Risk factors:
- Fetal malpresentation : Footling breech carriers the highest risk / most happen in vertex presentation
cause other presentations are less common to occur // Funic Presentation = cord presentation

- Prematurity / low birth weight : small size and inc fluid + prematurity itself is associated with
malpresentations

- multiple gestation : in the second twin, cause there is inc risk of malpresentation in second twin

- ROM : because a forceful gush of fluid may carry the cord beyond the presenting fetal part

- multiparity

- polyhydroamnios : associated with anunstable lie or unengaged presenting part

- Iatrogenic : iatrogenic ROM / internal scalp electrode / intrauterine pressure cath / manual rotation of
fetal head / amnioinfusion / ECV in pt with ROM

* Clinical presentation:
- CTG : first sign of cord prolapse is usually a sudden, severe, prolonged fetal bradycardia after a
previously normal tracing + variable decelerations
- Vaginal Exam : you may feel the Cord overt prolapse or by Direct Visualization

* Management: - prompt delivery by CS (vaginal delivery may be considered in select situations when, in
the clinician’s judgment, the fetus can be delivered safely and as quickly, or more quickly, than by
cesarean or if the fetus is dead already)

* special maneuvers:
- Manual elevation of the presenting part : the examiner's hand is placed in the vagina and used to
elevate the fetal head off of the cord while preparations for an emergency cesarean delivery are made è
DON’T TOUCH THE CORD
- Bladder filling : The distended bladder elevates the presenting part and keeps it off of the cord /
Tocolytics (eg, ritodrine) have been used as an adjunct to bladder filling to relieve cord compression
Placental
abruption

Premature separation (partial or complete) of placenta from uterine wall before delivery of infant.

Risk factors: trauma (eg, motor vehicle accident), smoking, hypertension preeclampsia, cocaine abuse.
Presentation: abrupt, painful bleeding (concealed or apparent) in third trimester; possible DIC, maternal
shock, fetal distress. Life threatening for mother and fetus.
Hemorrhage
Most common primary cause: UTERINE ATONY
Most common secondary cause: Retained products
Uterine
anomalies

Malignant
ovarian
masses
Endometriosis

- Endometriosis Is a common cause of chronic pelvic pain (>6 months) in reproductive-age women.
The location, quality, and timing of pain are unique to each patient and depend on the exact location of
endometriosis. Most commonly, patients report dysmenorrhea as well as noncyclic pain that can be
exacerbated by exercise. Physical examination findings vary but commonly include a fixed and immobile
uterus and rectovaginal nodularity. Adnexal mass or fullness should be confirmed by ultrasonography.
and the finding of a homogeneous cystic ovarian mass is highly suggestive of an ovarian
endometrioma. An endometrioma can be the only clinical manifestation of endometriosis, as In this
patient
- Infertility Is a common consequence of endometriosis, especially with the presence of endometrioma.
This patient's history of unprotected intercourse for two years without conception Is concerning for
primary Infertility. Surgical resection of endometriomas usually improves fertility.
Ectopic
pregnancy
CTG
Early deceleration head compression

gradual decrease and return to baseline with time from onset of the deceleration to the lowest point of
the deceleration (nadir) >30 seconds. The nadir of the early deceleration occurs with the peak of a
contraction

Late deceleration uteroplacental insufficiency

Variable decelerations umbilical cord compression

- Variable decelerations are an abrupt fetal heart rate (FHR) decrease to a nadir followed by a rapid
return to baseline. The drop from baseline to nadir occurs in <30 seconds, and the duration of the entire
deceleration is 15 seconds to 2 minutes; the duration and depth of each deceleration can be quite
variable. In contrast to early and late decelerations, variable decelerations are not always associated
with contractions.
- This patient's fetal heart rate tracing shows a normal baseline FHR and several variable decelerations,
which are most likely due to umbilical cord compression
HTN in
pregnancy
 OBGYN – Mini OSCE Notes:

COCP - Non contraceptive use ? Regulate the cycle, reduce dysmenorrhea& menorrhagia, useful for acne,
reduce risk of PID, endometrial & ovarian cancer

- Contraindications:

For effective contraception, when should the first pack started?

The first day of the cycle

Mention two factors that reduce the effectiveness of this medication?

Incompliance, anticonvulsant medications
HPV

Pap testing begins at age 21 in immunocompetent patients regardless of the age of onset of sexual
activity or number of sexual partners. Although most young women (age <30) become infected with
HPV shortly after the onset of sexual activity, the infection is typically cleared and does not progress to
cervical dysplasia or cancer.
PPROM

* PROM: Rupture of fetal membranes before the onset of labor whether at term or preterm . So when
we say premature rupture of membrane it is not related to the gestational age.
 * PPROM: Rupture of membranes before 37 weeks.

* Dx?
- Pelvic examination with STERILE speculum after ruling out placenta previa with U/S + pH Test

* Management: Admission, vitals, monitor pt for S&S of chorioamnionitis (fever + ROM + NO OTHER
CAUSES OF FEVER), give AB + dexa, send for labs and cultures, fetal assessment

* Aim of management ? Enhance lung maturity

* when to deliver?
- Maternal causes: chorioamnionitis, mother entered labor
- Fetal causes: fetal distress

* Complications?
- Worst? Cord prolapse
- Main? Chroaioamnionitis

PCOS
 * Laproscopic procedure as treatment? Ovarian drilling
Ovarian drilling, done during laparoscopy, is a procedure in which a laser fibreor electrosurgical needle punctures the ovary4
to 10 times. This treatment results in a dramatic lowering of male hormones within days and is often performed in women
who have polycystic ovarysyndrome (PCOS).Side effects: adhesion formation or ovarian failure if there are complications
during the procedure

* Medical tt ? Clomiphene citrate, metformin, COPC

* RF for? Endometrial hyperplasia / Endometrial CA / Infertility

Incisions

Polyhydramnios

DDX for large for gestational age?

