OBSTETRICS MATERIAL

BY :- DR. MOHAMMED ISMAIL KHAN

MBBS (GOLD MEDALIST), (MD, MRCOG)
 Index

S.No. Chapter Page From Page To

1. Obstetric Anatomy 2 5
2. Basics of Reproduction 5 7
3. Placenta & Amniotic Fluid 7 12
4. Maternal Adaptations 12 18
5. Puerperium & its disorders 19 22
6. Diagnosis in Obstetrics 23 26
7. Foetal Medicine 26 32
8. Pregnancy Loss 32 39
9. Ectopic Gestation 39 45
10. Gestational Trophoblstic Diseases 45 52
11. Normal Labour 52 55
12. Induction of Labour 55 57
13. Pre-term, Post-dates, PROM 57 61
14. Abnormal Labour 62 66
15. AntePartum Haemorrhage 67 75
16. 3RD Stage Complications 75 79
17. Multifoetal Gestation 79 83
18. Operative Obstetrics 84 88

ARISE MEDICAL ACADEMY Dr. MIK | 1

 CHAPTER - 1
OBSTETRIC ANATOMY

Maternal pelvis ➢ Inlet or the brim*

• The pelvis is the most important bone from the • it is formed by the following structures*
obstetric point of view • Pubic symphysis, pubic crest, pubic tubercle, pectineal
• The pelvis is considered as a single bone for all line, iliopubic eminence, ilio pectineal line, sacro iliac
obstetric purposes articulation, ala of sacrum and promontory of sacrum
• It is composed of 4 bones • It measures:
➢ The Innominate bones • Anteroposterior (AP) – 11cm*
➢ The sacrum (also called true or anatomical conjugate)
➢ The coccyx • Oblique – 12cm
• Transverse – 13 cm
• The bony pelvis has two parts :
➢ THE CAVITY
• The obstetric cavity is the plane of pelvis at the level
of ischial spines
• It is also called as the plane of least pelvic diameter
as the interspinous distance/ diameter* is 10cm
• The anatomical cavity is below the level of ischial
spines and above the outlet and measures 12cms in
all dimensions

THE SIGNIFICANCE OF ISCHIAL SPINES*

• OBSTETRIC SIGNIFICANCE:
➢ The false pelvis : the part of pelvis above the pelvic
➢ Internal rotation*
brim
➢ The zero station*
➢ The true pelvis : the brim of the pelvis and the part of ➢ The pudendal block
pelvis below the brim ➢ Deep transverse arrest*
➢ Forward curve (of carus)
• The true pelvis has three parts
➢ The inlet or the brim of the pelvis • GYNAECOLOGIC SIGNIFICANCE:
➢ The cavity or the mid pelvis or the plane of least pelvic ➢ The level of external os*
dimensions (obstetric cavity)
➢ The outlet ➢ THE OUTLET
• The outlet is represented by 2 triangles
❖ Types of pelvis • Formed by joining the S5, sacrotuberous ligaments,
• The following are the 4 major types of pelvis: ischial tuberosities and pubic symphysis
➢ Gynaecoid : the female type ( 50%)* • Dimensions are
➢ Android : the male type ( 20%) • AP – 13cm* (in non pregnant state 11cm)
➢ Anthropoid : the ape type ( 25%) • Oblique – 12 cms
➢ Platypelloid : the flat type ( 5%) • Transverse – 11cm
➢ Combinations* ______ AP OBLIQ TRANSVERSE
➢ Exceptions* INLET 11 12 13
✓ Anthropoplatypelloid CAVITY 12 12 12
✓ platypoanthropoid OUT LET 13 12 11
Non
preg:11

❖ The gynaecoid pelvis ❖ SPECIAL DIMENSIONS**

• It is the commonest type of pelvis* • The conjugates :

ARISE MEDICAL ACADEMY Dr. MIK | 2

 ➢ True conjugate measures 11 cm
➢ Obstetric conjugate measures 10 cm
➢ Diagonal conjugate measures 12 cm
➢ Posterior saggital diameter of the cavity:
• It is measured from S5 to the mid point of
interspinous line
• Measures 5cm
➢ Posterior saggital diameter of the outlet*
• It is measured from the tip of the coccyx to the
midpoint of intertuberous line
• Measures 7.5cm
❖ CONTRACTED PELVIS
• If any of the pelvic diameters are less than the critical •
pelvic diameters then it is described as contracted
pelvis
• The following are the critical diameters*
✓ Obstetric conjugate < 10cm
✓ Diagonal conjugate < 11.5cm
✓ Transverse dia of inlet < 12 cm
✓ Interspinous diameter < 10cm
✓ Inter tuberous diameter < 8cm
✓ Inter spinous diameter + post saggital diameter of
cavity < 13.5cm
AP: Anteroposterior
TC: True conjugate
OC : Obstetric conjugate
❖ Special types of contracted pelvis
➢ Rachitic pelvis
• Reniform shape of inlet with marked shortening of
antero – posterior diameter without affecting the
transverse diameter
• Sacrum is flat and tilted
• Widening of transverse diameter of the outlet and
pubic arch
➢ Tri radiate pelvis
• Triradiate shape of inletQ
• Approximation of the two ischial tuberosities*
and marked narrowing of pubic arch.
• Short sacrum with coccyx pushed forward.
➢ Naegele’s pelvis : arrested development of one ala of
the sacrum
➢ Roberts pelvis : arrested development of both the ala
of sacrum
❖ Dystocia dystrophia syndrome
• The patient is stockily built with bull neck, broad
shoulder and short thigh.
• She is obese with a male distribution of hairs.
• Pelvis is of the android type*
• Occipito-posterior position is common.
• They are usually subfertile, having dysmenorrhoea,
oligomenorrhoea or irregular period
• There is increased incidence of preeclampsia and a
tendency for postmaturity during pregnancy.
• During labour, inertia is common* and there is a
tendency for deep transverse arrest or outlet dystocia
leading to either increased incidence of difficult
instrumental delivery or cesarean section.
• There are increase chances of lactation failure during
purperium.
ARISE MEDICAL ACADEMY Dr. MIK | 3
………………………………………………………………………………………….
FOETAL SKULL
➢ The sutures :
• The sagittal or longitudinal suture
• The coronal sutures
• The frontal suture
• The lambdoid sutures
• The Significance : moulding and internal examination
➢ FONTANELLE OF FOETAL SKULL
• 6 fontanelles are present in fetal skull.
• Anterior fontanelle (bregma) - 1
• Posterior fontanelle (lambda) - 1
• Anterolateral fontanelle - 2
• Posteriolateral fontanelle – 2

• Sub occipito bregmatic* (SOB) : complete flexion :

vertex presentation – 9.5 cm
• Sub occipito frontal(SOF) : incomplete flexion :
vertex presentation – 10cm
• Occipito frontal(OF) : neutral position : vertex
presentation – 11.5 cm
• Mento vertical*(MV) : little extension : brow
presentation – 14cm
• Sub mento vertical(SMV) : incomplete extension :
face presentation* – 11.5cm
• Sub mento bregmatic(SMB) : complete extension :
face presentation* – 9.5cm
➢ Anterior fontanelle/ bregma:
• It is formed by joining of the four sutures in the ❖ THE TRANSVERSE DIAMETERS OF FOETAL SKULL
midplane. • Bi mastoid : 7.5cm
• Its anteroposterior and transverse diameters • Bi temporal : 8cm
measure approximately 3 cm each. • Super sub parietal* : 8.5 cm
• The floor is formed by a membrane and it becomes • Bi parietal diameter* : 9.5cm
ossified 18 months after birth.
❖ BASIC OBSTETRIC TERMINOLOGY
• It becomes pathological, if it fails to ossify even after
24 months. • LIE : relationship between spine of foetus and
• Significance : internal examination & hydrocephalus longitudinal axis of the uterus
➢ Posterior fontanelle: It is formed by junction of
three suture lines — sagittal suture and lambdoid • PRESENTATION
suture ➢Cephalic presentation*
• It is triangular in shape and measures about 1.2 x 1.2 ➢Breech presentation
cm (1/2" x 1/2"). ➢ Shoulder presentation
❖ THE LONGITUDINAL DIMENSIONS OF FOETAL SKULL
• POSITION OF THE FOETUS
• The commonest foetal position is _________*
• The transverse dia of foetal head engages in the ____
dia of pelvic inlet*
• The most common longitudinal diameter during
engagement is _________ & measures _________ cm*
• The commonest foetal position is _________*
ARISE MEDICAL ACADEMY Dr. MIK | 4
• The transverse dia of foetal head engages in the ____ tissue.
dia of pelvic inlet* - Has got no radiation hazard, hence biologically safe*
• The most common longitudinal diameter during - But it is expensive, requires more time and expertise
engagement is _________ & measures _________ cm*

❖ Cephalopelvic Disproportion
• Cephalopelvic Disproportion (CPD) is the disparity in
the relation between the head of fetus and maternal
pelvis.
• CPD can be diagnosed : TYPES OF PELVIS AND OBSTETRIC OUTCOME
A. Clinically: By per abdomen examination / Bimanual
examination (Muller-Munrokerr method)

• The Bimanual method is superior to the abdominal

method as pelvic assessment can be done
simultaneously
• Limitations of clinical assessment: Tr: transverse
• - It can assess the disproportion of the brim and not of AP: anteroposterior
the midpelvis or outlet.
• - The fetal head can be used as a pelvimeter to elicit
only the contraction in the antero-posterior plane of ❖ GYNAECOID PELVIS
the inlet. ➢ INLET : Transverse oval : no dificulty in engagement (
• (If contraction affects the transverse diameter of the Tr > AP )
inlet, it is of less use).* ➢ OUTLET : Spacious : no difficulty in extension
➢ Sub pubic angle : 90
B.Radiographically: ➢ Outcome : normal vaginal delivery
➢ X-ray pelvimetry
• For complete evaluation 3 views are taken: ❖ ANDROID PELVIS
a) Antero-posterior ➢ INLET : Heart shaped – Tr > AP – diameters smaller –
b) Lateral engagement delayed
c) Outlet ➢ OUTLET : very small – prominent ischial spines –
• Hazards of X-Ray pelvimetry: deep transverse arrest
a) radiation exposure to fetus. ➢ Outcome : normal delivery very difficult
b) Radiation exposure to gonads ( 885 milli rads)
❖ ANTHROPOID
➢ INLET : AP oval : AP > Tr – engagement occurs in AP
➢ CT Scan: diameter – position is OP
- Involves less radiation (44-425 milli rad) ➢ OUTLET : Ischial spines prominent – non rotation
- Is easier to perform. ➢ OUTCOME : Face to pubis delivery
- Accuracy is greater than that of conventional X Ray
pelvimetry*. ❖ PLATYPELLOID
➢ INLET : Transverse oval – Tr >>> AP – engagement
➢ MRI: Is more accurate to assess the bony pelvis. delayed or non engagement as BPD can’t pass
- Also helpful to assess the fetal size and maternal soft through AP diameter( very small)
ARISE MEDICAL ACADEMY Dr. MIK | 5
 ✓ If engagement occurs there is marked asynctilism • Least common pelvis – Platypelloid pelvis*
with litzmann’s obliquity • The only pelvis with AP > Tr – Anthropoid pelvis*
➢ OUTLET : Spacious • Face to pubis is M/c in – Anthropoid pelvis*
➢ OUTCOME : • OP position is M/c in – Anthropoid pelvis*
✓ non engagement : cesarean • DTA is M/c in – Android pelvis*
✓ Difficult engagement : normal • Flat bowl shaped pelvis is – Platypelloid pelvis*
• Marked posterior asynclitism is seen in – Platypelloid
IMPORTANT POINTS pelvis*
• M/c pelvis – Gynaecoid*

CHAPTER – 2
BASICS OF REPRODUCTION

❖ SPERMATOGENESIS :
• The developmental process from spermatogonium
to sperm takes about 61 days* and the entire
process, including the transit time in the ductal
system takes approximately three months*
➢ The primordial germ cells remain as it is in the
testis from birth to puberty
➢ Shortly before puberty, the primordial germ cells
develop into spermatogonia in the wall of
seminiferous tubules by several generations of
mitosis
➢ With the onset of puberty the primordial germ cells
divide by meiosis to form the primary and
secondary spermatocytes
➢ Meiosis is a special type of cell division that reduces
the diploid
number of chromosomes (i.e., 46) to the haploid
number of 23.
➢ It involves two meiotic cell divisions, meiosis I and
meiosis II.
• The first metotic division is a reduction division
because the chromosome number is reduced from ❖ OOGENESIS :
diploid (46) to haploid (23).
• The 2nd meiotic division is similar to mitosis as
daughter cell formed contain the same haploid
number of chromosomes as the mother cell.

ARISE MEDICAL ACADEMY Dr. MIK | 6

 • Therefore first polar body is released just prior to
ovulation*
• the secondary occyte then enters the second meiotic
division and gets arrested at metaphase of meiosis
• At the time of fertilization second division is
completed which results in the release of oocyte and
second polar body
• Therefore second polar body release occurs only at
the time of fertilisation*
❖ OVULATION

• The primitive germ cells take their origin from the

endoderm of yolk sac at about the end of 3rd week
• migrate to the developing gonadal ridge, at about
the end of 4th week.
• Oogenesis begins in the ovary at 6 - 8 weeks of
gestation. • LH SURGE precedes ovulation by 34-36 hours.
• The primitive germ cells in the ovary undergo • LH PEAK precedes ovulation by 10-16 hours.
extensive mitosis to form oogonium • Prior to ovulation :
• Maximum number of oogonia are in the ovary at ➢ Follicle reaches a size of 18-20 mm*
5th month/ 20 weeks of gestation of development ( Called Graafian follicle)
number ie 6-7 million ➢ Endometrium is 9 -10 mm thick*
• These oognia start undergoing the mitotic division ➢ Endometrium shows triple line on USG.*
when the baby is still intra uterine( they form the ➢ Ovulation occurs 14 days before the next
primary oocytes) menstruation.
• At birth no more mitotic division occur, all oogonia ➢ Maximum action of corpus luteum is at 22 day
are replaced by primary oocyte of menstruation (following which it starts regressing
• The primary oocytes formed then enter the meiotic ~ 8 days after ovulation
division but don’t form the secondary oocyte (they ➢ In absence of fertilisation and implantation the
get arrested in late prophase of the meiosis 1) corpus luteum persists for 12 -14 days.
• All female foetuses are born with primary oocytes in ➢ Maximum growth of corpus luteum of pregnancy
the ovary arrested in prophase* of meiosis 1 (2 is at 8th week of gestation and degenerates at 6
million primary oocytes) months of gestation.
• They remain arrested in this state till that oocyte is
chosen for development (puberty)
➢ FERTILISATION AND FURTHER DEVELOPMENT
• At puberty number is further decreased and is
300,000 – 500,000
• At puberty as a result of mid cycle preovulatory
surge, meiosis is resumed and completed just prior
to ovulation*
• This leads to the formation of secondary oocyte and
a polar body

ARISE MEDICAL ACADEMY Dr. MIK | 7


• Fertilisation occurs in the ampullary part of fallopian
tube*
• As fertilisation of the ovum occurs and a zygote is
formed, it undergoes cleavage to form 2, 4, 6 cell
stage.
• This cleavage continues till it is 16 cell staged and is
called as Morula*
• Zygote enters the uterine cavity in the form of-
Morula*
• Zygote enters the uterine cavity - On 18th day of
menstrual cycle i.e 4 days after the fertilisation*
• The morula now undergoes diffrentiation to form
the inner cell mass(embryoblast) and the outer cell
mass(trophoblast)
• From the time a fertilized ovum enters the uterine
cavity from the fallopian tube (which occurs 3-4
days after ovulation) until the time ovum implants
the uterine secretions called uterine milk provides
nutrition for the early dividing ovum*
• Some fluid passes from the uterine cavity into the
morula. So that the embryoblast attaches to
trophoblast on one side only. The morula now
becomes a 'blastocyst'.
• As the blastocyst develops further the
• inner cell mass/ embryoblast -into
• -ectoderm,
• -endoderm
• -mesoderm .
• Implantation of the zygote occurs in the form of
Blastocyst*
• Implantation occurs 7-8 days after fertilisation 21-
22 nd day of menstrual cycle*
➢ IMPLANTATION:
• Implantation occurs 7 - 9 days after ovulation
• In human, the blastocyst burrows in the uterine
cavity till whole of it lies within the thickness of
endometrium. This is called as interstitial
implantation.
• The Endometrium Is in the secretory phase
corresponding to 20 - 21 days of cycle" at the time
of implantation*
• After ovulation, the endometrium now
demonstrates a combined reaction to estrogen
and progesterone activity.
• Most impressive is that total endometrial height is
fixed at roughly its preovulatory extent (5- 6 mm)
despite continued availability of estrogen*
• At the time of implantation, on days 21-22 of
menstrual cycle the predominant morphologic
feature is EDEMAof the ENDOMETRIAL STROMA
• After implantation of the embryo the uterine
endometrium is called the "decidua".
• Well developed endometrium has three layers-
✓ Superficial compact layer,
✓ Intermediate compact layer
✓ Thin basal layer.
• Line of separation of placenta runs through the
intermediate compact layer.
• After implantation of zygote into the compacta,
decidua is renamed as
➢ Decidua Basalis - The part of decidua where the
placenta is to be formed.
➢ Decidua Capsularis - The part of the decidua that
separates the embryo from the uterine lumen.
➢ Decidua Parietalis (Vera) - The part of the decidua
lining rest of the uterine cavity.
• At the end of pregnancy, the decidua is shed off
along with placenta and membranes.
ARISE MEDICAL ACADEMY Dr. MIK | 8
INTRA UTERINE PERIODS
➢ Ovular or Germinal Period : Fertilisation-2 weeks
➢ Embryonic Period : 3 weeks-8 weeks
➢ Fetal Period : >8 weeks and till delivery
FOETAL CIRCULATION :
• Some of this oxygen rich blood passes into the
carotid and subclavian arteries to supply the brain,
the head and neck and the upper extremities.
• The rest of it gets mixed up with poorly oxygenated
blood from the ductus arteriosus.
• The parts of the body that are supplied by branches
of the aorta arising distal to its junction with the
ductus arteriosus, therefore, receive blood with
only a moderate oxygen content.
• Much of the blood of the aorta is carried by the
umbilical arteries to the placenta where it is again
oxygenated and returned to the heart.
• As a result, the pressure inside the left atrium is
greatly increased. Simultaneously, the pressure in
the right atrium is diminished because blood from
the placenta no longer reaches it.
• The net result of these pressure changes is that
pressure in the left atrium now exceeds that in the
right atrium causing the valve of the foramen ovale
to close
Umbilical arteries Medial umbilical ligaments*
Left umbilical vein Ligamentum teres
Ductus venosus Ligamentum venosum*
Ductus arteriosus Ligamentum arteriosum*

➢ LUNG MATURITY
• The oxygen rich blood reaching the right atrium • L/S ratio :
through the inferior vena cava is directed by the • (Lecitine /springomyline) >2
valve of the inferior vena cava towards the foramen
ovale. • PHOSPHATIDYL GLYCEROL:
• Most of it passes through the foramen ovale into the
left atrium. • Fluorescence Polarization
• The rest of it gets mixed up with the blood returning
to the right atrium through the superior vena cava,
and passes into the right ventricle.
• From the right ventricle, the blood (mostly
deoxygenated) enters the pulmonary trunk.
• Only a small portion of this blood reaches the lungs
and passes through it to the left atrium.
• The greater part is short circuited by the ductus
arteriosus into the aorta.
• We have seen that the left atrium receives:
➢ Oxygenated blood from the right atrium, and IMPORTANT TIME LINES
➢ A small amount of deoxygenated blood from the Fertilization O HOUR
lungs. 16 cell stage 4TH DAY
• The blood in this chamber is, therefore, fairly rich in Morula enters uterine cavity 4TH DAY
oxygen. Blastocyst 5TH DAY
• This blood passes into the left ventricle and then Interstitial implantation occurs 7TH DAY
into the aorta.

ARISE MEDICAL ACADEMY Dr. MIK | 9

 Placenta circulation established / 3rd WEEK
Fetal circulation established and
heart formed
Internal gonads formed 8TH WEEK
Fetal breathing movements 11TH WEEK
CHAPTER – 3
THE PLACENTA & AMNIOTIC FLUID
• The human placenta is discoid, because of its shape
• hemochorial, because of direct contact of the
chorion with the maternal blood
• deciduate, because some maternal tissue is shed at
parturition
❖ FORMATION OF PLACENTA
• Placenta is formed by the trophoblast.
The trophoblast differentiates into-
✓ syncytiotrophoblast
✓ cyto trophoblast.
• The syncytiotrophoblast all over its surface starts
developing chorionic villi
• The chorionic villi in relation to decidua BASALIS
develop further to form chorionic frondosum
• The chorionic villi in relation to decidua
CAPSULARIS degenerate to form a smooth surface
called chorionic levae
• The syncytiotrophoblast grows into the
endometrium ( decidua basalis) and erodes the
maternal blood vessels
Swallowing starts 12TH WEEK
External genitalia formed 12TH WEEK
.
.
• .
• Small cavities appear in the basal decidua called as
lacunae which get filled with maternal blood
• The lacunae are separated from one another by
partitions of syncytium called as trabeculae.
• Each trabeculas is, initially made up entirely of
syncytiotrophoblast.
• Chorionic villi can first be distinguished in the
human placenta on about 12th day after
fertilisation.
➢ PRIMARY VILLI
• Later cells of cytotrophoblast begin to multiply and
grow into each trabeculas. This is called as Primary
villi.
➢ SECONDARY VILLI
• Extra embryonic mesoderm then invades the centre
of each primary villus. This is now called as
secondary villus
➢ TERTIARY VILLI
• Soon thereafter, fetal blood vessels can be seen in
the mesoderm forming the core of each villus.
• The villus is called as Tertiary villus.
• Thus the maternal blood in the lacuna is never in
direct contact with fetal blood.
They are separated by: Syncytiotrophoblast -
Cytotrophoblast – extraembryonic Mesoderm -
Endothelium of fetal capillaries
➢ This is known as placental barrier
ARISE MEDICAL ACADEMY Dr. MIK | 10

➢ Further changes in villi
• Near term, thinning of the syncytial layer -
Vasculosyncytial membrane - These thin zones
(alpha zones) are for gas exchange.
• The thick - beta zones - patches are for hormone
synthesis
➢ THE TERM PLACENTA
• The placenta, at term, is almost a circular disk with a
diameter of 15-20 cm and thickness of 3 cms at its
center.
• It weighs 500 gms**, the proportion to the weight of
the baby being roughly 1:6 at term.
• (At 16 weeks of gestation the weight of the placenta
and fetus are equal)
• Occupies about 30% of the uterine wall.
• It presents two surfaces, fetal and maternal, and a
peripheral margin.
• Fetal surface: covered by the Smooth and
glistening amnion with umbilical cord attached at or
near its center. At term - four-fifths of placenta -
fetal origin.
• Maternal surface: Rough and Spongy- Maternal
blood gives it a dull red color. The maternal surface
has 15-20 convex polygonal areas known as
lobes or cotyledons which are limited by fissures.
Maternal portion - less than one-fifth of the total
placenta.
• The cotyledons are separated by fissures
• Each fissure is occupied by the decidual septum
which is derived from the basal plate. maternal
origin.
➢ PATHOLOGICAL CORELATIONS
• Folds of Hobokon - Umblical cord ( in tunica
media)
• Whartons jelly - Connective tissue of umblical
cord
• Multiple pregnancies, Diabetes mellitus, Macrosomy,
• Peg cells - Fallopian tube
• Langhans cells - Cytotrophoblast
• FFN (fetal fibronectin) has been called trophoblast
glue to suggest a critical role for this protein in the
migration and attachment of trophoblasts to
maternal decidua.
• The presence of FFN in cervical or vaginal fluid can
be used as a prognostic indicator for preterm labor
• The stroma of placenta has fetal macrophages
called as Hofbauer cells.
• The tumors which can metastasize to placenta
are melanoma, leukemias, lymphomas and
breast cancer.
❖ PLACENTAL CIRCULATION
• Placental circulation consists of independent
circulation of blood in two systems:
➢ Uteroplacental circulation
➢ Fetoplacental circulation
• Uteroplacental circulation: It is concerned with
the circulation of the maternal blood through the
intervillous space.
• The blood is brought in through a high pressure
system of uterine ARTERIS and taken away by a
low pressure system of VEINS
• The uteroplacental circulation is established 9-10
days after fertilization.
•
• Fetoplacental circulation: The 2 umbilical
ARTERIS carry the DEOXYGENATED blood from the
fetus to the placenta and the umbilical VEIN carry
OXYGENATED blood from the placaenta to the
foetus
• The fetal blood flow through the placenta is about
400 mL/min.
• Fetoplacental circulation is established 21 days post
fertilization.
❖ DISEASES OF PLACENTA
• Placental infarction: These are the most common
placental lesion. If they are numerous, placental
insufficiency may develop.
• When they are thick, centrally located and
randomly distributed, they may be associated with
preeclampsia or lupus anticoagulant
• They can also lead to placental abruption.
➢ Placentomegaly (big placenta) is seen in
Hydrops fetails (immune and nonimmune), Syphilis
ARISE MEDICAL ACADEMY Dr. MIK | 11

➢ Small placentas are seen in
• Postdatism, IUGR, Placental infarcts
➢ Succenturiate placenta
• When a small part of placenta is separated from the
rest of placenta and forms a separate lobe - A leash
of vessels connecting the mass to the small lobe
through the membranes.
• In case the communicating blood vessels are absent,
it is ealled as Placenta spuria.
• It can be retained leading to PPH, sub involution,
uterine sepsis and polyp formation
➢ Circumvallate placenta
• When the peripheral edge of the placenta is covered
by a circular fold of amnion & chorion and fetal
surface has a central depression.
• It can lead to abortion, APH, IUGR, Preterm delivery
and hydrorrhea gravidarum.
❖ THE UMBILICAL CORD
• Umbilical cord (or funis) extends from the fetal
umbilicus to the fetal surface of the placenta
• It develops from the connecting stalk.
• In the EARLY fetal life, cord has 2 arteries and 2 veins
but later right umbilical vein disappears, leaving
only the left vein
• Thus at term umbilical cord has 2 arteries and 1 vein
• When fixed in their normally distended state, the
umbilical arteries exhibit transverse intimal folds of
Hoboken across their lumen.
• The extracellular matrix, which is specialized
connective tissue consists of Wharton's Jelly.0
• Anatomically umbilical cord can be regarded as a
fetal membrane.
• The 02 Supply to fetus is at the rate of 5 ml/kg min
and this is achieved with cord blood flow of 105-320
ml/min
• Its length is 50cm - 55cm
• If it is < 32 cms it is considered abnormally short
• Folding and tortuosity of the vessels within the cord
itself creates false knots (which are essentially
varices).
• The two arteries are smaller in diameter than the
veins.
➢ SHORT CORD
• IUGR, Abnornal lie/presentation, Congenital
malformations, Prenature placental
➢ LONG CORD
• Cord entanglement, Cord around the neck of fetus,
Fetal distress, Cord prolapse , Fetal anomalies
➢ Single umbilical artery
• More common - diabetic patients, black patients,
with eclampsia,hydramnios and oligohydramnios,
epilepsy patients and in APH.
➢ Finding of a single umblical artery is significant and
is associated with - Renal anomaties. Genitourinary
anomalies and Trisomy 18 are common.
➢ Increased chances of abortion, prematurity, IUGR
and perinatal mortality
❖ ABNORMALITIES OF CORD
➢ Normal attachment of cord
• The umblical cord is attached to the placenta near
the centre
• Marginal - Cord is attached to the margin of the
placenta (this type of placenta is called Battledore
placenta)
• Furcate - Here the blood vessels divide before
reaching the placenta.
• Velamentous - Here the blood vessels are attached
to the amnion, where they ramify before reaching
the placenta
ARISE MEDICAL ACADEMY Dr. MIK | 12
 Composition of Amniotic Fluid
• Water-98-99%
• Solids-1-2%-include
✓ organic solids like proteins,glucose,lipid,urea,uric
acid,creatinine and hormones like-Prolactin,insulin
and renin.
✓ Inorganic solids are-Na,K and CI
• Amniotic fluid usually has a pH of 7.0 to 7.5

Origin of Amniotic Fluid

➢ Amniotic fluid originates both from maternal and
fetal sources:
• In early pregnancy - As an ultrafiltrate of maternal
plasma.
• By beginning of the second trimester - It consists of
extracellular fluid which diffuses through the fetal
skin.
• After 20 weeks - Cornification of skin prevents this
diffusion and amniotic fluid is composed mainly of
fetal urine.
➢ Other minor contributors:
• Pulmonary fluid
• Fluid filtering through the placenta
✓ The water in the amniotic fluid is completely changed
and replaced in every 3 hours.

Colour of Amniotic Fluid

❖ AMNIOTIC FLUID
➢ Impotant Facts
• Specific gravity of Amniotic fluid: 1.008 to 1.010
• Osmolality: 250 mosm/L
• It is completely replaced in 3 hours.
• Rate of amniotic fluid turn over is 500cc/hr.
• Volume of Amniotic fluid maximum is between 36-38
weeks and then decreases such that at term it is
roughly 800-900ml.
✓ Golden yellow - Rh incompatibility (Because bilirubin levels are increased in amniotic fluid in case of Rh
incompatibility).
✓ Greenish yellow (saffron) - post maturity.
➢ NORMAL
✓ Early Pregnancy – Colourless
✓ Near term - Pale straw coloured due to presence of
exfoliated lanugo hairs and epidermal cells from the
fetal skin.
➢ Abnormal
✓ Green - meconium stained - fetal distress/breech or
transverse position/Listeria infection

✓ Dark coloured - concealed hemorrhage.

✓ Dark brown (tobacco juice) - in case of IUD.

MEASUREMENT OF AMNIOTIC FLUID

➢ Techniques used for ultrasonographically measuring
are:
➢ Amniotic fluid index (AFI):

ARISE MEDICAL ACADEMY Dr. MIK | 13

 • The deformities include alteration in shape of the
skull, wry neck, club foot, or even amputation of the
limb
• Fetal pulmonary hypoplasia (may be the cause or
effect)
• Cord compression and High fetal mortality.

➢ Maternal:
• Prolonged labor due to inertia, operative
interference due to malpresentation, increased
maternal morbidity.

