I group of questions

1. Classification of breach presentations.

Breech: feet or buttocks present first. The major risk of SVD is entrapment of the after-coming
head.
⚫ Frank breech
⚫ Complete breech
⚫ Incomplete breech:
i. Footling breech: complete and incomplete
ii. Kneeling breech: Extended hips and flexed knee may be complete or incomplete

2. Definition of complete breech presentation.

Complete breech means buttocks is presenting part hips and legs flexed
Circumference of the buttocks – 34-35cm
C.of the shoulders – 34-35cm
C. of fetal head – 32cm

3. Definition of frank breech presentation.

Baby’s buttocks is the presenting part, baby’s hips are flexed and knees extended.
Circumference of the buttocks – 32cm
C.of the shoulders – 39-41cm
C. of fetal head – 32cm

4. Definition of incomplete foot-link presentation.

A footling breech presentation occurs when one of the infant's feet cover or push through the
cervix of the uterus. One hip or knee are not completely flexed, resulting in one feet presenting
before the buttocks
Circumference of the buttocks – 28cm
C.of the shoulders – 34-35cm
C. of fetal head – 32cm

5. Definition of complete foot-link presentation.

A footling breech presentation occurs when both of the infant's feet cover or push through the
cervix of the uterus.Both hips or knees are not completely flexed, resulting in both feet
presenting before the buttocks
Circumference of the buttocks – 28cm
C.of the shoulders – 34-35cm
C. of fetal head – 32cm

6. Classification of fetal malpresentations.

means any fetal orientation other than cephalic.
⚫ Breech Presentations
i. Frank breech
ii. Complete breech
iii. Incomplete breech:
Footling breech: complete and incomplete
Kneeling breech: Extended hips and flexed knee may be complete or incomplete
⚫ Dexlefed presentations:
i. Sinciput vertex D. fronto-occipitalis 12cm, 34cm
ii. Brow D.Mentooccipitalis 13 – 13,5cm, 39-41cm
iii. Face D. hyo-bregmaticus 9.5cm, 32cm
⚫ Malposition
i. Transverse lie: When the fetus is positioned with the head on one side of the pelvis and the
buttocks in the other (transverse lie), vaginal delivery is impossible.
ii. Occipito-posterior position: The head initially engages normally but then the occiput rotates
posteriorly rather than anteriorly. The anterior fontanelle is felt anteriorly. The posterior
fontanelle (three radiating sutures) may also be palpable posteriorly.

7. Classification of deflexed presentations.

i. Sinciput vertex D. fronto-occipitalis 12cm, 34cm
ii. Brow D.Mentooccipitalis 13 – 13,5cm, 39-41cm
iii. Face D. hyo-bregmaticus 9.5cm, 32cm

8. Definition of sinciput vertex presentation.

D. fronto-occipitalis 12cm, 34cm
⚫ In vaginal exam: sagittal suture, large and small fontanels are on the same level.
⚫ The fetal head presents with a fronto-occipital diameter.
⚫ The leading point is the large fontanel.
⚫ Cardinal movements: deflexion; internal rotation; flexion; extension; internal rotation of
body and external rotation of head.
⚫ SVD: posterior variety in, Not large fetus, Adequate contractions, normal pelvic sizes

9. Definition of brow presentation.

D.Mentooccipitalis 13 – 13,5cm, 39-41cm
⚫ In vaginal exam: the frontal suture, the large fontanel, orbital ridges, eyes, and root of the
nose. The nose and mouth can not be palpable.
⚫ The fetal head presents with a mento-occipital diameter – 13 – 13,5cm
⚫ The leading point is the middle of the frontal suture.
⚫ Vaginal delivery is impossible, only cesarean section is recommended.

10. Definition of face presentation.

⚫ On vaginal exam: face line with mouth, nose, the, orbits and chin are presented
⚫ The leading point is chin
⚫ The fetal head presents with hyo-bregmaticus diameter 9,5cm
⚫ The cardinal movements in labor are: deflexion; internal rotation; extension; internal
rotation of the fetal body and external rotation of the fetal head.
⚫ Vaginal delivery – in face posterior (chin anteriorly)
⚫ Cesarean section in face posterior.
⚫ Types: chin anterior and chin posterior

11. Classification of multiple pregnancies.

Acc to:
Number of fetus: Twins, triplets, quadruplets etc.
Number of fertilized eggs (dizygotic or monozygotic)
Number of placenta: Monochorionic or dichorionic
Number of amniotic cavities: diamniotic or monoamniotic
Acc to chorionicity and amnionicity
⚫ Dichorionic–diamniotic: Twins who have their own chorions and amniotic sacs. They
typically do not share a placenta and can be fraternal or identical.
⚫ Monochorionic–diamniotic: Twins who share a chorion but have separate amniotic sacs.
They share a placenta and are identical.
⚫ Monochorionic–monoamniotic: Twins who share one chorion and one amniotic sac. They
share a placenta and are identical.

12. Definition of polyhydramnios. The most probable reasons

Polyhydramnios is excessive amniotic fluid
If AFI >25cm, mpv>8cm
>2000 mL at 36 weeks
Causes
⚫ Fetal malformations (eg, gastrointestinal or urinary tract obstruction)
⚫ The fetus can’t swallow amniotic fluid due to a congenital disorder.
⚫ Maternal diabetes
⚫ Carrying identical twins with twin to twin transfusion syndrome (TTTS).
⚫ Multiple gestation
⚫ Fetal anemia, including hemolytic anemia due to Rh incompatibility
⚫ Fetal infection TORCH
⚫ Idiopathic
Fetal swallowing and intramembranous absorption, thought to occur by osmotic absorption of
fluid directly across the amnion and into fetal blood vessels, are the primary routes of amniotic
resorption. Therefore, fetal gastrointestinal anomalies, such as tracheoesophageal fistula

13. Definition of oligohydramnios. The most probable reasons.

Oligohydramnios is amniotic fluid volume that is less than expected for gestational age;
The 4-quadrant amniotic fluid index test assesses the deepest single vertical amniotic fluid pocket
in each of the 4 quadrants of the uterus. The sum of the pockets is AFI.
If AFI <5, it is oligohydraminos
The maximal vertical pocke measures the deepest area of your uterus to check the amniotic fluid
level. If MPV <2cm,

Causes:
⚫ Uteroplacental insufficiency ( preeclampsia, chronic hypertension, placental abruption,
 a thrombotic disorder, or another maternal disorder)
⚫ Rupture of membranes (premature or at term)
⚫ Post term pregnancy
⚫ Some medications (eg, [ACE] inhibitors, [NSAIDs])
⚫ Fetal chromosomal abnormalities (eg, aneuploidy)
⚫ Fetal malformations, esp of GUT; renal agenesis, onstruction urethra
⚫ Intrauterine growth restriction
⚫ Fetal death
⚫ Idiopathic
Fetal genitourinary can result in a diagnosis of oligohydramnios after 16 to 20 weeks gestation.
Examples include bladder outlet obstruction, dysplastic kidneys, and renal agenesis.

14. Pelvic classification according to the degree of contraction.

Four degrees
I degree: True conjugate 11-9 cm. SVD
II degree: True conjugate 9-7,5 cm. SVD
III degree:True conjugate 7,5 – 5,5 cm CS
IV degree: True conjugate is 5.5 cm. CS

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

1. Often occurred
⚫ generally contracted pelvis;
⚫ flat pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted flat pelvis.
2. Rare occurred:
⚫ obliquely contracted pelvis,
⚫ obliquely dislocated pelvis,
⚫ transverse contracted pelvis,
⚫ osteomalacic pelvis,
⚫ funnel-shaped pelvis,
⚫ spondylolisthetic pelvis,
⚫ contracted pelvis as a result of exostosis and bone tumors.
Management of labor. CS

16. Definition of anatomical and functional contracted pelvis.

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

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

1. Arresting of the head in the pelvic inlet
2. Uterine contractions abnormality.
3. Positive Vasten’ sign
4. Signs of urinary bladder compression.
5. Edema of the cervix, and vaginal walls, productions of fistulas.
6. Danger of uterine rupture – overdistension of lower uterine segment
7. Pushing occurs in location of fetal head in inlet.