- Wrong date
-Macrosomic fetus for a diabetic pt
-Multiple pregnancy
-Polyhydramnios
 * serious complication for polyhydramnios?
- prematurity

Incontinence
IUCD

Twins
*Risk factors ?
-Advanced maternal age, race -IVF –Family history
(Monozygotic twins have no identifiable risk factors)

* Complications?
-Fetal: preterm, IUGR, fetal abnormalities, fetal death, malpresentation
-Maternal: miscarriage , HTN, GDM, anemia, APH, Amniotic fluid embolism, PPH (MOST IMPORTANT
ONE FOR THE MOTHER), Hyperemesis gravidarum, Cholestasis of pregnancy, preclampsia

* Morbidity or mortality ?
-Prematurity

* Complication during labor?

-Locked twins, Cord prolapse
* Presentation in the following picture ?
-Cephalic / Cephalic
* Delivery method for both twins? -Vaginally (it only depends on the first one cause u can rotate the
second one)

* what is the sign in the images below and what is the type of twins?
- Twin peak sign (lambda sign)
- Diamniotic dichorionic

Lambda signs in dichorionic diamniotic

•Incidence?

Hellin's law. Hellin's Law is the principle that one in about 80 natural pregnancies ends in the birth of
twins, triplets once in 80^2 births, and quadruplets once in 80^3 births.

-triplet 1:6400
-Twin : 1:80

* At what GA u can determine the type of twin?

-Late in 1st trimester (ONLY)

* Mention 2 absolute indications for C\s in twins other than obstetric complications?
Monochorionic monoamniotic/ more than 2 fetuses / conjoined
TTTS:

* 28w pregnant with twins. Hb= 9g/dl, MCV= 70, MCHC= 26.
- Dx? Iron deficiency anemia
- cause in this case? Hemodilution, increase demand
- Management? ORAL iron supplement (give blood if hb is less than 7)
DUB Aetiology: Dysfunctional uterine bleeding i.e DUB (non-organic menorrhagia): 60% of cases of
menorrhagia. Is defined as excessive MBL in the absence of organic,(genital & systemic) diseases.
Two types

1. Ovulatory DUB: 85 % of cases, Occurs at reproductive age

The cause is a disorder in the endometrial function i.e endometrial prostaglandin imbalance (↑ PGE2/
↓PGF2α ratio) & increased endometrial fibrinolytic activity.

2. Anovulatory DUB: 15% of cases

– Mostly occurs at extremes of reproductive age.
– In the reproductive age occurs in chronic anovulation as in PCOS.

* Management of DUB:
A. Adolescent menorrhgia:
1. Explanation.
2. Treatment of anemia
3. Drugs
- Non-hormonal: Anti PG ( Mefenamic acid , SE: Gastritis & gastric bleeding), Antifibrinolytic (
Tranexamic acid, SE: Nausea & vomiting , and rarely intracranial thrombosis & central venous stasis
retinopathy, therefore it is contraindicated in H/O thromboembolism.).
- Hormonal: Hormones in use : Oral progestogen, COC. (best in anovulatory menorrhagia)
- Hormones not in use: GnRH analogues, Danazol (due to their side effects as adrogenic activity)

B. Childbearing age menorrhagia:

1. Explanation.
2. Treatment of anemia
3. Drugs – as above
4. Mirena: (Progestogen releasing IUCD)

C. Perimenopausal menorrhgia:
1.Explanation.
2.Treatment of anemia
3.Drugs –as above
4.Mirena: (Progestogen releasing) IUCD
5.Surgical treatment: Hysterectomy / Endometrial resection and ablation (contraindicated if there is
endometrial hyperplasia or endometrial cancer or fibroids).
Rh – * who get the problem?
isoimmunization Rh – mother, Rh + father Rh + baby

* Indications to give anti D?

It is routinely administered at 28-32 weeks gestation and again within 72 hours of

delivery if the baby is found to be Rh (D) positive. The initial timing of 28-32 weeks is selected
because the half-life of anti-D immune globulin is about 6 weeks, which would cover any
potential future exposure to fetal red blood cells through most of the third trimester

* Complications?
-Fetal anemia / Hydrops fetalis

* Next step if indirect coombsis +?

-Monitor the fetus

* How to manage RH isoimmunization in general?

-Check mother Rh group, Father Rh group, do indirect coombs’ test if needed, give anti-d when
indicated
* Management if there is severe anemia? / one management for isoimmunized mother?
Intrauterine Fetal Blood Transfusion

* what are the features of the blood that u will give to the baby?

* Investigations ? Indirect comb / CBC

* if we did did aminocentesis, next step? Give anti D

* Pt with Threatened abortion, and she is Rh – and her husband is Rh +?