Treatment:
• AIsolated oligohydramnios in the third trimester
with a normal fetus may be managed
conservatively.
• Oral administration of water increases amniotic
fluid volume.
• 10% fructose infusion improves the volume
• Amnioinfusion (prophylactic or therapeutic) for
✓ Uterus into four quadrants and measuring the meconium liquor is found to improve neonatal
largest vertical pocket of liquor in each of the four outcome
quadrants. ❖ POLYHYDRAMNIOS
✓ The sum of the four measurements is the AFI in cm.
• It is a condition where liquor amnii is in excessive
The range of 5 - 25 cm is considered normal. Less
amount i.e., > 2 litres at term.
than 5 is considered significant oligohydramnios
• Most common used definition is by ultrasound
and more than 25 as poly hydramnios
assessment i.e., when amniotic fluid index (AFI) is >
➢ Single deepest pocket (SDP):
25 cm
✓ It is the depth of a single cord free pocket of
• pocket of fluid measuring 8 cms or more in vertical
amniotic fluid. The normal range is 2 - 8 cm.
diameter.
• Over 8 cm is considered polyhydramnios. Less than
2 cm is considered as oligohydramnios. Grades of Polyhydramnios
• Mild defined as pockets measuring 8-11 cm in
vertical dimension (seen in 80% cases).
• Moderate defined as pocket measuring 12 -15 cms
in vertical dimension (seen in 15% cases).
• Severe defined as free floating fetus found in
❖ OLIGOHYDRAMNIOS pockets of fluid of 16 cms or more (seen in 5%
➢ Oligohydramnios is a condition where liquor amnii cases).
is deficient (< 200 ml at term).
➢ Sonographically it is defined as: Causes of Polyhydramnios
• Maximum vertical diameter of amniotic fluid pocket ➢ Fetus produces more urine for eg:
less than 2 cm or Amniotic fluid index less than 5 • Twin/multifetal pregnancy (number of fetus is
cms. more: more of urine)
• Maternal hyperglycemia/diabetes (Maternal
Complications hyperglycemia --- Fetalhyperglycemia --- Fetal
➢ Fetal polyuria --- increased amniotic fluid.)
• Abortion • Twin to Twin transfusion syndrome
• Deformity due to intra-amniotic adhesions or due to
compression. ➢ if fetal swallowing is impaired as in case of:

ARISE MEDICAL ACADEMY Dr. MIK | 14

 • Cleft lip and cleft palate • Preeclampsia (25%), Malpresentation and
• Esophageal atresia or stenosis persistence of floating head, Premature rupture of
• Duodenal atresia or stenosis the membranes, Preterm labor
• Bowel obstructione.
• Anencephaly (swallowing is decreased + increased ✓ During labor:
transudation of CSF into amniotic fluid due to • Early rupture of the membranes, Cord prolapse
absence of cranial vault) • Uterine inertia, Increased operative delivery due to
malpresentation, Retained placenta, postpartum
➢ Placental Causes hemorrhage and shock. (The postpartum
• Chorangioma of placenta hemorrhage is due to uterine atony).
• circumvallate placenta
✓ Puerperium:
➢ Fetal Causes • Subinvolution, Increased puerperal morbidity due
• Hydropsfetalis to infection
• Rubella, syphilis, Toxoplasma infection of fetus
• Trisomy (note - Triploidy leads to oligohydraminos) Management
• Sacrococcygeal teratoma ➢ Serial amniocentesis
• Thallasemia of fetus • It is the TOC if the patient is in distress.
• Amount of fluid removed is 500 ml/hr, Maximum
Complications fluid removed is 1 . 5 - 2 litres.
➢ Indomethacin therapy
Fetal: • Potential hazard of Indomethacin therapy -
• There is increased perinatal mortality Premature closure of Fetal ductus arteriosus.
• The deaths are mostly due to prematurity and • So, the therapy should be stopped at 32 weeks
congenital abnormality (40%).
• Dangerous complications of amniocentesis
➢ Cord prolapse & Abruptio placenta
➢ Maternal
✓ During pregnancy—There is increased incidence of:

CHAPTER – 4
MATERNAL ADAPTATIONS IN PREGNANCY
➢ Uterus – 1 kg
MATERNAL WEIGHT GAIN ➢ Breasts – 0.4kg
• There is no such thing as absolute weight gain in ➢ Accumulated fats and proteins – 3.5kg
pregnancy ➢ Increase in blood volume – 1.3kg
• Average maternal weight gain during pregnancy is ➢ Increase in extra cellular volume – 1.2kg
11-12 kgs ✓ TOTAL AMOUNT OF WATER RETAINED AT TERM IS
• Weight gain is due to 6.5 – 7 LT
➢ Foetus – 3 kg
➢ Placenta – 0.5 kg ❖ Weight gain depends on several factors
➢ Liquor – 1 kg

ARISE MEDICAL ACADEMY Dr. MIK | 15

✓ Pre pregnancy weight: If the pre pregnancy weight
is more than normal (obese), there is a tendency to
gain excessive weight during pregnancy.
✓ Race and ethnicity: American women tend to put
on more weight during pregnancy as compared to
Asians and Africans.
✓ Socio economic status: Women from higher socio
economic group have more weight gain as
compared to women from lower socio economic
group. This is because malnutrition prevents
optimum weight gain.
✓ Associated conditions like women with
gestational/over diabetes mellitus, twins and
polyhydramnios have higher weight gain during
pregnancy
✓ Parity: Multigravida females tend to gain less weigh
than primigravida
• Rapid weight gain i.e. more than 0.5 kg a week or 2
kg per month is an early manifestation of
preeclampsia.
• Stationary or falling weight suggests IUGR or IUD
• Smoking does not affect maternal weight gain
during pregnancy (smoking affects fetal weight gain
and is one of the causes of lUGR)
➢ Platelet count (Benign gestational
thrombocytopenia)
➢ Clotting factor 11, 13
➢ In normal pregnancy - Since plasma volume
increases more in comparison to Red cell volume so
viscosity of blood decreases
➢ Since total hemoglobin mass increases during
pregnancy. Therefore, oxygen carrying capacity of
blood also increases
➢ in pregnancy hemoglobin mass increases up to the
extent of 18-20%) but hemoglobin concentration
decreases due to hemodilution.
❖ CHANGES IN IRON DYNAMICS
• Serum Iron concentration -- Decreases
• Serum ferritin (Reflecting Iron stores) -- decreases
• Serum Total iron binding capacity -- Increases
• Percentage saturation (Serum ferritin / TIBC) ---
Decreases
• Serum Transferrin -- Increases
• During pregnancy there is marked demand of extra
iron especially in the second half.
• Even an adequate diet cannot provide the extra
demand of iron.
• Thus pregnancy is always a state of physiological
iron deficiency.

❖ HAEMATOLOGICAL ADAPTATIONS • The two Ts i.e. Transferrin and TIBC increase during
pregnancy, rest all parameters of iron metabolism
• The following components of the haematological decrease during pregnancy.
system show an ‘increase’
➢ Blood volume - (30-40%) ❖ RENAL PHYSIOLOGY
➢ Plasma volume - (40-50%)
➢ Red blood cell volume - (20-30%) Since the increase ➢ Increase in
in RBC volume is less in comparison to plasma • Renal blood flow (+50%)
volume there is hemodilution during pregnancy. • GFR (+50%)
➢ Hb mass (in gm's) (as RBC volume increases) • Creatinine clearance
➢ WBC count (Neutrophilic leucocytosis) • Glucosuria
➢ All clotting factors (except 11 and 13) i.e. pregnancy
is a hypercoagulable state ➢ decrease in
➢ S. fibrinogen (Clotting factor I) increases by 50% • Plasma osmolality
➢ ESR ( 4 times) • S. creatinine
• S Uric acid
• The following components show a ‘decrease’ in • S. K+ and Na+
value during pregnancy • S. Cl -
➢ Hemotocrit • Progesterone leads to relaxation of the smooth
➢ Packed cell volume muscles of ureter.
➢ Viscosity of blood • Therefore activity of ureters decreases and leads to
➢ Hb conc (i.e. g/dl) as increase in plasma volume is urinary stasis.
more compared in packed cells ( 50 : 30 ) • Glomerular filtration rate is increased by 50% which
means filtering capacity of the kidney is increased

ARISE MEDICAL ACADEMY Dr. MIK | 16

 so their is a decrease in maternal plasma levels of
creatinine, blood urea nitrogen and uric acid
• In pregnancy there is active retention of Na+, K+
and water due to increased estrogen, progesterone,
aldosterone and renin angiotensin activity
• And although there are increased total
accumulation of sodium and potassium, their serum
concentrations are decreased slightly becasue of
expanded plasma volume
• The average plasma sodium concentration during
pregnancy is 136 meq/L.
• This slight decrease in plasma sodiun concentration
during pregnancy is a result of the increased
amount of filtered sodium caused by the increased
GFR.
• In fact during pregnancy the amount of sodium
presented to the tubules for reabsorption is
approximately 30240 meq/L per day, whereas the
non-pregnant woman filters only about 26160
meq/L per day.
• Although the efficiency of tubular sodium
reabsorption during pregnancy is remarkable, the
serum sodiun equilibrates at slightly lower level
than it does in non-pregnant status maily due to
haemodilution
❖ ADAPTATIONS IN BLOOD COAGULATION SYSTEM
• Pregnancy is a hyper coagulable state all clotting
factors are increased
• serum fibrinogen levels are raised by 50% from 200
- 400 mg% in non pregnant to 300 - 600 mg% in
pregnancy
• All the clotting factors show an increase except
factor XI and XIII
• Factors II, VII, VIII, IX, X show a most increase and
others show a slight increase
• Platelet count decreases called as benign
gestational thrombocytopenia
➢ IMPORTANT:
• Clotting time and bleeding remain unaffected in
pregnancy.
➢ GESTATIONAL THROMBOCYTOPENIA/BENIGN
GESTATIONAL THROMBOCYTOPENIA
• It is the most common cause of thrombocytopenia
accounting for 80-90% of all cases of
thrombocytopenia occuring during pregnancy.
• Exact cause is not known (may be due to
hemodilution and increased platelet consumption.)
• Platelet count is rarely <70,000/mm3.
• Women are asymptomatic and their is no H/O
bleeding.
• Condition is benign and has no risk to mother or
infant.
• The only problem associated with it is - that
anaesthesioiogists are reluctant to give epidural or
spinal anaesthesia if platelet count is < 1 lakh/mm3.
• Treatment with steroids and IgG or platelet
transfusion before delivery is sometimes necessary.
❖ VENOUS THROMBO EMBOLISM
• Venous thromboembolism is the leading cause of
maternal deaths in developed countries.
• Pregnancy increases the risk of thromboembolism 6
times as all components of virchow's triad are
increased
• Left sided DVT is more common than Right sided
DVT.
• Homans sign-i.e pain in calf muscles on dorsiflexion
of foot is positive.
➢ Investigations
• Recommended method during pregnancy : Doppier
ultrasound
• Gold standard (in conditions other than pregnancy):
Venography
• Though objective evidence is ideal, treatment
should be started on clinical grounds if confirmatory
tests are not available
o ANTI COAGULANTS
• There are 2 main drugs for consideration as anti
coagulants in pregnancy ie Warfarin and Heparin:
➢ WARFARIN
• highly effective anticoagulant - Can cross placenta
and Lead to-short stature, stippled epiphysis, Nasal
hypoplasia, Saddle nose and frontal Bossing if used
in 1st Trimester.
• This is known as ‘contradi hunerman syndrome’ or
foetal warfarin syndrome.
➢ HEPARIN
• Cannot cross placenta and so does not lead to
foetal defects
• It is not as effective as warfarin
o Keeping these things in mind, during pregnancy
anticoagulants are used as
ARISE MEDICAL ACADEMY Dr. MIK | 17
• Uptil 12 weeks – unfractionated heparin ( 1st
trimester avoid warfarin)
• 12-36 weeks – warfarin can be used if indicated
• 36 weeks onwards and uptil 6hrs before delivery -
Unfractionated heparin ( warfarin if used now may
cause PPH after delivery)
• 6 hours before delivery or elective cesarean section
– no anti coagulant ( risk of bleeding during
delivery or surgery)
• From 6 hrs after vaginal delivery and 24 hrs after
cesarean – IV HEPARIN
• 3rd day after delivery or surgery once INR is
adjusted between (2-3) – stop heparin and start
warfarin (warfarin is completely safe during breast
feeding)
❖ SKIN CHANGES DURING PREGNANCY
• During pregnancy, skin undergoes varying degrees
of pigmentation, which varies among individuals.
• The dark line runn centrally below the umbilicus is
called the linea nigra.
• Chloasma It is hyperpigmentation of the skin
around the cheeks, forehead and eyes. The
pigmentation is thought to be due to increased
levels of endorphins and melanocyte stimulating
hormone and disappears spontaneously after
delivery
• Striae gravidarum are stretch marks of pregnancy
found during pregnancy caused due to stretching of
collagen beyond physiological limits
• Linea albicans are whitish stretch marks seen after
delivery due to unsuccessful attempts at collagen
regeneration
❖ CHANGES IN PLASMA PROTEINS
➢ Increase in
• Total proteins (g) (+ 20 to 30%), Globulin (+5%)
➢ Decrease in
• Plasma proteins concentration (measured in g/dl) (-
10%), Albumin (-30%), Albumin/globulin ratio in-
pregnancy - 1:1, In non pregnant- (1.5 to 1.7) : 1
➢ Changes in blood chemistry
• During pregnancy the pH is 7.42 (non pregnant
states - it is 7.9
• Pregnancy is a state of respiratory alkalosis with
metabolic acidosis.
❖ ADAPTATIONS IN RESAPIRATORY SYSTEM
✓ The following parameters increase
(TIdal voluMe Up)
➢ Tidal volume, Minute ventilation, Inspiratory
capacity, Minute oxygen up take
✓ The following parameters decrease
(Total Fuctional REserve)
➢ Functional residual capacity, Expiratory reserve
volume, Residual volume, Total lung capacity
✓ The following are unchanged
➢ Respiratory rate, Vital capacity, Inspiratory reserve
volume
❖ CARDIOVASCULAR PHYSIOLOGAL ADAPTATIONS
• Cardiac output = Stroke volume x HR
• Parameters which ‘increase’ in pregnancy.
➢ Cardiac output increase
✓ by 40% during pregnancy
✓ 50% during each uterine contraction in labour
✓ 80% immediately postpartum
• Hence Maxmimum risk of cardiac failure or
eclampsia in pregnany is in
• immediate postpartum period > intrapartum
period > 32 wks of pregnancy
• Parameters which ‘decrease’ in pregnancy
• Peripheral vascular resistances (as progesterone has
a smooth muscle relaxant effect)
• Diastolic BP
• Mean arterial BP
• [Systolic BP + (Distolic BP * 2)] /3
➢ CLINICAL FINDINGS IN CARDIOVASCULAR
PHYSIOLOGY
• Heart rate (resting) increases by about 10-15 bpm.
• Apex beat shifts to the 4th intercoastal space, 2.5
cms outside the mid clavicular line (as heart is
pushed upwards, outward, with slight rotation to
left).
• Slightly enlarged cardiac silhouette. (marked
enlarged cardiac silhoute is not normal in
pregnancy)
• Exaggerated splitting of the first heart sound (both
components loud).
• Second heart sound : Normal
• Third heart sound : Loud and easily auscultated.
➢ Murmurs : -
ARISE MEDICAL ACADEMY Dr. MIK | 18
• Grade II systolic ejection murmur is audible in aortic
or pulmonary area at about 10-12 weeks due to
expanded intravenous volume. It diappears in the
begining of post partum period.
• Mammary murmur. - Continuous hissing murmur
audible over tricuspid area in left 2nd and 3rd
intercoastal spaces known
• ECHO - Shows increased left atrial and ventricular
diameters.
• ECG - Shows left axis deviation.
• Note : None of the arrythmias are normal during
pregnancy, rather their presence indicates heart
disease during pregnancy
❖ ARTERIAL HAEMODYNAMICS
• REGIONAL DISTRIBUTION OF BLOOD FLOW DURING
PREGNANCY:
• Uterine blood flow is increased from 50 mL/min in
nonpregnant state to about750ml_ near term. The
increase is due to the combined effect of
uteroplacental and fetoplacental vasodilatation.
• Pulmonary blood flow (normal 6000 mL/min) is
increased by 2500 mL/min (i.e. 40% increase).
• Renal blood flow (normal 800 mL) increases by 400
mL/min (i.e. 50% increase) at 16th week and
remains at this level till term.
• The blood flow through the skin and mucous
membranes reaches a maximum of 500 mL/min by
36th week.
• Heat sensation, sweating or stuffy nose complained
by the pregnant women can be explained by the
increased blood flow.
❖ VENOUS HAEMODYNAMICS
• SUPINE HYPOTENSION SYNDROME (POSTURAL
HYPOTENSION):
• During late pregnancy, the gravid uterus produces a
compression effect on the inferior vena cava when
the patient is in supine position.
• In 90% cases this, however, results in opening up of
the collateral circulation by means of paravertebral
and azygos veins.
• In some cases (10%), when collateral circulation
fails to open up, the venous return of the heart may
be seriously curtailed.
• This results in production of hypotension,
tachycardia and syncope called as supine
hypotensive syndrome.
• The normal blood pressure is quickly restored by
turning the patient to lateral position. That is why
pregnant females are advised to lie in left lateral
positions
• Femoral venous pressure is markedly raised in
pregnancy especially in later months.
• The pressure exerted by gravid uterus on the
common iliac veins (more on right side due to
dextrorotation of the uterus
• causes pedal edema in pregnant women called as
physiological edema of pregnancy.
• No treatment is required for physiological edema or
orthostatic edema. It subsides on rest alone.
• Diuretics should not be prescribed in case of
physiological edema.
❖ ENDOCRINOLOGY
• The following hormones are increased during
pregnancy
➢ Growth Hormone, Prolactin, ACTH, Aldosterone,
Cortisol , T3 and T4 and BMR, Testosterone and
Androstenedione, Thyroid binding globulin, Insulin,
Insulin Resistance
• In pregnancy, the following hormones decrease
➢ Follicle Stimulating Hormone, Leutinising Hormone,
De Hydro Epi Aandrosterone, Serum Iodine
• The following remain unchanged
➢ Thyroid Stimulating Hormone and Anti Diuretic
Hormone
➢ In pregnancy there is hyperplasia of the Thyroid,
Parathyroid, Pituitary and Adrenal Cortex
➢ Although the size of thyroid gland increases and the
T3 and T4 released increase the patient remains
euthyroid.
➢ OESTROGEN :
• The form of estrogen produced mainly by placenta
is estriol.
• Placenta cannot synthesise estriol unless it gets
precursors from the fetual adrenals
• so estriol is the marker for Feto-maternal-placental
wellbeing.
• Estrogen is produced by placenta but not
exclusively because the precursors for synthesis of
estrogen are made available to the placenta by the
fetal adrenal cortex, without which it cannot
synthesise estrogen
• The evidence is provided by anecephalic fetus
where adrenal glands are absent or diminished in
ARISE MEDICAL ACADEMY Dr. MIK | 19
 size therefore there is limited availability of steroid
precursors and so rate of formation of placental
estrogen is severely limited.
• After ovulation the graafian follicle is converted to
corpus leuteum
➢ PROGESTERONE
• The corpus luteum then secretes high amounts of
progestrone whose main function now is
decidualisation
• Decidua is the specialised highly modified
endometrium of pregnancy.
• Decidual reaction/decidualisation is the conversion
of secretory endometrium into decidua and is
dependant on estrogen and progesterone.
• Decidual reaction is completed only with blastocyst
implantation.
• Progesterone is secreted by the corpus luteum until
6-7 weeks of gestation after which placenta is the
main source of production
• Progesterone is the main hormone which maintains
pregnancy
➢ PROLACTIN
• Maternal plasma levels of prolactin increase
markedly during the course of normal pregnancy
• Serum concentration levels are usually 10-fold
greater at term (about 150 ng/ml) compared with
normal non pregnant women.
• Paradoxically, after delivery, the plasma prolactin
concentration decreases even in women who are
breast feeding.
• During early lactation, there are pulsatile bursts
ofprolation secretion in response to sucking.
• Hormone responsible for lactation - Prolactin.
• Prolactin is synthesized by pitutary and decidua.
• Prolactin suppresses GnRH, LH and FSH, causing
lactational amenorrhea
➢ PLACENTAL HORMONES
✓ FROM SYNCYTIOTROPHOBLAST
➢ Protein hormones
• HCG, Human placental lactogen – HPL, Human
chorionic thyrotropin (HCT), Pregnancy specific
beta-1 glycoprotein PSBG, Pregnancy associated
plasma protein A (PAPPA)
➢ Growth factors
• Inhibin, Activin
➢ Steroid hormones:
• Estrogen(estriol,precursors of which come from
fetus), Progesterone
➢ Others:
• Relaxin (also secreted by corpus luteum & decidua).
✓ FROM CYTOTROPHOBLAST
• It produces hypothalamus like releasing factors
➢ Corticotrophin releasing hormone (CRH), Growth
hormone releasing hormone (GHRH), Neuropeptide
Y , Gonadotrophin releasing hormone (GnRH),
Thyrotrophin releasing hormone (TRH)
o HUMAN CHORIONIC GONADOTROPIN
• HCG is a glycoprotein
• It is synthesized by syncytiotrophoblast of the
placenta.
• HCG has 2 subunits ALPHA AND BETA
✓ ALPHA : biologically similar in LH, FSH and TSH.(i.e
non specific)
✓ BETA : unique to HCG. (i.e specific)
• Structurally it is similar to - FSH, LH, TSH but
functionally it is similar to LH (i.e luteotropic) helps
in maintaining corpus luteum.
• the main hormone which maintains activity of
corpus luteum during pregnancy is HCG and in non
pregnant state is LH.
• The half life of HCG is 36 hours.
• In early pregnancy the doubling time of HCG is 1.4
- 2 days.
• It can be detected in maternal serum as early as 8
days following fertilisation/Day 22 of menstrual
cycle/5 days before missed period by radio
immuno assay.
• The level is 100 IU/L or mlU/mL around the time of
the expected menses.
• The levels progressively rise and reach maximum
levels by about 8-10 weeks 170 days/1 st trimester.
• It then falls until about 16weeks and remains at low
level up to term.
• HCG disappears from circulation by 2 weeks
following delivery.
• Action :
• Sustains the corpus luteum and thereby maintains
the hormonal support to the pregnancy in early
weeks.
• Stimulates the Leydig cells of the male fetus to
produce testosterone and thereby induces
development of the male external genitalia.
• Immunosuppressive action which helps in the
maintenance of pregnancy.
ARISE MEDICAL ACADEMY Dr. MIK | 20
➢ Increased HCG values
• Pregnancy, Successful therapeutic insemination & in
vitro fertilization, Hydatiform mole,
Choriocarcinoma, Multifetal pregnancy,
Erythroblastotic fetus, Down syndrome
• Ovarian, testicular teratoma , certain neoplasm of
lung stomach & Pancreas
➢ Decreased HCG values
• Thereatened/spontaneous abortion, Ectopic
pregnancy & Trisomy 18
➢ MEASURING hCG
• There are 2 types of tests
➢ Urine tests
➢ Serum tests
✓ ELISA
✓ Radioimmunoassay ( beta sub unit)
✓ Immunoradiometric assay
o HUMAN PLACENTAL LACTOGEN
• It is also called human chorionic somatotropin.
• It is a polypeptide
• It is secreted by the syncytiotrophoblast.
• It is similar to pituitary growth hormone and
prolactin.
• It is first detected at 3rd wk after fertilisation or
5menstrual week gestation age (both mean the
same thing) and rises progressively until 36 weeks.
➢ Role of HPL
• HPL is mainly responsible for diabetogenic state
in pregnancy. (It antagonises the action of
insulin.
• It leads to maternal lipolysis and increases level of
circulating free Fatty Acid thus provides a source of
energy for maternal metabolism and fetal nutrition
• It is a potent angiogenic hormone therefore, may
play important in fetal vasculature formation.
• Levels of HPL are more in big babies and multiple
pregnancies, making them all prone to develop
gestational diabetes.
• As such HPL mainly plays role in maternal
endocrinal changes during pregnancy
• Due to it’s metabolic effects like in free fatty acids
and aminoacids it can indirectly lead to fetal
growm.
• Because hPL is secreted primarily into maternal
circulation with only small amounts in cord blood
• It’s role is more in maternal rather than in fetal
tissues
o SCHWANGERSHAFT PROTEIN OR PREGNANCY
SPECIFIC BETA 1 GLYCOPROTEIN
• Produced by trophoblast.
• Can be detected 18 days after ovulation.
• Its concentration rises steadiiy and reaches
200mg/ml at term.
• Role - measure of placental function for fertility
control
o INSULIN
• In pregnancy there is hyperinsulinemia ie increase
in the secreted amount of insulin
• This is associated with insulin resistance in the
mother to essentially shunt glucose selectively to
the baby
• On the whole the general plasma insulin level is
increased, so as to ensure continuous supply of
glucose to fetus.
• To be specific: The overall effect of pregnancy is
such that there is maternal fasting hypoglycemia
(due to fetal consumption), whereas postparandial
hyperglycemia and hyperinsulinemia.
➢ INCREASED SECRETION
• During pregnancy insulin levels are increased
because of increased insulin secretion as well as
increase in insulin resistance due to a number of
contra insulin factors.
✓ These are – Estrogen, Progesterone, Human
placental lactogen (HPL), Cortisol and Prolactin
➢ INSULIN RESISTANCE
• The main hormone responsible for insulin
resistance is HPL
• Insulin resistance is maximum between 24-28
weeks of pregnancy.
❖ VAGINAL CHANGES
➢ INCREASED VASCULARITY AND HYPEREMIA
• causes - violet colour characteristic of Chadwick sign
➢ VAGINAL pH:
• decreases i.e. becomes acidic and varies from 3.5 to
6 and this mainly occurs due to increase in number
of lactobacillus - inhibits the growth of pathogenic
bacteria.
➢ Histopathology:
ARISE MEDICAL ACADEMY Dr. MIK | 21
➢ In early pregnancy • Fetal growth is predominantly controlled by :
• the vaginal epithelial cells are similar to those seen 1. IGF-1, 2. Insulin, 3. Other growth factors
in the luteal phase. • Growth hormone is required for postnatal growth
of fetus
❖ FETAL ENDOCRINOLOGY:
• All anterior pituitary hormones are secreted at 10 Miscellaneous changes
weeks ➢ The following parameters increase in pregnancy
• All posterior pituitary hormones along with insulin • Total cholesterol
are secreted at 12 weeks • LDL and HDL
• Fetal thyroid gland beings to concentrate iodine at • C reactive protein
10-12 weeks. • Total alkaline phosphatase (due to placental
• Synthesis and secretion of thyroid hormone by fetus alkaline phosphatase)
ensues at 20 weeks.
• At birth 30% of T4 in umbilical cord blood is Hormones which have alpha and beta subunits
maternal in origin. • HCG, LH, FSH, TSH, Insulin
• Glucagon is secreted at 8th week.

ARISE MEDICAL ACADEMY Dr. MIK | 22

ARISE MEDICAL ACADEMY Dr. MIK | 23
ARISE MEDICAL ACADEMY Dr. MIK | 24
 CHAPTER 5
PUERPERIUM
• Puerperium is the time after child birth
GENERAL PHYSIOLOGICAL CHANGES IN PUERPERIUM
• Pulse - Increases for few hours and then settles
down to normal
• Temperature - In the first 24 hrs-temp should not
be above 99 F / On day 3, due to breast
engorgement there may be slight rise of
temperature
• UTI must be ruled out if there is rise of temperature
• Weight - Loss of 2 kg (5 lb) occurs due to diuresis.
• Blood volume - Decreases after delivery and returns
to pre pregnant levels by the second week.
• Cardiac output - Rises after delivery to 60% above
the pre-labour value, and returns to norm within
one week.
• Fibrinogen - Remain high upto the second week of
puerperium
• ESR - levels remain high.
• Urinary tract - Retention of urine is common due to
oedema of vulva and pain from perineum
• Patient should be encouraged to pass urine
following delivery.
• GIT tract - Thirst increased
• Constipation - due to intestinal paresis
LOCHIA:
• It is the vaginal discharge for the first fortnight
during puerperium
• The discharge originates from the uterine body,
cervix and vagina.
• It has got a peculiar offensive fishy smell.
• Its reaction is alkaline tending to become acid
towards the end.
• Depending upon the variation of the color of the
discharge, it is named as:
➢ Lochia rubra
• 1-4 days.
• It consists of blood, shreds of fetal membranes
and decidua, vernix caseosa, lanugo and
meconium.
• It has bacteria like anaerobic streptococci and
staphylococci
• It starts after delivery and extends 6 – 8 weeks
after child birth
➢ Lochia serosa
• 5-9 days
• the color is yellowish or pink or pale brownish.
• It consists of less RBC but more leukocytes,
wound exudate, mucus from the cervix and
microorganisms
➢ Lochia alba
• 10-15 days.
• It contains plenty of decidual cells, leukocytes,
mucus, cholestrin crystals, fatty and granular
epithelial cells and microorganisms
• The average amount of discharge for the first 5-6
days, is estimated to be 250 mL.
• The normal duration may extend up to 3 weeks.
• The red lochia may persist for longer duration
especially in women who get up from the bed for
the first time in later period.
➢ Clinical importance:
• The discharge is scanty following premature labors
or in case of infection
• It is excessive in twin delivery or hydramnios, or
subiinvolution of uterus and retained bits of
conception.
• If malodorous it indicates infection or retained plug
or cotton piece inside the vagina
• Persistence of red color beyond the normal limit
signifies subinvolution or retained bits of conceptus.
• Duration of the lochia alba beyond 3 weeks
suggests local genital lesion.
INVOLUTION OF UTERUS
➢ The process by which the post partum uterus
returns to its pre pregnant state is called as
Involution.
➢ Involution is achieved by decrease in the size of
muscle fibres and not in the number
• Immediately following delivery, the fundus is just
below the umbilicus 13.5 cms above the symphysis
pubis/ 20 weeks gestational age size.
• After 24 hours of delivery, height of uterus
decreases by 1.25 cm/day.
• Uterus is a pelvic to organ by the end of 2 weeks.
(Just after delivery uterus is 13.5 cms above pubic
symphysis and thereafter its size decreases by 1.25
cm/ day which means by 10-12 days it will be an
intra pelvic organ)
ARISE MEDICAL ACADEMY Dr. MIK | 25
• Uterus returns almost to its normal size (pre
pregnant size) by the end of 8 weeks.