18. Definition of the general contracted pelvis.

Is characterized by diminution of all true pelvic diameters (anteroposterior, transverse, and
oblique) into 1-2 cm. Subpubic arch is narrow.
Average sizes of the pelvis are:
D. spinarum – 23 cm,
D. cristarum – 26 cm.
D. trochanterica - 29 cm
C. externa – 18 cm
C. diagonalis – 11 cm
C. vera – 9 cm.

19. Definition of simple flat pelvis.

Is defined as shortening of anteroposterior diameters at all levels of true pelvis, as a result of
this sacrum is inclined anteriorly to pubis.
Average sizes of the pelvis are:
D. spinarum – 26cm
D. cristarum – 29 cm
D. trochanterica - 31 cm
C. externa – 18 cm
C. diagonalis – 11 cm
C. vera – 9 cm.

20. Definition of flat rachitic pelvis.

True conjugate is shortened.
Sidewalls converge, as result of this D. spinarum and D. cristarum are the same.
Additional promontorium may be presented between 1 and 2 vertebrae of sacrum
Subpubic arch is shallow and wide
Top of the sacrum is situated posteriorly that’s why dimensions of the pelvic outlet are normal or
even increased.
Average sizes of the pelvis are:
D. spinarum – 26cm
D. cristarum – 26 cm
D. trochanterica - 31 cm
C. externa – 17 cm
C. diagonalis – 10 cm
C. vera – 8 cm.

21. Classification of uterine contractions abnormalities.

⚫ Hypotonic uterine dysfunction: (Uterine inertia): uterine contractions is less than normal.
responds to oxytocin. The contractions are synchronous but weak or infrequent.
⚫ Hypertonic uterine dysfunction: uterine tone elevated and contractions are incoordinative.
Contractions of increased frequency but decreased coordination. It is seen more often with
fetal malpresentation and uterine overdistension.

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

Large fetuses birthweight > 4000 g
giant babies birthweight > 5000 g

23. Definition of hypotonic uterine dysfunction.

⚫ Hypotonic uterine dysfunction: (Uterine inertia): uterine contractions is less than normal.
responds to oxytocin. The contractions are synchronous but weak or infrequent.

Signs and Symptoms of HYPOTONIC UTERINE INERTIA:

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

24. Definition of hypertonic uterine dysfunction.

Contractions are ineffectual, erratic, uncoordinated, and of poor quality that involve only a
portion of the uterus. Increase in frequency of contractions, but intensity is decreased, do not
bring about dilation and effacement of the cervix.
⚫ PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain
⚫ Dilation and effacement of the cervix does not occur.
⚫ Prolonged latent phase. Stay at 2 - 3 cm. don’t dilate as should
⚫ Fetal distress occurs early– uterine resting tone is high, decreasing placental perfusion.
⚫ Anxious and discouraged

25. Etiology of hypotonic uterine dysfunction.

Overstretching of the uterus: large baby, multiple babies, polyhydramnios, multiple parity
Bowel or bladder distention preventing descent
Excessive use of analgesia

26. Indications for perineotomy, episiotomy,

An episiotomy is an incision made in the perineum — the tissue between the vaginal opening and
the anus — during childbirth to enlarge the outlet in order to make room for the fetal head
descent during labour
Indications
⚫ forceps delivery, vacuum delivery,
⚫ vaginal breech, face to pubes,
⚫ previous history (H/O) of perineal tear,
⚫ maternal exhaustion: ineffective maternal pushing
⚫ rigid perineum: resistant perineum causing delay in the fetal head delivery
⚫ abnormal fetal heart rate during delivery
⚫ fetal macrosomia
⚫ shoulder dystocia
The two most common types: midline and right mediolateral.

27. Indications for amniotomy.

• When internal fetal or uterine monitoring is needed
• For induction of labor
• For augmentation of labor: it leads to an increase in plasma prostaglandins;
• Medical disorders like PIH
• obstetrical conditions like post term pregnancy
• Hypotonic uterine contractions
Artificial rupture of the amniotic sac with amniohook (a long crochet type hook, with a
pricked end) or an amnicot (a glove with a small pricked end on one finger).

28. Indications for c-section

Maternal:
⚫ Previous caesarean section
⚫ High order multifetal gestation ≥3 fetuses
⚫ Twin pregnancy – when the first twin is not a cephalic presentation
⚫ Cephalo-pelvic disproportion
⚫ Uterine rupture
⚫ Eclampsia and HELLP syndrome
⚫ Transmissible disease: henital herpes, hiv
⚫ Failure of induction
⚫ Cervical cancer
⚫ Previous perineal trauma
Fetal
⚫ Fetal malpresentations
⚫ Dystocia (Ineffective or prolonged labour)
⚫ Fetal distress
⚫ Macrosomia
⚫ Placenta praevia, Abruptio placentae (with live fetus)
⚫ Cord prolapse
⚫ Failed trial of Forceps / Vacuum delivery
⚫ Fetal malformations likely to cause obstructed labour
⚫ Post term

29. Indications for vacuum extraction of the fetus.

⚫ Prolonged second stage: >2hr in nullipara, >1hr in multipara +1hr with epidural
⚫ Category III EFM strip. The fetal heart rate monitor pattern suggests the fetus is not
tolerating labor.
⚫ Shortening 2nd stage: Maternal exhaustion, bleeding, cardiac or pulmonary disease, and
history of spontaneous pneumothorax. Fetal distress
Avoid maternal pushing: e.g., cardiac, pulmonary, or neurologic disorders

30. Indications for application of obstetrics forceps.

⚫ Prolonged second stage: >2hr in nullipara, >1hr in multipara +1hr with epidural
⚫ Category III EFM strip. The fetal heart rate monitor pattern suggests the fetus is not
tolerating labor.
⚫ Shortening 2nd stage: Maternal exhaustion, bleeding, cardiac or pulmonary disease, and
history of spontaneous pneumothorax.
⚫ Fetal distress
⚫ Avoid maternal pushing: e.g., cardiac, pulmonary, or neurologic disorders.
⚫ Breech presentation. Shorten the time to deliver the head of a vaginal breech fetus.
⚫ Face presentation, After coming head of breech
⚫ Preterm head
⚫ Dead fetus

31. Conditions for obstetrics forceps operation.

⚫ Cervix fully dilated
⚫ Fetal head engaged (vertex presentation) station >+2
⚫ Rupture of membranes
⚫ Knowledge of the fetal head position: Head has to be rotated, occiput behind pubic
symphisis, sagital suture fixed longitudinally.
⚫ Fetal weight has been estimated
⚫ Maternal pelvis adequate for vaginal delivery: no cpd
⚫ Anesthesia administered
⚫ The maternal bladder is empty
⚫ Maternal consent obtained, risks and benefits thoroughly explained
⚫ The operator should be competent in the use of the instruments and the recognition and
management of potential complications.

32. The conditions for the c-section

⚫ Justified indication
⚫ Mothers blood group is known and cbc
⚫ No blleding diathesis
⚫ Availability of Antibiotic prophylaxis: iv cefazolin 2g single dose
⚫ Presence of anesthisiologist
⚫ Valid informed consent
⚫ Stomach should be empty: preoperative fasting time of at least 2 hours from clear liquids, 6
hours from a light meal, and 8 hours from a regular meal.
⚫ Bladder should be catheterized
⚫ Fetal presentation, position and FHS should be checked
⚫ surgical site prepared (shaved)
⚫ Establish iv acess
⚫ Routine prophylaxis of gastric acid aspiration
Inj Ranitidine 50 mg IV half to one hour before the procedure
Inj Metoclopramide 10 mg IV half to one hour before the procedure
⚫ – Skilled human resources for determining whether surgery is indicated, administering the
anaesthesia and performing the surgery
⚫ Appropriate facilities (operating room, sterilisation, post-operative recovery room and blood
transfusion).
⚫ Appropriate equipment.
⚫ Appropriate care and monitoring.

33. Anesthesia for the c-section .

⚫ Epidural Block: Injection of local anesthetic into the epidural space to block the lumbosacral
nerve roots.
⚫ Hypotension is treated with IV fluids and IV ephedrine.
⚫ Spinal headache is treated with IV hydration, caffeine, or blood patch.
⚫ Spinal Block: injection of local anesthetic into the subarachnoid space to block the
lumbosacral nerve roots. It is used as a saddle block for cesarean delivery.
Subarachnoid block
Spinal block
Saddle block (low spinal)
Lumbar epidural block
Anesthesia
Inhalation -Nitrous Oxide + Oxygen
General anesthesia: In emergency propofol, ketamine, thiopental.