- what you should give her? Anti D / Progestrone& Bhcg/indirect combs every 4 weeks

* complication ? Hydrops fetalis

* how present in the antennal period ? Fetal (anemia = due to extra vascular hemolysis in the spleen
of the baby , ascites, edema , IUFD ) , polyhydroamnios ,enlarge fetal heart , reduce fetal movement

* Note: ABO incompatibility is a ((protective factor)) – Naturally occurring anti-A and anti-B
antibodies rapidly lyse foreign RBCs before maternal lymphocytes are stimulated to produce active
antibodies

* Signs of fetal anemia: Usaually features of fetal anemia are not obvious unless the fetal Hb <6 g/dl:
- Polyhydramnios
-Enlarged fetal heart
-Ascites & percardial effusion
-Hyperdynamic fetal circulation by Doppler US
- reduced fetal movement
-Abnormal CTG with reduced variabiliaty
* Dose: (1 microgram = 5 IU), Each 100 IU = 1 ml of fetal blood
oBefore 20 weeks: 250 IU
oAfter 20 weeks: 500 IU
+ Additional dose (Kleihauer-betke test): 100 IU/ 1 ml fetal blood

* Once a women who is D rhesus negative has been sensitized to the D rhesus antigen , NO amount of
anti-D will ever turn the clock back.

* At booking : mother blood group

If negative ask about father blood group
If Both are negative >> we do indirect comb’s test.
• Just before 28 weeks : repeat indirect comb’s test

* No need to check Indirect Coomb’s test after anti-D administration as it may be positive due to anti-
D itself

* ASSESSMENT FOR SEVERITY OF FETAL ANEMIA:

- Middle cerebral artery-peak systolic velocity: the anemic fetus preserves oxygen delivery to the
brain by increasing cerebral flow of low viscosity blood

Normal
- Spectral analysis of amniotic fluid – looking for Bilirubin which correlates with hemolysis
- Fetal blood sampling
Vaccines during
pregnancy

pregnant women should avoid receiving live vaccines such as MMR immediately before or during
pregnancy due to potential adverse effects on the fetus.
Mirena Mirena is similar in shape to the Copper T380 in that it also consists of a small T-shaped frame with a
reservoir that contains levonorgestrel, a progesterone.

main side effect: break through bleeding

LNG ↓↓ menstrual flow & cramping ,suitable for women with menorrhagia & dysmenorrhea

Mirena decreases cramping and bleeding while copper increase it

Fallopian Tube * what is this image?

obstruction

Laparoscopy with methylene blue dye spillage = patent tube

* causes obstructed tubes? PID, endometriosis, pelvic surgery,adhesions

* other test to check tubes? HSG

3 INDICATIONS for HSG ?
-Infertility investigation
-Dx uterine anomalies
-Post sterilization

* Contraindications?
-pregnancy
-allergy to contrast
-lower UTI
Uterine •Downward descent of the uterus and /or the vagina through the introitus (vaginal orifice)
prolapse
•Uterine Prolapse: 3 types
(1) First degree : [ cervix within vagina ]
(2) Second degree : [ cervix descend through the interious]
(3) Third degree : [procidentia the whole uterus and cervix is outside !]

•Vaginal Prolapse:
-Cystocele: upper ant 2/3 of the vaginal wall
-Urethrocelle: lower ant 1/3 of the vaginal wall
-Rectocele: post vaginal wall
-Enterocele: post vaginal fornix and pouch of dogulas(true hernia , contain intestine)
-Vaginal vault prolapse is usually caused by weakness of the pelvic and vaginal tissues and muscles. It
happens most in women who have had their uterus removed (hysterectomy))

* Ligaments support uterus ?

Pubo-cervical, Utero-sacral , transverse cervical lig

•Round ligament + Broad ligament DON’T give support !

•Other RF : difficulut delivaeris with using instruments , prolong labor , / inc intra abdominal Pressure
as obesity, chronic constipation, chronic cough, abdominal masses & Ascites

•multipara10-30 % but in nulliparaits extremely rare , except if there is Connective Tissue disease or
pediatric surgery

HX : feeling of something going down

* TT:
- Treat UTIs and any cause of increased pressure + give HRT,
- PESSARIES, tension free tape (preserve fertility)
- Surgical options:
Placenta Previa * Presentation? ((painless vaginal bleeding)) after 28 weeks (can’t be dx before that cause the lower
And late uterine segment develops near 28 weeks) – the uterus has two segments (upper segment which is
pregnancy thick and good in contraction,, and a thin lower segment which is weaker in contraction).
bleeding
IT is the MOST COMMON cause for APH (bleeding after 24 w of pregnancy)

* Risk factors or Causes? Previous C/S, Age >35 , Previous PP, smoking , multiple gestation

* Risk on baby? Prematurity, IUGR, Malpresentation, umbilical cord prolapse

* Risk on mother? PPH (hypovolemic shock), sepsis, air embolism, complications of CS and
anesthesia

- This patient's ultrasound is consistent with placenta previa, which occurs when the
placenta implants over the internal cervical os. Risk factors for placenta previa include
multiparity and advanced maternal age (>35). Patients with this condition are at risk for
antepartum bleeding, which is typically painless and occurs with or without contractions on the
tocodynamometer.
- Placenta previa is usually diagnosed during a routine antenatal ultrasound. Pelvic rest is
recommended for the duration of the pregnancy as intercourse can cause contractions, which in
turn can lead to bleeding (as seen in this patient) by shearing the placenta off the cervix and lower
uterine segment. Patients diagnosed antenatally undergo cesarean delivery at 36-37 weeks (late
preterm/early term) to avoid risks associated with labor and to minimize prematurity
complications. - Although this patient has stable vital signs and a normal fetal heart rate tracing,
cesarean delivery should be performed urgently given the patient's vaginal bleeding at 37 weeks
in the setting of placenta previa
* current definition? 2 cm or less from the cervical OS