• Placental site involution: Immediately after delivery SYNTHESIS AND SECRETION OF BREAST MILK
placental site is palm size. By the end of 2 weeks it
is 3-4 cm in diameter.
Stage Description Main hormone Supportive
hormones
Mammogenesis Mammary • Estrogen (for • Hpl For milk
Growth and Ductal growth) • Growth hormone Secretion to
Development • Progesterone • Insulin thyroxine occur
(For alveolar growth) Nursing effort
is not
Essential
Lactogenesis Initiation of Prolactin Estrogen
Milk secretion
Galactokinesis Ejection of milk Oxytocin Suckling of
Or let down Breast
reflex
Galactopoiesis Mantainence of Prolactin Continous
lactation suckling

• It has higher specific gravity and higher protein,

Breast milk
➢ Composition of Breast Milk:
✓ Carbohydrate - Lactose is present in high
concentration in breast milk.
✓ Protein content is low, as the baby cannot
metabolise a high protein diet. The proteins are
mainly lactalbumin and lactoglobulin, which are
easily digestible.
• It is also rich in the aminoacids taurine and cysteine,
which are necessary for neurotransmission and
neuromodulation.
✓ Fats - Breast milk is rich in polyunsaturated fatty
acids (PUFA) needed for myelination.
✓ Water and electrolytes - The water content is 86 -
87%.
✓ Immunological superiority - Breast milk contains
immunoglobulins, especially IgA and IgM, lysozyme,
lactoferrin (which protects against enterobacteria),
bifidus factor (to protect against E.coli), PABA
(which protects from malaria).
➢ Colostrum
• It is a deep yellow serous fluid secreted from
breasts starting from pregnancy and for 2-3 days
after delivery.
➢ Composition
vitamin A, D, E, K, immunoglobulin, sodium and
chloride content than mature breast milk.
• It has lower carbohydrate, fat and potassium than
mature milk.
➢ Advantages
• Antibodies (IgA, IgG, IgM) and humoral factor
(lactoferrin) provide immunological defence to the
new born.
• Laxative action due to fat globules.
• It is an ideal natural starter food.
Lactation amenorrhea
• After child birth the normal menstrual cycles
cessate/ stop for some time, this period is called
lactational amenorrhoea
CONTRACEPTION IN PUERPERIUM
➢ The Rule of 3's :
• In the presence of FULL breast feeding, a
contraceptive method should begin in the 3rd
postpartum month.

ARISE MEDICAL ACADEMY Dr. MIK | 26

• With PARTIAL breast feeding or no breast feeding,
a contraceptive method should begin during the 3rd 1. Necrotizing enterocolitis (NEC)
postpartum week. 2. Otitis media
• But it is not a reliable method if mother is nursing 3. Bottle feeding
only in day time. Waiting for first menses involves a • Carries a huge risk of infections due to unsterile
risk of pregnancy because ovulation usually conditions
antedates menstruation. 4. Hypocalcemia
CONTRACEPTIVES IN PUERPERIUM The only benefit……
➢ 1st contraceptive of choice in lactating mother • In formula feeds vitamin K is added in higher levels
• Progesterone only pill or progesterone implant or than in breast milk to reduce the risk of
DMPA injection. hemorrhagic diseases in new born. So, vitamin K
➢ 2nd choice is lUCD's deficiency can never be a complication of formula
• Can be used as an alternative to progesterone only fed babies.
pills by lactating mothers but only following
complete uterine involution in woman who are CAUSES OF INADEQUATE MILK PRODUCTION
sexually active. (LACTATION FAILURE)
• Infrequent suckling.
FORMULA FEEDS vs. BREAST MILK • Depression or anxiety state in puerperium
• Reluctance or apprehension to nursing.
• There is no substitution of formula milk for breast • Poor development of nipples/retracted nipple.
milk • Painful breast lesion viz cracked nipple/ breast
• Breast milk is the best milk for the child and has no abscess.
replacement • Endogenous suppression of prolactin.
• The following are few potentially dangerous side
effects of formula feeds
LACTATION SUPRESSORS GALACTOGOUGES/ LACTATION STIMULATORS
BROMOCRIPTINE/ CABERGOLINE STIMULATION OF NIPPLE/ GENITALS
TESTOSTERONE METOCLOPRAMIDE
ETHINYL OESTRADIOL INTRANASAL OXYTOCIN
PYRIDOXINE
SULPIRIDE

BREAST DISEASE ASSOCIATED WITH LACTATION

CONTRAINDICTIONS TO BREASTFEEDING
➢ Mastitis:
• Mother on IV drug abuse/excess alcohol.
• In females undergoing treatment for breast cancer
• Mother on anticancer drugs or other teratogenic
drugs.
• Active Herpes simplex lesions of the breast.
• Active/untreated pulmonary tuberculosis in
mother.
• Galactosemia and congenital lactose intolerance in
infant.
• HIV-positive mother
• Hepatitis B/C infections in the mother are not • It is parenchymatous infection of breast.
contraindications to breast feeding. Infants of
seropositive hepatitis B mothers should be given
Hepatitis B Immunoglobulin (I.M.) within 12 hours
of birth

ARISE MEDICAL ACADEMY Dr. MIK | 27


➢ Most common organism causing breast infection
Staphylococcus aureus
• The immediate source of organism that cause
mastitis is almost always the infant's nose and
throat
➢ Others:
• Coagulase negative Staphylococci
• Viridian Streptococci.
➢ Symptoms
• appear in the 3rd or 4th week
• Characterised by pain, swelling, redness and
tenderness
• Infection is almost always unilateral
• Predisposing factors : fissures / abrasions or cracks
in nipples
➢ Treatment
• Mastitis is not a contraindication for breast feeding.
• DOC : Dicloxacillin (In patients not sensitive to
penicilin )
• Eythromycin (In patients sensitive to penicillin)
• Treatment to be given for 10-14 days.
• About 10% of women with mastitis develop an
abscess due to variable destruction of breast tissue.
• If abscess is formed - surgical drainage is done
under general anaesthesia
Puerperal pyrexia
• It is defined as a rise of temperature reaching
100.4° F (38° C) or more (measured orally) on
separate occasions at 24 hours apart (excluding first
24 hours) within first 10 days following delivery.
• Any infection of genital tract which occurs as a
complication of delivery is called as Puerperal
sepsis.
CHAPTER – 6
DIAGNOSIS OF PREGNANCY
PREGNANCY IS DIAGNOSED BY THE FOLLOWING
METHODS
• M/C site of Puerperal infection - Placental site.
• M/C manifestation of Puerperal infection -
Endometritis.
• M/C/C of Puerperal sepsis - Streptococcus.
• M/C route of infection - Direct spread.
PUERPERAL BLUES/ 3 DAYS BLUES / BABY BLUES
• It is transient state of mental illness observed 4-5
days after delivery in nearly 50% of post partum
women.
• Postpartum blues occurs at the height of hormonal
changes
• It is due to a sudden increase in oestrogen and
progesterone
• Patients present with depression, anxiety,
tearfulness, insomnia, helplessness and negative
feelings towards infant.
• It may last from a few days to 2-3 weeks.
• Generally self limited, 20% of women may develop
depression in the first postpartum year.
• Treatment: Reassurance and psychological support
of family members.
Post-partum Depression
• It is observed in 10 - 20% of mothers.
• It is more gradual in onset over the first 4 - 6
months following delivery or abortion.
• Changes in hypothalarno-pituitary-adrenal axis may
be a cause.
• Manifested by loss of energy and appetite,
insomnia, social withdrawal, irritability and even
suicidal attitude.
• Risk of recurrence 50 -100% in subsequent
pregnancies.
• Treatment: Should be started early. Fluoxetine or
paroxetine is effective and has fewer side effects.
➢ CLINICAL METHODS ( TRIMESTER WISE)
➢ ULTRASONOGRAPHIC METHODS
➢ BIOCHEMICAL/ IMMUNOLOGICAL METHODS
ARISE MEDICAL ACADEMY Dr. MIK | 28
 SIGN DESCRIPTION SEEN AT / SEEN IN
GOODELS SIGN SOFTENING OF CERVIX (CERVIX FEELS LIKE LIP OF 6TH WEEK OF
MOUTH WHEREAS IN NON PREGNANT STATE IT PREGNANCY & IN OC
FEELS LIKE TIP OF NOSE) PILL USERS
HEGARS SIGN ON BIMANUAL EXAMINATION WITH 2 FINGERS IN 6 – 10 WEEKS
ANTERIOR FORNIX & FINGERS OF OTHER HAND
BEHIND THE UTERUS, THE ABDOMINAL & VAGINAL
FINGERS SEEM TO APPOSE BELOW THE BODY OF
UTERUS. IT OCCURS BECAUSE OF SOFTENING OF
ISTHMUS
JACQUIMER’S SIGN OR CHADWICK’S DUSKY HUE OF VESTIBULE AND ANTERIOR 8TH WEEK AND IN
SIGN VAGINAL WALL DUE TO PELVIC CONGESTION PELVIC TUMORS LIKE
FIBROID
OSIANDERS INCREASED PULSATION FELT THROUGH THE 8TH WEEK AND IN PID
LATERAL FORNICES

o SECOND TRIMESTER SIGNS

• QUICKENING - It refers to the perception of active

fetal movements felt by 18 weeks of pregnancy in
primipara and 2 weeks earlier in multiparae.

• Chloasma - Pigmentation over forehead & cheeks

• Breast changes - 12 weeks of pregnancy -

Appearance of secondary areola and tubercles of
montegomerry
• Size of the uterus - The uterus becomes an
abdominal organ in second trimester
➢ Braxton hick contractions
• Starts early and persists till term - Irregular,
infrequent, spasmodic & painless contractions
without any effect on dilatation of the cervix
• Intrauterine pressure is <8 mm of Hg
• Symptomatised as tightening of abdomen
• Elicited between 16 - 20 weeks of pregnancy
• Ballottement of uterus on bimanual examination
gives the impression of a floating object inside the
uterus.
• It may also be seen in case of uterine fibroid, ascites
or ovarian cyst
• External ballotment is elicited by 20 weeks and
internal ballotment from 16 – 28 weeks

➢ Palpation of fetal parts & active fetal movement

• Elicited by 20 weeks
• They are positive signs of pregnancy

➢ Ballottement of foetus ➢ Auscultation of fetal heart sound

• Most conclusive sign of pregnancy
• Begin in early pregnancy & continue till term
• Heard by stethoscope between 18-20 weeks of
pregnancy
• Fetal cardiac motion can be detected by doppler by
10 weeks

ARISE MEDICAL ACADEMY Dr. MIK | 29

 • It is based on the rationale of
➢ Uterine souffle ➢ First trimester for exact SEDD
➢ Funic or fetal souffle ➢ Second trimester scan for congenital anomalies
➢ Third trimester scan for placenta, presentation, AFI
o SIGNS OF THIRD TRIMESTER etc

➢ LIGHTENING
• It is a sense of relief from the pressure symptoms THE FIRST TRIMESTER SCAN
due to engagement of the presenting part.
• lt is felt at 38th week in primigravida • The first definitive sign of confirming pregnancy is
• the visualisation of gestational sac
ULTRASONGRAPHIC DIAGNOSIS • The first sign of confirming intrauterine gestation is
the visualisation of yolk sac
• Ultrasound is the safest and best diagnostic tool in • Best parameter to assess the foetal age is crown
pregnancy rump length
• It is recommended that a patient undergoes 3 scans • It is always possible to visualise gestational sac,
in pregnancy, one in each trimester yolk sac and cardiac activity earlier by TVS than by
• The radiologists rule for calculating the gestational TAS
age is from the menstrual age and not from the
hour of fertilisation
VISUALIZATION TVS TAS
GESTATIONAL SAC 4w5d 5w3d
YOLK SAC 5 WEEKS 7 WEEKS
CARDIAC ACTIVITY 6 WEEKS 7 WEEKS

• Gestational sac is visualised with TVS at 4 and a half 5weeks - Gestation sac, embryo yolk sac
weeks and corresponds with 1000 mIU/L of hCG in
serum 6weeks - Fetal pole, cardiac activity
• Gestational sac is visualised with TAS at 5 and a half
weeks and corresponds with 6000 mIU/L of hCG in 7weeks - Lower limb buds, midgut herniation
serum (physiological)
• Using transvaginal transducers with frequency of 5
MHz, the size threshold for sac detection is 2 - 3 8weeks - Upper limb buds, stomach
mm.
• Mean sac diameter + 30 gives the gestational age 9weeks - Spine. Choroid plexus
• Failure to visualise the embryo when MSD is 6
indicates pregnancy loss CROWN RUMP LENGTH

• Best method of assessing gestational age

THE YOLK SAC
• The yolk sac appears by 5 weeks in TVS and by 7
weeks in TAS
• Absence of yolk sac denotes a blighted ovum or
miscarriage
WEEKS OF MENSTRUAL AGE AND USG FINDINGS
4 week - Choriodecidual thickness, chorionic sac
THE SECOND TRIMESTER DIAGNOSTIC SCAN
➢ The intercerebellar or the trans cerebellar
diameter is the best indicator of gestational age
when the scan is being performed between 14 – 28
weeks
• The trans cerebellar diameter in mm equals the
gestational age in weeks
• The other parameter used in the second trimester
for age estimation is BPD ( bi parietal diameter)

ARISE MEDICAL ACADEMY Dr. MIK | 30

• The bi parietal diameter is measured in the trans
thalamic view at the level of the thalami and cavum
septum pellucidum
➢ Cephalic index = BPD divided by occipito frontal
diameter (OFD)
• It head shape is flattened (dolichocephaly) or
rounded (brachycephaly), then HC is more reliable
than BPD.
➢ Best indicator of fetal growth -Abdominal
circumference
• So the best USG parameter to detect IUGR is
Abdominal circumference.
• The best USG parameter to detect Macrosomia is
Abdominal circumference.
• AC is measured from the skin surface of the foetus
at the level of stomach, left umbilical vein and
portal sinus and spine visible
FOETAL ANOMALIES IN SECOND TRIMESTER SCAN
• Fetal anomaly which can be earliest detected by
USG- Anencephaly.
FOETAL ANOMALIES IN SECOND TRIMESTER SCAN
• The two best ultrasonographic markers of Down
syndrome in first trimester are.
➢ Absent or hypoplastic nasal bone
➢ Increased nuchal translucency
➢ If a single ultrasound examination is planned for the
purpose of evaluating fetal anatomy, it is to be
performed at 18-20 weeks*.
➢ It is possible to demonstrate foetal skeleton
radiologically by 16th week
THE THIRD TRIMESTER DIAGNOSTIC SCAN
• The best parameter to detect gestational age in
third trimester is femur length
• The best parameter to assess foetal growth is
abdominal circumference
DURATION OF PREGNANCY
• The duration of pregnancy has traditionally been
calculated by the clinicians and radiologists in terms
of ‘10 lunar months’ or ‘9 calendar months and 7
days’ or ‘280 days’ or ‘40 weeks’, calculated from
the first day of the last menstrual period.
• This is called menstrual or gestational age.
• But, fertilization usually occurs about 14 days after
the first day of the period. Thus, the true gestation
period is to be calculated by subtracting 14 days
from 280 days, i.e. 266 days.
• This is called fertilization or ovulatory age and is
widely used by the embryologist.
PSEUDOCYESIS or PHANTOM PREGNANCY or
SPURIOUS PREGNANCY or FALSE PREGNANCY.
• It is a psychological disorder where the women has
a false but firm belief that she is pregnant,
although no pregnancy exists.
• Patient is often infertile and has an intense desire to
have a baby.
➢ Patient presents with:
• Cessation of menstruation.
• Enlargement of abdomen (due to deposition of fat).
• Secretions from breasts.
• Fetal movement (actually intestinal movement).
➢ On examination:
• No positive signs of pregnancy are found i.e. fetal
heart sound is not heard, no fetal movement felt
and no fetal parts palpable by the examiner.
➢ USG and Xray do not reveal any signs of
pregnancy.
BASICS OF ANTENATAL CARE
THE ANTENATAL VISITS
➢ Ideally the schedule for antenatal visits should be:
• Monthly visits upto 28 weeks.
• Two weekly visit between 28 and 36 weeks.
• Weekly visit from 36 weeks onwards
• This means a total of 12-15 visits.
➢ WHO recommends atleast 4 visits
• 1 st at - 16 weeks
• 2nd at - 24-28 weeks
• 3rd at - 32 weeks
• 4th at - 36 weeks
➢ As per Indian scenario - minimum 4 visits are
essential according to central guidelines
ARISE MEDICAL ACADEMY Dr. MIK | 31
• The first visit that a woman makes to a health care
facility is called the booking visit.
• A booked case is one that has at least 4 ante natal
visits with at least two in the last trimester and
two doses of tetanus toxoid
FOLIC ACID
• Folic acid is used to reduce the risk of neural tube
defect
• Prophylactic dose : ( to be given to avoid NTD) it is
400mcg or 0.4mg
• Therapeutic dose : (to be given in females with
previous history of baby with NTD) - 4mg.
• Duration: should be started 1 month before
conception and continued till first 6-12 weeks of
pregnancy.
CHAPTER – 7
DIAGNOSIS IN OBSTETRICS AND FOETAL MEDICINE
FOETAL MEDICINE
SOURCES OF FOETAL TISSUE
• Chorionic villus sampling
• Amniocentesis
• Chorionic villus sampling :
• It can be performed trans abdominal method or
trans cervical
• Performed at 10-13 weeks.
VACCINATION IN PREGNANCY
• Killed vaccine are safe in pregnancy.
• Live vaccines are best avoided in pregnancy.
• Avoid all vaccines except tetanus toxoid in
pregnancy except indicated otherwise
KIEGELS EXERCISE
➢ Kegels exercises - Time for initiating kegels
exercise:
• Pregnancy-1st trimester
• After vaginal delivery-after 24 hrs
• After cesarean section-after 24 hrs.
• A catheter is passed through the cervix or through
the abdominal wall into the uterus under
ultrasound guidance, and a sample of chorionic villi
surrounding the sac is obtained.
• The chorionic villi are formed by trophoblast and
hence study material is trophablast.
• Amniocentesis
ARISE MEDICAL ACADEMY Dr. MIK | 32
• It is an invasive procedure performed between 15
to 20 weeks for detecting fetal karyotype.
• It is done under ultrasound guidance using a 22
gauge spinal needle.
• The spinal needle is passed through the mothers
lower abdomen into the amniotic cavity inside the
uterus and 10-20 ml of amniotic fluid is collected.
• Amniotic fluid has cells from amnion, fetal skin and
lungs which are collected and cultured for fetal
karyotyping, biochemical and metabolic analysis.
MONITORING FOETAL WELL BEING
• Foetal well being is monitored by the following
ways
• Cardiotocography
• Non Stress Test
• Biophysical Profile and Manning Scores
• Foetal Scalp pH
• Umbilical artery Doppler
• MCA Doppler
CARDIOTOCOGRAPHY
• It is a procedure wherein the foetal heart activity (
cardio) and the uterine contactions ( toco) are
studied simultaneously by recording them ( graphy )
on a single time frame
• A cardio tansducer is applied on the abdomen at
the level of foetal heart ( measures the FHR) and a
toco transducer is applied over the fundus of the
uterus ( measures the pressure)
• Measurements on a CTG
✓ Baseline FHR – Tachycardia, Bradycardia, Baseline
variability
✓ Accelarations
✓ Decelarations
• Baseline FHR
• Normal baseline FHR’s are
• 12 – 30 weeks : 140 – 180 bpm
• 30 – 40 weeks : 120 – 160 bpm
• A normal component of foetal FHR is ‘ baseline
variability ’
• Abnormalities in baseline FHR are manifested as
• Foetal Tachycardia
• Foetal Bradycardia
✓ Baseline variability
• Unlike normal adult HR which is more or les fixed at
a particular level FHR is not fixed
• It is found to vary between 5 – 15 beats every 10 –
20 seconds
• Hence it changes at the frequency of 3 – 6 beats per
minute
• Due to this the FHR seen on CTG is saw toothed in
appearance
• ‘Baseline variability’ is best assessed during periods
of uterine relaxation during labour
• Too little or too much variability is abnormal
• Variability
• < 5 bpm : omnious
• 5 – 10 bpm : normal but keep under observation
• 10 – 20 bpm : healthy
• 20 – 25 bpm : normal but keep under observation
• > 25 bpm : critical observation
o Sinusoidal pattern
• Fixed or flat short-term variability.
ARISE MEDICAL ACADEMY Dr. MIK | 33
• Oscillation of the sinusoidal waveform above or • The dip is ‘ v’ shaped - The tip of ‘ V ‘ coincides with
below a baseline (smooth wave) the apex of uterine contaction - It starts
• Absence of accelerations. immediately after beginning of a contraction ( early)
- ----- - Ends with the end of contraction
✓ Foetal tachycardia • Short lived
• FHR >160 bpm observed over 10 minutes • Baseline FHR and baseline variability remain normal
• Mild tachycardia – upto 180 in between contactions
• Severe tachycardia – beyond 180
o Causes
o Causes
• Head compression
• Maternal fever due to 'amnionitis' is the
commonest cause, Maternal
parasympathomimetics (atropine) or ✓ Late decelaration
sympathomimetics (terbutaline), Epidural analgesia • The deceleration starts a little after the begenning
• ‘May’ indicate fetal compromise of contraction ( late decel) the time gap between
contaction and decel is called as lag phase
✓ Bradycardia : • Doesn’t reach the base line after the end of
contraction - It is usually ‘ U’ shaped and wide
• FHR <110 bpm observed over 10 minutes
mouthed - The lowest point of ‘U’ doesn’t co incide
with the height of contraction
o Causes • It is long lasting
• Hypoxemia, Due to mild head compression in the • FHR may not reach baseline between late
second stage of labour, Mild cord compression decelarations
• Indicates serious fetal compromise
- ------ • Always indicates foetal distress
• Accelarations
✓ Variable deceleration
• It is defined as a sudden increase in FHR by at least
15bpm for at least 15 seconds
• As the word suggests they are variable with no
• At least one contraction should occur in 15 minutes
relation with uterine contactions
• Presence of accelarations is indicative of a normal
• They may come sometimes during contractions also
foetus with intact neurohumoral and cardio
co incidentally
vascular system
•
• Absence of accelarations is a sign for concern
- ------ • Always indicates a disturbance in umbilical blood
flow
• Deceleration
• A decrease in FHR by at least 15 bpm for atleast 15 Non Stress Test
seconds is called deceleration
• A deceleration shouldn’t last longer than 2 minutes
otherwise it is considered more of a bradycardia
• It is of three types
• Early deceleration ( type 1 dip)
• Late decelation ( type 2 dip)
• Variable deceleration
• Presence of any type of deceleration is indicative of
distress or problem

✓ Early deceleration

ARISE MEDICAL ACADEMY Dr. MIK | 34


• It is the most commonly used test for antepartum
evaluation of the fetal status.
• Principle :
• The test looks for the presence of temporary
accelarations of fetal heart rate (FHR) associated
with fetal movement.
• Presence of spontaneous fetal heart rate
acceleration associated with fetal movements is an
indicator of fetal well being
• Absence of fetal reaction suggests the possibility of
fetal hypoxia
✓ Method :
• Place patient in the semi-Fowler's position.
• Apply the tococardiographic equipment to the
maternal abdomen, and observe the uterine activity
and FHR for 10 minutes.
• Instruct the patient to push the calibration button
of the uterine contraction tracing every time she
feels fetal movement.
• Interpretation :
o Reactive or Positive NST - 2 or more accelerations
of at least 15 beats per minute, each lasting for at
least 15 seconds and occurring within 20 minutes of
the beginning of the test.
• If in 20 minutes test is not reactive, do a 20 minute
repeat test to account for fetal sleep cycle before
concluding the test or awaken the foetus by
vibroacoustic stimulation
• Reactive test means that fetus is in no danger for at
least 7 days.
o Non reactive test
• To be called as non reactive, there should be <2
accelerations or no accelerations in a period of n40
minutes (to exclude those cases in which fetus
might be sleeping in first 20 minutes)
• A non reactive non stress test should be followed by
contraction stress test.
• Most common condition for non reactive NST - fetal
hypoxia.
• Sometimes a sleeping normal foetus gives a non
reactive NST
• For this problem we can either do
✓ A vibroacoustic stimulation which wakes up the
sleeping foetus
✓ Wait for the foetus to wake up
• Timing
• Testing should begin by 32 to 34 weeks.
• In pregnancies with severe complications, begin at
26 - 28 weeks.
• In case test is being performed before 32 weeks,
accelerations are defined as having 10 bpm or more
above baseline for 10 seconds or longer ( not 15 )
• Interval between NST testing
•Ideally - repeat weekly
•In high risk pregnancies like diabetes mellitus,
IUGR and Gestational hypertension twice
weekly
•In severe preeclampsia remote from term -
done daily
Biophysical Profile (BPP)
Biophysical score
• Manning proposed a method using 5 fetal
biophysical variables to assess the status of fetal
well being antenatally.
• These 5 variables are
• Fetal Tone
• Fetal Breathing Movements (seen in 30 minutes)
• Fetal gross body Movements (seen in 30 minutes)
• Amniotic Fluid Volume
• Non stress test
ARISE MEDICAL ACADEMY Dr. MIK | 35
 • Diastolic flow is inversely related to peripheral
• The variables are observed for atleast 30 minutes resistance
and assigned a score of 2 each to normal variables • If there is a reduction in the EDF and increase in the
and a score of to abnormal variables. resistance indices it suggests increased resistance to
• Thus the highest score possible for a normal fetus is flow as in preeclampsia ( placental vessel spasm)
10. and IUGR.
• A score of 8 to 10 is normal, 6 is equivocal and 5 or
less is abnormal • There are three abnormal flow patterns
• reduced EDF
• absent EDF
DOPPLER STUDIES
• reversal of flow.
• Doppler ultrasound is used to assess the uterine,
placental and fetal arterial and venous system.
• Doppler detects the direction of blood flow, the
amount of blood flow and the velocity of flow
• Two special tests used are
• Umbilical artery doppler
• Middle cerebral artery doppler

• UMBILICAL ARTERY DOPPLER

• Umbilical artery vessels:

• Blood flow across the umbilical arteries provides a
comprehensive overview of the maternal - fetal
blood supply and helps in detecting fetal circulatory
compromise.
• The systolic component of blood flow reflects the
cardiac pump
• The diastolic component the distal vascular bed (
placenta)
• The umbilical artery is characterised by forward low
resistance flow.
• As gestation increases, there is gradual fall in all the
resistance indices so the amount of forward
diastolic flow increases
Middle Cerebral Artery (MCA) Doppler
• Normally the middle cerebral vessels have high
resistance flow and are characterised by little
diastolic flow.
• In case of IUGR a brain-sparing effect is seen with a
reduction in the resistance indices in the middle
• cerebral vessels (i.e. increased flow) due to the
shunting of blood to the brain in IUGR.
Fetal Scalp Ph
• Normal fetal scalp pH ranges from 7.25 to 7.35.

ARISE MEDICAL ACADEMY Dr. MIK | 36

• Fetal hypoxia is indicated by 'acidosis' or fall in fetal It is used to corroborate the significance of fetal
scalp pH to values below normal

FETAL GROWTH

• Fetal growth is characterized by sequential patterns of tissue and organ growth, differentiation, and maturation.
• Fetal growth has been divided into three phases.
• The initial phase of hyperplasia occurs in the first 16 weeks and is characterized by a rapid increase in cell number.
• The second phase, which extends up to 32 weeks' gestation, includes both cellular hyperplasia and hypertrophy
•After 32 weeks, fetal growth is by cellular hypertrophy, and it is during this phase that most fetal fat and glycogen are
accumulated.
•

GESTATIONAL AGE AND BIRTH WEIGHT

• Previously, the birth weight of < 2500 g was taken as the index of prematurity without taking any consideration of
the gestational period or any other factors.
• But now it is not so
• Gestational age has to be correlated with the weight to get an idea of the condition of the baby
• Therefore, survival outcome of an infant depends both on the gestational age as well as on the birth weight

TERMINOLOGY

• Small for gestational age (SGA): Birth weight less than 10th percentile for gestational age
• Appropriate for gestational age (AGA): Birth weight lies between the 10th and 90th percentiles for gestational age
• Large for gestational age (LGA): Infant's birth weight above the 90th percentile for gestational age
• Low birth weight (LBW) infant is defined as one whose birth weight is less than 2500 g irrespective of the
gestational age.
• Very-low birth weight (VLBW) infants weigh 1500 g or less
• Extremely-low birth weight (ELBW) infants weigh 1000 g or less

ARISE MEDICAL ACADEMY Dr. MIK | 37

•
Types of SGA Fetus

• Based on clinical evaluation and ultrasound examination there are two types of SGA babies ie type 1 and type 2

• Type 1 – 70% (apparent IUGR)

• Type 2 – 30% (true IUGR)
• symmetrical – 20% (more dangerous)
• assymmetrical – 80% (less dangerous)

• Type 1
• Fetuses that are small and healthy
• They have normal ponderal index, normal subcutaneous fat and usually have uneventful neonatal course.
• They constitute about 70% of SGA infants
• Birth weight below the 10th percentile are found normally grown.
• They are constitutionally small and not at any increased risk for adverse outcome. They present at the end of the
normal spectrum for growth

• Type II
• They constiturte 30% and are truly growth restricted.
• Fetuses where growth is restricted by pathological process (true IUGR)
• All these babies are growth retarded and as such are considered abnormal/ pathological
• These are further divided into symmetrical IUGR (20%) and asymmetrical IUGR (80%).