⚫ Spinal anesthesia. In spinal block, local anesthetic is injected through the third, fourth, or
fifth lumbar interspace into the subarachnoid space
⚫ Epidural block:
Lidocaine 1%, 5 mL ampule, for skin infiltration
Lidocaine 1.5% with epinephrine 1:200,000, 5 mL ampule, for epidural test dose and bolus
Fentanyl: IM 50-100 /j,g; IV 25 to 50 /xg
Epidural: fentanyl, 1-2 g with 0.125% bupivacaine, 8-10 ml/hr;
Meperidine, fentanyl, nalbuphine

34. Etiology and pathogenesis of perineal and cervical lacerations.

Etiology:
Cervical: Large fetus, Fast labor, Operative labor, deep cervical conization, primigravida status
Perineal:midforceps delivery, fetal macrosomia, inflexible, inelastic perineum In primigravida
nulliparity, midline episiotomy, malpresentation (persistent occiput posterior position) and
advancing gestational age,
If the baby delivers too fast, does not allow the cervix to dilate and efface which leads to
cervical lacerations
Pathogenesis of perineal and cervical lacerations they occur at the expulsion stage of
labour which is usually accompanied by a marked distension in the of the birth canal
structures including the cervix and the perineum. in excessive strain beyond the
elastic threshold of these parts, they rupture or lacerate.

35. Classification of cervical lacerations.

⚫ First-degree laceration is up to 2 cm. Such tears heal rapidly and are rarely the source of any
difficulty. In healing, they cause a significant change in the shape of the external os from
round before cervical effacement and dilation to appreciably elongated laterally after and
recovery from effacement and dilatation.
⚫ Second-degree laceration is more than 2 cm but it doesn’t extend to the vaginal fornices.
⚫ Third-degree laceration extend to the vaginal fornices.

36. Classification of perineal lacerations

⚫ First degree: involves the; fourchette, perineal skin, and vaginal mucous membrane but not
the underlying fascia and muscle. Suture repair is often not needed.
⚫ Second degree: involve skin and mucous membrane of vagina, the fascia and muscles of the
perineal body but not the anal sphincter. Suturing is necessary.
⚫ Third degree: involve the vagina, the perineal body, and the anal sphincter but not the rectal
mucosa. Suturing is necessary to avoid anal incontinence. incomplete laceration
⚫ Fourth degree: involve all the way from the vagina through to the rectal mucosa. Complete
laceration involves the rectal mucosa

37. Etiology, pathogenesis of uterine rupture.

Uterine rupture is complete separation of the wall of the pregnant uterus with or without
expulsion of the fetus that endangers the life of the mother or the fetus, or both. The rupture
may be incomplete (not including the peritoneum) or complete (including the visceral
peritoneum)
Etiology
⚫ Traumatic: oxytocin stimulation, difficult forceps delivery, breech extraction, unusual fetal
enlargement, such as hydrocephalus;
⚫ Spontaneous rupture: cephalopelvic disproportion, or abnormal fetal presentations, such as brow,
high parity, Preciptuous labor
⚫ Scar rupture: previous CS, myectomy
Clinically contracted pelvis: causes overdistension of lower uterine segment

Pathogenesis uterine rupture results from the overdistention of the uterus beyond its elastic
threshold in the induction of the forces of labor during the expulsive stage , which results in the
disruption of the integrity of its wall. This causes stopping of uterne contractions, fetal distress,
acute abdominal pain, hemorrahge and in severe cases death

38. Classification of uterine rupture.

1. By etiology:
⚫ Traumatic: oxytocin stimulation, difficult forceps delivery, breech extraction, unusual fetal
enlargement, such as hydrocephalus;
⚫ Spontaneous rupture: cephalopelvic disproportion, or abnormal fetal presentations, such as
brow.
⚫ Scar rupture: previous CS, myectomy
2. Depending relation with peritoneal cavity
⚫ incomplete (not including the peritoneum)
⚫ complete (including the visceral peritoneum).
3. By the time of occurring: during pregnancy; during labor.
4. By localization:
⚫ uterus fundus;
⚫ uterine body;
⚫ lower uterine segment;
5. By clinical duration:
⚫ Threatening of uterine rupture;
⚫ Initial uterine rupture
⚫ Uterine rupture

39. Classification of puerperal genital tract infection after Sazonov and Bartels.
⚫ Stage 1:the infection is limited to the area of the birth wound (endometritis, postpartum
ulcer)
⚫ Stage 2: infection has spread beyond the postpartum wounds, but remained localized within
the pelvis: (parametritis, salpingitis, pelvic peritonitis, vein thrombophlebitis, femoral veins)
⚫ Stage 3: infection is outside the pelvis and has a tendency to generalize, clinical
manifestations is similar to generalized (peritonitis, progressive thrombophlebitis)
⚫ Stage 4: generalized infection (sepsis, septic shock)

40. Pathogenesis of puerperal genital tract infection.

infection of birth canal in postpartum period, which is accompanied by high temperature during
at least 2 days from the first 10 days postpartum. Infection during the period of about six weeks
after childbirth and it is directly related to pregnancy and childbirth and due to bacterial
infection.
Microorganisms: Gonocossus, BhStrep, klebsiella, Ecoli, proteus, staph aureus, pseudomonas,
enterocossus, bacteroides
⚫ Risk factors ( anemia, malnutrition, obesity, PROM, Chorioamnionitis, Prolonged labor,
Multiple vaginal examinations after the rupture of membranes, coitus in late pregnancy
lacerations e.t.c ), leaves the uterus susceptible to invasion and colonization by bacteria.
⚫ The Infection of uterus can also occur due to ascending route from the tubular canals of the
genital tract.
⚫ The pathogen infects the uterus causing endometritis, or infect wound
⚫ Then it spreads to the fallopian tubes and ovaries then to other organs and tissues in the
pelvis. Causing parametritis, salpingitis, pelvic peritonitis.
⚫ The infection then spreads outside the pelvis
⚫ Eventually, it can then invade the bloodstream and lymph system and spread cause sepsis.

41. Pathophysiology and Etiology of placenta previa.

Definition: abnormal location of the placenta over, or in close proximity to, the internal cervical
os.
No specific cause of placenta praevia has yet been found but
⚫ Normally, the lower implanted placenta atrophies and the upper placenta hypertrophies,
resulting in migration of the placenta.
⚫ It is said to be related to abnormal vascularisation of the endometrium caused by scarring,
fibroid, endometritis or atrophy from previous trauma, surgery, or infection.
⚫ In Vitro Fertilization whereby the artificially implanted trophoblast may be
placed too low
⚫ Pathology of gestational sac causes delayed maturation of the trophoblast, the
sac attaches in isthmus or cervix.
⚫ Multiple gestation makes

Risk factors:
⚫ Previous previa
⚫ Uterine scarring
⚫ Advanced maternal age
⚫ Multiple gestation
⚫ Clsely spaced pregnancy

42. Classification of placenta previa

⚫ complete or total: if the entire cervical os is covered;
⚫ partial : if the margin of the placenta extends across part but not all of the internal os;
⚫ Marginal: if the edge of the placenta lies adjacent to the internal os;
⚫ low lying - if the placenta is located near but not directly adjacent to the internal os till 6
cm.
Complete, partial, marginal, low lying till 2cm:CS;
low lying > 2cm: AROM and oxytocin induction of labor.
If the hemorrhage exceeds 250-300ml – immediate cesarean section

43. Pathophysiology and Etiology of placental abruption

Premature separation of the normally implanted placenta from the uterine wall.
Etiology: when there is hemorrhage into the decidua basalis, leading to premature placental
separation and further bleeding. The cause for this bleeding is not known.
Patients at risk:
Maternal hypertension
Multiply pregnancy
Polyhidramnios
External trauma
Preterm prematurely ruptured membranes
Cigarette smoking
Cocaine abuse
Uterine leiomyoma,
Main complication: Apoplexy blue uterus+uterine atony