* IMPORTANT: NO VAGINAL EXAM IN PLACENTA PREVIA !!! palpation can put the pt in risk of
bleeding and separation.
 Management PPH?
Resuscitation (2 large IV cannulas, packed RBC and FFP)
Labs (coagulation factors, platelets)
uterine massage
Drugs: oxytocin, ergometrine, misopositol
Surgical: uterine artery ligation, hystrerectomy
Important terms * Presentation: Part of the fetus which occupies the lower segment of the uterus, that lies closet to
and Abnormal or has entered the true pelvis.
presentation -Types: Cephalic (MC, normal) / Breech 3-4% at term / Shoulder / Compound
‫الجزء الي بتشوفه‬

* Position: Relationship of presenting part (dominator) to maternal pelvic wall.

Types: Vertex [occipit]/ Breech [sacrum] / Face [mentum]
-(occipito-anterior is the MC)
‫العظمة الي تحت‬

* The denominator: is a bony landmark on the presenting part used to denote the position.
-In vertex it is the occiput.
-In face it is the mentum(chin).
-In breech it is the sacrum.
-In shoulder it is the scapula.

* Lie: Relationship between the longitudinal axis of fetus and mother.

- Types: Longtuidinal [cephalic / Breech ] / Transverse [ shoulder ] / Oblique [ unstable ]

* Attitude: Relationship of the fetal head to spine. (only for cephalic)

- Types: Flexed, neutral , extended
‫شو وضعية الرأس نفسه‬

* Station is the position of baby's head as it relates to the ischial spines (bony spots on each side of
the pelvis)

* Engagement of the fetal head is considered to have occurred when the largest transverse diameter
of the fetal head, has traversed the pelvic inlet.
* Breech: feet or buttocks present first. The major risk of vaginal breech delivery is
entrapment of the after-coming head.
– Frank breech means thighs are flexed and legs extended. This is the only kind of breech that
potentially could be safely delivered vaginally. (( MOST COMMON TYPE ))
– Complete breech means thighs and legs flexed.
– Footling breech means thighs and legs extended

• Management at 34 weeks of GA ? Only reassurance since she is in her 34th week (MC cause foro
breech is prematurity as most children will turn near term)

* Management if she is on 37? do ECV

* Most common complication of Breech? Cord compression

* RF ? Uterine anomalies / Placenta previaP / Fetal malformation / Multiple Pregnancy / Prematurity

/Poly or oligo

* Contraindications for ECV?

It can be performed between 37 weeks gestation and the onset of labor and has been shown to
reduce the rate of cesarean deliveries

-What are the structures: A, B. C?

- What is the name of the area marked in yellow
- If this was the presentation, what will be the name of the largest
presenting diameter?

Answers:
- A: Anterior fontanelle, B: Posterior fontanelle, C: Sagittal suture
 - Vertex
- Sub-occipitopregmatic

Menopause Clinical signs of menopause, which occurs In women at an average age of 51, include Irregular
or absent menses, heat Intolerance, flushing. insomnia, headaches, and night sweats.
During menopause. the circulating estrogen level decreases, resulting in a decrease In the feedback
Inhibition on the hypothalamic-pituitary axis. This results in the elevation of serum FSH and LH
levels.

What are the black dots?

Menopause

Fibroid
DUB 60% / 2 types,
ovulatory and
non ovulatory
Genital tract Uterus (fibroid,
CA,
adenomyosis,
endometriosis,
PID)
Cervix
Vaginal
Systemic Thyroid
causes (hypothyroidism)
Drugs
Bleeding
disorders
Liver failure
 - Medical: Hormonal (prog. Only), COC,
GnRH agonist
- Surgical: embolization, ablation,
myomectomy (reserve fertility) /
hysterectomy if no fertility is required

When to interfere? SUDDEN CHANGES in

size, bleeding .. etc + if it the cause of
infertility

Small fibroids are typically asymptomatic. Large fibroids can cause local compressive symptoms such
as constipation, urinary frequency/retention. and back/pelvic pain.

A uterus with fibroids typically feels enlarged, firm, and irregular on examination.

* MC Presentation? Menorrhagia (The most common symptom is heavy and prolonged menstrual
bleeding due to endometrial distortion)
* other presentation? SECONDARY DYSMENNORHEA
* MC way to find it? Accidental

*Risk for? Miscarriage, uterine dyskinesia and obstructed labor, post partum hemorrhage

* RF? Age (YOUNG), RACE (blacks), nulliparity, family history, increase BMI

* Types of degenerations? (due to changes in blood supply)

Hyaline – Most common
Cystic – Most severe
Red degeneration – during pregnancy ( PAIN + FEVER )

(memorize the location)

( intramural 95 % )
* Investigations after US?
Hystreoscopy guided biopsy, pap smear

* treatment of submucosal? Myomectomy (Only women with submucosal fibroids are eligible for a
hysteroscopic myomectomy, all the other types need LAPROSCOPIC).

* Surgical options to treat fibroids?