• Symmetrical IUGR (20%):

• The fetus is affected from the noxious effect very early in the phase of cellular hyperplasia.
• The total cell number is less.
• This form of growth retardation is most often caused by structural or chromosomal abnormalities or congenital
infection (TORCH).
• The pathological process is intrinsic to the fetus and involves all the organs including the head
• Good feeding after birth doesn’t resolve the problem

• Asymmetrical (80%)
• The fetus is affected in later months during the phase of cellular hypertrophy.
• The total cell number remains the same but size is smaller than normal.
• The pathological processes that too often result in asymmetric growth retardation are maternal diseases extrinsic to
the fetus.
• These diseases alter the fetal size by reducing uteroplacental blood flow or by restricting the oxygen and nutrient
transfer or by reducing the placental size.(intra uterine malnutrition)
• Good feeding after birth resolves the problem

CAUSES OF IUGR

ARISE MEDICAL ACADEMY Dr. MIK | 38

➢ MATERNAL CAUSES :
✓ Constitutional, Small mothers, Poor maternal
nutrition during pregnancy, Social deprivation
✓ Toxins: Alcohol, Smoking, Heroin, Morphine, CEPHAL HAEMATOMA AND CAPUT SUCCEDANEUM
Cocaine
✓ Drugs: Chemotherapeutic agents, Warfarin and ➢ Cephalhaematoma:
Phenytoin
• Maternal diseases - Chronic hypertension/PIH,
Thrombophilia, Hemoglobinopathy, Heart diseaseQ
Class III and IV, Chronic renal disease, Collagen
vascular disease, Diabetes with vascular lesion,
Sickle cell anemia

✓ FOETAL CAUSES - Structural anomalies,

Cardiovascular, Renal, Osteogenesis imperfect,
Chromosomal abnormalities - Trisomy 13, 18, 21,
Turner syndrome, Infections
➢ Placental :
• Causes leading to poor uterine blood flow to the
placental site for long time, i.e. placental
insufficiency - Placenta praevia, Abruption
Infarction
COMPLICATED CAUSES
➢ Maternal Anaemia:
• Maternal anemia does not causes fetal growth
restriction
➢ Maternal Diabetes and IUGR
• Insulin dependant diabeties, Diabetic Vasuclopathy
and excessively tight control of diabetes mellitus in
pregnancy has been linked to intrauterine growth
restriction
• Gestational diabetes is associated with macrosomia
➢ Maternal short stature and IUGR
• While an arbitrary measurement of 5ft. is
considered as short stature in western countries, it
is 4'7" in India considered the low average height.
• A short statured mother has a constitutionally small
baby and not IUGR
➢ Maternal Smoking and IUGR
• It is the single most preventable cause of IUGR
• Collection of blood in between the pericranium (
periosteum of skull bone) and the flat bone of the
skull due to rupture of a small emissary vein from
the skull.
• It may be associated with fracture of the skull bone.
• Usually unilateral.
• Lies over a parietal bone.
• Caused generally by forceps delivery but may also
be met with following a normal labour.
• Ventouse application does not increase the
incidence of cephalhaematoma.
• It is never present at birth but gradually develops
after 12-24 hours of birth and disappears by 6-8
weeks
• It is circumscribed, soft, fluctuant, and
incompressible.
• The swelling is limited by the suture lines of the
skull as the pericranium is fixed to the margins of
the bone.
• No active treatment is necessary.
• Prognosis is good.
➢ Caput succedaneum

ARISE MEDICAL ACADEMY Dr. MIK | 39


• This is a localised swelling of the scalp due to
effusion of serum above the periosteum.
• There is obstruction of venous and lymphatic return
of the foetal head due to pressure by the cervix.
• This leads to stagnation of fluid and oedema over
scalp
• Site of the caput depends upon the position of the
head.
• It is present at birth and disappears by about 24 -
36 hours.
• The size indicates the amount of pressure on the
head.
Sternomastoid tumour / Hematoma
• Presents at about 7 - 10 days after birth.
• Situated at the junction of upper and middle third
of the muscle.
✓ Etiology
• Rupture of sternocleidomastoid muscle fibres and
blood vessels due to
- Hematoma and cicatricial contracture
- Difficult breech delivery
- Attempted delivery after shoulder dystocia
- Excessive lateral flexion of neck following normal
delivery.
✓ Clinical features : Transient torticollis
✓ Treatment:
– No treatment required, disappears spontaneously
by 6 months
– Gentle movements and stretching of muscle done
after feeds
– Do not massage
ARISE MEDICAL ACADEMY Dr. MIK | 40
CEPHALHAEMATOMA
Sharply circumscribed
Soft but does not pit on pressure
Under the periosteum
Does not cross suture lines
Fixed in one place
May be associated with fracture
Appears some time after birth, grows larger
disappears only after weeks or months
CHAPTER – 8
ABORTION
➢ Nomenclature
• Abortion is the expulsion or extraction from its
mother of an embryo or fetus weighing 500 g or
less when it is not capable of independent survival
(WHO).
• This 500 g of fetal development is attained
approximately at 22 weeks (154 days) of gestation.
EARLY PREGNANCY LOSS
• Early Pregnancy loss is of two main types
➢ Blighted ovum
➢ Early Foetal demise
CAPUT SUCCEDANEUM
Diffuse
Soft and pits on pressure
Above the periosteum
Lies over and crosses suture lines/midiine
Movable over dependant part
Not associated with fracture
Largest at birth
Immediately starts to
regress and disappears in a few hours
✓ Blighted ova: Those early pregnancy losses in which
fetal development is not observed with ultrasound
(so that only a gestational sac is present with or
without a yolk sac) and fetal tissue is absent on
histologic examination of the products of
conception.
✓ Early Fetal demise: Those early pregnancy losses in
which fetal development is clearly observed by
ultrasound and fetal tissue is found on the
histologic examination.
• The difference between these two types of abortion
is of fundamental importance.
• The lack of development of fetal structures as in
blighted ovum defines a subset of abortions of
ARISE MEDICAL ACADEMY Dr. MIK | 41
 genetic origin. Therefore, the patients with blighted
ova do not require extensive work up
[ foetal pahology]
• In contrast, the early interruption of fetal life is a
complex phenomenon with multiple
etiologies.these are those patients who have
aborted cytogenetically normal fetuses and need an
extensive search for non genetic factors responsible
for the pregnancy loss. [maternal pathology]
SPONTANEOUS ABORTION
Spontaneous abortion: unexplained natural abortion is
called spontaneous abortion
Recurrent abortion: It is defined as a sequence of three
or more consecutive spontaneous abortion before
20 weeks.
Its types are – Threatened, Inevitable, Complete,
Incomplete & Missed
• Threatened Abortion
• It is a clinical entity where the process of abortion
has started but has not progressed to a state from
which recovery is impossible
✓ C/o - Slight bleeding
✓ O/E - Uterus - corresponds to gestational age, Cx -
Internal os is closed
✓ USG - live foetus with subchorionic haemorrhage
• Inevitable Abortion
• It is a clinical entity where process of abortion has
progressed to a state from where continuation of
pregnancy is impossible
✓ C/o - heavy bleeding and severe pain
✓ O/E - Shock, Uterus - corresponds to gestational
age or less, Cx - Internal os is open
✓ USG – dead foetus
• Complete Abortion
• Here the products of conception are expelled en
masse.
✓ C/o - severe bleed which stopped
✓ O/E – Shock, Uterus – less than gestational age, Cx -
Internal os is closed
✓ USG – empty uterine cavity
• Incomplete Abortion
• Here the entire products of conception are not
expelled but a part is left inside the uterine cavity.
✓ C/o - ongoing moderate to heavy bleed
✓ O/E - Uterus – less than gestational age & Cx -
Internal os is open
✓ USG – products of conception in uterine cavity
➢ Missed Abortion
• When the fetus is dead and retained inside the
uterus for a variable period, it is known as missed
abortion
✓ C/o - no bleed, no morning sickness and regression
of breast changes
✓ O/E - Uterus – lesser than gestational age ( arrested
at the stage when foetus was lost) Cx - Internal os
is closed
✓ USG – dead foetus
SPONTANEOUS ABORTION
➢ Incidence:
• Of all the spontaneous abortions 50-75% are due to
chromosomal anomalies (Germplasm defect).
➢ Aetiology
• Maternal
• Foetal
➢ Foetal
• Chromosomal abnormalities
• Hydropic degeneration of villi
• Multiple pregnancy
➢ Maternal
• Maternal infections like: TORCH infections, malaria,
ureoplasma, chlamydia, brucella and spirochaetes
• Maternal medical disorders like: Hypertension,
Chronic renal disease, Cyanotic heart disease and
Hemoglobinopathies
• Endocrine problems like: Luteal phase defect
(deficiency of progesterone), Thyroid abnormalities
ARISE MEDICAL ACADEMY Dr. MIK | 42
 hypothyroidism, Poorly controlled diabetes mellitus
and PCOD
• Immunological causes: Antiphospholipid antibody
syndrome, Inherited thrombophilias
• Anatomical factors: Cervical incompetence,
Mullerian anomalies, Large and multiple submucous
leiomyoma, Ashermann syndrome & DES exposure
in utero
• Others like Trauma; Subchorionic hematoma;
Defective placentation
• Environmental factors like: Alcohol, Caffeine,
Exposure to radiation (> 5 rads) and Anaesthetic
gases
➢ CHROMOSOMAL ANOMALIES AS AN AETIOLOGICAL
FACTOR FOR SPONTANEOUS ABORTION
• Majority of genetically originated abortions occur
before 8 weeks and are blighted ova
• Commonest cause of early miscarriages are due to
chromosomal abnormality
• Commonest chromosomal abnormality is
autosomal trisomy - Commonest chromosome -
chr. 16
• Other common trisomies are of chromosome 13,
18, 21 and 22, although any chromo-some except
chromosome 1 can be involved
• Apart from trisomies, triploidy, monosomy X and
tetraploidy are also seen frequently
RECURRENT ABORTIONS
It is defined as a sequence of three or more consecutive
spontaneous abortion before 20 weeks.
➢ Aetiology
• The most common cause of recurrent abortions is
incompetent cervix
• The most common cause of recurrent first trimester
abortions is chromosomal anomalies of which most
common is balanced translocation in mother
• The most common cause of recurrent second
trimester abortion is incompetent cervix
• Infections don’t cause recurrent abortions ****
➢ WORKING UP OF A CASE OF RECURRENT
PREGNANCY LOSS
1.Parental peripheral blood karyotyping with banding
technique
• Karyotyping of the both partners is recommended
in recurrent miscarriage.
• Prenatal diagnosis is usually advised in the next
pregnancy.
2. Assessment of the intrauterine cavity with either
office hysteroscopy or hysterosalpingography.
• Anatomic malformations and diseases like big
fibroid can cause recurrent pregnancy loss
3. Thyroid function tests
• Hypothyroidism is an important cause of recurent
abortions
4. Anticardiolipin antibody and lupus anticoagulant
testing (aPTT or Russell Viper venom testing)
• This is an important cause of recurrent abortions
• SLE is an established cause for recurrent abortion
• SLE is associated with antiphospholipid syndrome
(anti-cardiolipin antibodies)
5.Parental blood grouping and coombs test
• Rh incompatibility is a known cause for
spontaneous abortion and may lead to recurrent
abortions if it remains unrecognized
6.Thrombophilia testing:
• Factor V leiden, prothrombin gene mutation, Protein
S activity.
• In the presence of a family or personal history of
venous thromboembolism, protein C and
antithrombin activity
7. Blood Glucose and Hb A1C
ARISE MEDICAL ACADEMY Dr. MIK | 43
 • In women with recurrent pregnancy loss, evaluation
with blood glucose and HbA 1 C level is indicated for
those with known or suspected diabetes, but
otherwise it is unwarranted
8.Serum homocysteine level.
➢ INFECTIONS AS AN AETIOLOGICAL AGENT FOR
RECURRENT PREGNANCY LOSS
• All causes of spontaneous abortion may cause
recurrent abortions EXCEPT infections
• TORCH profile should not be included in the set of
investigations done to find out the cause of
recurrent abortion
• Syphillis lead to recurrent abortions. ***
Septic Abortion
Septic abortion: Any abortion associated with clinical
evidences of infection of the uterus and its contents is
called Septic abortion.
➢ CRITERIA FOR SEPTIC ABORTION:
• Rise of temperature is at least 100.4-degree F for 24
hours or more.
• Presence of offensive or purulent vaginal
discharge.
• Presence of other evidence of pelvic infection such
as lower abdominal pain and tenderness.
• In majority of the cases the infection occurs
following illegal induced abortion but may occur
following spontaneous abortion.
• Infection is polymicrobial from the normal flora of
genital tract and is due to gram positive, gram
negative and anaerobic pathogens.
➢ CLINICAL PRESENTATION
• Patients will present with fever, abdominal pain,
purulent offensive vaginal discharge and vomiting.
➢ COMPLICATIONS:
• Uterine infection i.e. endomyometritis (M/C
manifestaion) parametritis, peritonitis, septecemia
• ARDS (M/c cause of death) , DIC and Acute renal
failure
➢ SEQUELAE:
• Chronic pelvic pain & Tubal block and infertility
ANTIPHOSPHOLIPID ANTIBODY SYNDROME
It is a treatable, autoimune disorder associated with
recurrent second trimester pregnancy loss
Antiphospholipid antibodies are acquired antibodies
targeted against a phospholipid.
They can be IgM, IgG or IgA
Most important antiphospholipid antibodies are:
✓ Lupus anticoagulant
✓ Anticardiolipin antibody
✓ BFP-ST
THE SYNDROME
➢ PATHOGENESIS
The antiphospholipid antibody syndrome is
characterised by an increased tendency for
thrombosis
Placetal thrombosis decreases the blood supply to
placenta causing - Smaller size of placenta, PIH,
Foetal loss, IUGR
➢ Clinical features
✓ General Medicine
• It is due to arterial occlusion(less common) or
venous occlusion(more common)
• The following are its manifestations
1. Venous thrombosis (more common)
2. CNS – Stroke
3. Heart - Myocardial infarction
4. Lungs - Pulmonary hypertension
5. Kidney - Glomerular Thrombosis due to Renal
artery occlusion
6. Bones - Avascular Necrosis
➢ Clinical features
ARISE MEDICAL ACADEMY Dr. MIK | 44
➢ Obstetrics
1.Recurrent spontaneous abortions
2.Pregnancy induced hypertension
(Preeclampsia and eclampsia)
3. Placental insufficiency/Abruption
4. Intrauterine Growth retardation
5. Post partum comlicatons like pulmonary infiltrates,
fever and cardiac symptoms
Management
• Treatment as proposed by ACOG is a combination
of low dose aspirin (81 mg) daily and low molecular
weight heparin (LMWH) in prophylactic doses (e.g.
dalteparin 5000 units S/C twice daily), started as
soon as pregnancy is confirmed,
CERVICAL INCOMPETENCE
Cervical incompetence is characterised by painless
cervical dilatation in the second or early third
trimester
It is characterised by ballooning of the amniotic sac into
the vagina, followed by rupture of membranes and
expulsion of a usually live fetus.
The usual timing is 16 to 24 weeks.
➢ AETIOLOGY:
✓ Congenital
• Developmental weakness of cervix.
• Associated with uterine anomalies like septate
uterus.
• Following in utero exposure to diethyl stilbestrol.
✓ Acquired due to previous cervical trauma
• Forcible dilatation during MTP and D and C.
• Conisation of cervix.
• Cauterisation of cervix.
• Amputation of cervix or Fothergill's operation.
➢ DIAGNOSIS:
✓ History: The typical history of painless rupture of
membranes followed by the quick delivery of a live
fetus in midtrimester is very suggestive
✓ Non pregnant state
• The internal os allows the passage of a No. 8 Hegar's
cervical dilator or Foley's catheter filled with 1 ml
water without resistance.
• Premenstrual Hysterocervicography will show the
typical funneling of
the internal os
✓ In Pregnancy:
• Transvaginal ultrasound is the ideal method to
follow up and detect early incompetence.
• The normal cervical length at 14 weeks is 35 - 40
mm.
• A cervical length less than 25 mm and funneling of
the internal os > 1 cms on USG indicates cervical
incompetence.
➢ TREATMENT
• The treatment is surgical by a cervical circlage.
➢ Time of operation:
• Cervical circlage is usually delayed up to 12 -14
weeks so that miscarriage due to other causes can
be eliminated
• it should be done atleast 2 weeks earlier than the
lowest period of earlier wastage (but never earlier
than 1O weeks).
➢ Note: Sonography should be done prior to circlage
to confirm a live fetus and to rule out anomalies.
➢ Removal of Cerclage Stitch:
• The Stitch should be removed at 37 - 38 week or
earlier if labour pain starts or features of abortion
appear.
➢ Circlage is of two types
ARISE MEDICAL ACADEMY Dr. MIK | 45
✓ Vaginal circlage
• Mc Donald’s suture
• Shirodkars suture
✓ Abdominal circlage
MEDICAL TERMINATION OF PREGNANCY
Medical Termination of Pregnancy Act, 1971
In India, the MTP act was passed in August 1971 and
came into effect from April 1972.
In extends to the whole of India except in the state of
Jammu and Kashmir.
➢ Indications
✓ Therapeutic:
• When the continuation of pregnancy endangers the
life of woman or may cause serious injury or harm
her physical or mental health.
✓ Humanitarian
• When pregnancy has been caused by rape.
✓ Social:
• When pregnancy has resulted from the failure of
contraceptive methods in case of a married
woman, which is likely to cause serious injury to
her mental health.
• When social or economic environment, actual or
reasonably expected can injure the mother's health.
✓ Eugenic:
✓ When there is risk of the child being born with
serious physical or mental abnormalities.
LEGISTATION RULES
➢ WHO CAN DO THE MTP
• Only a qualified registered medical practitioner
possessing prescribed experience can terminate
pregnancy.
• ChiefMedical Officer of the district is empowered
to certify that a doctor has the necessary training to
do abortions based on these criteria
1. RMP with 25 MTPS done in approved institution
2. 6-month housemanship in Obstetrics and
Gynecology
3. Post graduate qualification in Obstetrics and
Gynecology
4. 3 years practice in Obstetrics and Gynecology who
are registered before 1971
5. 1 year practice in Obstetrics and Gynecology for
those registered on or after the date of
commencement of the act
➢ WHERE CAN IT BE DONE
• The pregnancy should be terminated in
Government hospitals, or in the hospitals
recognised by the Government for this purpose
• Non-governmental institutions may take up
abortion if they obtain a licence from Chief Medical
Officer of the district
➢ PATIENT PROTECTION
• The consent of the woman is required before
conducting abortion.
• Written consent of the guardian is required if the
woman is a minor (<18 years) or a mentally ill
person.
• Consent of husband is not necessary.
• Abortion cannot be performed on the request of
the husband, if the woman herself is not willing.
• The woman need not produce proof of her age/
Sexual assault
• The statement of the lady is accepted without any
doubt and she need not prove it.
• It is enough for the woman to state that she was
raped, and it is not necessary that a complaint was
lodged with the police.
• Professional secrecy has to be maintained.
• The Admission Register for the termination of
pregnancies is secret document, and the
ARISE MEDICAL ACADEMY Dr. MIK | 46
 information contained therein should not be
disclosed to any person.
➢ WHEN CAN THE TERMINATION BE DONE
• If the period of pregnancy is below 12 weeks, it can
be terminated on the opinion of a single doctor.
• If the period of pregnancy is between 12 and 20
weeks, two doctors must agree that there is an
indication and once the opinion is formed, the
termination can be done by any one doctor.
• Termination is permitted upto 20 weeks of
pregnancy only.
➢ EXCEPTION
• In an emergency, pregnancy can be terminated by
a single doctor, even without required training
(even after twenty weeks even without consulting
a second doctor, in a private hospital which is not
recognised.)
➢ PUNISHMENT
• The termination of pregnancy by a person who is
not registered medical practitioner, the person
concerned is punishable
• The termination of pregnancy in an unrecognised
hospital , the administrative head) shall be punished
• with rigorous imprisonment for a term which shall
not be less than two years, but which may extend to
seven years.
METHODS OF PERFORMING MEDICAL TERMINATION
OF PREGNANCY
➢ FIRST TRIMESTER
✓ Medical
• Mifepristone and Misoprostol (PGE,)
✓ Surgical
• Menstrual regulation
• Vacuum Aspiration (MVA/EVA)
• Suction evacuation and/or curettage
• Dilatation and evacuation (Rapid method/Slow
method)
➢ SECOND TRIMESTER
✓ Medical
• Prostaglandins PGE1 (Misoprostol), 15
methylPGF2a (Carboprost), PGE2 (Dinprostone)
and their analogues (used-intravaginally,
intramuscularly or intra-amniotically)
✓ Surgical
• Dilation and evacuation
• Intrauterine instillation of hyperosmotic solutions
- Intra-amniotic hypertonic urea (40%), saline (20%)
- Extra-amniotic—Ethacrydine lactate,
Prostaglandins
- (PGE2, PGF2a)
• Hysterotomy (abdominal)— less commonly done
➢ Most suitable method for 2nd trimester abortions is
by prostaglandins
➢ Mifepristone + Misoprostol
• 200 mg of mifepristone is given orally on day 1
followed 2 days / 48 hrs later by
• Vaginal misoprostol 800 mcg (4 tablets of 200mcg
each) is placed in the posterior fornix of vagina
•
• The combipack of 1 tablet mifepristone and 4
tablets misoprostol (i.E. 5 tablets) is approved by
DGHS, govt, of india.
• Mifepristone blocks progesterone receptors in the
endometrium which leads to disruption of the
embryo, production of prostaglandins and a
decrease in human chorionic gonadotropin levels.
• Combination of mifepristone and misoprostol is
effective for inducing abortion within 63 days of
amennorhea
MENSTRUAL REGULATION
• Consists of aspiration of contents of uterine cavity
by means of plastic cannula (Karman's cannula) and
a plastic 50 cc syringe.
ARISE MEDICAL ACADEMY Dr. MIK | 47
• It is carried out effectively within 14 days of missed
period.
➢ Suction Evacuation
• It is the most suitable method for 1st trimester
abortions.
• It is done under local anaesthesia / paracervical
block.
• The cervical os is first dilated using Hegar's dilators.
• Instrument used for evacuation is Karman suction
cannula.
• Diameter of suction cannula should be equal to the
weeks of gestation.
• Suction pressure is 60-70 cms of water
• The end point of suction is denoted by:
1 No more material sucked out.
2. Gripping of the cannula by the contracting smaller
uterus.
3. Grating sensation.
4. Appearance of bubbles in the cannula.
➢ Dilatation and currettage
• it is the second most common method of first
trimester abortion
• The cervix is dilated with hegars dilators
• The whole uterine cavity is curetted with a curette
➢ Intrauterine extra amniotic instillation
• Ethacridine lactate is drug of choice for extra-
amniotic instillation
• Available as injection Emcredil (0.1%)
• Foleys catheter is introduced into extra-amniotic or
extra-ovular space and bulb is inflated by 10-20 ml.
of Ethacridine solution.
• Dose is calculated as 10ml/week of gestation upto
maximum of 150 ml
• Catheter is left for 6 hrs.
• Uterine action begins in 16-18 hrs.
• In 30% cases abortion is incomplete and requires
oxytocin drip or supplementation with
prostaglandin.

CHAPTER – 9

ECTOPIC GESTATION

An ectopic gestation is the one in which the fertilized

ovum implants and develops outside the normal
endometrial cavity ✓ Uterine ectopics (1.5%)
• Cervical ( 1% ) - commonest
• It could be • Angular
✓ uterine ( 1.5%) • Cornual
✓ extra uterine ( 98.5%) • Scar ( cesarean )

ARISE MEDICAL ACADEMY Dr. MIK | 48

 • Contraception failure
• Previous genital infection
✓ Extrauterine ectopics (98.5%)
• Multiple partners
• Tubal (97%) – commonest
• In utero DES exposure.
• Abdominal ( 1%)
• Ovarian ( 0.5% )
✓ Slight risk

The criteria
• Previous pelvic or abdominal surgery
• Smoking
• Douching
• Intercourse before 18 years
✓ Primary Abdominal Pregnancy
✓ Studiford criteria
Risk Factors In Ectopic

✓ Ovarian pregnancy ✓ Contraception

✓ Speilberg’s criteria • With any form of contraceptive, the absolute
number of ectopic pregnancies is decreased
because pregnancy occurs less often.
✓ Cervical pregnancy
✓ Rubin’s criteria
✓ Pelvic Inflammatory Disease
• M/C cause of ectopic pregnancy is PID
TUBAL PREGNANCY

• It refers to the implantation in the fallopian tube

• It order of occurrence they are
✓ Ampulla ( 55% )
✓ Isthmus ( 25 %)
✓ Infundibulum ( 18%)
✓ Interstitial ( 2% )
Pathology of Ectopic Gestation
• Risk Factors for ectopic pregnancy:
✓ Decidualisation in ectopic pregnancy
✓ High risk
• In ectopic pregnancy under the hormonal
• Tubal corrective surgery (M/c risk factor) influence of Progesterone and Estrogen uterine
• Tubal sterilization endometrium is converted to decidua (Similar to
• Previous ectopic pregnancy Intrauterine pregnancy)
• Artificial reproductive technology • But ectopic can not survive for a long time
• Pelvic inflammatory disease • When the ectopic is interrupted
• Documented tubal pathology • Levels of progesterone and Estrogen decrease
• Congenital tubal anomalies withdrawal of support to uterine endometrium
(decidua) leads to it’s shedding off in the form of
Decidual cast
✓ Moderate risk
• Infertility treatment with CC

ARISE MEDICAL ACADEMY Dr. MIK | 49

✓ Arias Stella Reaction
• It is a histological change seen in endometrium
when it is undergoing decidualisation if the
progesterone support to it is suddenly lost
• It indicates loss of hCG stimulus to release
progesterone
• Seen in - ectopic pregnancy, blightening of
conceptus, abortion
o Villi are absent – it is an ectopic
o Villi are present - it is a failed intrauterine
pregnancy
PRESENTATION OF A TUBAL PREGNANCY
• A patient with a tubal pregnancy may present to us
in two ways
✓ Unruptures ectopic
✓ Ruptured ectopic
• The diagnostic methods, investigative approach
and management techniques vary according to the
presentation
❖ Ruptured ectopic pregnancy
• Ectopic pregnancy is the leading casue of early
pregnancy related deaths.
• Most common casue of death in ectopic pregnancy
is tubal rupture —> severe hemorrhage —> death.
✓ Symptoms - In Ectopic pregnancy triad of:
• Abdominal pain (seen in 100% cases, it is the most
consistent symptom of ectopic pregnancy).
• Amenorrhea (seen in 75% cases)
• Appearance of vaginal bleeding are seen
• Amenorrhoea followed by pain followed by vaginal
bleed
• Amenorrhoea of 1 – 2 months
• Abdominal pain is severe and localised to lower
abdomen, spasmodic in nature
• Vaginal bleed almost always small but persistent
and consists of dark altered fluid blood or dark
coagulated blood.
• “ History of acute abdominal catastrophe with
fainting attack and collapse i.e. shock following
short period of amenorrhea, in a woman of child
bearing age always points towards ectopic
pregnancy (ruptured) unless proved otherwise “
• The above triad may be accompanied by nausea,
vomiting, fainting attacks or syncope.
• Patient may present in shock with pallor,
tachycardia, hypotension and cold clammy
extremities.
• Internal hemorrhage floods the peritoneal cavity
and irritates the undersurface of diaphragm and
phrenic nerve, the patient complains of shoulder
tip and epigastric pain.
✓ General Examination:
• Pallor + VE
• BP - decreased
• Slight intermittent pyrexia due to absorption of
products of degeneration.
✓ Per abdominal Examination
• Per Abdomen - Abdomen is tense, tender and
distended.
• Shifting dullness may be present (depending on
the amount of hemorrhage).
• Rigidity / muscle guarding
• Cullen's sign - bluish discolouration around the
umbilicus may be present.
✓ On Bimanual examination
• Vaginal mucosa appears blanched.
• Uterus: normal size / slightly bulky.
• Extreme tenderness on cervical movement
• Fornices – tender
(tenderness in pelvis is the most constant sign of
Ectopic pregnancy).
• U/L adnexal mass is palpable in one third to half of
patient and usually well separated from ovary
✓ Culdocentesis:
ARISE MEDICAL ACADEMY Dr. MIK | 50
 • It is a simple technique used to identify
hemoperitoneum.
• Fluid is aspirated from cul-de-sac via posterior
fornix with the help of a needle.
• If non clotting blood is obtained, it is indicative of
an intraperitoneal bleed and probably a ruptured
ectopic.
• If the aspirated blood clots, it may have been
obtained from an adjacent blood vessel rather than
from bleeding ectopic pregnancy.
❖ Unruptured Ectopic Pregnancy
• It is also called chronic or sub acute ectopic
• It is very difficult to daignose
• Ectopic awareness and ectopic mindedness of the
physician alone helps to diagnose an unruptured
ectopic
✓ It features are:
✓ Pain abdomen
• Most common and the most consistent symptom
of ectopic pregnancy (undisturbed) is Abdominal
pain.
• It is seen in 95-100% cases.
• Pain is located in the lower abdomen / pelvic
region.
• It can be unilateral or bilateral.
• The confusing points are
✓ Absence of vaginal bleed
✓ Abdominal pain follows vaginal bleed
( cf Ruptured ectopic)
✓ Patient is stable and vitals are normal
✓ An adnexal mass on palpation
✓ Culocentesis may or may not reveal blood
• Because of several diagnostic difficulties several
investigative tests are done to diagnose an
unruptured ectopic
• Diagnosing an unruptured ectopic can help save
the life of that patient, avoid permanent damage to
the tubes and prevent operational morbidity and
mortality

feature Ruptured ectopic Unruptured ectopic

Synonyms Acute ectopic Chronic ectopic

Sub acute ectopic

Presentation 6 – 8 weeks amenorrhoea followed by a 4 - 6 weeks amenorrhoea presenting with

catastropic abdominal pain, vaginal abdominal pain moderate.
bleed and syncopal attacks
(confused with n. preg)

General Condition Shock Stable

Risk of peritonoitis Vitals normal

Pallor proportionate to bleed No pallor

Risks Risk of death due to internal RISK OF IMMINENT RUPTURE

haemorrhage or operative / ‘TIME BOMB’

anaesthetic complications

ARISE MEDICAL ACADEMY Dr. MIK | 51

 ‘ BOMB BLAST ’

Symtomatology Amennorhoea then abd pain then vaginal Abdominal pain is always present
bleed
Vaginal bleed may or may not be present
Vaginal bleed is always present

Diagnostic work up Don’t waste time All investigations possible to confirm ectopic

UPT – confirm hCG

USG – confirm absence of intrauterine

gestation

Blood grouping and typing – blood for resus

No other investigation

Management Emergency laparotomy and resuscitation Conservative management

‘OPEN AND SEE’ Medical management

Surgical management ( if medical fails or is

contra indicated only)

‘WAIT AND SEE WHAT HAPPENS’

• Fluid in the pouch of Douglas (Cul-de-sac).

INVESTIGATIVE WORK UP IN RUPTURED ECTOPIC

• Adnexal mass clearly separated from the ovary.
• Gestational sac in the adnexa surrounded by a
✓ USG hyperechoic ring (Bagel sign/ tubal ring sign)
• Transvaginal / transabdominal ultrasound is the • Ring of fire on US Doppler
investigation most commonly done to diagnose
ectopic pregnancy.
• Transvaginal ultrasound is more informative.
✓ Findings in case of ectopic pregnancy:
• Absence of intrauterine pregnancy with positive
pregnancy test.