The bleeding could be concealed between the separated placenta and the uterine wall forming a
hematoma (concealed type)
could be seen externally
Decidual Hematoma leads to degeneration and necrosis of decidua basalis and adjacent placental
parts

44. Diagnostic evaluation of placental abruption.

⚫ External bleeding can be profuse or there may be no external bleeding (concealed
hemorrhage)
⚫ Uterine tenderness
⚫ Back pain
⚫ Fetal distress
⚫ Uterine hypertonus or high-frequently contractions
⚫ Dead fetus when placenta is totally sheered.
⚫ Coagulation disorders
⚫ Ultrasonography can help in diagnosis: space between placenta and uterine wall of
hematoma in between incase of concealed

45. Etiology of Postpartum hemorrhage

Postpartum hemorrhage is defined as blood loss in excess of physiologic blood loss at the time of
vaginal delivery – 0,5% from body weight
Blood loss >500ml after vagina delivery or >100ml after CS
Early pph: 4Ts
Tonus, Tissue: retention of placenta, membranes, Traumatic injury, Thrombotic disorder
⚫ uterine atony: total absence of uterine contractions into the external irritation
Overdistended uterus: multiple fetuses, Hydramnios, distention with clots.
Anesthesia or analgesia: halogenated agents, conducted analgesia with hypertension.
Exhausted myometrium:fast labor,prolonged labor, oxytocin/prostaglandin stimulation.
Chorionamnionitis.
Previous uterine atony.
⚫ genital tract trauma:
Complicated vaginal delivery.
Cesarean section or hysterectomy, forceps or vacuum.
Uterine rupture: previously scarred uterus, high parity, hyperstimulation, obstructed labor
Large episiotomy, including extensions.
Lacerations of the perineum, vagina or cervix.
⚫ bleeding from the placental site (retained placental tissue, low placental implantation, focal
or partial placental adherence, placenta increta, acreta and percreta, uterine inversion)
⚫ coagulation disorders: like DIC syndrome
46. Principles for monitoring women who are at risk of postpartum haemorrhage.
⚫ during hospitalization patient should be assessed on the prognostic risk OH and made all the
arrangements for its prevention and timely treatment
⚫ Routine prophylactic oxytocin 10 U IM in 3rd stage of labor reduces the risk of OH
⚫ In absence give ergometrine, misoprostol
⚫ Ensuring all lacerations are sutured carefully
⚫ PP uterine tone assesment: massage every 15 minutes during the first 2 hours
⚫ For 1 hr post partum, Blood pressure, uterine blood loss and pulse rate, urine output must
be monitor closely ~ 15 minutes
⚫ Be suspicious with increased heart rate, pelvic pain or decreased BP!!!!!!
⚫ High risk for postpartum hemorrhage from: Uterine atony, retained placental fragments,
unrepaired lacerations of vagina, cervix or perineum.
⚫ Occult bleeding may occur – vaginal hematoma

47. Etiology of the third stage of labour bleeding.

Postpartum hemorrhage before delivery of the placenta is called third-stage hemorrhage.
Bleeding from placental site: due to placental abruption, retained placenta, acreta, percreta,
increta
Genital tract trauma
Uterine atony
⚫ uterine atony: total absence of uterine contractions into the external irritation
Overdistended uterus: multiple fetuses, Hydramnios, distention with clots.
Anesthesia or analgesia: halogenated agents, conducted analgesia with hypertension.
Exhausted myometrium:fast labor,prolonged labor, oxytocin/prostaglandin stimulation.
Chorionamnionitis.
Previous uterine atony.
⚫ genital tract trauma:
Complicated vaginal delivery.
Cesarean section or hysterectomy, forceps or vacuum.
Uterine rupture: previously scarred uterus, high parity, hyperstimulation, obstructed labor
Large episiotomy, including extensions.
Lacerations of the perineum, vagina or cervix.
⚫ bleeding from the placental site (retained placental tissue, low placental implantation, focal
or partial placental adherence, placenta increta, acreta and percreta, uterine inversion)

48. Etiology of the early postpartum period bleeding.

⚫ uterine atony: total absence of uterine contractions into the external irritation
Overdistended uterus: multiple fetuses, Hydramnios, distention with clots.
Anesthesia or analgesia: halogenated agents, conducted analgesia with hypertension.
Exhausted myometrium:fast labor,prolonged labor, oxytocin/prostaglandin stimulation.
Chorionamnionitis.
Previous uterine atony.
⚫ genital tract trauma:
Complicated vaginal delivery.
Cesarean section or hysterectomy, forceps or vacuum.
Uterine rupture: previously scarred uterus, high parity, hyperstimulation, obstructed labor
Large episiotomy, including extensions.
Lacerations of the perineum, vagina or cervix.
⚫ bleeding from the placental site (retained placental tissue, low placental implantation, focal
or partial placental adherence, placenta increta, acreta and percreta, uterine inversion)
⚫ coagulation disorders: like DIC syndrome

49. Causes of postpartum pathological haemorrhage.

Postpartum hemorrhage is defined as estimated blood loss ≥500 mL after vaginal
birth or ≥1000 mL after cesarean delivery of fetus.
⚫ uterine atony: total absence of uterine contractions into the external irritation
Overdistended uterus: multiple fetuses, Hydramnios, distention with clots.
Anesthesia or analgesia: halogenated agents, conducted analgesia with hypertension.
Exhausted myometrium:fast labor,prolonged labor, oxytocin/prostaglandin stimulation.
Chorionamnionitis.
Previous uterine atony.
⚫ genital tract trauma:
Complicated vaginal delivery.
Cesarean section or hysterectomy, forceps or vacuum.
Uterine rupture: previously scarred uterus, high parity, hyperstimulation, obstructed labor
Large episiotomy, including extensions.
Lacerations of the perineum, vagina or cervix.
⚫ bleeding from the placental site (retained placental tissue, low placental implantation, focal
or partial placental adherence, placenta increta, acreta and percreta, uterine inversion)
⚫ coagulation disorders: like DIC syndrome

50. Main terminal states in obstetrics

⚫ Hemorrhagic shock: a state of severe hemodynamic and metabolic disorders that result
from blood loss characterized by the inability of circulatory system to provide adequate
perfusion of vital organs. Major cause is blood loss
Risk of hemorrhagic shock: blood loss 15 - 20% of BCC or 750 - 1000 ml.
Bleeding,up to 1,500 mL (25-30% of BCC or 1.5% of body weight) is massive.
⚫ DIC-syndrome: pathological syndrome, based on the activation of vascular-platelet or
coagulation hemostasis, resulting initially blood clotting in the microvasculature, deposition
of fibrin, leading to microvascular thrombi in various organs, then depletion potential
clotting and anticoagulation system loses its ability to clot, which manifests with profuse
bleeding and the development of multiple organ failure syndrome.
⚫ Amniotic fluid embolism (AFE):sudden, and often fatal obstetric complication caused by
entry of amniotic fluid into the maternal pulmonary circulation, Causing sudden dyspnea
and cardiovascular collpase, hypotension commonly followed within minutes by
cardiorespiratory arrest. It also precipitates DIC development
⚫ Septic shock: infection caused by endotoxin-releasing gram-negative aerobic coliform
organisms. Endotoxin, is released into the circulation at the time of bacterial death, resulting
in multiple hemodynamic effects. These toxins damage the small blood vessels, causing
them to leak fluid into the surrounding tissues, leading to severe drop in blood pressure
⚫ Anaphylactic shock: exagerated allergic reaction of human organism that leads to release of
histamine, serotonin, acetylcholine, and some substances of anaphylaxia. They cause
vasodilation, increase vascular permiability, and provoke dropping of arterial blood
pressureg and , as result, development of hypovolemia and tissual hypoxia. It also provokes
bronchoconstriction

51. Stages of Hemorrhagic shock.

Class 1 Class 2 Class 3

Blood loss (ml) 750-1000 1000-1500 1500-2500

% blood volume 15-20% 21%-30% 31%-40%

Heart rate 100 - 110 110 - 120 120 - 140

BP systolic 90-100 70-90 50-70

Shock index 0,8-1.0 1.0-1.5 1.5-2.0

Respiratory rate 20-25 25-30 30-40

Class 1 Class 2 Class 3 Class 4

CAP 2-3 s >3 s >3 s >3 s

Hematocrit 0.30 - 0.38 0.25 - 0.30 0.20 - 0.25 <0.20

Diuresis 30-50 25-30 5-15 0-5

CVP, mm.w.c 40-60 30-40 0-30 0

Mental Calm Anxiety Moderate anx Fear or confu Confusion or co

Shock
iety sion ma
index
(SI) is
defined as the heart rate (HR) divided by systolic blood pressure (SBP)