Myomectomy / hysterectomy/ Uterine Art embolization

* Gyne cause for fibroid ? Estrogen releasing tumor

* Fibroid + pregnancy:
- tt? Conservative, GnRH analog –3-6 months ( SE: osteoporosis) Don’t do surgery during
pregnancy cause it is highly vascular
- Complication during preg? Red degeneration / IUGR
- Complication during delivery ? Obstruction of birth canal & Uterine dyskinesia lead to increase
incidence of CS, miscarige
- presentation ? Menorrhagia& Anemia, secondary Dysmenorrhea

- serious changes ? Degenerative changes & rarely malignant changes

•Fibroid tt for 27y old female causing infertility? MYOMECTOMY

* don’t remove the ovaries if the pt is young.

Infant of diabetic
mother

* Steps before next allowed pregnancy if still bith happened ?

-Strict glycemic control to achieve HbA1C < 6
-Diet change, exercise, & weight loss.
-Folic Acid supplementation 3 months before pregnancy
-Ophthalmology consultation to rule out proliferative retinopathy
 * Screening ? 50 challenge test
* Confirm ? OGTT (3 hour , 100 g)
* Best time ? 24-28 weeks

(pt on type 1 , want to get pregnant)

* 2 assessments? Ophthalmic/ neurologic
* 2 invest ? HbA1c / KFT
* other invest ? CBC , urine analysis , urine dipstick
* 2 anomalies ? CVS / CNS
* advices ? Shift to insulin if type 2 / take folic acid

(HbA1c 7.5 , 2 h post prandial10.5)

* Dx? Poor controlled DM
* signs of bad control ? IUFD , polyhydroamnios

** Chronic DM vs GDM?
Intrauterine Growth restriction is strictly related to advanced DM, since there is
threefold increase in growth restriction in mothers with long standing microvascular disease
i.e. advanced, chronic DM. GDM is a transient process and is unlikely to cause this problem.

Depot * Mechanism: Inhibiting the secretion of pituitary gonadotropins suppression of ovulation , ↑↑

viscosity of Cx mucous, Induces endometrial atrophy .. 150 mg IM every 12 Wks

Uses:
Women with contraindication to estrogens
- Women >35 Y who smoke
- Women with migraine headache
- Women who are breastfeeding
- Women with endometriosis
- Women with sickle cell disease
- Women taking anticonvulsant medications
- Mentally handicapped women

Absolute contraindications
- Pregnancy
- Unexplained vaginal bleeding
 - Current breast ca

Relative contraindications
- Severe liver cirrhosis
- Active viral hepatitis
- Benign hepatic adenoma

* Side effects:
Menstrual cycle disturbance / Hormonal side effects / Weight gain / Mood effects / Delayed return
of fertility / Reduction in bone mineral density / Continuous spotting
Infertility primary Infertility, defined as failure to conceive after a year of unprotected, timed sexual
intercourse in a nulliparous patient age <35. (After age 35, infertility investigation can begin after 6
months).
(secondary infertility: failure to concive after having a pregnancy more than 24 w regardless of it’s
outcome)

Normal sperm analysis:

- asthenospermia: problem with the motility

- teratozoospermia: problem with the shape
- azoospermia: no sperm .. Next step? REPEAT SAMPLE !! the causes of azoospermia might
be obstructive (there is sperms production but there is something obstructing them from
reaching the ejaculation) or non obstructive (there is no sperms production) … Next step?
HORMONAL profile for the male … Next step? Testicular biopsy

* Female factors? Anything !

- ovaries: PCOS, thyroid, cushing
- tubes: scars, smoking
- uterus: masses
- cervical: infection

* Important tests for the female?

- Hormonal profile (progesterone at day 21-23 to detect if there is ovulation, other
hormones as LH, FSH, TSH, prolactin, testosterone, estradiol at day 2)
- US
- HSG, and laproscopy with methylene blue dye (check patency) at 10 th or 11th day of the
cycle
- Endometrial biopsy
* Treatment options?
- Ovulation induction (metformin, clomid, Letrozole)
- Intrauterine insemination (normal semen analysis is necessary, for women who had previous
cervical surgeries as in a case of cervical stenosis and women with any mechanical obstruction that
prevents the sperm from swimming up in the tube)
- In Vitro Fertilization (GnRH agonist for 2 to 3 weeks stimulate the ovaries with synthetic FSH and
LH injections when follicular growth occour give human menoposal gonadotropin to release egg,
colelct them and mix them with partner sperms within 12 hours)

* what is the picture below and what is an Indication for it?

- ICSI
- Severe male infertility
* Evidence it’s successful ?
-Division of the cells

* COMPLICATIONS?
- Headaches
- Blurring of vision
- Nausea and vomiting (rare)
- Cysts
- Hot flushes
- multiple pregnancy
- Ovarian hyperstimulation syndrome: here the ovaries have an exaggerated response to
stimulation so they will make load of follicles at the same time. In these patients, the ovaries will
leak fluids and toxins to the systemic circulation, and this will induce vasodilatation and leakage
from the vessels
(shifting of fluids from intravascular to extravascular), so the patient becomes toxic and accumulates
fluid all over her body (ascites, hydrothorax, pulmonary edema, pleural effusion…) This syndrome is
divided into mild, moderate, severe and critical.