ARISE MEDICAL ACADEMY Dr. MIK | 52


INVESTIGATIVE WORK UP IN UNRUPTURED ECTOPIC
✓ Urinary hCG or Gravidex
• Simple urine testing is positive
• Disadvantage - Not specific just confirms
pregnancy
✓ Serum beta hCG measurement
• Results : Abnormally low level of beta hCG for
gestational age
• Rise in hCG < 66% in 48 hours
✓ Serum progesterone
• Levels are lower in ectopic pregnancy than in
viable pregnancy
• Levels > 25 ng = normal l/U pregnancy
• Levels < 5ng = abnormal (? Ectopic / uterine
abortion)
➢ Sonography(TVS/TAS)
• Transvaginal USG is the logical first step for
diagnosing ectopic pregnancy
• Transvaginal ultrasound is the best available
diagnostic modality for diagnosing ectopic
pregnancy.
The following are the usg findings
✓ Specific
• Fetal pole / cardiac activity / yolk sac seen outside
the uterus in tubal ring (bagel sign)
• Demosntration of an extra uterine gestational sac
appearing as fluid containing structure with an
echogenic ring (the tubal ring sign)
✓ Nonspecific
• Absence of intrauterine gestational sac
• Complex adnexal mass clearly separated from
ovary
• Fluid in pouch of douglas
• Rarely cardiac motion may be seen in an
unruptured tubal ectopic pregnancy
Doppler sonography
• It is used to diagnose those cases of ectopic
pregnancy which cannot be identified by TVS
• Ring of fire pattern (placenta)
• Blood flow pattern outside uterus
✓ Combination of hCG & sonography
• it gives a greater accuracy for diagnosing ectopic
pregnancy.
• β hCG levels above the discriminatory zone but no
intrauterine gestational sac visualized.
o Discriminatory levels :
• The minimum level of hCG at which a G.sac is
visualised by TVS is 1500mIU/ml (or 1000mIU/ml)
at 4 weeks 5 days usually
• The minimum level of hCG at which G.sac is
visulalised by TAS is 6000mIU/ml at 5 weeks 3
days
• Culdocentesis
• Reserved for emergency situation when USG is not
possible
• Laparoscopy
✓ Results
• Direct visualization of pelvis specially the tube
• Also identifies endometriosis, adhesions
✓ Advantages
• Gold standard for identification of ectopic preg.
ARISE MEDICAL ACADEMY Dr. MIK | 53
• Therapeutic management can also be done at the
same time
• Feasible in hemodynamically stable patient.
TREATMENT GUIDELINES FOR RUPTURED ECTOPICS
• Immediate laparotomy should be done along with
- general resuscitative measures together
• Even in those cases where there is doubt of
ruptured ectopic pregnancy - Laparotomy should
be done to open and see
• Even if blood is not available then also a
laparotomy is done
• Immediate laparotomy and clamping of the
bleeding vessels may be the only means of saving
the life of moribund patient
✓ Surgery of choice-
• Salpingectomy
TREATMENT GUIDELINES FOR UNRUPTURED
ECTOPICS
➢ Unruptured
• Depending on the patient's condition & other
criteria there are 3 types of treatment
✓ Expectant management
✓ Medical management management
✓ Laparoscopy
✓ Laparotomy
➢ Expectant management
• Only observation is done in hope of spontaneous
resolution.
✓ Indication:
• Decreasing serial hCG titres
• No evidence of intraabdominal bleeding or
rupture assessed by vaginal sonography
• Diameter of the ectopic mass less than 3.5 cms.
• Baseline HCG < 1000 IU/L & falling
• The potentially grave consequences of tubal
rupture and the established safety of medical and
surgical therapy, require that expectant therapy
be undertaken only in appropriately selected and
counseled women
• Minimal side effects of methotrexate make it
preferable to avoid the prolonged surveillance the
of expectant management and associated patient
anxiety.
➢ Medical management
• It involves the use of a sysytemic agent to treat
an unruptured ectopic
• Drug most commonly used: Methotrexate
✓ Methotrexate
• It is a folic acid analogue which inhibits
dehydrofolate reductase
• This leads to a deficiency in folic acid
• This prevents synthesis of DNA.
• This will lead to cytological death of the
conceptus and trophoblastic tissue
✓ Indications
o Absolute requirements
• Patient should be hemodynamic stable
• No evidence of acute intra-abdominal bleeding
• Reliable commitment to comply with required
follow-up care
• No contraindications to treatment viz woman
should not be breast feeding / renal / hepatic
dysfunction ( for methotrexate)
• Serum beta HCG level less than 10,000 IU/L (best
results seen with HCG < 2000 IU/L
• Absent heart activity
• Ectopic gestational mass less than 4 cms in
diameter
✓ Single Dose Medical Treatment Protocol For
Ectopic Pregnancy.
• Day 0 / Day I = Measure serum hCG, TLC, DLC,
Liver Function Test and Renal Function Test
• Day 2 = Single dose Methotrexate 50 mg/m2 IM
given
• Day 4 = S. hCG and counts repeated
• Day 7 = S. hCG and counts repeated
• hCG titres on day 4 and day 7 are decisive
✓ Prognosis and futher treatment
ARISE MEDICAL ACADEMY Dr. MIK | 54
 • The main factor here is the difference in hCG • It is done in all those patients who do not fulfill
between day 4 and day 7 the criteria laid down for medical management
o If the decline is > 15% - No further treatment is • Surgical management could be done either by
required laproscopy or laparotomy
• If the decline is < 15% - Repeat another cycle of 7
days
✓ Disadvantages of medical management ✓ Laparoscopy
• It fails in 10 – 15% of all the patients • Indicated in hemodynamically stable patients and
✓ Don’ts during medical management not in emergencies
• Sexual intercourse, Alcohol to be avoided, Folic
acid
✓ Laparotomy
• Patient is hemodynamically unstable
✓ Surgically administered medical management: • Ruptured ectopic pregnancy
• Extensive abdominal & pelvic adhesion making
laparoscopy difficult
• Certain drugs can also be administered into the • Any ectopic gestation other than tubal pregnancy
gestational sac directly under laparoscopic or
ultrasonographic guidance.
• The method delivers a high concentration of the TYPES OF TUBAL SURGERY
drug to the site of implantation
• Tubal surgeries for ectopic are of 2 types
➢ Conservative
o Drugs used are • Salpingostomy
• Methotrexate (1 mg/kg) • Salpingotomy
• Prostaglandins • Segmental resection
• Hyperosmolar urea • Fimbrial expression
• Mifepristone (RU486)
• Actinomycin D
➢ Radical
• Vasopressin
• Salpingectomy
• KCI (Potassium Chloride)
➢ Fate Of The Ovary
• Salpingo-oophorectomy i.e. removal of tubes
along with the ovaries is not recommended in
➢ Surgical management young patient
• It should be done in all cases of ruptured ectopic

CHAPTER – 10
GESTATIONAL TROPHOBLASTIC DISEASES
• Definition
• Gestational Trophoblastic Disease (GTD) ➢ Classification
encompasses a spectrum of proliferative ✓ Conventional classification
abnormalities of trophoblasts associated with • Hydatidiform mole
pregnancy. • Invasive mole
• Persistent GTD (persistently raised (hCG) is referred • Choriocarcinoma
as gestational trophoblastic neoplasia (GTN) • Placental site trophoblastic tumor (PSTT).
ARISE MEDICAL ACADEMY Dr. MIK | 55

HYDATIDIFORM MOLE
• Hydatidiform mole is a benign neoplasm of
chorion with malignant potential.
• It is the most common form of gestational
trophoblastic disease.
• It is an abnormal condition of the placenta where
there are partly degenerative and partly
proliferative changes in the young chorionic villi.
➢ TYPES
• There are two types of hydatidiform moles
✓ Complete mole
✓ Partial mole
✓ Complete mole
➢ EPIDEMIOLOGY
✓ Incidence
• Incidence is maximum in Asia and South America
and least in U.S.
• Maximum incidence is in Philippines (1 in 80).
• In India it is 1 in 400 pregnancies.
✓ Risk Factors
• Risk is more in women too elderly (> 35) or too
younger (< 18 years).
• Low socioeconomic status.
• History of molar pregnancy.
• Diet deficient in protein, folic acid and vitamin A.
• Blood group ‘A blood group’ lady married to ‘O
blood group’ man.
• Partial mole is linked to the use of oral
contraceptive pills and history of irregular
menstruation.
➢ Genetics
• Familial repetitive hydatidiform mole has been
linked to a missense mutation in the NLRP7 locus on
chromosome 19;
• This mutation is present in 60% of patients who had
two molar pregnancies
➢ Complete Mole
• Complete H. mole shows no evidence of fetal tissue
at all.
• Complete hydatiform moles exhibit characteristic
swelling and trophoblastic hyperplasia.
• Most common karyotype is 46XX 90%
• 10% may have a 46XY karyotype
• The molar chromosomes are entirely of paternal
origin (although mitochondrial DNA is of maternal
origin.)
• Characterised by multiple grape like vesicles filling
and distending the uterus, usually in absence of an
intact fetus
✓ Origin
• The complete moles arises from an ovum that has
been fertilized by a haploid sperm, which then
duplicates its ownchromosomes called as
Androgenesis.
• The ovum nucleus may be either absent or
inactivated!
➢ Partial Mole
• Some embryonic or fetal tissue is identifiable.
• Chorionic villi of varying size with focal hydatidiform
swelling, cavitation, and trophoblastic hyperplasia
(whereas complete mole shows diffuse
hydatidiform swelling and trophoblastic
hyperplasia.)
• Marked villous scalloping.
• Prominent stromal trophoblastic inclusions.
✓ Origin
• Partial moles generally have a triploid karyotype (69
chromosomes); the extra haploid set of
chromosomes usually is derived from the father.
• When a fetus is present in conjunction with a partial
mole, it generally exhibits the stigmata of triploidy,
including growth retardation and multiple
congenital malformations such as syndactyly and
hydrocephaly
ARISE MEDICAL ACADEMY Dr. MIK | 56
 • DIFFERENCES IN COMPLETE AND PARTIAL MOLE:

CHARACTER COMPLETE MOLE PARTIAL MOLE

KARYOTYPING 46XX - 90% or 46XY - 10% i.e. 69XXX or 69XXY i.e. it is triploid
it is diploid
Embryo/fetus ABSENT PRESENT
Trophoblastic DIFFUSE OVERALL AFFECTION FOCAL AFFECTION
hyperplasia
Fetal RBC in ABSENT PRESENT
villi
Hydropic PRONOUNCED AND DIFFUSE VARIABLE AND FOCAL
degeneration
of villi

➢ Clinical Features ✓ Signs

✓ Symptoms
• Amenorrhea
• It is of varying duration followed by continuous or
intermittent brown or bloody discharge (usually not
profuse) evident by 12 weeks (Three fourths of
these patient present prior to the end of the first
trimester)
• uterine bleeding is all most universal (it is the most
common presenting feature , occuring in more than
90% of patients with molar pregnancies).
• Passage of vesicles per vaginum
3. Hyperemesis (due to the high levels of circulating
HCG).
➢ Patient complaining of extremes of nausea,
vomiting + bleeding in first trimester + size of
uterus more than the period of amenorrhea-
think of Molar pregnancy
• The fundal height of uterus is more than the period
of amenorrhea
( The size of the uterus is more than that
expected for the period of amenorrhea in 70%,
corresponds with the period of amenorrhea in 20%
and smaller than the period of amenorrhea in 10%.
)
• Uterus is doughy in consistency (due to absence of
amniotic fluid).
• Fetal parts will not be felt.
• Fetal heart sounds will not be heard (even on
doppler).
• External and internal ballottement can not be
elicited.
• Adnexal mass felt on P/V examination – theca leutin
cyst

ARISE MEDICAL ACADEMY Dr. MIK | 57

➢ SPECIAL POINTS
• Patients with partial mole do not have dramatic
clinical features of complete molar pregnancy. In
general these patients have signs and symptoms of
incomplete or missed
• When hypertension appears before 24 weeks, it is
important to rule out hydatidiform mole.
• Clinical Thyrotoxicosis seen due to the
thyrotrophin-like effect of hCG
➢ Investigations :
1. Ultra sono graphy
• USG is a reliable and senstive technique for the
diagnosis of molar pregnancy.
• USG alone is adequate, quick and a safe procedure
• Ultrasound shows "Snow storm" appearance in
the uterus.
✓ In case of complete molar pregnancy:
• Chorionic villi exhibit diffuse hydropic swelling
• Absence of fetal shadow.
✓ In case of partial molar pregnancy:
• Focal cystic spaces are seen in placental tissue
• Some fetal tissue is identifible.
➢ In either case theca lutein cyst may be seen.
2. Serum beta hCG
• Serum beta hCG levels are very high in case of
molar pregnancy.
• Levels more than 40,000 as detected by radio
immunoassay are seen in trophoblastic diseases.
• Rapidly increasing serum values of HCG are also
suggestive of molar pregnancy.
3. Chest X-ray
• Done to rule out lung metastasis
• Straight X ray of chest should be carried out as a
routine, for evidence of pulmonary embolization
even in benign moles.
4. CTscan
• Done to rule out brain and liver metastasis.
5. Gold Standard
• Definitive diagnosis is done by histological
examination of products of conception.
➢ MANAGEMENT OF H. MOLE
1. Suction curettage
• It is the treatment of choice irrespective of uterine
size
• Suction evacuation is done first. After most of the
molar tissue has been removed by aspiration,
oxytocin is given.
• Once the myometrium has contracted, thorough
but gentle curettage with a large sharp curette is
performed.
• Intraoperative ultrasonographic examination may
help document that the uterine cavity has been
emptied
• As far as pulmonary embolisation in concerned -
acute pulmonary insufficiency due to pulmonary
embolization of trophoblastic cells can occur during
suction evacuation
2. Hysterectomy:
✓ Indications
• Female has completed her family irrespective of age
• Age of patient - >35 years (as chances of malignancy
are more).
• Uncontrolled haemarrhage during scutum
evacuation
✓ Advntages
• In women aged 40 or older because atleast a third
of these women will go on to develop gestational
trophoblastic neoplasia.
• Hysterectomy when performed in molar pregnancy
significantly decreases the chances of developing
choriocarcinoma (by 5 fold times)
✓ Disadvantages
• Following hysterectomy, persistent GTD is
observed in 3-5% cases and hence does not
eliminate the necessity of follow up
ARISE MEDICAL ACADEMY Dr. MIK | 58
✓ Guidelines
• The enlarged ovaries (theca lutein cysts) found
during operation should be left undisturbed as they
will regress following removal of mole.
• But, if complication arises, like torsion, rupture or
infarction then the ovaries can also be removed
➢ Fate of a complete mole
• Spontaneous expulsion occurs at around 16 weeks
and rarely delayed beyond 28 weeks.
• Complete moles have a potential for local invasion
and dissemination after molar evacuation
• Persistent - 15-20%,
• metastatic disease-5%,
• recurrence - 1-4%,
• Choriocarcinoma - 2-10%.
➢ Fate of a partial mole
• Persistent tumour - 2-4% .
• Most of the pregnancies are aborted
➢ Following-up Molar Pregnancy
• Routine follow up is mandatory for all cases for
atleast 6 months following molar pregnancy.
• The chances of persistent trophoblastic disease and
choriocarcinoma are high after evacuation of H.
mole therefore regular follow up is mandatory.
• Doing hysterectomy does not negate the need for
followup.
✓ First B-hCG level is obtained 48 after evacuation.
✓ Then patients should be monitored with weekly
determinations of beta -subunit HCG levels until
these levels are normal for 3 consecutive weeks
✓ (The average time to achieve the first normal HCG
level after evacuation is about 9 weeks )
✓ After normal levels are achieved monthly
determinations for 6 consecutive months
• After a patient achieves a nondetectable hCG level,
the risk of developing tumour relapse is very low
and may approach zero
• Prevent pregnancy for a minimum of 6 months
following normal levels of hCG
• After 6 months of monitoring pregnancy is allowed
( previous guidelines to avoid pregnancy for a period
of 1 – 2 years are not followed)
• Chemotherapy is not indicated as long as these
serum levels continue to regress.
• A rise or persistent plateau in the level demands
evaluation for gestational trophoblastic neoplasia
and usually treatment by chemotherapy.
▪ Median time for resolution of partial mole is 7
weeks and for complete mole is 9 weeks.
➢ Contraceptive Advice during follow up
• All patients with H. mole have to compulsorily
avoid pregnancy during the followup period
• Estrogen-progestin contraceptives or depot
medroxyprogesterone is usually used to prevent a
subsequent pregnancy during the period of
surveillance.
• Contraceptive of choice being combined oral pills.
• Earlier the contraceptive of choice was Barrier
method.
• Earlier patient was advised to avoid pregnancy for
atleast 1 year after H mole evacuation but now it is
restricted to 6 months following a negative hCG
titre
➢ Prophylactic Chemotherapy
✓ Indications
• Initial high levels of β HCG (> 100,000 mill/ml)
• If hCG fails to becomes normal by stipulated time
(10-12 weeks) normal time being 9 wks and 7 wks
• Reelevation of serum HCG after reaching normal
levels
• Evidence of metastasis irrespective of HCG levels.
• Post evacuation hemorrhage.
• Age : patient >35 years.
• Theca lutein cysts > 6 cms.
✓ Drug used : Methotrexate / Actinomycin D
✓ Methotrexate
• 1mg/kg is given on days 1, 3, 5 and 7
• Alternately give folinic acid 0.1 mg/kg on day 2, 4, 6
and 8
• A total of 3 such courses can be given
• hCG falls within 4 days to 1 week following single
cycles
ARISE MEDICAL ACADEMY Dr. MIK | 59

✓ Actinomycin D
• Can be given as 12mcg/kg iv for 5 days
• More costly
• Less toxic
➢ Theca lutein cysts:
• They vary in size from microscopic to 10 cms size.
• Yellow coloured.
• It occurs due to overstimulation of the luteal
elements by the large amounts of circulating hCG
especially in complete moles to about 25 – 60 %
• Persistent trophoblastic disease is more likely in
women with theca lutein cysts >6 cms ( FIGO
guidelines)
• Patients with theca lutein cysts (> 6 cms) have high
risk of developing choriocarcinoma (FIGO and WHO
) villi.
• Theca lutein cyst regress spontaneously after
suction evacuation & do not need any specific
management.
✓ Complications
• It may undergo torsion, infarction or hemorrhage
✓ Management
• If found during hysterectomy they are left
untouched – NO OOPHORECTOMY
• It may undergo torsion, infarction or hemorrhage
and if found pathological during hysterectomy then
oophorectomy may be done
➢ PERSISTENT GESTATIONAL TROPHOBLASTIC
DISEASE
• Definition: Persistent GTD is defined where there is
persistence of trophoblastic activity as evidenced by
clinical, imaging, pathological and or hormonal
study following initial treatment.
• This may be following treatment of hydatidiform
mole ( called post molar GTD)
• A postmolar GTD may be benign or malignant.
• GESTATIONAL TROPHOBLASTIC NEOPLASIA
• It refers to a spectrum of diseases with invasive,
malignant or metastatic potentials.
• It is composed of 4 variants
✓ Persistant Hydatidiform mole
✓ Invasive Mole
✓ Choriocarcinoma
✓ Placental site Trophoblastic Tumor
➢ Invasive mole :
• Also called chorioadenoma destruens
• It accounts for 15 % of all GTN
• It has extensive penetration abilities through all the
layers of uterus
• It may present with multiple purple perforated
areas with massive intra peritoneal haemorrhage
• Later may metastasize to vagina or distant sites
• Excessive trophoblastic over growth and extensive
penetration by the trophoblastic cells including the
• The villus structure is retained well without signs of
muscle necrosis
➢ Placental Site Trophoblastic Tumor(PSTT) :
• It arises at the placental implantation site
• It is the rarest variant of GTN
• The tumor arises from the intermediate
trophoblasts Local invasion occurs into the
myometrium and lymphatics
• This tumor metastasises less commonly into the
vasculature (different from choriocarcinoma)
• Patient presents with vaginal bleeding.
• These tumors have been associated with
modestly elevated serum beta - hPL (human
placental lactogen) is also a tumor marker for these
tumors.
ARISE MEDICAL ACADEMY Dr. MIK | 60
✓ Treatment
• PSTT is not responsive to chemotherapy.
Hysterectomy is the preferred treatment
➢ Choriocarcinoma
• Most malignant tumor of uterus
• It arises from the chorionic epithelium
• It is not a tumor of uterus but the uterus is
secondarily affected
• Mostly presents as irregular bleeding or uterine
hemorrhage following an abortion, a molar
pregnancy or a normal delivery
✓ Gross :
• It usually starts at any place in the uterus
• May rarely start from the fallopian tube or ovary
• Usually appears as localised nodular lesion
✓ Histopathology :
• Absence of villous pattern
• Columns and sheets of trophoblastic cells
penetrating the muscle and blood vessels
• Cellular atypia
✓ MC mode of spread is hematogenous
➢ METASTASIS
• Most common sites of metastases in
choriocarcinoma are
• Lung (80%) > Vagina (30%) > Pelvis (20%) > Liver
(10%) and Brain (10%)
• The sites associated with lesser risk is lung and
vagina
• Metastasis to brain and liver are associated with
worse prognosis
• Patients with brain or liver metastasis are at great
risk of sudden death from hemorrhage from these
lesions
• Therefore it is a standard practice to include whole
brain or whole liver irradiation concomitantly with
combination chemotherapy
➢ Lung Metastasis
• It is seen in 80% cases
• Patient presents with respiratory symptoms like
dyspnoea, hemoptysis, chest pain etc.
• On X-ray it may produce the following four patterns
✓ An alveolar snow storm pattern
✓ Discrete rounded densities or canon ball
appearance
✓ Pleural effusion
✓ An embolic pattern caused by pulmonary arterial
occlusion
➢ Vaginal Metastasis
• It is seen in 30% cases
• Metastasis occurs in suburethral or in fornicesQ
• Metastasis appears as purple hemorrhagic
projections which are highly vascular and bleed on
touch (pathognomic of choriocarcinoma)
• Where else do we see purplish spots in the fornices
_____________?
ARISE MEDICAL ACADEMY Dr. MIK | 61
➢ CHEMOTHERAPY
• It is of two types
✓ Single agent chemo
✓ Combination chemo
✓ Single agent chemo
• Methotrexate is the drug of choice.
• If the patient has jaundice then actinomycin D should
be given.
• Given on day 1, 3, 5 and 7
• Alternating with folinic acid on day 2, 4, 6 and 8
• Repeat every 7 days
✓ Combination chemo
• Most commonly is Bagshaw regime consisting of-
o E = etoposide
o M = methotrexate
o A = actinomycin D
o C = cyclophosphamide
o O = vincristine (oncovin)
• EMA-CO regimen results in response rates of about
90% and survival rates of 80-100%.
• Treatment must be continued until beta HCG
titres return to nondetectable levels.
• Complete remission is documented after 3
consecutive weekly normal beta HCG titres
• It is recommended that all high risk patient should
receive at least three courses of triple agent
chemotherapy after beta HCG titres have returned to
normal
➢ SURGERY
✓ Total hysterectomy
• It is done if required in choriocarcinoma .
• The ovaries are usually not involved and if involved,
can be effectively cured with postoperative
chemotherapy, hence bilateral salpingoopherectomy
is not done.
✓ NEO ADJUVANT CHEMOTHERAPY
• It is preferable to start chemotherapy 3 days before
surgery
• Then perform the surgery followed by chemotherapy
as per schedule.
✓ Metastatic resections
• Lung resection (thoracotomy) is done in pulmonary
metastasis in drug resistant cases.
• Craniotomy is for control of bleeding.
➢ Radiation
✓ Brain metastasis:
• Whole-brain radiation therapy (3000 cGy over 10
days).
• Intrathecal high dose methotrexate may be
administered to prevent hemorrhage and for
tumor shrinkage.
✓ Liver metastasis:
• Interventional radiology (hepatic artery ligation or
embolization) or whole liver radiation (2000 cGy over
10 days) along with chemotherapy maybe effective.
• Hepatic metastasis has a poor prognosis
➢ Prognosis
• The cure rate is almost 100 percent in low risk
• about 70 percent in high risk metastatic groups.
• Follow up is mandatory for all patients at least for 2
years.
• Serum hCG is measured weekly until it is negative for
three consecutive weeks.
• Thereafter it is measured monthly for 6 months and 6
monthly thereafter for life.
ARISE MEDICAL ACADEMY Dr. MIK | 62
 CHAPTER – 11
NORMAL LABOUR
• Normal labour is defined as a series of events that
take place in the genital tract in order to expel the
viable products of conception from the uterus to the
outside world through the vagina
➢ TRUE VS FALSE*
THE EDD
True labour pains False labour pains
• The Expected Date of Delivery is calculated by the
Naegele’s formula • Sharp pain • Dull pain
• The formula is d+7 / m+9 for the LMP • Intensity , duration • Intensity , duration and
• 4% of females deliver on the EDD* and frequency frequency don’t
• 50% of the females deliver within one week of the increase progressively increase
EDD* • Associated with show • Not associated with
• The EDD calculated by the first trimester ultra sound • Associated with show
scan is most accurate* cervical dilatation and • Not associated with
effacement cervical dilatation and
• Associated with effacement
➢ ONSET OF LABOUR descent of presenting • Not associated with
part descent of presenting
• Mainly due to increase in the level of oestrogen
• Associated with bag of part
relative to progesterone
membrane formation • Not associated with
• The raised levels of Oestrogen then cause:
• Not relieved on bag of membranes
✓ Increase the release of oxytocin*
sedation / enema • Relieved on sedation /
✓ Increase oxytocin receptors ______ times *
enema
✓ Increases Prostaglandin synthesis
✓ Increases exitability of the myometrial cell
✓ Increases contractility of the myometrium*

➢ THE LABOUR PAINS

THE BIOPHYSICS OF LABOUR
• Causes are :
TONE/TONUS
1) Uterine angina*
2) Peritoneal stretching • The tone or intensity refers to the intra uterine
3) Compression of nerve ganglion
pressures
✓ The distribution of pain* is along the cutaneous
nerves T10 to L1 • During pregnancy it is 2mm Hg
4) Cervical dilatation and stretching*
✓ The distribution is along the sacral plexus • During Braxton Hicks* it is < 8 mm Hg

• During first stage* of labour it is 40 – 50 mm Hg

ARISE MEDICAL ACADEMY Dr. MIK | 63

• During second and third stage* it is 100 – 120 mm Hg

• Other units measured are montevideo units

• MONTEVIDEO = intensity(mm hg) x frequency

(/10mins)*

FREQUENCY ❖ THE FIRST STAGE

• The number of contractions in a period of 10 minutes

• In first stage of labour it is usually 1 contaction in 10

minutes

• In second stage it is atleast 3 contractions in 10

minutes*

DURATI0N

• The time each contraction lasts is the duration

• During first stage it lasts for 30second each

• During second stage it lasts for 45seconds to 90

seconds
❖ STAGES OF LABOUR
1ST STAGE • ONSET OF TRUE
LABOUR PAINS TO
FULL DILATATION OF
CERVIX*
✓ ( Primi* 12-18 hrs ;
multi 6 - 8 hrs)
2ND STAGE • FULL DILATATION OF
CERVIX TO EXPULSION
OF THE BABY
✓ (Primi 2 hrs ; multi 30
mins)
3RD STAGE • EXPULSION OF THE
PLACENTA
✓ (Expectant 15 mins ;
active* 5 mins)
4TH STAGE • STAGE OF
OBSERVATION* – 1Hr
➢ It consists of some important events :
✓ Cervical dilatation
✓ Cervical effacement
✓ Formation of bag of waters
✓ Cervical effacement
✓ Taking up of the cervix by the uterus
✓ Effacement occurs before dilatation in primis*
✓ Effacement and dilatation occur together in multis
➢ Clinically the first stage of labour is divided into:
• Latent phase
• Active phase
Latent phase Active phase
• It is the preparatory • The cervix dilates
phase of cervical from 3cm to 10cm
dilatation in this phase
• It is 8 hrs in primi • This is the phase of
and 4hrs in multi* actual quick cervical
• The cervix dilates dilatation
only 3 cms during • The cervix dilates @
the latent phase* 1cm/hr in primis
and @ 1.5cm/hr in
multis

ARISE MEDICAL ACADEMY Dr. MIK | 64

 • Rate of dilatation in • Time of active phase
latent stage is of stage 1 in primis is
_______ ---------------------
• Time taken for active
phase of stage 1 in
multis is ----------------
--
• Decision for referral to higher centre ________
• Decision for ARM* _________
• Decision for cesarean section* __________
• Distance between alert line and action line is
_________
• A senior obstetrician is informed if _________

❖ THE SECOND STAGE

❖ PARTOGRAM
• The second stage starts after full dilatation of cervix
and ends with the expulsion of the baby
• The membranes rupture after full dilatation of cervix*
• Sometimes they rupture immediately after full
dilatation and sometimes a little later after the start of
second stage of labour*

• A partogram is the best method to assess the

progress of labour
• Though a partogram has several components the
most important components are :
➢ Cervical dilatation : accessed by vaginal
examination
➢ Descent of head : accessed by abdominal
examination
• Cervical dilatation is plotted as cervical dilatation in
cms on Y axis against time in hours on X axis
• Descent of head is accessed as 5/5 method
( descent of head is a part of both first and second
stage of labour starts at 7cm and ends with the
second stage) *
➢ The partogram is best to diagnose prolonged labour
at the earliest and intervene timely
• It is a comprehensive record in cases of referral to
higher centres
• It is a guideline for senior intervention and surgical
decision making

ARISE MEDICAL ACADEMY Dr. MIK | 65


❖ THE MECHANISM OF LABOUR*
• Defined as the series of movements on the foetal
head in order to adapt to the maternal pelvis
They are as follows*:
( ______ = ______ cm) enters the brim of the pelvis
• Engagement occurs at the end of 37th week in primi*
and with the onset of labour in multi*
• M/c position – LOT then LOA*
• M/c diameter for the entry of head – transverse*
• M/c the BPD enters along the – AP diameter*
• Internal rotation occurs at the level of ischial spines*
• The timing of episiotomy is decided by crowning*
• The head is born by the process of extension*
❖ THIRD STAGE OF LABOUR
It is composed of 2 important steps:
✓ Placental separation
✓ Placental expulsion

❖ PLACENTAL SEPARATION

There are 2 ways of palcental separation:

1. Central separation: Schultz mechanism

2. Peripheral: Duncan mechanism.

1) Engagement* 1. Central separation:

2) Descent
3) Flexion • Most commonly during placental delivery, a
4) Internal rotation* retroplacental hematoma forms and pushes the
5) Crowning* center forward
6) Extension* • This causes it to separate toward the uterine cavity.
7) Restitution • Weighted by this hematoma, the placenta descends,
8) External rotation drags the membranes, and peels them from their
uterine attachment.
❖ Engagement: • Consequently, the glistening amnion, covering the
placental surface, presents at the vulva.
• It is defined as the process by which the largest • The retroplacental hematoma either follows the
transverse diameter of foetal head placenta or is found within the inverted sac.