52. High risk factors for postpartum hemorrhage.

non-use of oxytocics
⚫ uterine atony: risk factors
⚫ Overdistended uterus: multiple fetuses, Hydramnios, distention with clots.
⚫ Anesthesia or analgesia: halogenated agents, conducted analgesia with hypertension.
⚫ Exhausted myometrium:fast labor,prolonged labor, oxytocin/prostaglandin stimulation.
⚫ Chorionamnionitis.
⚫ Previous uterine atony.
⚫ genital tract trauma: risk factors
⚫ Complicated vaginal delivery.
⚫ Cesarean section or hysterectomy, forceps or vacuum.
⚫ Uterine rupture: previously scarred uterus, high parity, hyperstimulation, obstructed labor
⚫ Large episiotomy, including extensions.
⚫ Lacerations of the perineum, vagina or cervix.
⚫ bleeding from the placental site (retained placental tissue, low placental implantation, focal
or partial placental adherence, placenta increta, acreta and percreta, uterine inversion)
⚫ coagulation disorders: risk factors
⚫ Placental abruption.
⚫ Prolonged retention of dead fetus.
⚫ Amnionic fluid embolism.
⚫ Saline-induced abortion.
⚫ Sepsis with endotoxemia.
⚫ Severe intravascular hemolysis.
⚫ Massive transfusions.
⚫ Severe preeclampsia or eclampsia.
⚫ Congenital coagulopathies

53. Anatomy of Female Reproductive Organs.

External: called the Vulva.
⚫ Mons Pubis: Is rounded, soft subcutaneous fatty tissue, seen over the symphysis pubis. It is
the anterior border of the external reproductive organs and is covered with pubic hair.
⚫ Labia Majora : Two rounded, fleshy folds that extends from the mons pubis to the perineum.
It is protects the labia minora, urethra.
⚫ Labia Minora: inside the majora. Their lateral and anterior aspects are usually pigmented.
⚫ Clitoris: Erectile organ. it’s rich vascular, highly sensitive to temperature, touch, and pressure
sensation
⚫ Vestibule: oval-shaped area between the labia minora, clitoris, and fourchette.It contains
urethra, vaginal introitus, and Bartholins glands.
⚫ Perineum: Is the most posterior part of the external female reproductive organs.It extends
from fourchette anteriorly to the anus posteriorly.

54. Female Internal Genitalia.

⚫ Vagina: Elastic fibro-muscular tube and membranous tissue. 8 to 10 cm long.
between the bladder anteriorly and the rectum posteriorly.
The vagina connects the uterus above with the vestibule below. It has folds that stretch during
child birth
⚫ Uterus: hollow,
pear shaped muscular organ. 7.5 X 5 X 2.5 cm and weight about 50 – 60 gm. It is anteverted
(rotated forward and slightly antiflexed (flexed forward)
The uterus has three layers: Endo, myo, para
Three parts: Fundus, body isthmus
It is important for menstruation and pregnancy
⚫ Fallopian tubes: 2 tubes extended from the cornu of the uterus to the ovary.
It runs in the upper free border of the broad ligament.
Length 8 to 14 cm average 10 cm
1. Interstitial part: 1-2cm in length.
2. Isthmus: narrow part 2-3cm
3. Ampulla: 5cm, wide, fertilization occurs here
4. Infundibulum: Trumpet shaed with fimbriae holding the ovary
⚫ Ovaries:
Oval solid structure, 1.5 cm thick, 2.5 cm wide and 3.5 cm in length respectively. Each weights
about 4–8 gm. Ovary is located on each side of the uterus, below and behind the uterine tubes
Secrete estrogen & progesterone.
Production of ova

55. Blood supply of the female genitalia.

Arterial:
Ovarian artery branch of abdominal aorta supplies the: ovary, ovarian ligament
Gives off tubal banches: for fallopian tube,
Uterine artery: round ligament of the uterus, ovary, uterus, vagina, uterine tube uterus
Vaginal artery: Urinary bladder, vagina, ureter
From internal iliac
⚫ internal pudendal artery Branches to give off:
Inferior anorectal artery,
perineal artery,
urethral artery;
artery of bulb of vestibule,
deep artery of clitoris,
dorsal artery of clitoris,

Venous
External and internal pudendal veins. For external genitalia
Uterus: plexus in the broad ligament that drains into the uterine veins.
Vagina: vaginal venous plexus drains to internal iliac vein
Ovary: ovaran vein drains to IVC

External pudendal →great saphenous →femoral vein.

Femoral becomes the external iliac vein.
internal pudendal →internal iliac vein.
Both the external and internal iliac veins merge to form the common iliac veins. The common
iliac veins → inferior vena cava.

56. Instrumental methods of examination in gynecology.

⚫ Speculum examination
Warm and lubricate the speculum with warm water. Take consent
Place two fingers in vagina; exert downward pressure against posterior wall; wait for muscles to
relax.
Insert closed speculum with blades at oblique angle over your fingers; direct at a 45-degree
downward angle into the vagina. Continue to insert downward toward rectal wall and rotate
speculum so that blades are horizontal.
Open blades and lock blades into position.
Uses: Examination of cervix, vagna, papsmear, culture, colposcopy
⚫ Colposcopy– visual examination with a portable microscope
Use for biposy, abnormal pap smear,
⚫ Ultrasound examinations: uterus, ovary, liver, kidneys, and gallbladder. measuring follicular
size, endometrium, uterine wall (myometrium), and fibroids, ovarian masses, pregnancy
⚫ Hysterosalpingography: a contrast material is put through a thin tube that is put through
the vagina and into the uterus. Pictures taken by fluoroscope
⚫ Endometrial, cervical Biopsy: Remove tissue for histological and cytological exam
⚫ Culdocentesis: a long thin needle is inserted through the vaginal wall just below the uterus
and a sample is taken of the fluid within the abdominal cavity
⚫ Laparoscopy
⚫ Hysteroscopy

57. General and special methods of investigation in gynecology.

58. Instrumental methods of examination in gynecology.

⚫ Speculum examination
Warm and lubricate the speculum with warm water. Take consent
Place two fingers in vagina; exert downward pressure against posterior wall; wait for muscles to
relax.
Insert closed speculum with blades at oblique angle over your fingers; direct at a 45-degree
downward angle into the vagina. Continue to insert downward toward rectal wall and rotate
speculum so that blades are horizontal.
Open blades and lock blades into position.
Uses: Examination of cervix, vagna, papsmear, culture, colposcopy
⚫ Colposcopy– visual examination with a portable microscope
Use for biposy, abnormal pap smear,
⚫ Ultrasound examinations: uterus, ovary, liver, kidneys, and gallbladder. measuring follicular
size, endometrium, uterine wall (myometrium), and fibroids, ovarian masses, pregnancy
⚫ Hysterosalpingography: a contrast material is put through a thin tube that is put through
the vagina and into the uterus. Pictures taken by fluoroscope
⚫ Endometrial, cervical Biopsy: Remove tissue for histological and cytological exam
⚫ Culdocentesis: a long thin needle is inserted through the vaginal wall just below the uterus
and a sample is taken of the fluid within the abdominal cavity
⚫ Laparoscopy
⚫ Hysteroscopy

59. Endoscopic methods of investigation in gynecology.

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

⚫ Special:
⚫ Speculum exam
⚫ Bimanual exam
⚫ Rectovaginal
⚫ Rectobadominal
⚫ Colposcopy, Laparoscopy, Hysteroscopy
⚫ Ultrasound, Hysterosalpingograph, fluoroscopy
⚫ Culdocentesis:
⚫ Endometrial, cervical Biopsy
⚫ Bacterioscopy examination
⚫ fractional diagnostic curettage of cervical canal and uterine cavity with the