- Complications of the procedures done in IVF (organ injury, infections)

- Risk of miscarriages and ectopic pregnancies
Bishop score

Amniotic hook

cervical polyp * anything related to the cervical = post coital bleeding (PCB)
* investigation? Pap smear (anything related to the cervix u do pap smear)
* tt ? excision

Cervical - It is not an ulcer (normal physiological change), due to the eversion of the columnar
ectropion epithelium of the endocervixon the ectocervix.
- Occurs in the childbearing age, and most frequently during pregnancy & in COC users ,due
to high oestrogen levels.
- Pt present with hx of IMB , PCB

* TT :
1.Conservative during pregnancy & in COC users.
Wait for 2-3 months after delivery & after stopping of COC. If symptoms persist after that
time, treatment is by local destruction.
2.Local destruction: The best by cryotherapyor thermal cautery

* cell types? Squamous and columnar

* cause? High estrogen exposure
*prevent it? Stop using COCP
* investigation? Pap smear + vaginal swap
Fever after
delivery

* why fever in first 24 hours is normal?

Early puerperium is characterized by several physiologic processes that can be mistaken for
signs of pathology. Immediately after placental delivery, shivering occurs commonly and is
theorized to be due to thermal imbalance.
 * + high vaginal swap.

Antiphospholipid
syndrome

(ACQUIRED disease)

- Obstetrical complications? early onset PET, IUGR

UTI in pregnancy

Neural tube
defect

Screen? Detailed anomaly scan (14-20 weeks)

Advice for next pregnancy? start folic acid 4mg 3 months before pregnancy
Premature - Premature ovarian failure Is defined as primary hypogonadism in a woman under age 40.
ovarian failure Causes of premature ovarian failure Include chemotherapy, radiation, autoimmune ovarian
failure, Turner's syndrome, and fragile X syndrome.

- loss of feedback Inhibition of estrogen on FSH and LH, causing FSH and LH to both become
elevated. The elevation of FSH is generally greater than that of LH; this Is due to slower
clearance of FSH from the circulation (Choice A). Symptoms of premature ovarian failure
Include amenorrhea, hot flashes, vaginal and breast atrophy, and psychologic symptoms
such as anxiety, depression and irritability. All patients with secondary amenorrhea should
receive a pregnancy test, prolactin level, and FSH level. A markedly elevated FSH level in a
woman under age 40 who has experienced > 3 months of amenorrhea confirms the
diagnosis of premature ovarian failure.

* long term complications? Osteoporosis, cardiovascular diseases

* investigation? DEXA
* TT? HRT, Ca + vitamin D
Primary amenorrhea is the failure of menses to occur by age 16 years, in the presence of
normal growth and secondary sexual characteristics. If by age 14 menses has not occurred
and the onset of puberty, such as breast development, is absent, a workup for primary
amenorrhea should start.
Anesthesia

* Epidural:
- SE? headache, hypotension, urine retention
- Contraindications?

wound * indications for CS?

dehiscence
 * Complications CS?

* risk of uterine rupture if the pt. has previous one lower segment C/S?
less than 1%
APGAR

`
- Administered to patients for whom preterm delivery is imminent as it decreases the risk for cerebral
palsy in premature infants. Because magnesium is solely excreted by the kidneys, a common risk factor
for magnesium toxicity is renal insufficiency.

- Oxytocin is a hormone secreted by the posterior pituitary that stimulates uterine contractions.
Oxytocin is similar in structure to antidiuretic hormone. Consequently, prolonged administration of high
doses of oxytocin can cause water retention and hyponatremia. Hyponatremia can present with
headaches, abdominal pain, nausea, vomiting, lethargy, and tonic-clonic seizures. Management of
hyponatremia involves gradual administration of hypertonic saline (eg, 3% saline) to normalize sodium
levels.
 Important Topics from old PYQ
Cord Active management of the third stage of labour (AMTSL) consists of a group of interventions, including
traction administration of a prophylactic uterotonic (after delivery of the anterior shoulder of the baby), cord clamping
and cutting, controlled cord traction (CCT) to deliver the placenta, and uterine massage.

Controlled cord traction (CCT) is traction applied to the umbilical cord once the woman's uterus has contracted
after the birth of her baby, and her placenta is felt to have separated from the uterine wall, whilst counter-
pressure is applied to her uterus beneath her pubic bone until her placenta delivers

* In the image below, at which stage this Procedure is done? Third stage of labor
* Duration of this stage? Up to 30 min
* Name of this Procedure ? Controlled cord traction
* What is the first step to be done in the active managment? Administer a Uterotonicdrug (Ergometrin,
Syntocinon)
* when u give it ? When u deliver the ant shoulder
*benefit of 1ststep ? Increases Uterine contractions, Decreases postpartum bleeding
* bad complications if not done? Uterine inversion, PPH

* Signs of placental separation? Globular uterus / Prolongation of the cord / Gush of blood / uterus rise in the
abdomen
* Management after placental seperation ? Oxytocin/ CCT

Anemia - Pregnant lady (22 GA , Hb8), MCV 70.

* Dx? IDA
* Risk for her pregnancy? IUGR + Prematurity
* Treatment? give oral iron supplements
* Other tests for anemia ? Ferritin/ TIBC

- Macrocytic anemia;
* Causes? Decrease in VitB12 / Folic acid
* RF? Anti convulsion drugs / vegetarian diet / pernicious anemia

Blighted A blighted ovum(also known as “anembryonicpregnancy”) happens when a fertilized egg attaches itself to the
Ovum uterine wall, but the embryo does not develop. Cells develop to form the pregnancy sac, but not the embryo
itself. A blighted ovum occurs within the first trimester, often before a woman knows she is pregnant. A high
level of chromosome abnormalities usually causes a woman’s body to naturally miscarry
 SLE , 14 w , vaginal bleeding, and the following image