ARISE MEDICAL ACADEMY Dr. MIK | 66

• blood from the placental site pours into the
membrane sac and does not escape externally until
after extrusion of the placenta.
2. peripheral separation:
In the other method of placental extrusion, known as the
Duncan mechanism:
✓ the placenta separates first at the periphery. As a
result, blood collects between the membranes
and the uterine wall and escapes from the vagina.
✓ In this circumstance, the placenta descends
sideways, and the maternal surface appears
first".
✓ Placenta separates after the birth of the baby and
the line of separation is through the decidua
spongiosum.
SIGNS OF PLACENTAL SEPARATION
PER ABDOMEN FINDINGS :
• Uterus becomes globular, firm and ballotable (
earliest sign)
• Supra pubic bulging
• The cord doesn’t retract on pushing the uterus
upwards(Kustner’s sign)
• A slight raise in supra pubic height (Schroeder’s sign)
PER VAGINAL FINDINGS
• Gush of fresh blood
• Permanent leghthening of the cord
PHYSIOLOGICAL HAEMOSTASIS
• The uterine arteries pass through the uterine
musculature
• The contraction of uterus leads to compression of
these arteries leading to haemostasis ( stoppage of
bleeding)
• Which layer* of uterine myometrium forms the living
ligatures _______
• In the other method of placental extrusion, known as
the Duncan mechanism
• the placenta separates first at the periphery. As a
result, blood collects between the membranes and the
uterine wall and escapes from the vagina.
• In this circumstance, the placenta descends sideways,
and the maternal surface appears first"
• Placenta separates after the birth of the baby and the
line of separation is through the decidua spongiosum.
❖ ACTIVE MANAGEMENT OF THIRD STAGE
• The third stage of labour is potentially the most
dangerous of all stages
• The active management includes the following as
recommended by the WHO
➢ Administer oxytocin immediately after delivery of the
baby*
➢ Deliver the placenta by controlled cord traction and
counter traction*
➢ Delayed cord clamping*
❖ CORD CLAMPING
• Immediately after birth hold the baby below the level
of the vaginal interoitus*
• Clamp the cord approximately 1- 2 mins after
complete expulsion of the baby*
• This is to facilitate transfer about 100ml of blood from
the placenta to the baby
• The WHO has advocated early cord clamping in the
following conditions:
➢ HIV positive mothers
➢ Rh negative mothers
➢ Diabetic mothers
➢ Preterm baby
➢ Birth asphyxia
❖ LEVEL OF UTERUS AFTER DELIVERY
• After 2nd stage the uterus is at the level of the
umbilicus*
• After 3rd stage the uterus is below the level of the
umbilicus*
• Anterior asynclitism is common in multis*
• Posterior asynclitism is more common in primis
ARISE MEDICAL ACADEMY Dr. MIK | 67
 CHAPTER – 12
INDUCTION OF LABOUR

• Induction: Implies stimulation of contractions

before the spontaneous onset of labor ➢ ABSOLUTE CONTRINDICATIONS
• Often the cervix is closed and uneffaced, labor (Most High CAPUT)
induction is commenced by first making cervix soft, • Macrosomia
the process is called as cervical ripening. • Severe hydrocephalus
• Contracted pelvis /advance cancer cervix
• Augmentation of labor implies increasing the • Active genital herpes, high viral load of active HIV
strength of uterine contractions such that labor • Placenta previa, cord prolapse
progresses fast. • Uterine scar due to
• Induction of labor is indicated in all those conditions - 2 or more LSCS
when the benefits to either mother or fetus outweigh - Previous classical cesarean section
those of pregnancy continuation. - Myomectomy entering the endometrium
- Hysterotomy
INDICATION - Unification surgery
• Transverse lie
➢ MATERNAL INDICATIONS
• Preeclampsia/eclampsia ➢ RELATIVE CONTRAINDICATIONS
• Maternal medical complications like • Breech presentation
- Diabetes mellitus • Oligohydramnios
- Chronic renal disease • Multiple gestation
• Abruptio placenta • Grand multipara
• Premature rupture of membrane • Prematurity
• Chorioamnionitis
• Chronic hydramnios/Oligohydramnios
BISHOP SCORE
➢ FOETAL INDICATIONS • It is a quantitative method for prediction of
• Intrauterine fetal death successful induction of labour.
• IUGR • It includes the following parameters:
• Prolonged pregnancy ➢ D = Cervical Dilatation(most important parameter)
• Rh incompatibility ➢ P = Cervical Position
• Lethal malformation ➢ E = Cervical Effacement
• Unstable lie after correction into longitudinal lie ➢ S = Head Station
(versions) ➢ C = Cervical Consistency
• Fetus with major congenital anomaly
• Non reassuring fetal statues

CONTRAINDICATIONS OF INDUCTION OF LABOUR

ARISE MEDICAL ACADEMY Dr. MIK | 68

 THE SCORING SYSTEM
SCORE CERVICAL CERVICAL CERVICAL HEAD CERVICAL
DILATATION POSITION EFFACEMENT STATION CONSISTENCY

0 CLOSED POSTERIOR 0 – 30 % - 3 FIRM

1 1 – 2 CM MID 40 – 50 % -2 MEDIUM
2 3 – 4 CM ANTERIOR 60 – 70 % -1, 0 SOFT
3 > 5 CM > 80 % 1, 2

• It involves rupturing the membranes overlying the

cervix using a Kocher's forcep
➢ CLINICAL SIGNIFICANCE • Stripping of Membranes is the digital separation of
• Induction is successful only if scores are more than 9 membranes from the wall of the cervix and lower
• If scores are less than 4 then ripening of cervix uterine segment
should be done before starting induction of labour
➢ ADVANTAGES:
Techniques for cervical ripening • Promotes labour, encourages application of the fetal
➢ Pharmacological method head to the cervix, Colour of the liquor can be
✓ Prostaglandin observed and meconium staining ruled out
• Dinoprostone gel (PGE2) - it is the gold standard for
cervical ripening ➢ DISADVANTAGES:
• Misoprostol (PGE1) tablet - vaginal or oral • Cord prolapsed, Amnionitis, abruption in case of
➢ Non Pharmacological method polyhydramnios.
✓ Stripping the membrane • Vasa-previa
✓ Mechanical dilators:
PROSTAGLANDINS

ARTIFICIAL RUPTURE OF MEMBRANES

• For obstetric purposes the following prostagladins are

used
➢ PG E1 – Tab. Misoprost
➢ PG E2 – Gel. Dinoprost
➢ PG F2 alpha – Inj Carboprost

FORMULATIONS AND DOSAGES

• ARM is a method for inducing and augmenting ➢ PG E1
labour. • Tab Misoprost
• Available as 200mcg tablet

ARISE MEDICAL ACADEMY Dr. MIK | 69

➢ PG E2
• Available as tablet dinoprostone and gel dinoprostone
• Tablet dinoprostone 3mg
• Gel as 0.5 mg single use gel is syringe and catheter
➢ PG F2alpha
• It is available only as injection carboprost
• It is available as 250 mcg in a 1ml ampoule
• The analogue of prostaglandin which is
contraindicated in scarred uterus and should not be
used in previous LSCS patients-PGE1
• The analogue of prostaglandin which is not used for
inducing labour PGF-2 alpha
• The analogue of prostaglandin which is used only in
PPH -PGF-2 alpha

USES OF PROSTAGLANDINS VAGINAL BIRTH AFTER CESAREAN DELIVERY

➢ PG E1 (VBAC)
• Abortion/ MTP 1st trimester
✓ 200mcg P/V or P/O 4 tablets fourth hourly (48 hrs
after mifepristone)
• Induction of labour –
✓ 25mcg P/V every 4th hourly upto max 8 times
✓ 50mcg P/V every 3rd hourly upto max 6 times
✓ 50mcg P/O every 4th hourly upto max 6 times
• PPH
✓ 1000mcg P/R stat

➢ PG E2 / dinoprostone
• Ripening of cervix prior to induction of labour
✓ Gel dinoprost 0.5mg in cervical canal taking care not
to go beyond internal os
✓ Tab Dinoprost 3mg P/V twice 6 hours apart
➢ PG F2alpha
• PPH
✓ Inj 250 mcg intramuscular ( gluteal)
✓ Inj 125 mcg intramyometrial
GOLD STANDARDS
• The gold standard agent for cervical ripening is PGE2
i.e dinoprost gel.
• The gold standard agent for inducing labour is PGE2
• The analogue of prostaglandin recently approved by
ACOG for cervical ripening – PGE1 (misoprost)
➢ selection of candidate for inducing a VBAC
• No more than one prior LSCS.
• Clinically adequate pelvis (no CPD).
• No other uterine scars or previous rupture.
• Physician immediately available throughout active
labour who is capable of monitoring labour and
performing emergency cesarean.
• Availability of anesthetist and operation theatre
facilities.
• Availbility of blood and resuscitation
• absolutely contraindication in VBAC induction
• Induction and trial of scar is absolutely
contraindicated in CPD/contracted pelvis.
• In case of previous classical cesarean section, the risk
of rupture of uterus during trial is 4-9%, hence trial of
scar is an absolute NO

ARISE MEDICAL ACADEMY Dr. MIK | 70

 CHAPTER – 12
PRETERM, POST DATED, PROM & PPROM

PRETERM LABOUR (PTL) • Medical and surg. disorders in preg : fever,

• Preterm labour is defined as labour (regular, painful
frequent uterine contractions causing progressive
effacement and dilatation of cervix) occurring before
37 completed weeks of gestation
➢ High risk factors
pyelonephritis, diarrhoea, acute apendicitis,
abdominal surgery
✓ Iatrogenic : indicated disorder for termination of
pregnancy
✓ Idiopathic : majority of the cases

✓ Foetal : multiple pregnancy, congenital

malformations, IUFD

✓ Placental : infarction, thrombosis, previa, abruption

• Most common cause of preterm labour is idiopathic

followed by infection like urinary tract infection,
vaginal infections
• Other common cause is short Cx
• Most common organisms responsible for preterm
labour: Ureoplasma urealyticum and Gardenerella
vaginum causing bacterial vaginosis.

✓ History ➢ CERVIX AND PRE TERM LABOR

• Past H/o preterm labor, Pregnancy after ART,
Asymptomatic bacteriuria, Smoking, Low socio
• Length of cervix (measured by TVS) <2.5 cm and
economic and nutritional status, Maternal stress
tunneling of internal os is an important risk factor for
preterm
✓ Maternal • Shape of Cx and Correlation
• Pregnancy complications : pre eclampsia, APH,
polyhydramnios, PROM, short Cx
SHAPE OF CERVIX CORELATION

T shaped Normal
Y shaped Suspicious of preterm labor

U shaped Funneling of os -seen in incompetent os , preterm

labor

ARISE MEDICAL ACADEMY Dr. MIK | 71

DIAGNOSIS OF PRETERM LABOUR
• Regular uterine contractions with or without pain (at
least one in every 10 min).
• Dilatation (> 2 cm) and effacement (80%) of cervix.
• Resting pressures more than 20mm hg
• Fetal fibronectin if present in vaginal /cervical
secretions before 37 weeks
➢ Fetal fibronectin equal to or more than 50 ng/ml and
cervical length <2.5 cm on TVS are the best
predictors especially in a woman with a prior history
of preterm birth.
➢ Fetal Fibronectin:
• It is a fetal glycoprotein.
• Normally it is found in the cervico vaginal discharge
before 22 weeks and again after rupture of
membranes.
• If detected in cervicovaginal secretions prior to
rupture of membranes, it indicates disruption of the
maternal-fetal interface and may be predictive of
impending preterm labour.
• When the test is negative it reassures that delivery
will not occur within next 7 days.
➢ MANAGEMENT
• Glucocorticoids : to reduce RDS, IVH and NEC
• Tocolysis : To allow the steroids to act and gives time
to allow the mother to be shifted to higher centre
• Antibiotics : if indicated to avoid infections and
Neonatal sepsis
• Rescue circlage ( debatable)
➢ Steroid therapy in preterm labour:
• Steroids are recommended for all women in preterm
labour before 32 weeks with or without membrane
ruptures in whom there is no evidence of
chorioamnionitis.
• Steroid of choice for lung maturity is
Betamethasone.
• Dosage is 2 doses of 12 mgs of steroid (i.e., 3
ampules) are given i/m - 24 hours apart.
➢ Advantage:
• Steroids reduce the rate of respiratory distress
syndrome, intraventricular hemorrhage and
necrotising enterocolitis in the newborn.
• It also prevents periventricular leukomalacia
➢ Adverse effects of steroid therapy
✓ On Mother
• Pulmonary edema, Infection, More difficult glucose
control in diabetic women, No long term maternal
adverse effect
✓ On Foetus
• Early onset neonatal sepsis, Chorioamnionitis,
Neonatal death
➢ CONTRAINDICATIONS
• Corticosteroids can be given even in presence of
maternal hypertension or diabetes mellitus
• Be avoided if PROM is associated with definitive
evidence of chorioamnionitis / overt infection
➢ Tocolysis:
• Tocolytics are not given with the aim to arrest
preterm labor for a long time, but to prolong the
labor for 48 hours.
✓ This servers the following purposes:
- The corticosteroids get time to act.
- Allows time for transport of the woman to better
obstetrical centre.
➢ Antibiotics:
• Do not have a role in preterm pregnancy with intact
membranes.
ARISE MEDICAL ACADEMY Dr. MIK | 72
• Ruptured membranes - avoid the spread of infection
from vagina to the uterus / foetus - main organism -
group B streptococcus
TOCOLYTIC DRUGS
➢ BEST CHOICE FOR PATIENT
• Best first line tocolytic—Nifedipine
• Overall tocolytic of choice – Nifedipine
• Most efficacious tocolytic agent – Nifedipine
• 2nd line tocolytic—Betamimetic agents like ritrodine,
salbutamol.
• Safest tocolytic agent – Atosiban
• Tocolytic preferred in heart disease – Atosiban >
MgSO4
• Tocolytic with maximum side effects-Betamimetic
agent
➢ Most commonly used tocolytics in case of preterm
previa.
✓ Nifedipine
✓ Magnesium sulphate
➢ Tocolytics which are not used in preterm previa
• Terbutaline and Ritodrine: They cause tachycardia
and make the assessment of patient's pulse rate
unreliable.
• Indomethacin: It causes inhibition of platelet cyclo
oxygenase system and prolongs the bleeding time.
PREMATURE RUPTURE OF MEMBRANES
(PROM)
➢ Definition
• Premature Rupture Of Membrane ( PROM) is defined
as spontaneous rupture of membranes before the
onset of labour
• Preterm premature rupture of membranes (PPROM)
is defined as premature rupture of membranes before
37 completed weeks.
➢ Risk factors for PROM:
• Incresing friabilty/decreased tensile strength of
membranes
• Infections like bacterial vaginosis
• Polyhydramnios
• Multiple pregnancy
• Cervical incompetence
• Previous H/O PROM.
• The predominant risk for patients with PROM
between 28 and 32 weeks is hyaline membrane
disease. Administration of glucocorticoids and
prolongation of the latent phase are beneficial for
these patients if they do not have clinical or
subclinical chorioamnionitis.
• The predominant risk for patients with PROM
between 32 and 36 weeks is chorioamnionitis.
Therefore the dominant tendency in their
management should be toward delivery.
• The most probable cause of PROM is a reduction in
membrane tensile strength caused by the effect of
bacterial proteases or by repeated stretching caused
by uterine contractions
• Most common infection is bacterial vaginosis (
Chlamydia and group B streptococcus)
PRESENTATION
ARISE MEDICAL ACADEMY Dr. MIK | 73
 • The membranes probably are intact if the color of the
• Patients present with a typical history of sudden paper remains yellow or changes to olive-yellow (pH
gush of clear or pale yellow fluid leaking from 5.0 to 5.5).
vagina.
• However many women may present with history of • False result: Antiseptic solution, urine, blood, and
intermittent or constant leaking of small amounts of vaginal infections alter the vaginal pH and cause false-
fluid or just sensation of wetness within the vagina ( positive results.
confused with vaginal discharge)
➢ Fern test
➢ O/E :
• Per speculum examination - First step in the
diagnosis of PROM is a sterile per speculum
examination to demonstrate leaking.
• Pooling of fluid in the posterior fornix or leakage of
fluid from the cervical os confirms the diagnosis of
PROM.
• A per vaginal examination should not be done as it
increase the risk of intrauterine infection and
preterm labour.
• If the condition is still doubtful some tests are done

Tests done to confirm amniotic fluid

• Ferning results from the drying of salts contained in
the amniotic fluid.

• Nitrazine Test and

➢ Nitrazine test for Diagnosis of PROM :
• To perform the test, a sample of fluid is placed on a
glass slide and allowed to dry.
• The preparation is observed under the microscope,
looking for a crystallization pattern that resembles a
fern, which is the seen if membrane have ruptured.
• The accuracy of the test is affected by blood,
meconium and cervical mucus.
• The diagnosis of PROM is close to 100% reliable if the
vaginal fluid gives both positive nitrazine and
positive fern tests

• Principle: The vaginal pH is normally 4.5 to 5.5,

where as amniotic fluid usually has a pH of 7.0 to 7.5.
• Test: Nitrazine paper is smeared with vaginal
secretions.
• Result: Nitrazine paper will turn deep blue if
amniotic fluid is present in vagina i.e. if membranes
have ruptured
• This is because pH will become alkaline.
MANAGEMENT
➢ PPROM without amnionitis and foetal distress
• < 34 weeks : expectant management with
antimicrobials in a high obstetric dependency unit
with well equiped NICU
• 34 – 37 weeks : wait for spontaneous onset of labour
for 24 – 48 hrs, if it fails then LSCS

ARISE MEDICAL ACADEMY Dr. MIK | 74

• > 37 weeks : wait for spontaneous onset of labour for
24 – 48 hrs, if it fails then LSCS
➢ CHORIOAMNIONITIS and PROM
• Acute Chorioamniotis is diagnosed Clinically in
presence of fever ( >100 for 37.8 C) and atleast two of
the following:
• a. Maternal Tachycardia
• b. Fetal Tachycardia
• c. Uterine tenderness
• d. Foul smelling amniotic fluid
• e. Maternal leucocytosis
• When chorioamnionitis is diagnosed, fetal and
maternal morbidities increase and delivery is
indicated regardless of the fetus's gestational age.
POST DATED PREGNANCY
• A pregnancy continuing beyond two weeks of the
expected date of delivery (> 42 weeks or >294 days)
is called postmaturity or post-term pregnancy
➢ Causes of Post term pregnancy:
• Wrong dates: due to inaccurate LMP (most common).
• Biologic variability (Hereditary) may be seen in the
family.
• Maternal factors: Primipara / elderly multipara / H/o
previews prolonged pregnancy, sedentary habit.
• Fetal factors: Congenital anomalies: Anencephaly -
(Abnormal fetal HPA axis), adrenal hypoplasia
(Diminished fetal Cortisol response).
• Placental factors: Sulphatase deficiency (Low
oestrogen).
CHAPTER – 14
ABNORMAL LABOUR
UTERINE RUPTURE
➢ Post Dated Pregnancy : Confused Doctor &
Patient
• Most common cause is wrong dates
• If the patient is sure about her date - regular cycles - ,
it is reliable
• The previous well documented antenatal records of
first visit in first trimester if available, are useful
guides.
• If not available then consider any other EDD
COMPLICATION
❖ FOETAL COMPLICATION
➢ Still Birth
✓ Ageing of placenta – foetal hypoxia – foetal
acidosis – foetal distress – foetal death
➢ Foetal macrosomia
✓ Increased weight gain by the baby – macrosomia -
--difficulty in vaginal birth
➢ Shoulder dystocia and cord prolapse
✓ Gestation increases – amniotic fluid decreases –
oligogydramnios – more chances of shoulder
dystocia and cord prolapse
➢ Meconium Aspiration Syndrome
✓ Foetal distress and oligohydramnios
➢ IVH
✓ Oligohyramnios – less proper engagement – less
moulding
❖ Neonatal complications:
✓ Chemical pneumonitis, atelectasis and pulmonary
hypertension due to meconium aspiration.
✓ Hypoxia and respiratory failure.
✓ Hypoglycemia & Polycythemia.
ARISE MEDICAL ACADEMY Dr. MIK | 75
➢ Rupture Uterus 1. Spontaneous
• Disruption in the continuity of the all uterine layers 2. Scar rupture
(endometrium, myometrium and serosa) any time 3. Iatrogenic
beyond 28 weeks of pregnancy is called rupture of the
uterus. • Each of them is further classified as
• Any disruption before 28 weeks is called as ✓ During pregnancy
perforation ✓ During labour

1. SPONTANEOUS RUPTURE

➢ During pregnancy
• It is rare for an apparently uninjured uterus to give
way during pregnancy. -
o The causes are:
• (1) Previous damage to the uterine walls following
dilatation and curettage operation or manual removal
of placenta
• (2) Grand multiparae ( due to weak uterine walls)
• (3) Congenital malformation of the uterus (bicornuate
variety)
❖ PATHOLOGICAL CLASSIFICATION
• (4) In Couvelaire uterus.
• Uterine rupture can be complete and incomplete
o Spontaneous rupture during pregnancy is usually
depending on whether the peritoneal coat is involved
complete, involves the upper segment and usually
or not.
occurs in later months of pregnancy
• Incomplete rupture usually results from rupture of
the lower segment scar or extension of a cervical tear
into the lower segment with formation of a broad
➢ During labor:
• Spontaneous rupture which occurs predominantly in
ligament hematoma.
an otherwise intact uterus during labor. It is due to:
• Complete rupture usually occurs following disruption
o Obstructive rupture—This is the end result of an
of the scar in upper segment.
obstructed labor. The rupture involves the lower
segment and usually extends through one lateral side
❖ CLINICAL CLASSIFICATION
of the uterus to the upper segment.
➢ Scar dehiscence:
o Non-obstructive rupture—Grand multiparae are
✓ Disruption of part of scar and not the entire
usually affected and rupture usually occurs in early
length
labor. The rupture usually involves the fundal area
✓ Fetal membranes remain intact and
and is complete.
✓ Bleeding is almost nil or minimal.
➢ Scar rupture:
2. SCAR RUPTURE
✓ Disruption of the entire length of the scar
✓ The incidence of lower segment scar rupture is
✓ Complete separation of all the uterine layers
about 1-2%, while that following classical one is 5-
including serosa
10 times higher.
✓ Rupture of the membranes with
✓ Uterine scar, following operation on the non-
✓ Varying amount of bleeding from the margins or
pregnant uterus such as myomectomy or
from its extension
metropiasty hardly rupture.
✓ Uterine cavity and peritoneal cavity become
✓ Uterine scar following hysterotomy behaves like
continuous
that of a classical scar.
• During pregnancy :
❖ TYPES OF RUPTURE
➢ Classical cesarean or hysterotomy scar is likely to give
• The causes of rupture of the uterus are broadly
way during later months of pregnancy.
divided into:
• Lower segment scar rarely ruptures during pregnancy.

ARISE MEDICAL ACADEMY Dr. MIK | 76

 ➢ During labor : • Use of prostaglandins for induction of abortion or
➢ The classical or hysterotomy scar is more vulnerable labor
to rupture during labor. lower segment scar • Forcible external version specially under general
predominantly ruptures during labor, although rare anesthesia

➢ During labor.
• Internal podalic version—specially following
obstructed labor
• Destructive operation
• Manual removal of placenta
3.IATROGENIC OR TRAUMATIC • Application of forceps or breech extraction through
incompletely dilated cervix
➢ During pregnancy: • Injudicious administration of oxytocin for
• Injudicious administration of oxytocin augmentation of labor

---------------------------------------------------------------------------------------------------------------------------------------------------------------
✓ Mother will immediately go into shock and may die
on the labour table itself
❖ RECURRENCE RATES IN SCAR RUPTURE
✓ Classical : 2-9 % ❖ MORTALITY
✓ One low-transverse : 0.2-1.8 % ✓ With rupture and expulsion of the fetus into the
peritoneal cavity, the chances for intact fetal
❖ Clinical features of Ruptured Uterus survival are dismal
✓ Foetal Morality rates range from 50% to 75%.
➢ Impending Sear Rupture (Scar Dehiscence) ✓ Maternal mortality rates are very high,
✓ Unexplained maternal tachycardia emergency cesarean with caesarean
✓ Weak, thready & fast pulse hysterectomy are the only options
✓ Hypotension shock
✓ Fetal tachycardia
✓ Persistent fetal bradycardia
✓ Variable and late decels
✓ Uterine scar tenderness.
✓ Bleeding p/v SHOULDER DYSTOCIA
✓ Hematuria
➢ Definition
➢ Ruptured uterus • The term shoulder dystocia is used to define a wide
✓ Electronic fetal monitoring finding is sudden, severe range of difficulties encountered in the delivery of
heart rate decelerations that may evolve into late the shoulders.
decelerations, bradycardia, and undetectable fetal • A head to body delivery time exceeding 60 secs
heart action. defines shoulder dystocia
✓ In some cases in which the fetal presenting part has
entered the pelvis with labor, loss of station may be ➢ Risk factors:
detected by pelvic examination. • Shoulder dystocia can occur in all those conditions
✓ If the fetus is partly or totally extruded from the site where fetus is too big or in case of mismanaged
of uterine rupture, abdominal palpitation or vaginal labour.
examination may be helpful to identify the presenting • Maternal diabetes
part, which will have moved away from the pelvic • Maternal obesity and fetal obesity i.e macrosomia
inlet. • Post term pregnancy
✓ A firm contracted uterus may at times be felt • Anencephaly
alongside the fetus. • Fetal ascites

ARISE MEDICAL ACADEMY Dr. MIK | 77

❖ COMPLICATIONS
➢ MATERNAL
• Intrapartum chorioamnionitis, Laceration of birth
canal, Rupture uterus, Genital fistula, Urinary or anal
incontinence, Genital organ prolapse, PPH
➢ FOETAL
• Most common complication of shoulder dystocia is
Brachial plexis injury
• Death due to asphyxia
• Meconium aspiration syndrome
• Erb’s paralysis ( C5,C6, C7) adducted, internally ➢ 3rd Line
rotated and pronated arm • Cleidotomy (# clavicle of baby)
• Klumpke’s paralysis ( C8, T1) claw hand • Symphiosotomy (divide pubic symphysis of mother)
• Clavicle or Humerus # • Zavaneilli manouvre
• Sternocleidomastoid tumor (push head backand do cesarean)

❖ SHOULDER DYSTOCIA DRILL

• It is a series of events done in order to deliver a
shoulder dystocia

➢ McRoberts' manoeuvre

➢ 1st Line of management

• Stop giving fundal pressure
• Can give supra-pressure
• Best/most effective pubic pressure manouvre Mc
Roberts manouvre
(flexion and abduction of thigh)
➢ 2nd Line :Woods Corkscrew manouvre
• It consists of forcible abduction of patients legs by
sharply flexing them on the abdomen.
• It is the single most effective manoeuvre and should
be the first manoeuvre to be performed in case of
shoulder dystocia.
• McRobert's manoeuvre results in straightening of the
sacrum relative to the lumbar vertebra along with

ARISE MEDICAL ACADEMY Dr. MIK | 78

 rotation of symphysis pubis towards the maternal
head and it decreases the angle of pelvic inclination.
• Sometimes, over zealous use of McRobert's
manoeuvre may result in separation of the maternal
pubic symphysis and injury to lateral cutaneous
nerve of thigh.
❖ Partum Neuropathies
• Prolonged second stage of labour can injure the
Common Fibular Nerve caused by inappropriate leg
positioning in the stirrups
• M/C Nerve injury seen in post partum females =
✓ Lateral femoral Cutaneous nerve followed by
femoral nerve
✓ Nerve injuries seen with cesarean delivery
include iliohypogastric and ilioinguinal nerves.
Risk factors for neuropathy
✓ Nulliparity
✓ Prolonged second stage of labor
✓ Pushing for a long duration in the semi fowler position
OBSTRUCTED LABOUR
➢ DEFINITION
✓ Labour is said to be obstructed when despite
good uterine contractions, there is arrest of
progress due to mechanical factors causing
obstruction to delivery.
✓ The uterine contractions are normal ( power is
normal)
✓ There is a problem in passage or passenger
➢ Causes:
✓ Maternal:
• Contracted pelvis/CPD.
• Pelvic tumours like fibroids or ovarian tumours.
• Cervical dystocia due to previous scarring.
✓ Fetal:
• Malposition (persistent occipito-posterior or deep
transverse arrest).
• Malpresentations (neglected shoulder, brow or
persistent mentoposterior).
• Macrosomia.
• Fetal anomalies (hydrocephalus, fetal ascites and
abdominal tumours, conjoined twins).
❖ Clinical Features
➢ General examination:
• The mother is exhausted, dehydrated, febrile and
urine may show ketone bodies.
• Hematuria i.e., blood is present in urine
➢ Abdominal examination:
• Uterus may be tonically contracted over the fetus.
• Difficulty in palpating the fetal parts.
• Bandl's ring running obliquely over the uterus and
rising up.
• The upper and lower segments will be sharply
demarcated.
• Evidence of fetal distress/Fetal heart sounds are
usually absent.
➢ Vaginal examination:
• Vagina is usually hot and dry and there may be
offensive discharge
• Cervix is fully dilated and may be felt hanging loose.
• Membranes are absent
• Presenting part is usually jammed in pelvis.
• There may be hand prolapse in a neglected shoulder
presentation.
• In cephalic presentations, there will be a large caput
and irreducible moulding.
• So the lower pole may appear to be quite low even
when the major part of the head is above the pelvic
inlet and palpable per abdomen.
➢ BLADDER IN OBSTRUCTED LABOUR
• In obstructed labour the bladder becomes an
abdominal organ due to compression of urethra
between the presenting part and symphysis pubis
• The patient fails to empty the bladder.
ARISE MEDICAL ACADEMY Dr. MIK | 79
• The transverse depression at the junction of the
superior border of the bladder and the distended
lower segment is often confused with the Bandles
ring.
• The bladder wall gets traumatised which may lead to
blood stained urine, a common finding in obstructed
labour
• The bladder wall compressed between the foetal
head and pubic symphysis may undergo pressure
necrosis and lead to formation of VVF
✓ Though hematuria can also indicate impending
uterine rupture but for that obviously the patient
should have a previous scar
❖ Management Of Obstructed Labor
✓ Three main principles in ther are-
• Never wait and watch
• To control sepsis.
• Never use oxytocin.
✓ In case of obstructed labor there is a problem with
either the passage or the passenger bur the uterus
contracts adequately, so if we increase uterine
contractions by giving oxytocin it will lead to uterine
rupture.
➢ Management of obstructed labor-
• Management of dehydration- by giving i:v fluids
• Antibiotics are given to prevent infection
• Most important step is to relieve obstruction
➢ The mode of relieving obstruction is based on foetal
viability
✓ Viable foetus
• Immediate cesarean
✓ Dead foetus
• Perform a destructive procedure and relieve the
obstruction
• If the obstetrician is not well versed with destructive
procedures then immediate cesarean
• Immediate cesarean even in a dead baby because
even a dead baby causing obstruction can lead to
rupture or severe infections
❖ Bandl's ring
• It is also called as Pathological retraction ring.
• It is formed in cases of obstructed labour0.
➢ Pathophysiology :
• In case of obstructed labour, the upper segment of
the uterus contracts and retracts vigorously, in an
attempt to overcome the obstruction while the lower
segment dilates.
• With each contraction there is myometrial shortening,
so that the actively contracting upper segment
becomes progressively thicker and shorter.
• The passive lower segment is progressively stretched
and becomes thinner.
• The junction between the two segments stands out
prominently as a pathological retraction ring or
Bandl's ring.
• Situation: It runs obliquely and is always situated at
the junction of upper and lower segment.
➢ On abdominal examination:
• Uterus is tense and tender
• Fetal parts are not easily felt
• Ring is felt as a groove placed obliquely
• FHS is absent
• Round ligaments are palpable.
➢ On vaginal examination: Ring cannot be felt
vaginally.
❖ Schroeder's ring
• It is also called as constriction ring
• Constriction ring is a form of incoordinate uterine
action where there is localised spastic contraction of a
ring of circular muscle fibres ofthe uterus.
• Usually situated at the junction of the upper and lower
segment around neck in cephalic presentation.
• It forms a constriction through which the foetus cant
pass
➢ Management:
• If the ring is diagnosed at the time of cesarean
section: it should be cut vertically to deliver the baby.
• If there is failure to deliver the head even after
correct application of forceps: constriction ring
should be suspected and LSCS should be done.
• If the ring is diagnosed at the time of manual removal
of placenta, plane of anesthesia should be deepened.
ARISE MEDICAL ACADEMY Dr. MIK | 80
FEATURE RETRACTION RING CONSTRICTION RING
BANDL’S RING SCHROEDER’S RING