Bimanual
Apply a small amount of lubricant, Uncover the vulva and lower abdomen
Spread the labia by left hand and Insert lubricated middle and index fingers in to the vaginal
opening: gradually insert fingers full length into vagina.
⚫ PALPATE vagina.
⚫ position of the uterus: Move finger tips to anterior fornix of vagina. Move hand on
abdomen toward pubis, with fingers pressing downward. Palpate the uterus with the
abdominal hand to determine the location of the fundus and the position of the uterus, Size,
Shape, and Contour, movability of the uterus
⚫ Palpation os the adnexa and ovaries: Place fingers within vagina to left fornix of the vagina,
and place abdominal hand in left lower quadrant of abdomen. Sweep fingers of abdominal
hand to palpate left ovary. Repeat process on right side

60. Regulation of menstrual cycle.

⚫ Days 1-5: Estrogen Falls, FSH Rises.
⚫ During the last few days prior to Day 1, a sharp fall in the levels of estrogen and
progesterone signals the uterus that pregnancy has not occurred during this cycle. This
signal results in a shedding of the endometrial lining of the uterus.
⚫ Menstrual bleeding starts on Day 1 of the cycle, lasts 3-5 days.
⚫ The drop in estrogen now permits the level of follicle stimulating hormone (FSH) to rise. FSH
stimulates follicle development.
⚫ By Day 5-7, one of the follicles responds to FSH stimulation more than others and become
dominant, and begins secreting large amounts of estrogen.
⚫ Days 6-14: Estrogen Is Secreted, FSH Falls.
⚫ Estrogen is secreted by the follicle during this phase. It stimulates the endometrial
lining of the uterus suppresses the further secretion of FSH.
⚫ Mid-cycle on day 14, estrogen helps stimulate a large and sudden release of luteinizing
hormone (LH).
⚫ And it is accompanied by a transient rise in body temperature, is a sign that ovulation is
about to happen.
⚫ The LH surge causes the follicle to rupture and expel the egg into the Fallopian tube.
⚫ Days 14-28:
⚫ Estrogen And Progesterone Secretion First Rise, then Fall.
⚫ After rupture of the follicle, it becomes corpus luteum and produces progesterone.
⚫ P supports to prepare the endometrial lining for implantation of the fertilized egg.

61. Definition of menarche.

A woman's first menstruation, and occurs typically around age 12-13. The menarche is one of the
later stages of puberty in girls.
occurs due to maturing hypothalamic-pituitary-ovarian (HPO)

62. Definition of menopause

Defined as 12 months of amenorrhea, associated with the elevation of gonadotropins (FSH and
LH). An end to woman's reproductive phase, which commonly occurs somewhere between the
ages of 45 and 55. due to lack of estrogen
Pre: 5 years prior
Post: 1 year after

63. Definition of Oligomenorrhea.

Abnormal frequency of menstrual cycle where Duration > 35 days
Four to nine menstrual cycles in a year,
Normal 28 ± 5days

Causes: PCOS, hypothyroidism, Androgen secreting tumor of the ovary or adrenal gland, PID,
cushings, prolactnoma

64. Definition of Polymenorrhea.

Abnormal frequency of menstrual cycle where Duration > 28 days
Causes: Endometriosis, Peri menopause, Birth control pills
65. Definition of Amenorrhea.
Amenorrhea — absence of menses ( bleeding) for more than 6 month

66. Classification of Amenorrhea.

⚫ Primary amenorrhea: is the absence of menstrual function from puberty age. Absence of
menses at age 14 without secondary sexual development or age 16 with secondary sexual
development
⚫ Secondary amenorrhea: is the suppression of menstrual function in woman who has
menstruated before.
⚫ Physiological amenorrhea: is absence of menses before puberty period, during pregnancy
and lactation, in menopause period.
⚫ Pathological amenorrhea: In normal states.
⚫ Genuine: absence of cyclic changes in women’s organism, most frequently associated with
acute insufficiency of sexual hormones.
⚫ False amenorrhea: absence of menstrual blood excretion even in presence of cyclic changes.
It is a clinical sign of genital organ dysgenesis: athresia of hymen or vagina, when blood,
having no exit, is accumulated in vagina, uterus and uterine tubes.

67. Definition of Polycystic Ovary Syndrome. PCOS

Defined as bilateral enlargement of the ovaries with multiple peripheral cysts (20-100 in
each ovary), due to high circulating androgens and high circulating insulin levels causing
arrest of folliclular development in various stages.
It is a condition of chronic anovulation with resultant infertility. Patient presents typically
with irregular vaginal bleeding. Other symptoms include obesity and hirsutism.
Triad
1. Oligomenorrhea or menstrual dysfunction
2. Hyperandrogenism, clinically or biochemically
3. Polycystic ovaries on TV sonogram (≥12 peripheral cysts)

68. .Definition of Dysfunctional uterine bleeding.

⚫ Defined as abnormal uterine bleeding with no demonstrable organic cause, it is not
associated with organic diseases of women’s genitals, interrupted pregnancy or systemic
diseases.
⚫ Patients present with abnormal uterine bleeding; Heavy menses, prolonged menses, or
frequent irregular bleeding. .
⚫ The classic history is that of bleeding that is unpredictable in amount, duration and
frequency without cramping occurring.
Dub occurs most often shortly after menarche and at the end of the reproductive years.
Mechanism. The most common cause of DUB is anovulation. Anovulation results in unopposed
estrogen. With unopposed estrogen, there is continuous stimulation of the endometrium with no
secretory phase.
69. Definition of Sheehan’s syndrome
is postpartum hypopituitarism caused by ischemic necrosis of the pituitary gland. It is usually the
result of severe hypotension or shock caused by massive hemorrhage during or after delivery.

70. Definition of Premature ovarian failure

Failure of the ovary to function adequately due to Ovarian follicular depletion before age 40.
serum estradiol is low, FSH is elevated
Patient presents with amenorrhea, hypoestrogenism, and elevated serum gonadotropin

Causes
autoimmune diseases: thyroiditis, SLE
Genetics: Turner syndrome, CAH
Infectious:
physical insult :Rad, Chemo.

Hypoestrogenism: Hot flashes, Night sweats, Irritability, Poor concentration, Decreased sex drive,
Pain during sex, Vaginal dryness, Difficulty getting pregnant, Dry eyes, Irritability or difficulty
concentrating

71. Definition of Asherman’s syndrome

Defined as intrauterine adhesions and occurs when scar tissue forms inside the uterus and/or
the cervix usually after Curettage, Uterine surgery. Other causes: infections of the endometrium.
Leading to decreased uterine cavity volume
S/S: Miscarriage, Dysmenorrhea, Hypomenorrhea

72. .Definitions of Premenstrual Syndrome

Recurrent psychological or physical symptoms during the luteal phase of menstrual cycle,
resolves by the end of menstruation, and interferes with some aspect of function.
5 days prior to menses
Symptoms:
⚫ Behavioral: Mood lability, Food cravings, Increased appetite (70)
⚫ Oversensitivity, Anger, Crying easily, Feeling isolated (65)
⚫ Psychological: Irritability, Fatigue, Anxiety/tension, Depression, Forgetfulness, Poor
concentration
⚫ Physical: Fatigue, Bloating, Breast tenderness, Acne, Swelling, Headache, palpitations.

73. Definition of Endometriosis.

Endometriosis is a benign condition in which functioning endometrial glands and stroma are seen
outside the uterine cavity.
Present: Pain, in lower back, in pelvic region, while urnating, dyspareneua, dysmenorhea

Most common site: ovary, the functioning endometrium, bleeds on a monthly basis and can
create adnexal enlargements known as endometriomas or chocolate cyst.
The second most common site of endometriosis is the cul-de-sac,
Causes: exact unknown. Retrograde menses, lymphatic disssemination, hematologic
dissemination
74. Classification of Endometriosis.
Genital and extragenital.
⚫ Genital:
i. Internal: the body of the uterus, isthmus, interstitial tubal departments
ii. External:
⚫ Peritoneal endometriosis: ovaries, fallopian tubes, pelvic peritoneum
⚫ Extraperitoneal endometriosis: vaginal part of cervix, vagina, vulva,retrocervical, uterine
ligaments, Parametrium, paravezical, paravaginal tissue with or without invasion into the
bladder, rectum
⚫ Extragenital:
i. skin,
ii. upper and lower extremities,
iii. spine,
iv. pleura, lungs, diaphragm,
v. urinary organs, intestine, omentum,
vi. posteoperative scars and navel

The revised American Fertility Society of endometriosis clasification based on scores assigned to
implants and adhesions depending mainly on the size of lesions.
⚫ Stage 1 (minimal):
Score: 1-5 with superficial peritoneal and ovarian implants and filmy adhesions in one or both
ovaries.
⚫ Stage 2 (mild):
Score: 6-15 with a few superficial and a few deep implants in the peritoneum and ovaries, filmy
adhesions and small chocolate cysts in the ovaries.
⚫ Stage 3 (moderate):
Score: 16-40 with deep implants in the peritoneum, cysts in the ovaries, dense adhesions in the
fallopian tubes and/or partial posterior cul-de-sac obliteration.
⚫ Stage 4 (severe):
Score: >40 with many deep implants in the peritoneum, large chocolate cysts, many dense
adhesions and complete cul-de-sac obliteration.