* S&S? small for gestational age , Minor abdominal cramps

* RF in this patient ?SLE / age

Down Screening for chromosomal anomalies: Usually we do it at the end of the first trimester (10 -14 weeks of
syndrome gestation) and it is very important and in this screening test we measure NUCHAL TRANSLUCENCY which
shows fluid accumulation behind fetal neck and absence for NASAL BONE. And they have found that nuchal
translucency increases in down’s babies (up to 85% of babies with trisomy 21 has higher nuchal translucency
measurements). Also about 80% of down babies have small, hypoplastic or absent nasal bone so that’s one
thing we can also see in U/S

* Risk of association? 1:650 for all maternal ages

* Presentations? IUGR, Mal-presentation, Polyhydramnios
* X ray sign in the image below? Nuchal Translucency
US uses in * Most accurate measure? CRL (crown-rump length).
early * Wrong date due to? BREAST FEEDING
pregnancy * Other things to look for? Fetal viability / Number of fetuses / Adnexal masses
Maneuvers !!!

Maneuver Description Image

McRoberts Hyper flexing the mother's
legs tightly to her abdomen.

suprapubic Downward and lateral to

pressure release the ant shoulder

Gaskin (all fours) Mother on hands and knee

Woods or Rubin

Zavenelli
Straia * What is the name of the skin changes shown in the image below? Stria gravidarium
gravidarium * What is the cause during pregnancy? Polyhydroamnius, multiple pregnancy, sudden weight gain
* Medical causes? Cushing’s syndrome, liver failure

OCP If the lady uses OCP & she forgot to take the pill last night, & she notices that there are 4 pills in packet,
troubleshooting what to do?
• The old packet, start the new packet, & emergency contraception if she had sexual intercourse

<12 hrs Take the pill as soon as you remember ( this means taking 2 in 1 day)

>12 hrs, use another method for 1 week

ITP - A pregnant women at 12 weeks gestation came for routine antenatal care, her inx are:
HB 13
Platlets 70 000
Reubella igG 90IU
Wbc 8 500
BG: AB+
RBS 4.6
1- WHAT IS HER PROBLEM: Thrombocytopenia
2- MENTION THE MOST LIKELY CAUSE: ITP
3- MENTION 2 TREATMENT OPTIONS IN THE THIRD TRIMESTER? Steroid, IVIG

Malignant GTN (hx of molar , HCG stable)

follow-up * follow up duration? Weekly until 3 consecutive normal result then Monthly until normal for 1 or 2 years
according to the prognosis.
Distended •2 gyne causes ? Ovarian cancer / large fibroid
Abdomen •Investigation ? US (trans vag , abdominal), CA-125 , MRI
•worrying signs on US? Septations (multi-locularity), Solid

Uterine rupture

* Pt with previous C/S, presented with uterine rupture in her next pregnancy.
- C/P? Maternal tachycardia, Fetal distress, Lower abdominal pain, Vaginal bleeding
- Recurrence ?! 30% ?
Sacroccoygeal Sacrococcygeal teratoma (SCT) is an unusual tumor that, in the newborn, is located at the base of the
teratoma tailbone (coccyx). They are germ cell tumors occur outside of the gonads, they are known as extragonadal
tumors. One theory suggests that germ cells accidentally migrate during to unusual locations early during
the development of the embryo (embryogenesis). Normally, such misplaced germ cells degenerate and die,
but in cases of extragonadal teratomas researchers speculate that these cells continue to undergo mitosis,
the process where cells divide and multiply, eventually forming a teratoma.

Sacrococcygeal teratomas are thought to arise from an area under the coccyx called “Henson’s Node”. This
is an area where primitive cells persist (germ cells) that can give rise to cells of the three major tissue layers
of an embryo: ectoderm, endoderm, and mesoderm. These embryonic layers eventually give rise to the
various cells and structures of the body. Sacrococcygeal teratomas can contain mature tissue that looks like
any tissue in the body, or immature tissue resembling embryonic tissues.

these tumors can cause polyhydramnios (too much amniotic fluid), fetal urinary obstruction
(hydronephrosis), bleeding into the tumor or rupture of the tumor with bleeding into the amniotic space,
or dystocia

•Complications during preg? IUGR, Polyhydramnios, fetal urinary obstruction (hydronephrosis), rupture
•Dx? US
•2 presentations for this case? uterus larger for date / found on US during routine ANC

Omphalocele

* Associated with? GIT defects / Heart defects / NTD defects / Lip defects
• Clinical presentation? Elevated AFP / polyhydramnios
Turner

•Presentation? Amenorrhea/infertility
•Hormonal related? Hot flashes / Osteoporosis
•Increase risk for which CANCER? Dysgerminoma

Bimanual pelvic •Indications:

exam -Uterus: size, shape, symmetry, & position.
-Cervica lexcitation.
-Adnexal masses, shape, size
-Assessment of uterus in less than 12wks of gestation

* Give 2 contraindications for Bimanual Examination in a not fully sedated pt?

1.Physical immaturity & intact hymen.
2.Physical &/or mental disability.
Hormones Normally GnRH released in ___ pattern, every ___min.

Answer: (Pulsatile/ 30 min)

Labor

•The next stage after the internal rotation is____.

Answer: (Extension)

•Next step after head extension?