NATURE END RESULT OF TONIC CONTRACTIONS IN AN RESULT OF IN CO ORDINATE UTERINE

OBSTRUCTED LABOR CONTRACTION
CAUSE OBSTRUCTED LABOUR UNDUE IRRITABILITY AND IN CO ORDINATE
ACTIVITY
SITUATION BETWEEN UPPER AND LOWER SEGMENTS USUALLY BETWEEN UPPER AND LOWER
MOVES PROGRESSIVELY UPWARDS SEGMENTS
CAN BE FORMED ELSEWHERE
DOESN’T MOVE UPWARDS
UTERUS UPPER SEGMENT CONTRACTS AND RETRACTS UPPER SEGMENT TONICALLY CONTRACTED
WITH RELAXATION AND THICK
LOWER SEGMENT REMAINS THICK AND LOWER SEGMENT PROGRESSIVELY THINS OUT
LOOSE

GENERAL CONDITION EXHAUSTED, KETOTIC, DEHYDRATED AND GOOD

SEPTIC

P/A UTERUS TENSE & TENDER UTERUS NON TENDER

FOETAL PARTS NOT FELT FOETAL PARTS FELT
RING FELT AND MOVES UP RING NOT FELT
ROUND LIG. – TAUT AND FELT ROUND LIG. – NOT FELT
FHS ABSENT FHS PRESENT

P/V FEATURES OF OBSTRUCTION PRESENT FEATURES OF OBSTRUCTION

RING NOT FELT ABSENT
RING FELT

END RESULT BAD GOOD

CHAPTER – 15
ANTEPARTUM HAEMORRHAGE

ANTE PARTUM HAEMORRHAGE

• Ante partum haemorrhage is defined as bleeding ➢ CAUSES of Antepartum Hemorrhage
from or into the genital tract after foetal viability or • Placenta previa
upto viability • Abruptio placenta
• Viability is considered upto 28 weeks • Vasa previa
• Latest developments in obstetrics and neonatology • Circumvallate placenta
has lowered the cut off age to 22 weeks

ARISE MEDICAL ACADEMY Dr. MIK | 81

▪ Local causes like: Polyp, Carcinoma cervix, Varicose
veins, Trauma
• Unclassified or indeterminate
➢ GUIDELINES FOR ADEQUATE BLOOD
TRANSFUSION
• Maintainence of
• Central venous pressure at 10 cm of water.
• Hematocrit = 30%
• Urinary output = 30 ml/hour
• FOETAL AND MATERNAL BLOOD ADMIXTURES
✓ In ante partum haemorrhage the bleeding occurs per
vagina
• This bleeding could be from the uterine maternal
sinuses or from the foetus or both mixed in various
proportions
✓ In Rh incompatibility
• At the time of birth few foetal RBC’s enter maternal
circulation
• This leads to foeto maternal admixture
• In order to detect these and to differentiate foetal
blood from maternal blood the following tests are
done
➢ Alkali denaturation test
➢ Kleihauer Bhetke test
➢ Singers alkali denaturation test
• Also called as ‘Apt test’ or Apt Downey Test
• It was invented by a paediatric ophthalmologist
Leonard apt
--------------------------------------------------------------------------
VASA PREVIA
• It is a condition in which the fetal blood vessels
unsupported by either umbical cord or placental
tissue overlies the internal os and is vulnerable to
rupture when supporting membrane rupture.
• Thus bleeding in case of vasa previa is of fetal origin
and not maternal origin (unlike placenta previa and
abruptio)
✓ Principle:
• Fetal blood has fetal hemoglobin (HbF) and maternal
blood has adult hemoglobin (HbA). - HbF is resistant
to alkali denaturation (not HbA) - when KOH/NaOH is
added, it remains pink if blood is of fetal origin.
• If it is maternal blood it turns yellow brown in 2
minutes as HbA is denatured easily.
✓ Application
• Used to detect the presence or absence of fetal blood
(qualitative) in a vaginal discharge
• To detect the origin of a neonatal blood vomiting,
upper Gl hemorrhage or swallowed maternal blood
during delivery or from cracked nipple.
➢ Kleihauer Bhetke test
• It is a quantitative method of detecting how much
foetal blood has leaked into maternal circulation
✓ Principle
• A standard blood smear is prepared from the
mother's blood, and exposed to an acid bath.
• This removes adult hemoglobin, but not fetal
hemoglobin, from the red blood cells.
✓ Rationale
• When fetal blood needs to be differentiated from Apt
test is used (Qualitative estimation) maternal blood
• When the amount of fetal bleeding needs to be
estimated Kleihauer-Betke test is used (Quantitative
estimation)
• It is rare condition and occurs in 1 in 2000 - 3000
deliveries but is a dreaded condition
• Blood loss which occurs is fetal in origin and so there
is increased fetal mortality - (75 to 90%), maternal
mortality is not increased
✓ Vasa previa is associated with high fetal mortality
because
• Wharton's jelly is absent around the fetal vessels,
hence they can be easily lacerated at the time of
ARISE MEDICAL ACADEMY Dr. MIK | 82
 rupture of membranes leading to severe fetal • Emergency LSCS should be done if it is diagnosed
bleeding. intrapartum.
• Vessels can be easily compressed by the fetal
presenting part during uterine contractions leading to
fetal exsanguination.

✓ Vasa previa should be suspected if

• Velamentous cord insertion
• Bilobed placenta
• Succenturiate lobed placenta
• Placenta previa /low lying placenta in second
trimester ➢ Circumvallate placenta
• Pregnancy resulting from IVF
• Multiple pregnancies • It is an uncommon cause of antepartum hemorrhage,
• In this condition, the chorionic plate which is on the
fetal side of the placenta is smaller than the basal
plate on the maternal side.
• The fetal surface of the placenta presents a central
depression surrounded by a thickened grayish white
ring.
• These pregnancies may be complicated by IUGR and
an increased chance of fetal malformations.
• Bleeding is usually painless
• Antenatal diagnosis is unlikely and the diagnosis is
usually made after examination of the placenta post
delivery

✓ Diagnosis

o Antenatal
• Doppler examination can also reveal fetal blood
vessels traversing below the presenting part

o Intra partum
• In all cases of antepartum and intrapartum
hemorrhage, the possibility of vasa previa should be
kept in mind and blood should be tested for fetal
hemoglobin characterized by resistance to
denaturation by alkaline reagent (Singer alkali
denaturation test/Apt test)
• When bleeding occurs: Sinusoidal fetal heart rate
pattern seen
DIC – DISSEMINATED INTRAVASCULAR
COAGULOPATHY
• Management-
• In a diagnosed case of vasa previa elective cesarean
section should be done

ARISE MEDICAL ACADEMY Dr. MIK | 83

• It is a pathological condition associated with
inappropriate activation of coagulation and
fibrinolytic system.
• This leads to coagulation inside the blood vessels
• This extensive coagulation all over the body leads to
usage (consumption) of platelets and all clotting
factors
• Hence the platelet and coagulation factor deficiency
leads to bleeding tendencies, haemorrhages and
death
• It is secondary phenomenon resulting from an
underlying disease state.
• Several system disease can lead to DIC but obstetric
diseases have special predisposition to DIC
OBSTETRIC CAUSES OF DIC
➢ More common - Intrauterine fetal death, Amniotic
fluid embolism, Pre eclampsia- Eclampsia, HELLP
syndrome, Placenta Abruption, Septic Abortion
➢ Less common
• Chorioamnionitis, Pyelonephritis in pregnancy, H.
mole, Instillation of intraamniotic hypertonic saline,
Feto maternal bleed, Incompatible blood transfusion,
Viremia -HIV, varicella, CMV hepatitis
PATHOGENESIS
➢ Endothelial injury is the inciting factor which leads to
tissue distruction
• Damaged tissue releases thromboplastin
• This thromboplastin acts as factor III and activates the
coagulation cascade
• The activated cascade then causes deposition of fibrin
and platelets onto the vessel lumen
• This leads to consumption of all platelets and clotting
factors
• Deposition of fibrin in vessels leads to microvascular
occlusion which can further lead to ischemia of
several organs firstly kidney
• The fibrin activates anti fibrinolytic pathways leading
to conversion of plasminogen to plasmin
• Plasmin then degrades fibrin to form fibrin
degradation products (FDP’s)
• These FDP’s cause further bleeding
LABORATORY FINDINGS IN DIC
✓ Pathological findings
• The platelet count is low.
• Blood film shows the features of microangiopathic
hemolytic anaemia.
• There is presence of schistocytes and fragmented red
cells (helmet shaped)
• These fragmented cells are formed due to damage
caused by trapping and passage through the fibrin
thrombi.
✓ Biochemical findings
• Prothrombin Time (PT) elevated to 11 – 16 secs
(N is 12 – 13 secs)
• Activated Partial Thromboplastin Time aPTT is
prolonged to > 40 secs
(N is 22 – 37 secs)
• Plasma fibrinogen levels are reduced < 200mg/dl
(N is 200 – 400 mg/dl)
• Fibrin degradation products (FDPs) are raised
(N is < 10 mcg/dl)
• D-dimer levels are raised (N is < 0.5 mcg/dl)
• Platelets are reduced (N is 1.5 – 3.5 lakh / cumm)
AMNIOTIC FLUID EMBOLISM
➢ It occurs due to sudden entry of amniotic fluid into
systemic circulation
➢ Onset
• It usually may present on the labour table when the
patient is at the height of uterine contraction
• It is usually fatal and is characterised by an abrupt
onset of respiratory distress and coagulopathy.
• It should be considered in all cases of peripartum
collapse.
• Classically a woman in late labor or immediate
postpartum gasps for air, has bronchospasm,
becomes cyanotic and undergoes immediate collapse
and cardiorespiratory arrest usually accompanied by
haemorrhage
• Sudden death is usual.
➢ Timing:
• After ARM and at cesarean section.
ARISE MEDICAL ACADEMY Dr. MIK | 84
• In labor with strong uterine contractions. • Deliver foetus immeditely to avoid cord compression
• Immediate postpartum. and distress

➢ Pathogenesis • Named classifications and Regimes

• Embolic component causes acute respiratory distress
syndrome and ultimately death. ➢ Macaffee and Johnson Regime
• Coagulation failure causes hemorrhage, DIC and • Expectant management of placement previa
consumptive coagulopathy. ➢ Page classification
• Abruptio plcenta
➢ Risk factors: ➢ Sher classification
• Advanced maternal age • abruption placenta
• Multiparity
• Tetanic uterine contraction ➢ Clarke's classification
• Use of uterine stimulants • Classification of heart disease based on
maternal mortality
• Uterine rupture
➢ Lytic cocktail regime (used 3 drugs -
• Cesarean section chlorpromazine, Promethazine and pethidine)
• Premature separation of placenta • Proposed by Menon for management of
• Intra uterine fetal death. convulsion in eclampsia
• Amniotic fluid enters maternal circulation as a result ➢ Whites classification
of breech in the physiological barrier that normally • Earlier used for classification of diabetes in
exists between maternal and fetal compartments pregnancy
zso, any cause leading to this mixing like cesarean ➢ Caldwell and mohoy classification
section, premature separation of placenta, rupture • Types of pelvis
uterus etc predisposes to amniotic fluid embolism.

➢ Management
• Aimed at minimizing hypoxemia with supplemental
oxygen, mantaining blood pressure and managing
associated coagulopathy
PLACENTA PREVIA ➢ Type 4 Central Placenta covers the internal os even
when fully dilated
➢ Definition
• Placentra praevia is defined as a placenta located
partly or completely in the lower uterine segment.
The bleeding
• It is called inevitable or unavoidable haemorrhage as
dilatation of the internal os inevitably results in
haemorrhage.

➢ Browne's classification for placenta previa

➢ Type 1 Lateral Placenta-dipping into the lower
segment but not reaching uptothe os
➢ Type 2 Marginal Placental edge reaches the internal
Os • Incidence of placenta previa ranges from 0.5 to 1%
➢ Type 3 Incomplete central Placenta covers the among hospital deliveries.
internal os when closed, but not when fully dilated • According to 2003 birth certificate data in the US,
placenta previa complicated almost 1 in 300 deliveries

ARISE MEDICAL ACADEMY Dr. MIK | 85

• Type 1 and 2 are called minor degrees and type 3 and
4 called major degrees of placenta previa.
• Type 1 and 2 can be anterior or posterior.
➢ Dangerous type
Type 2 posterior placenta is also called the 'dangerous
type' as it is more likely to be compressed producing
cord compression.
This can cause fetal asphyxia and even death.
➢ Risk Factors
• Previous history of placenta previa (12 times more
risk)-most important risk factor.
• Multiparity and increased maternal age
• H/O any previous uterine surgery (4 time more risk)
• Previous uterine currettage
• Increased placental size as in multifetal pregnancy
• Succenturiate lobe
• Smoking (due to defective decidual vascularisation) -
two fold times
• Elevated prenatal maternal serum alpha fetoprotein
levels (unexplained)
CONTRACEPTION AND PREVIA
• Increased family planning acceptance with limitation
and spacing of birth, lowers the incidence of placenta
previa.
• Hence previa is less in the developed world
Clinical Features
➢ SYMPTOMS
• The classical presentation is painless antepartum
haemorrhage.
• The typical history is of the woman waking up lying in
a pool of blood.
• The bleeding is usually massive in amounts
➢ SIGNS
• Pallor, if present, will be proportionate to the amount
of bleeding (cf abruptio)
• Size of the uterus corresponds to the period of
amenorrhoea. (cf abruptio)
• Uterus is soft and non tender. (cf abruptio)
• Malpresentations are common and if it is a cephalic
presentation, the head if usually floating.
• Fetal heart sounds will usually be heard (c.f.
abruption).
• Slowing of the fetal heart rate on pressing the head
down into the pelvis and prompt recovery on release
of the pressure is termed Stallworthy's sign and is
suggestive of posterior placenta previa.
• VAGINAL EXAMINATION SHOULD NOT BE DONE IN
SUSPECTED PLACENTA PREVIA
➢ P/V in placenta previa
• In placenta previa P/V examination is contraindicated
since the finger passes beyond the internal os inorder
to know the exact location of the placenta
• This in turn can lead to more separation of the
placenta and cause torrential haemorrhage
➢ Stallworthy's sign:
• Slowing of the fetal heart rate on pressing the head
down into the pelvis and prompt recovery upon
release of the pressure is termed
• It is suggestive of posterior placenta previa.
• Presence of this sign is not always significant because
it may be due to fetal head compression even in an
other normal case.
INVESTIGATIVE WORK UP
➢ Investigation of choice: TVS
• Though P/V examination is contraindicated TVS is safe
- the probe never touches the cervix or maximally is
kept in the cervical canal
➢ Double set up examination
• This refers to the P/V examination in the operation
theatre with all arrangements of cesarean section
• These days the need for double set up has decreased
as the placental location can always be ascertained
sonographically.
• This is a more bookish approach wherein if the margin
of placenta is beyond 2cm from internal os then a
vaginal delivery can be attempted
➢ Avoid double set up examination in
• Double set up should be avoided in those patients
where there is an emergency so no point in wasting
time to know the type of placenta previa by vaginal
ARISE MEDICAL ACADEMY Dr. MIK | 86
 examination and taking the risk of occurrence of brisk • Patient is admitted for the rest of the pregnancy
hemorrhage • Complete bed rest with only bathroom previledges
• These conditions mandate cesarean section • Periodic inspection of vulval pads
• Avoid a P/v even in OT • Correct anaemia if any by blood transfusion
• Inj betamethasone is given to hasten the lung
maturity of the fetus
• Blood is crossmatched and kept ready just in case
patient starts bleeding again
• Tocolysis if bleed is associated with uterine
contractions
MANAGEMENT • Should be continued till 37 weeks only and not
beyond that even if all the criteria are met
There are two types of management for placenta previa • If anytime during expectant management patient
based on certain criteria rebleeds, pregnancy should be terminated
They are: immediately with out foetal concerns
➢ Expectant management • Anti D injection to all Rh –ve patients
➢ Active management

▪ The most important guiding principle is when the ➢ Active management

mother’s life is at risk don’t think about saving the
baby
➢ Expectant management
• It is called as Macaffee and Johnson regime
➢ Goal
• To carry pregnancy till term without putting mother’s
life at risk with an aim to achieve fetal lung maturity.
➢ Indications
• No active bleeding present
• Hemodynamically stable and haematocrit > 30%
• Gestation age <37 weeks
• CTG-should be reactive
• No fetal anomaly on USG
• Co operative or educated patient with supportive
family
➢ Pre requisites for Macafee
• 24 hours blood bank services with readily available
blood (kept cross matched for the patient)
• Round the clock surgical obstetrician to immediately
perform cesarean section and terminate the
pregnancy if required
• Round the clock anaesthetist and operative OT’s
• Possible only for co – operative patients
Protocol:
➢ Goal: To terminate pregnancy immediately
irrespective of gestational age to save the mother
Baby is not of prime concern
➢ Indications
• If active bleeding is present
• Hemodynamically unstable/shock
• Gestational age >37 weeks and patient in labour
• Fetal distress present/ FHS absent
• USG shows fetal anomaly or dead fetus
➢ Mode of delivery
• Mode of delivery practically in all patients of placenta
previa is -Cesarean section
• Earlier it was said that for minor degrees of placenta
previa, vaginal delivery can be tried
• Presently irrespective of degree of placenta previa,
cesarean section is done and recommended.
COMPLICATIONS OF PREVIA
➢ Maternal
• Antepartum haemorrhge, Intrapartum hemorrhage,
Postpartum haemorrhage, Malpresentation, Cord
prolapsed, Retained placenta, Preterm labour,
Premature rupture of membranes, Slow dilatation of
cervix

ARISE MEDICAL ACADEMY Dr. MIK | 87

➢ Fetal
• Asphyxia, Birth injuries, Low birth weight, Congenital
malformation, Intrauterine death, M/C fetal
complication of placenta previa: Low birth weight
baby

➢ Placenta previa and PPH

• A major problem with placenta previa, is that after
delivery of fetus, it leads to PPH as bleeding occurs
from the placenta site.
• There is a greater chance to bleed from the lower
segment because it is deficient in muscles and the
muscles in this segment lack power hence it is more
difficult for natural ligatures to be applied
• This should be managed like PPH & if all conservative
measures fail-hysterectomy is done.
➢ Concealed
In this the bood gets collected behind the placenta and
forms the retro placental clot
Sometimes it may be due to collection between the
decidua and membranes but it can’t present at vagina
because the presenting part is firmly pressed over the
cervix

➢ Placenta previa and placenta accreta are M/C causes

of peripartum hysterectomy.

➢ Placenta previa and placenta accreta

• These both conditions are neither the cause or effect
of each other
• But they are related because
• Placenta previa is implantation in lower uterine
segment ➢ Mixed
In this type it is partly revealed and partly retroplacenta
• Placenta accreta is more common in lower uterine
segment due to poor decidual reaction
• Hence they are both related by ‘lower uteruine
segment’

ABRUPTIO PLACENTA

➢ Definition
• Abruptio placenta is defined as haemorrhage
occurring in pregnancy due to the separation of a
normally situated placenta.
➢ Risk Factors
• It is also called accidental haemorrhage or premature
• The risk factors usually are not diagnosable at the
separation of placenta.
time of presentation

➢ Types of abruption
➢ Usual risk factors are
• Hypertension (most important predisposing factor)
➢ Revealed
• High birth orders (> 5) – three times more than in
In this type the blood seeps between the decidua and the
primi
membranes to present at the vagina

ARISE MEDICAL ACADEMY Dr. MIK | 88

• History of previous abruption (5 – 17 % recurrence)
• Advanced age of mother, Low socio economic areas
• Maternal malnutrition, Maternal smoking

➢ Other causes include

• External trauma, Sudden decompression of uterus,
Short cord, Supine hypotension syndrome,
Circumvallate placenta, Sick placenta, Uterine
myomas, Torsion uterus, Cocaine abuse,
Thrombophilias, Folic acid deficiency

➢Pre eclapsia and abruption

• Pre eclampsia causes spasm of the vessels in the
utero placental bed (decidual spiral artery) - anoxic
endothelial damage - leads to bleeding from the
damaged vessel - collects as blood beneath the
placenta and clots (retroplacental clot)

Couvelaire Uterus
• It is also called as utero placental apoplexy
• It occurs due to massive extravasation of blood into
the myometrium upto the serosa - Spreads from the
cornua - May spread to broad ligament (haematoma)
• Uterus appears as dark port wine discoloration diffuse
or patchy - petechial haemorrhages appear beneath
the peritoneal layer
• Blood may spill in the peritoneal cavity
• The only diagnosis is laprotomy
• Conservatively managed with regular coagulation
screening
• If bleeding is not controlled hysterectomy
➢ Incidence
• It is 1: 200, It is less than previa
• Accounts for 5 % maternal mortality and 20%
perinatal mortality
CLINICAL FEATURES
➢ Symptoms
➢ Severe and constant abdominal pain
Bleeding is present in the revealed and mixed types, but
may be absent in the concealed type
More in the concealed and less in the revealed types
➢ Bleeding per vaginum.
➢ Loss of fetal movements.

➢ Signs
➢ Pallor, which is usually out of proportion to the extent
of bleeding especially is conceled and mixed
➢ Hypertension (if there is associated pre-eclampsia)
➢ The uterus will be larger than expected for the period
of amenorrhoea especially in concealed and mixed
➢ Uterus may be tense and tender and even rigid
(woody hard) - couvelaire uterus
➢ Difficulty in palpating the underlying fetal parts easily
➢ Fetal distress or absent fetal heart sound

ARISE MEDICAL ACADEMY Dr. MIK | 89

 • Haematocrit and Hb%
COMPLICATIONS
➢ Ultra sonography
➢ Maternal
• The complications in revealed variety is usually • Early bleed presents as hyperechoic or isoechoic
proportionate to the amount of blood lost, • Concealed variety presents as a retroplacental blood
complications are less, less severe and death is rare clot
• The complications in concealed are out of • Abruption may be diagnosed on USG as a diagnosis of
proportionate to blood loss, complications are more, exclusion
more dangerous and permanent morbidity or
➢ Coagulation profile
mortality is common
• Of DIC

➢ The complications are ➢ Warnings:

• Haemorrhage, Maternal shock, DIC, Oliguria and
anuria, Post partum haemorrhage, Puerperal sepsis,
Sheehan’s syndrome
➢ Foetal
• Foetal death is very common with abruption
• In revealed variety it is 25 – 30%
• In concealed variety it is 50 – 100%
• Death is due to anoxia or sometimes due to
prematurity (delivered alive at an earlier date)
INVESTIGATIVE WORK UP
➢ The most important investigations are
• Ultra sonography
• Coagulation profile
• Never give tocolytics in patients of abruptio
➢ Mode of Termination
– Fetus dead
• Vaginal delivery without wasting time (ARM +
oxytovin)
• LSCS if there is the presence of severe torrential bleed
not controlled even by massive blood transfusions
and other indicative obstetrical factor.
– Fetus living
• Fetal distress present – LSCS without wasting time
• No fetal distress and vaginal delivery is obstetrically
possible - vaginal delivery without wasting time (ARM
+ oxytocin)

CHAPTER – 16
COMPLICATIONS OF THE THIRD STAGE

POST PARTUM HAEMORRHAGE ✓ Quantitative definition

• As the word suggests PPH is the haemorrhage or
bleeding after birth of the baby
• It is usually referred to the bleeding in anytime after
the second stage of labour
• The most common of rapid death in obstetrics is PPH
• In PPH we can lose a patient within minutes
• In India PPH is the largest contributor to maternal
mortality rate
• It is the most dreaded labour complication
➢ The Definitions
• Post Partum Hemorrhage (PPH) is blood loss of more
than 500 ml from the genital tract following child
birth
• Major PPH: blood loss more than 1000ml
✓ Operational definition
• PPH is the amount of bleeding sufficient enough to
cause a considerable fall in BP and an appreciable rise
in heart rate
✓ According to ACOG
• PPH is defined as a drop in hematocrit of 10%.

ARISE MEDICAL ACADEMY Dr. MIK | 90

Types of PPH Traumatic PPH

➢ Primary PPH • Genital tract injuries like, lacerations of the cervix,

• Hemorrhage occurring within 24 hours following child vagina, perineum, Colporrhexis and Rupture uterus
birth • It occurs due to
• Most common cause: Atonic PPH • Instrumental delivery

➢ Secondary PPH
• Vaginal birth after cesarean

• Hemorrhage occurring after 24 hours and upto 6 • Face to pubis delivery

weeks postpartum • Precipitate labour
• Most common cause: Retained placenta • Macrosomia
• Mismanaged labour / improper surgical skills and
inexperienced hands
➢ Causes of PPH:
✓ Atonic PPH (Tone) Coagulation Defects
✓ Traumatic PPH (Trauma)
✓ Coagulopathy (Thrombin) • Disseminated intravascular coagulation (DIC) and
hypofibrinogenemia are rare causes of PPH
✓ Retained placenta / membranes (Tissue)
• It occurs due to
• Abruption
Atonic PPH • Sepsis
• Intrauterine death
• It is the most common cause of primary PPH • Severe preeclampsia
accounting for 90% of cases. • HELLP syndrome
• The bleeding occurs as the blood vessels are not
obliterated by contraction and retraction of uterine Retained products of conception
muscle fibres
• All the products of conception relate to the
o The causes of atonicity are connection between the foetus and mother
• Grand multipara • All these are supposed to be expelled outside
• Malnutrition/Anemia • If any of these products remain attached to uterus it
• Previous H/o atonic PPH causes bledding (from uterine maternal blood
• Antepartum hemorrhage sinuses)
• Overdistended uterus due to multiple pregnancy, • It may occur due to
hydramnios and macrosomia • Morbidly adherent placenta
• Uterine malformations or fibroid uterus • Retained placenta
• Precipitate labour and prolonged labour • Succenturiate lobe of placenta
• Mismanaged third stage of labour • A big clot of blood covering the placental site
• Inadvertent use of oxytocin
• Use of general / epidural anaesthesia especially MANAGEMENT OF PPH
halothane
➢ Primary PPH
• Step 1 – resuscitative, investigative and immediate
management of cause
• Step 2 – medical methods
• Step 3 – mechanical methods

ARISE MEDICAL ACADEMY Dr. MIK | 91

• Step 4 – surgical methods
➢ Secondary PPH
• D and C
Step 1: General Measures
• Including Resuscitative Measures + Investigations +
Confirmation of Diagnosis
• The first and basic step in the management of PPH is
resuscitation of the patient which includes:
• Securing I/V lines
• Volume restoration by crystalloids (normal saline/
Ringer lactate)
• Oxygen inhalation
• Crossmatching and arranging for blood.
• The Cause of PPH i.e., whether it is atonic (diagnosed
by abdominal palpation) or traumatic should be
looked and managed accordingly.
• At the same time investigations like Blood group,
Hemoglobin, plotting time, Coagulation profile,
Electrolytes should be sent
• When diagnosis of Atonic PPH is confirmed - Uterus
should be massaged continuously and medical
methods should be adopted.
• When diagnosis of traumatic PPH is confirmed –
immediately try to stop the bleeding by repairing the
defect
• When diagnosis is retained placenta immediately
send for an anaesthetist and OT
• When diagnosis is a coagulative disorder immediately
order for FFP and blood
➢ acute management of PPH
• a 'rule of 30' has been proposed.
• If the patient's
✓ systolic blood pressure (SBP) falls by 30 mm Hg
✓ heart rate (HR) rises by 30 beats/min
✓ respiratory rate increases to >30 breaths/min
✓ haemoglobin or haematocrit drop by 30%
✓ urine output is < 30 ml/hour, then
• the patient is most likely to have lost at least 30%
of her blood volume and is in moderate shock
leading to severe shock
• The use of the 'shock index' (SI) is invaluable in the
monitoring and management of women with PPH.
• It refers to heart rate divided by the systolic BP.
• The normal value is 0.5-0.7 (80 / 120 = 0.6)
• With significant haemorrhage, it increases to 0.9-1.1.
• The change in SI of an individual patient appears to
correlate better in identifying early acute blood lost
• It is better than monitoring HR, SBP or diastolic blood
pressure used in isolation.
Step 2: Medical management
• Atonicity is the most common cause of PPH
• Any drug which increases the tone of uterus or the
force of contraction is used to control PPH and is
called oxytocic.
• Commonly used oxytocics in the management of PPH
are
✓ Oxytocin
✓ Methergin
✓ Misoprost (PG E1)
✓ Carboprost (PG F2α)
✓ Oxytocin
• Immediately start RL or NS through two wide bore iv
cannular on both hands
• Add 20 units in both the iv fluids and give slow
infusion, never give bolus
• Other routes: im
• Side effects: nausea, water intoxication
• Warning: never give bolus oxytocin
• It is a drugs used for prevention and treatment of PPH
➢ Oxytocin pharmacology
• It is a nonapeptide (Peptide of nine amino acids).
• Released by posterior pituitary and synthesized in the
supra optic and paraventricular nucleus of
hypothalamus
• Half life 3-4 mins.
• Mechanism of action - Acts through calcium
mediated channels to initiate myometrial
contractions
✓ Methergin
ARISE MEDICAL ACADEMY Dr. MIK | 92
• Injection methergin 0.2 mg is given im stat and can be
repeated every 2- 4 hours if required
• Other routes: iv and im
• Side effects: Nausea, vomiting and hypertension
✓ Misoprostol
• Available as 200mcg tablets
• Place 1000 mcg or 4 – 5 tablets P/R stat
• Other routes – po
• Side effects: fever and tachycardia
✓ 15 methyl PG F2α
• Injetion carboprost 0.25 mg or 250 units given im can
be repeated every 15-90 mins to a maximum of 8
doses
• Other routes: intra myometrial
• Side effects: Nausea, vomitings, chills and diarrhoea
• Warning: never give to patient with bronchial asthma
or active cardiac, renal or hepatic disease
Step 3: Mechanical methods
• When medical methods fail to control PPH the
following mechanical methods are adopted:
• Bimanual compression
• Uterine packing under anesthesia
• Balloon tamponade with a sengstaken tube inserted
into the uterus.
• Shivkars pack i.e condom inflated with saline can also
be used as a tamponade.
Step 4: Surgical methods
• When all other methods fail - Surgical intervention
should be carried.
• The choice of surgery is dictated by the condition of
the patient and her family status
✓ If Family is not completed
• Application of B lynch sutures
• Radiographic embolization of pelvic vesels
• Uterine and ovarian artery ligation
• Internal iliac artery ligation
• If these methods fail then hysterectomy is done as
final resort.
• Warning: never give to a hypertensive or cardiac
patient and in pre eclamptics /eclamptics
--------------------------------------------------
✓ Family is completed
• Hysterectomy
UTERINE INVERSION
• Uterine inversion is a condition in which there is
inside out turning of the uterus.
• It is a rare cause of postpartum collapse but collapse
occurs suddenly after labour.
• It is acute in onset.
• Mostly uterine inversion is complete i.e. of third
degree
➢ Aetiology
• Mismanagement of the third stage (M/C cause) -
Attempting to deliver a placenta by cord traction that
has not yet separated
• Spontaneous inversion can occur with an atonic
uterus (in 40% cases).
• Placenta accreta is a rare cause.
➢ Clinical Features
• Patient present with shock and hemorrhage
• degree of shock being out of proportion to the
amount of bleeding (due to vagal shock)
• Bleeding is due to attempts to detach the placenta
before correcting the inversion.
• Vaginal examination reveals a soft, globular swelling
in the vagina or cervical canal.
• On abdominal palpation, the fundus of the uterus is
felt to be absent
➢ Complications
• Neurogenic shock
ARISE MEDICAL ACADEMY Dr. MIK | 93
• Hemorrhage
• Pulmonary embolism ➢ Classification/Variants
• Uterine sepsis and subinvolution • Placenta accreta - chorionic villi are attached to the
superficial myometrium (< 50%)
➢ Management • Placenta increta - villi invade the myometrium (> 50
• Resuscitation and replacement of inverted uterus %)
should be done simultaneously. • Placenta percreta - villi penetrate the full thickness
✓ Manual replacement or Johnsons maneuver myometrium up to the serosal layer, sometimes also
involving the bladder and rectum
• Best step if diagnosis is made immediately.
• The part which comes out first i.e fundus should be ➢ Risk Factors
last to reposited
• Placenta previa in present pregnancy, History of
• After replacing oxytocics should be given to promote operative interferences, Previous cesarean section,
contraction. This is called as! Previous curettage, Previous manual removal,
Previously treated Ashermann syndrome,
✓ Hydrostatic or O’ sullivan method Synechiolysis, Myomectomy, Multiparity, Advanced
• Warm saline is run into vagina with labia apposed to maternal age > 35 years
prevent leakage.
• The vagina ballons with the fluid and the inversion ➢ Diagnosis (intra partum)
corrects on its own. • Presents as retained placenta
• during attempted manual removal of placenta the
diagnosis is made
• It is made when the plane of cleavage between the
• SUDDEN POST PARTUM COLLAPSE placenta and uterine wall cannot be made out.
➢ The causes are
• Amniotic fluid embolism ➢ Diagnosis (ante partum)
• PPH ✓ Transvaginal sonography - absence of the
subplacental sonoluscent zone (which represents the
• Uterine inversion
normal decidua basalis) indicates a placenta accreta.
• Eclampsia. ✓ Doppler imaging-shows
RETAINED PLACENTA • A distance less than 1mm between the uterine
serosal bladder interface and retroplacental vessels.
• Retained placenta is defined as failure of the placenta • Presence of large intraplacental lakes.
to be expelled within 30 min of delivery of the fetus.
➢ Complications
➢ Morbidly Adherent Placenta • Antepartum haemorrhage (due to associated placenta
• A condition wherein the placenta is firmly adherent to previa) and Uterine rupture before labour (due to
the uterine wall and doesn’t separate during the third myometrial invasion by placental villia at the site of
stage previous C.S. scar.
• Postpartum haemorrhage
✓ Pathological Findings • Infection
• Absence of decidua basalis or improper decidua • Inversion of uterus (rare).
basalis formation
• Absence of Nitabuch's fibrinoid layer ➢ Management
• The trophoblasts completely invade the endometrium
and have the potential to invade the myometrium ✓ Complete Morbid Adherent Placenta
o If female has completed her family

ARISE MEDICAL ACADEMY Dr. MIK | 94

• Hysterectomy
o If has not completed her family
• Cut the umblical cord as high as possible and leave
the placenta as such.
CHAPTER – 17
MULTIFETAL GESTATION
• It is defined as simultaneous development of more
than one foetus in the uterus
• Two Foetuses – Twins, Three Foetuses – Triplets Four
Foetuses – Quadruplets, Five Foetuses – Quintuplets,
Six Foetuses - Sextuplets
INCIDENCE
➢ According to Hellin's rule
• The mathematical frequency of multiple pregnancy is:
• Twins 1 in 80
• Triplets 1 in (80)2
• Quadruplets 1 in (80)3 and so on
• The incidence of twins is highest in Nigeria (1 in 20)
• It is lowest in far Eastern countries
• Incidence in India - 1 in 80.
• Incidence of twins is increasing in India because of the
use of ovulation inducing drugs like clomiphene and
gonadotropins
ZYGOSITY OF TWINS
• Twin pregnancy can be Dizygotic (binovular) or
monozygotic (uniovular)
✓ Dizygotic / binovular twins refer to release of 2 ova
and their fertilisation by 2 sperms leading to the
formation of 2 zygotes (hence DI ZYGOTIC)
✓ Monozygotic / uniovular twinning occurs due to
fertilisation of 1 ovum by a 1 sperm leading to
formation of 1 zygote but then followed by fission of
single fertilized ovum leading to formation of two
‘cell’ groups
• Each ‘cell’ group develops into an embryo
• The patient should be given antibiotics and
methotrexate in hope of autolysis.
• Monitor βhCG levels
✓ Placenta increta and percreta are treated by
hysterectomy alone
DIZYGOTIC TWINS
• Dizygotic twins are more frequent than monozygotic
twins (3:1).
• They are also called as non identical twins
• They are formed from different ova and sperm so
they are 2 different individuals
• They may be of the same sex or opposite sexes
• They are not identical but ‘may’ show a degree of
resemblance no more than that of brothers and
sisters from different births
• This is the reason they can be called as "fraternal
twins".
MONOZYGOTIC TWINS
• It is less common than binovular twins 25% of all twin
births
• These twins are formed from the same ova and sperm
hence are genetically similar
• They are hence called identical twins
• Monozygotic / uniovular twins are always of the same
sex and are identical in appearance, resembling each
other both physically and mentally
• They also show the same pathological tendencies.
CHORIONICITY AND AMNIONICITY OF TWINS
• After fertilisation the zygote forms the morula which
then forms the blastocyst
• The blastocyst has an outer cell mass / trophoblast
which forms the placenta
• From the inner cell mass develops the whole body of
the baby and the amnion
• Chorion development occurs before amnion
development
ARISE MEDICAL ACADEMY Dr. MIK | 95
 • Monochorionic Diamniotic
➢ IN DIZYGOTIC TWINS
• As they develop from two distinct embryos they have
two different chorions and amnions
• Dichorionic Diamniotic Dizygous twins

➢ IN MONO ZYGOTIC TWINS

• Development of chorion and amnion in monozygotic
twins is not that simple
• It is dependent upon the time at which the fission
occurs
• For our convineance we shall study them as
✓ before 3rd day of life
✓ 4th to 8th day of life ➢ After the 8th day
✓ After 8th day of life • By this time both the chorion and amnion are
✓ After 14th day of life formed
➢ Before 3rd DOL • Hence there is a single chorion (mono
• The fission occurs before the third day chorionic) and 1 placenta and a single amnion
• The outer cell mass is formed after the fission (mono amniotic)
hence there are 2 outer cell mass ie. 2 chorions • Monochorionic Monoamniotic
(dichorionic) and hence 2 placentas
• Later the amniotic cavity is formed hence each
developing ovum forms it’s own amnion ie 2
amnions (di amniotic)
• Dichorionic Diamniotic

➢ After 14th day

➢ 4th to 8th day of life
• If the fission is occuring after the 3rd day (when
the outer cell mass is being formed), the outer
cell mass which is already formed can not
divide later hence it has 1 chorion (mono
amniotic) and one placenta
• The amniotic cavity doesn’t form before the 8th
day hence there is formation of 2 amniotic
cavities (di amniotic)
• By this time the germ disc is also formed hence any
fission after this will lead to conjoined twins ie they
share similar body parts
• It is also called as Siamese twins
CHORIONICITY AND CLINICAL IMPLICATION
• Dichorionic twins, whether monozygous or dizygous,
develop as two distinct individuals and are hence not
at increased risk of complications.
• Monochorionic twins are at increased risk because of
the vascular anastomosis between the two
circulations.

ARISE MEDICAL ACADEMY Dr. MIK | 96

 • Chorionicity can be detected prenatally by ultrasound.
(Best time - 6 to 9 weeks of gestation). ➢ Fetal papyraceous or compressus
• It is a state which occurs if one of the fetus dies early -
TERMINOLOGY dead fetus is compressed between the membranes of
the living fetus and the uterine wall.
➢ Superfecundation
• It is the fertilization of two different ova released in ➢ Fetal acardiacus
the same cycle, by separate acts of coitus within a • Here one fetus does not possess a heart and the
short period of time. development of upper part of the body is almost
absent - normal twin is called "pump twin".
➢ Superfetation • It occurs only in monozygotic twin
• It is the fertilization of two ova released in different
menstrual cycles.
• This is theoretically possible until the decidual space is
obliterated by 12 weeks of pregnancy.
Terminology Feature

THORACOPHAGUS TWINS JOINED IN REGION OF THORAX

( COMMONEST)
ISCHIOPHAGUS TWINS JOINED IN THE REGION OF PELVIS
PYOPAGUS TWINS JOINED IN THE REGION OF BACK
CRANIOPAGUS TWINS JOINED THE REGION OF HEAD
DICEPHALUS DOUBLE HEADED MONSTERS IN WHICH THE LOWER PARTS ARE MORE OR LESS
FUSED INTO ONE.
SYNCEPHALUS SINGLE HEADED MONSTER WHICH SHOW DUPLICATION OF THE LOWER LIMB
AND SOME TIMES OF THE LOWER PART OF THE TRUNK.

➢ Route of delivery:

OBSTETRIC PRESENTATIONS IN TWINS ✓ In case of discordant growth vaginal delivery is

➢ LIE indicated if:
• In twins most common lie of both the fetus at term is • Cervix is ripe
longitudinal. • Presentation is vertex / vertex
• Rarest lie is both the twins transverse. • Weight of smaller twin is > 1500gms

➢ PRESENTATIONS TWIN TO TWIN TRANSFUSION SYNDROME (TTTS)

• Both vertex (Most common) 60%
• Vertex (1ST) - Breech (2ND) 20% • It is always seen in monochorionic placenta.
• Breech (1ST)-Vertex (2ND) 10% • There is an arteriovenous malformation such that
• Both Breech 8-10% there exists a communication from the umbilical
arterial system of the "donor" twin to the umbilical
➢ Interlocking of twins is a rare complication seen in vein of the "recipient" twin.
twins with 1STBreech presentation and 2ND vertex • The donor twin is growth restricted, hypovolemic, has
presentation. oligohydramnios and is anemic because it gives blood
to the recipient twin.

ARISE MEDICAL ACADEMY Dr. MIK | 97

• The recipient is larger, hypervolemic, has
polyhydramnios and is plethoric, CHF—due to volume
overload and can have thrombosis since it has
polycythemia
• It has also been termed as ‘Twin Oligohydramnios -
Polyhydramnios Sequence’ (TOPS).
• The earlier the TOPS appears, worse will be the
prognosis.
• TTTS is more common in female fetuses.
• TTTS can cause Preterm delivery due to
Polyhydramnios, IUGR or fetal demise.
➢ Diagnosis of TTTS
• It is based on two criteria
✓ Presence of a monochorionic diamnionic pregnancy
✓ One twin having polyhydramnios and the other twin
having oligohydramnios
• Hydramnios defined if the largest vertical pocket is > 8
cm in one twin
• Oligohydramnios defined if the largest vertical pocket
is < 2 cm in the other twin.
➢ Management
• The preferred management these days is laser
ablation of individual anastomosis.
• Selective reduction can be considered if severe
amniotic fluid and growth disturbances develop
before 20 weeks.
MATERNAL COMPLICATIONS IN TWIN PREGNANCY
➢ ANTEPARTUM
• Hyperemesis, Hydramnios, Pre-eclampsia, Pressure
symptoms, Anaemia, Antepartum hemorrhage
➢ INTRAPARTUM
Twin peak or lambda sign:
• It is characteristic of dichorionic pregnancies and
is due to the chorionic tissue between the two layers
of the intertwin membrane at the placental origin.
• A potential space exists in the intertwin
membrane which is filled by proliferating piancental
villi, giving rise to a twin peak sign.
• Dysfunctional labour, Malpresentations, Increased
chance of operative delivery, Postpartum
hemorrhage, Retained placenta
FOETAL COMPLICATIONS IN TWIN PREGNANCY
• ANTEPARTUM
• Prematurity, IUGR, Single fetal demise,
Monochorionic monoamniotic twins, Twin-twin
transfusion syndrome, Vanishing twin and abortion
• Congenital anomalies including acardiac fetus and
conjoined twins
➢ INTRAPARTUM
• PROM and cord prolapsed, Abruption in the second
twin, Interlocking of twins (extremely rare)
➢ Complications Specific to Monochorionic twins
• Twin-twin transfusion syndrome, Monoamniotic
twinning, Conjoined twinning, Acardiac fetus
INVESTIGATIVE WORK UP IN TWINS
• Ultrasound Determination of Chorionicity
➢ Number of Sacs: This is applicable only before 10
weeks when 2 sacs indicate dichorionic and single sac
indicates monochorionic pregnancy.
➢ Placenta: Two placentae indicate a dichorionic
pregnancy.
➢ Sex: Discordant sex indicates dichorionicity but
concordant sex does not imply monochorionicity.
➢ Intertwin membrane: is thicker and more echogenic
in dichorionic twins, whereas it is thin in
monochorionic. It is best examined between 16-24
weeks, near the placental insertion of membranes.
ARISE MEDICAL ACADEMY Dr. MIK | 98

• Twin peak appears as a triangle with base at chorionic
surface and apex in interwin membrane.
✓ In monochorionic twins there is no chorionic tissue,
and interwin membrane is composed of 2 Amnion
only giving rise to the "T" sign on ultrasound.
• Monochorionic pregnancies have a dividing
membrane that is so thin, it may not be seen until the
second trimester.
• The membrane is generally less than 2mm thick and
magnification reveals only 2 layers (of amnion)
➢ Delivery of twins
• In twins, the chances of vaginal delivery are high if the
first twin or presenting twin is cephalic
• The interval between delivery of twins should be less
than 30 minutes. If there is a delay of more than 30
mins, interference should be done
➢ Indications of urgent delivery of the second baby:
• (1) Severe (intrapartum) vaginal bleeding
• (2) Cord prolapse of the second baby
• (3) Inadvertent use of intravenous ergometrine with
the delivery of the anterior shoulder of the first baby
• (4) First baby delivered under general anesthesia
• (5) Appearance of fetal distress.
➢ Extraction of The Second Twin
• A rational scheme is given below which depends on
the lie, presentation and station of the head.
✓ Head
• - If low down, delivery by forceps
• - If high up, delivery by internal version under general
anesthesia
✓ Breech should be delivered by breech extraction
✓ Transverse lie—internal version followed by breech
extraction under general anesthesia.
o If, however, the patient bleeds heavily following the
birth of the first baby, immediate low rupture of the
membranes usually succeeds in controlling the blood
loss.
INDICATIONS OF CESAREAN IN TWINS
• Twins with bad prognosis viz- Conjoint twins and
• Monochorionic and monoamniotic twins
• Twin to twin transfusion syndrome (seen in
monochorionic twins)
• Discordant twin with weight of smaller twin less than
1500gms
• Severe IUGR of one or both twins
• First twin non vertex
• All other obstetric (maternal and foetal) which are
indications for cesarean
ARISE MEDICAL ACADEMY Dr. MIK | 99
 CHAPTER – 18
OPERATIVE OBSTETRICS
EXTERNAL CEPHALIC VERSION
CONTRAINDICATIONS
• ECV is the procedure where presentation other than
➢ Maternal causes
cephalic is converted by external manipulation into a
cephalic presentation • APH - Placenta previa/abruptio placentae, Pre
eclampsia (hypertension), Precious pregnancy as bad
• It can be carried out in breech presentation or in
obstetrics history, Elderly primigravida, Multiple
transverse lie.
pregnancy, Obesity
• It is more successful in transverse lie.
• Ruptured membranes (because liquor has drained),
Oligohydramnios, Contracted pelvis, Congenital
➢ Indications:
abnormalities of uterus, APH - Placenta
• Breech presentation, Transverse lie. previa/abruption, Placentae

➢ Timing:
• A prior uterine incision is a relative contraindication
• It should be done after 35 weeks, Ideal time is 36 ➢ Foetal causes
week.
• Precious pregnancy, IUGR, Significant fetal
anomalies/dead Fetus, Compromised foetal status,
➢ Factors associated with successful version
Foetal distress, Short cord
• Multiparity,
• Adequate liquor. FORCEPS
• Unengaged fetus.
• Tocolysis ➢ THERAPEUTIC INDICATIONS
• Fetal distress in the second stage like in case of
➢ Procedure: abruptio placentae or cord prolapsed, Maternal
• The manoeuver is carried out after 35 weeks under distress in the second stage, Cardiac disease, PIH,
the effect of. Terbutaline 0.25 mg s.c. or Isoxsuprine Chorioamnionitis, Maternal exhaustion in 2nd stage,
50-100 mcg IV Prolonged second stage, Inadequate contraction,
• Ultrasound examination is done to confirm the Ineffective maternal effort
diagnosis and adequacy of amniotic fluid volume.
• A reactive NST should precede the manoeuver.
• Then ECV is attempted
• This is followed by a repeat NST after the procedure.

➢ Complications
➢ PROPHYLACTIC INDICATIONS
• PROM, Abruption, Fetomaternal hemorrhage,
Amniotic fluid embolism, Uterine rupture (very rare)

ARISE MEDICAL ACADEMY Dr. MIK | 100

• Medical diseases like cardiac disease and pre-
eclampsia, Low brith weight infants (No obvious
advantage), After coming head in breech.
➢ PRE REQUISITES
• The fetal head must be engaged
• The cervix must be fully dilated
• The membranes must be ruptured
• The position and station of the fetal head must be
known with certainty
• No major cephalopelvic dispropor tion by clinical
pelvimetry
• Bladder must be emptied
• Adequate analgesia
COMPLICATION OF FORCEPS DELIVERY
➢ Maternal
✓ Immediate
• Injury -Vaginal laceration or sulcus tear, extension of
episiotomy to involve the vaginal vault, complete
perineal tear, cervical tear
• Nerve injury -Femoral (L2, 3, 4), Lumbosacral trunk
(L4,5)
• Postpartum hemorrhage may be traumatic or atonic
or both
• Anaesthetic complications following local or general
anaesthesia
• Puerperal sepsis and increased maternal morbidity
➢ Foetal
• Facial bruising, Facial palsy, Intracranial hemorrhage
(rupture of the great vein of Galen),
Cephalhematoma, Skull fracture, Cervical spine injury
(rotational forceps), Asphyxia
VENTOUSE
➢ Ventouse/Vaccum extraction
• Ventouse is an instrument which assists in delivery by
creating a vaccum between it and fetal scalp.
➢ PROCEDURE
• Vacuum cup should be applied over the sagittal
suture at the median flexion point located 3cm
anterior to the posterior fontanelle.
• Maximum pressure created by vaccum = 0.8 kg/cm2
• The direction of pull of vaccum should follow the
Curve of Carus, i.e. downwards and backwards; then
downwards and finally upwards (similar to forceps).
• Delivery should occur within three pulls over a period
of 15 mins.
• If the cup slips, despite correct application or delivery
does not occur after three pulls-cesarean section is
indicated.
➢ Indications:
• As an alternative to forceps operation.
• As an alternative to rotational forceps in occipito
transverse or posterior position.
• Delay in descent of the head in case of the second
baby of twins.
• Deep transverse arrest
• To cut short the second stage of labour as in heart
disease patients.
➢ Prerequisite:
• Bladder should be empty
• Cervix should be at least 6 cm dilated
• Vertex presentation
• Head should be engaged
• No bony resistance below the head / No evidence of
CPD
VENTOUSE APPLICATION FOR MALPRESENTATION
➢ Ventouse can be applied in:
• Vertex presentation:
• Occipito anterior position
ARISE MEDICAL ACADEMY Dr. MIK | 101
• Occipito transverse/posterior position
• Deep transverse arrest COMPLICATIONS

➢ Ventouse should not be applied in: ✓ Maternal

• Face presentations (Mento anterior and posterior) • (In ventouse maternal complications are less than
with forceps)
• Breech presentation
• Brow presentation • Soft tissue injuries to the vagina, cervix & perineum
• Annular detachment of the cervix
CONTRAINDICATIONS: • Traumatic PPH
• Prematurity (< 34 weeks or weight < 2 kg) as chances
of scalp avulsion or sub periosteal hemorrhage are ✓ Foetal
more (In ventouse foetal complications are more than with
• Fetal coagulopathy forceps)
• Fetal macrosomia (wt > 4 kg) • MC is retinal hemorrhage
• Non engaged fetal head • Scalp injury
• Fetal distress where urgent delivery is needed • Cephalhematoma (More common with vacuum)
Intracranial hemorrhage
• CPD
• Presentation other than vertex (including face • Subgaleal hemorrhage (More common with vacuum)
(50: 10000)
presentation)
• Contraindication - recent scalp blood sampling • Neonatal jaundice (More common with vacuum)
• Asphyxia in difficult vacuum
ADVANTAGES • Shoulder dystocia (More common with vacuum)
• Erb paralysis
• The 2 main advantages of vaccum are • 6th and 7th nerve palsy.
• It can be applied through incompletely dilated cervix
(not undilated cervix)
• Can be used in unrotated or malrotated
occipitoposterior position of head e.g. in deep
transverse arrest with adequate pelvis.
FORCEPS ADVANTAGES VENTOUSE DISADVANTAGES

No maternal effort needed, therefore Requires maternal effort

Suitable in case of Requires maternal effort hence unsuitable
maternal heart disease
Quick in cases of fetal distress Takes time in fetal distress
Less cephalhematomas More cephalhematomas/subgaleal
hematoma/jaundice
Can be used in preterm Cannot be used in preterm (< 34 weeks)
Can be used in face and breech Cannot be used in other presentations

Requires anaesthesia No need for anaesthesia

Maternal injuries may occur Less maternal injuries

ARISE MEDICAL ACADEMY Dr. MIK | 102

 No autorotation, occupies space at the sides
Requires full dilatation
More traction force needed
EPISIOTOMY
• It is defined as a surgical incision made over the
perineum and vulva during delivery to increase the
diameter of the vulval outlet (and not the whole of
birth canal) during child-birth and to prevent perineal
tears.
• Thus episiotomy is a planned surgically given perineal
tear of second degree.
• Perineal Tears
➢ 1° - Is a laceration of the vaginal mucosa and the
perineal skin, but not the underlying fascia and
muscle.
➢ 2° - Involves the vaginal mucosa, perineal skin, and
the fascia and muscles of the perineal body.
➢ 3° - Involves the vaginal mucosa, skin and perineal
body and the anal sphincter is also disrupted.
➢ 4° - In addition, the rectal mucosa is also torn.
• All perineal tears (whatever reason) should be
repaired immediately
Promotes autorotation, can be used in
unrotated or malrotated occipito posterior
position of the head
Does not require full cervical dilatation
Can be applied if cervix > 6 cm dilated
Less traction force needed
• If the patient presents late (after 24 – 48 hrs) don’t
repair leave it for secondary healing
➢ Types of Episiotomy:
✓ The oldest was median episiotomy which is not done
now in modern obstetrics as it has a high incidence of
grade 3 tears
✓ Mediolateral is the most common type and is the
most accepted
(Commonly a right mediolateral episiotomy is
performed, angled at
45 from the vulvar rim)
✓ Lateral episiotomy gained some importance in past
but is now discontinued as it injures the bartholins
glands
✓ J shaped is less accepted because repair is difficult as
perineal anatomy is very badly destroyed
➢ Structures cut in Mediolateral episiotomy (Very
Important)
• Posterior vaginal wall
• Superficial and deep transverse perineal muscles,
bulbospongiosus and part of levator ani
• Fascia covering those muscles
ARISE MEDICAL ACADEMY Dr. MIK | 103
• Transverse perineal branches of pudendal vessels and
nerves
• Subcutaneous tissue and skin.
CESAREAN SECTION
➢ Common indications
• Cephalopelvic disproportion
• Malposition and malpresentation (transverse lie and
breech)
• Fetal distress
• Placenta previa
• Preeclampsia and eclampsia remote from term
• Multiple gestation
• Fetal abnormalities (hydrocephalus)
• Cervical cancer
• Active herpes infection
• Patients choice (now gaining popularity).
➢ Types of Cesarean section
• Classical section
• Lower segment section
➢ Classical cesarean:
Indications of classical section in modern obstetrics
• Dense adhesions (due to previous surgery)
• Severe CP (osteomalacia or rickets)
• Big fibroid lower segment
• Ca Cx
• Severe placenta previa with engorged vessels
• Post mortem CS
➢ Lower segment cesarean section
• It is the only cesarean section performed now-a-days
(unless there is an indication for classical)
• Here the insision is given in the lower segment of
uterus (identified as the UV reflection)
• After identifying the lower segment an incision is
given either (transverse >99%) or vertical (1%)
• Healing of the lower segment incision is better as it is
located in the lower segment which is quiescent.
• Hence tensile strength is more and so the chance of
scar rupture in the next pregnancy is minimal.
➢ Cesarean hysterectomy
• Cesarean hysterectomy refers to an operation where
cesarean section is followed by removal of the uterus.
• Peripartum hysterectomy is the surgical removal of
the uterus either at the time of cesarean delivery or
vaginal delivery or in the immediate postpartum
period
✓ M/C cause of cesarean/peripartum hysterectomy is
PPH
✓ Second most common cause is morbidly adherent
placenta
✓ Couvelaire uterus in abruption is not an indication for
hysterectomy.
VAGINAL BIRTH AFTER CESAREAN SECTION (VBAC) OR
TRIAL OF SCAR
• Earlier previous cesarean section was considered as
an absolute contraindication for the next vaginal
delivery
• The rule was once a cesarean always a cesarean
• But now this statement is considered as an
exaggeration
• Now the rule is once a cesarean try vaginal next time
if possible
• All VBAC’s are trial of labour but all trial of labour are
not VBAC
➢ Essential Criteria
• One prior low - transverse cesarean delivery.
• Clinically adequate pelvis. (No CPD)
• No other uterine scars or previous rutpure.
• Physician immediately available throughout active
labor who is capable of monitoring labor and
performing emergency cesarean delivery.
• Availability of anesthesia and personel for emergency
cesarean delivery.
➢ Vaginal delivery can be tried in post LSCS cases in
institutions equipped with facilities and personell to
respond to emergencies (i.e., rupture uterus) with
physicians immediately available to provide
emergency care at any time
ARISE MEDICAL ACADEMY Dr. MIK | 104
➢ VBAC and trial of scar are synonyms of each other but
VBAC and trial of labor have two different meanings
➢ Contraindications:
• Prior classical or T or J-shaped uterine incision or
extensive transfundal uterine surgery (eg,
myomectomy).
• Previous 2 or more LSCS
• Previous history of uterine rutpure
• Contracted pelvis or CPD
• Medical or obstetrical complications that preclude
vaginal birth (eg, placenta previa), malpresentations
• Previous history of puerperial infection
• Inability to perform emergency CS due to factors
related to the facility, surgeon, anesthesia, or nursing
staff.
Symphysiotomy
• Symphysiotomy is the operation designed to enlarge
the pelvic capacity by dividing the symphysis pubis.
• It is not prctised in modern obstetrics
DESTRUCTIVE PROCEDURES
• There is no place for destructive operations in
modern day obstetrics.
• They are - Craniotomy, Craniocentesis, Decapitation,
Cleidotomy, Spondylotomy, Embryotomy or
evisceration
ARISE MEDICAL ACADEMY Dr. MIK | 105