75. Definitions of Climacteric syndrome.

Climacteric syndrome: a complex of symptoms, that complicates the transition from the
reproductive phase to non-reproductive state
Clinic.
⚫ Amenorrhea.
⚫ Neurovegetative: Hot flashes: Unpredictable profuse sweating and sensation of heat,
palpitation, dizziness,Headache.
⚫ Reproductive tract: decreased vaginal lubrication, increased vaginal pH, and increased
vaginal infections, decreased libido, painful sexual intercourse,
⚫ Urinary tract: increased urgency, frequency, nocturia, and urge incontinence.
⚫ Psychic:mood alteration, emotional lability, sleep disorders, anxiety and depression
⚫ Cardiovascular disease.
⚫ Osteoporosis. Decreased bone density and pathologic fractures

76. Classification of Benign Breast Diseases.

Epithelial: (adenoma, fibroadenoma, adenofibroma, papilloma of the milk ducts);
Nonepithelial (fibroma, lipoma, chondroma, osteoma, angioma);
Cystic (lactic cysts, mastopathy).
Benign breast diseases constitute a heterogeneous group of lesions including developmental
abnormalities, inflammatory lesions, epithelial and stromal proliferations, and neoplasms.
CLASSIFICATION
Non-proliferative : no increase in risk
⚫ Cysts :micro & macro
⚫ Ductal ectasia
⚫ Mastitis
⚫ Fibrosis
⚫ Metaplasia :Squamous or apocrine
⚫ Mild hyperplasia
Proliferative without atypia :RR 1.5-2.0 (RR- relative risk)
⚫ Complex fibroadenoma
⚫ Papilloma
⚫ Sclerosing adenosis
⚫ Hyperplasia :moderate or severe
Proliferative with Atypia: RR 4.5- 5.0
⚫ Atypical ductal hyperplasia
⚫ Atypical lobular hyperplasia (RR- relative risk)

77. Classification of Gestational trophoblastic disease.

Definition: GTN, or molar pregnancy, is an abnormal proliferation of placental tissue involving
both the cytotrophoblast and/or syncytiotrophoblast. It can be benign or malignant.
Classification
⚫ Benign GTD or hydatidiform mole (H-mole).
i. Complete molar pregnancy: It results from fertilization of an empty egg with a single X
sperm resulting in paternally derived (androgenetic) normal 46,XX karyotype. No fetus,
umbilical cord or amniotic fluid is seen. The uterus is filled with grape-like vesicles
composed of edematous avascular villi.
ii. Partial molar pregnancy: It results from fertilization of a normal egg with two sperm
resulting in triploid 69,XXY karyotype. A fetus, umbilical cord and amniotic fluid is seen
which results ultimately in fetal demise.

⚫ Malignant GTN is the gestational trophoblastic tumor (GTT) which can develop in 3
categories.
i. Choriocarcinoma: Forms inside a pregnant woman’s uterus, usually occur when growths
from molar pregnancies turn cancerous.
ii. Invasive mole:Trophoblast cells form abnormal mass that grows into myometrium
iii. Placental-site trophoblastic tumor: develops where the placenta attaches to the uterine
wall.
iv. Epithelioid trophoblastic tumor:
It also may be
i. Non-metastatic disease is localized only to the uterus.
ii. Good Prognosis: distant metastasis, to the pelvis or lung. Cure rate is >95%.
iii. Poor Prognosis distant metastasis to the brain or the liver.
iv. serum b-hCG levels >40,000, >4 months from the antecedent pregnancy, and following a
term pregnancy.

78. Classification of Benign cervical lesions.

⚫ true cervical erosion
⚫ false cervical erosion (pseudoerosion, endocervicosis)
⚫ cervical leukoplakia (without atypia, simple one)
⚫ cervical polyps (simple, proliferating, epidermizing polyps); papilloma, condylomas
⚫ endometriosis
⚫ posttraumatic changes (ectropion, scars)
⚫ exo- and endocervicite

⚫ True cervical erosion: pathological process, that result from damage and exfoliation of
original stratified squamous epithelium. Absence of epithelium on cervical vaginal part
appears. Purulent discharge after gynecological examination and sexual intercourse
⚫ Cervical pseudoerosion: Presence of original columnar endocervical tissue on exocervical
surface. vaginal discharge, pain in lower abdomen, sometimes contact bleeding
⚫ Polyps : fingerlike growths that start on the surface of the cervix or endocervical
canal. THEY hang from a stalk and push through the cervical opening.
⚫ Cervical endometriosis: presence of rust colored, dark brown spots those have been
described as “mulberry” or “raspberry” on the cervical surface
⚫ Cervical ectropion: inversion of cervical mucous as a result of badly renewed cervix after
labour trauma
⚫ Cervical Leukoplakias: pathological state of epithelium that is characterized by its thickness
and cornification. No complaints
⚫ Cervicitis: inflamation of cervix
They are optional precancerous states, they undergo malignization rarely.
cervical dysplasia, leukoplakia with atypical neoplasia, erythroplakia, adenomatosis are obligatory
precancerous lesions

79. Definition of Cervical Dysplasia

It is the abnormal growth of cells on the surface of the cervix, usually caused by certain types of
human papillomavirus (HPV). The most common site for cervical dysplasia is the transformation
zone (T-zone) IE squamocolumnar junction
i. mild (CIN I): hyperplasia and basal cell atypia occupies 1/3 of epithelium layer
ii. moderate (CIN II):abnormal cells can be found in 2/3 of the lining of the cervix
iii. severe dysplasia ( CIN III)- dysplasia affects greater the 2/3 of the cervix and up to the full
thickness of the lining

80. Classification of uterine leiomyoma.

Classification:
⚫ The fibroid of the uterus body
⚫ The fibroid of the cervix
i. Anterior
ii. Posterior
iii. Lateral
iv. Central
Depending on the location of the nodes the fibroid are divided into:
⚫ Intramural: Most common, location is within the wall of the uterus. When small it is usually
asymptomatic and cannot be felt on examination unless it enlarges to where the normal
uterine external contour is altered.
⚫ Submucosal: Located beneath the endometrium and can distort the uterine cavity. The
distorted overlying endometrium, results in unpredictable, often intermenstrual, bleeding,
abnormal vaginal, Menometrorrhagia consists of both heavy menses and bleeding in
between the menses.
⚫ Subserosal: These are located beneath the uterine serosa. As they grow they distort the
external contour of the uterus causing the firm, nontender asymmetry. Depending on their
location they can put pressure on the bladder, rectum or ureters. If they are pedunculated,
attached to the uterus by a stalk, they can become parasitic fibroids. They break away from
the uterus and receive their blood supply from another abdominal organ (such as the
omentum or the mesentery of the intestine).

81. Prevention of genital tract infection

PID: Endometritis Pelvic cellulitis Oophoritis tubo-ovarian abscess Pelvic peritonitis
⚫ teaching adolescents safe sex practices: Abstinence, one sexual partner
⚫ promoting use of condoms and chemical barrier methods.
⚫ Universal screening of women at high risk for chlamydia and gonorrhea;
⚫ Screening for active cervicitis;
⚫ STDs testing for sexually active women2
⚫ Increasing use of sensitive tests to diagnose lower genital infection;
⚫ Treatment of sexual partners;
⚫ Education to prevent recurrent infection.
⚫ Wiping from front to back after bowel movements,
⚫ Not wearing tight fitting bottoms
⚫ Avoid potentially irritating feminine products. such as douches and powders, in the genital
area can irritate the urethra.
⚫ Empty your bladder soon after intercourse. Also, drink a full glass of water to help flush
bacteria
⚫ Get vaccinated. Getting vaccinated early, before sexual exposure, is also effective in
 preventing certain types of STIs. Vaccines are available to prevent human papillomavirus
(HPV vaccine- Gardasil)

82. Etiology of vaginal infections

⚫ organisms that cause sexually transmitted disease
⚫ e.g trichomonas vaginalis: trichomoniasis.
⚫ vulvovaginal candidiasis caused by candida albicans , O
⚫ Bacterial infections chlamydia and gonorrhea, •
⚫ Viral vaginal infections: herpes simplex virus type 2 (HSV-2), human papillomavirus (HPV),
which causes genital warts.
⚫ Bacterial vaginosis- normal vagina flora in the case of bacterial vaginosis which is as a result
of an overgrowth of both anaerobic bacteria and aerobic bacteria gardnerella vaginalis
others include; mycoplasma hominis, mobiluncus spp, bacteroides spp, peptostreptococcus,
ureaplasma urealyticum
⚫ Wearing underwear that is tight or non-cotton
⚫ Weakened immune system
predisposing factors for colonization and inflammation include:
-changes in reproductive hormone levels associated with premenstrual periods, pregnancy and
oral contraceptive use
prolonged use of antibiotics (this eliminates the protective vaginal bacterial flora)
diabetes mellitus
immunosuppressive states, eg hiv infection

83. Etiology of pelvic inflammatory disease

PID: inflammation caused by infection in the upper genital tract; Often used synonymously with
acute salpingitis.

The most common etiology:

⚫ Chlamydia trachomatis - 30%
⚫ Neisseria gonorrhoeae – 25-40%
⚫ Anaerobic bacterial species found in the vagina, particularly Bacteroides spp.,
⚫ Anaerobic gram-positive cocci, (Peptostreptococci),
⚫ E. coli
⚫ Mycoplasma hominis
⚫ Actinomyceta israeli

These organisms initially cause lower genital tract infections and then spread into the upper
genital tract via the endometrium.
Many cases polymicrobial etiology but Pure gonococcal or chlamydial PID is possible.

Risk factors in adolescents

⚫ Younger age at first intercourse, Older sex partners
⚫ Consumption of alcohol before sex
⚫ Current chlamydia infection
⚫ IUDs, Bacterial vaginosis

Provoking factors
⚫ Menses, Intercourse
⚫ Abortion; miscarriage
⚫ Curettage of uterine cavity, Hysterosalpingography
⚫ IVF

84. Clinical signs of gonorrheal infection

⚫ Abdominal pain (usually bilateral and in the lower quadrants)
⚫ Onset of pain in association with menses,
⚫ Menometrorrhagia,
⚫ Vaginal discharge, mucopurulent urethral discharge (Creamy or slightly green)
⚫ Dyspareunia,
⚫ Dysuria, (burning during urination)
⚫ Cervical motion tenderness
⚫ Adnexal tenderness (usually bilateral) or adnexal mass
Menorrhagia: Heavy or prolonged vaginal bleeding with menstrual cycle.
Metorrhagiableeding from the uterus that occurs in between periods,

85. Role of human papillomavirus infection in development of genital problem

⚫ Low risk HPV,; 6 and 11colonizes the ginital tract and there is development of genital warts
⚫ High risk HPPVs; 18 It Causes cervical dysplasia, particularly at the T zone, eventually this
leads to CIN 1, if CIN 1 is cleared by the mmune system, all is well and good. If not, there is
development of CIN2 where 2/3 of epithelial cells are abnormal
⚫ Eventually, CIN3 develops, where ther is Severe dysplasia; abnormal cells can be found in
more than 2/3 of the lining of the cervix and up to the full thickness of the lining
⚫ CIN2 and 3 can become malignant, causing cervical squamous cell carcinoma.
⚫ HPV can cause other cancers, including cancer of the vulva, vagina, penis, or anus.

86. Classification of method of contraception

⚫ Fertility Awareness Methods
i. Calendar methods
ii. Basal body temperature
iii. Symptothermal method (cervical mucus+BBT)
⚫ Barrier Methods
i. Chemical: spermicides (Nonoxynol-9)
ii. Mechanical:
⚫ male (condom)
⚫ Female (condom, cervical diaphragm, cervical cap)
⚫ Hormonal Methods
i. Combined: (oral, injection, transdermal, vaginal ring)
ii. Pogestin only: (oral, injection, implantable)
⚫ Intrauterine Device
⚫ Emergency Contraception
⚫ Sterilization

87. Etiology of female infertility

⚫ Tubal factors:
PID, Acute and Chronic salpingitis, Obstruction of tubes by polyps, Altered tubal motility,
Distortion of tuboovarian relations
⚫ Endocrine infertility
i. hyperprolactinaemia, hyperandrogeny,
ii. PCOS, premature ovarian failure, anovulation
iii. adrenogenital syndrome
iv. dysfunction of hypothalamic-pituitary system ( amenorrhea, hypomenstrual syndrome)
⚫ Scar:
i. Intrauterine scarring: due to curettage,
ii. Pelvic adhesions, scarring from surgery
⚫ Tumors of the uterus and ovary: Fibroids, Endometrial cancer, Endometriosis
⚫ Unexplained
⚫ Impaired oocyte pickup
⚫ STD’s: N. gonorrhea and C. trachomatis
⚫ Trauma
⚫ Genetic disese: Turner
⚫ Age, stress, poor diet, athletic training, over orunderweight, tobacco use

88. Symptoms of “Acute abdomen”

⚫ Acute onset of severe abdominal pain.
⚫ PAIN: stabbing, usually localized and SEVERE
⚫ Extremely rigid with severe voluntary and involuntary guarding in R lateral decubitus
position
⚫ Exquisitely tender to light, deep and rebound palpation
⚫ Positive “bed-bump” test, psoas, obturator, and Rovsing’s sign
⚫ Depending on etiology, usually see elevated Temperature and pulse rate
⚫ Absent bowel sounds (sometimes)
⚫ Tender adnexa are present at bimanual examination. cervical motion causes pain. posterior
fornix is painful.

Etiology in gynecology: Ruptured Ectopic Pregnancy, Ruptured or hemorrhagic ovarian cyst, PID,
Tubo-ovarian abscess
Others: Peritonitis, appendicitis, cholecystitis, bowel perforation, pancreatitis

89. Classification of ectopic pregnancy

Acc to site of implantation
⚫ Tubal pregnancy: most commonly in the ampulla; in isthmus,
⚫ Uterine Cornu
⚫ Ovarian
⚫ Abdomen
⚫ Cervical Pregnancy: cervix
⚫ Interstitial Pregnancy: in the uterine part of the fallopian tubethe parts that penetrates the
myometrium
⚫ Interligamentous Pregnancy: r pregnancy in the broad ligament
⚫ Heterotropic Pregnancy: the presence of multiple gestations, with one being present in the
uterine cavity and the other outside the uterus,

Acc to course
⚫ Spontaneous Resolution
⚫ Persistent Trophoblastic Tissue: the tissue stays, grows further into the lining of the womb
and, like a cancer, spread to other areas of the body
⚫ Chronic Ectopic Pregnancy: instead of a single episode of bleeding, incites an inflammatory
response that leads to the formation of a pelvic mass

It could also be
⚫ Unruptured: Patient presents with amenorrhea, vaginal bleeding, and unilateral
pelvic-abdominal pain.
⚫ Ruptured: symptoms vary with the extent of intraperitoneal bleeding and irritation.

90. Etiology of ectopic pregnancy

⚫ Infectious: Pelvic inflammatory disease, Sexually transmitted diseases, salpingitis
⚫ Postsurgical: Tuboplasty/ligation, Tubal sterilization procedures/hysterectomy
⚫ Congenital: Diethylstilbestrol syndrome
⚫ Contraceptives: Progesterone-only OCP, Intrauterine devices
⚫ Induction of ovulation, IVF
⚫ Idiopathic