Answer: (External Rotation)

 https://www.youtube.com/watch?v=66jMER1Savg

Postpartum
blue

•Reassurance, no need for medical therapy

* Other 2 DDx? Postpartum psychosis, Postpartum depression

Scalp PH Fetal scalp blood testing is a technique used in obstetrics during labor to confirm whether fetal
oxygenation is sufficient or not and it is a good indicator for placental gas exchange. Normal value (>7.25),
less than (7.20 which is acedemia) need immediate CS and (7.20-7.25 which is pre-acedemia) wait and
repeat within 30 min.
 •Scalp PH =7.12 what next?
-immediate delivery (CS)

Pap smear

* Screening to detect pre-Cancerous stage

* Parts?
-A : Bivalve speculum
-B : Spatula
-C : Posterior lip of the cervix

Hormonal
interpretation

1.Hyper-prolactimenia.
2.PCOS.
3.Hypo-gonadotropic hypogonadism.
4.Ovarian failure (POF/ resistant ovary syndrome/ menopause).
5.Primary Hypothyroidism.
 AWN
Imperforated
hymen

1-Imperforated hymen
2-Hematocolpos
3-Surgical incision
4-Turner syndrome,, PCOS ,, hypothyroid ,, etc

Imperforate Hymen
• Primary amenorrhea
• (+) breasts and uterus
• Normal height and weight

Atrophic
vaginitis

Clinical presentation? Loss of rugae , heavy bleeding , dryness

G and P

Pregnant women had previous molar pregnancy, previous ectopic, previous CS, previous IUFD. She is
G___P___

Answer: (G5P2+2)

A 45 year old G3P2 (both were NVD) , known to have DM type 2 , her LMP 3-7-2017 ( sure date )
1.How many weeks of pregnancy she is today? ‫😊 الجواب حسب تاري خ امتحانهم‬
2.What do you call her current pregnancy condition?
3.What is the best management foe her current condition?

1. 42+5 3 months = 13 w / 1 month = 4 w + 2 days

2. Post date
3. Induction of labor

* On 1/7/2101 she was 12 wks GA, what’s her GA on 30/12/2010?

Answer: (37 weeks + 5 days).

Drugs * Aspirin: _____ (stopped 7-10 days prior).

* Prednisolone: ____ (stop it & give IV hydrocortisone).
* COCP: ___ (stopped 2-3 months prior).
* Warfarin: ___ (stopped till normal INR then give LMWH till 12hrs before surgery).
1- pH ,, concentration ,, blood flow (others: lipid solubility, surface area, protein binding)
2- methyldopa (Between January 2004 and October 2012, 6 individuals taking METHYLDOPA reported
MICROCEPHALY to the FDA.)
3- Nifedipine
4- IUGR or IUFD

* Answer these questions depending on your knowledge about drugs during pregnancy:

A- what anticoagulant can be given in the first trimester?

LMWH

B- what is the effect of NSAID on amniotic fluid?

Oligohydramnios

C- what is the side effect of using tetracycline?

Permanent teeth discoloration

D- if a woman took methotrexate, for how long does she used to be in contraception?
At least 3 months

E- what is the FDA category for levothyroxine and folic acid?

Category A

Category |A| Safety has been established using human studies, no fetal risk.
Category |B| Presumed safety based on animal studies, but no well-controlled human studies.
Category |C| Uncertain safety. Animal studies show an adverse effect, no human studies.
Category |D| Evidence of fetal risk, but benefits outweigh risks.
Category |X| Highly unsafe. Risk outweighs any possible benefit.
 * Her newborn died 4 hours after birth, mention one medication to stop lactation
Cabergoline or bromocriptine (potent dopamine receptor agonist on D₂ receptors)

Pulse 6th year

Mitral stenosis A 19 year old primigravida, known to have mitral stenosis, came for booking at 13 weeks gestation.
She is asymptomatic now .

What is the main complication she is at risk of ?

Mention 3 main points in her management during labor .

Heart Failure
- pain relief
- decrease the second stage duration ( Don’t use epidural anesthesia) .
- Avoid Uterus inversion
* There are quite a few reasons for not supplementing iron in the first trimester of pregnancy in women
with no iron deficiency:

There is no or negligible demand by the embryo.

Taking iron tablets is associated with a lot of gastric discomfort which is usually compounded by the
morning sickness which is at its peak during the first trimester.

High iron stores in the body have been associated with malformations of the embryo in animal
studies.

Please note that the iron supplementation is inevitable in the second half of the pregnancy as the iron
demand from the growing embryo cannot be fulfilled by dietary iron alone and will lead to iron
deficiency

a recent study in the British Journal of Obstetrics and Gynaecology found that while routine iron
supplementation did marginally improve hemoglobin concentrations during the third trimester in non-
anemic women, it also increased the risk of high blood pressure in pregnancy and small-for-gestational
age babies.

An IUD can be inserted right after you give birth, whether you've delivered vaginally or by c-section. It
can be done while you're still in the delivery room, ideally within 10 minutes after the placenta is
delivered.

Previously, you had to wait about six weeks after delivery to have an IUD inserted. Experts were
concerned that an IUD might not stay in if it was inserted before your uterus had returned to its pre-
pregnant state.

But when the U.S. Centers for Disease Control (CDC) and the American Congress of Obstetricians and
Gynecologists (ACOG) reviewed the evidence from other countries, they decided to change their
recommendations.

They found that the IUD is somewhat more likely to come out if inserted right after childbirth, but they
decided that women still benefited from the option to insert it early.
Ovulation occurs after ____ hrs from onset of LH secretion & ____ hrs from high peak of it

Answer: (36) hrs / (12) hrs

• Prostaglandins: