BASIC OBSTETRICS

Physiology of reproduction the 1st meiotic division to form 2 secondary

spermatocytes (23X or 23Y)
Gametogenesis: The process of maturation of
spermatozoa in male and ovum in female is called •• During the 2nd meiotic division, these form 4
gametogenesis spermatids (23X, 23X, 23Y, 23Y)

1. Spermatogenesis •• A total of 4 spermatids are formed

•• These undergo further differentiation to form
4 spermatozoa: This is known as spermiogenesis
•• In spermiogenesis the following take place
–– Formation of acrosome
–– Formation of neck, middle piece and tail
–– Condensation of nucleus
–– Shedding of most of cytoplasm
•• Spermatogenesis depends on LH and FSH
•• Time: 60-64 days
•• Spermatozoa further undergo more maturation
in the epididymis
•• Changes in sperm before fertilization
–– CAPACITATION: Biochemical changes
enabling them to bind and fertilize with
the ovum. Only a capacitated sperm can
penetrate the corona radiata
–– ACROSOME REACTION: Occurs after the
sperm binds to the zona pellucida (ZP). The
•• The process of formation of spermatozoa glycoprotein of the ZP is responsible for
from the primordial male germ cells is called this. It results in release of acrosin and
spermatogenesis. trypsin needed to penetrate the zona

•• Just prior to puberty, the dormant primordial

cells convert into spermatogonial stem cells
from which spermatogonia arise
•• The spermatogonia undergo Mitosis to form
primary spermatocyte (46XY) which then enter
the 1st meiotic division
•• Primary spermatocytes rest for about 22
days in prophase and then rapidly complete
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Obstetric and Gynecology

2. Oogenesis

•• About 15-20 primary oocytes begin to mature

under the influence of FSH during each
menstrual cycle
•• Only 1 of these will reach maturity and ovulate
•• The rest will degenerate (corpus atreticum)
•• The primary oocyte undergoes meiotic division
to produce 2 unequal daughter cells under the
influence of the mid-cycle LH surge
•• Each daughter cell has haploid (23X) number of
chromosomes
•• Oogenesis is the process of formation of a
mature ovum form the primordial female germ •• The large cell which receives most of the
cell cytoplasm is called the secondary oocyte and
the smaller one is called the 1st polar body
•• The primitive germ cells migrate from the yolk
sac to the gonadal ridge by the end of the 4th •• The secondary oocyte immediately enters
week the 2nd meiotic division and gets arrested in
METAPHASE of meiosis II.
•• In the female gonads, the germ cells multiply by
mitosis to differentiate into oogonia to reach a •• Thus ovulation takes place when the oocyte is
maximum of about 7 million at 20th week. still in metaphase

•• Then they steadily undergo atresia and •• This ovum travels along the fallopian tube
apoptosis and decline in number towards the uterus

•• At birth: 1 to 2 million •• The 2nd meiotic division is completed only

AFTER FERTILIZATION by sperm resulting in
•• 400 000 at puberty the formation of again 2 unequal daughter cells:
•• 100 follicles at menopause The MATURE OVUM (23 X) and the 2nd POLAR
BODY (23X)
•• If fertilization does not happen, the secondary
oocyte degenerates in 12-24 hours without
proceeding for MEIOSIS II.

STRUCTURE OF THE MATURE

GRAAFIAN FOLLICLE:
•• The primary follicle (also called pre-antral
follicle) is basically the follicular cells
surrounding the oocyte
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Basic Obstetrics

•• This then matures into a secondary (or antral STRUCTURE of a MATURE OVUM
follicle) which has an antrum (containing
follicular fluid) and an outer layer called the •• Diameter: 130µ in diameter
theca interna •• Largest cell in the body
•• The cavity gradually increases in size and finally •• Ooplasm is the cytoplasm
forms a pre-ovulatory follicle (Mature Graafian
•• Nucleus is eccentric
follicle)
•• Haploid (23X)
–– The cavity is eccentric
•• Enveloped by a vitelline membrane and an outer
–– The granulosa cells surrounding the oocyte
thick zona pellucida (mucoprotein)
are called the cumulus oophoricus.
•• The ouvum is alecithal
–– The granulosa cells attached to the wall of
the oocyte is called discus proligerus •• Follicular cells surround the ova and are called
the corona radiata
–– Inner lining is called theca interna
–– Outer is called theca externa

Structure of a Mature Graafian Follicle

OVULATION
•• Process by which a secondary oocyte is
extruded from the ovary after rupture of a
mature ovarian follicle
•• Usually occurs 14 days before the next cycle
is due
•• Causes of ovulation
–– LH surge: This is due to sustained raised
estradiol levels
–– FSH rise
•• Timing: Ovulation occurs
Structure of the human ova –– 24-36 hours after onset of LH surge
–– 48 h from the estradiol peak
–– 12-18 from peak of LH surge
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Obstetric and Gynecology

•• After ovulation, the corpus luteum is formed IMPLANTATION

which will degenerate to form the corpus
•• 6th-7th day after fertilization (20th-21st day) of a
albicans if pregnancy does not occur
regular menstrual calendar

FERTILIZATION •• 4 steps
•• Happens in the fallopian tube (ampulla) –– Apposition (disappearance of the ZP and
ecape of embryo – zona hatching)
•• 3 main steps
–– Adhesion
1. Penetration of the corona radiata: Hyaluronidase
and acrosin are secreted from the acrosomal cap –– Penetration
of the capacitated sperm help it penetrate the –– Invasion
corona radiata
2. 2. Penetration of the Zona Pellucida (ZP) DECIDUA
a. ZP has sperm receptor zona proteins (ZP1,2 and •• Thickened vascular endometrium of the
3) which mediate the acrosomal reaction and pregnant uterus is called the decudua
binding
•• It has 3 parts
b. Once 1 sperm enters, there is a zona reaction
1. Superficial compact layer: Role in
or vitelline block which disallows other sperms
trophoblastic invasion and penetration
from entering. This happens because
2. Immediate spongy layer: Layer of placental
i. Cortical reaction: Causes hardening of the ZP
separation
ii. Depolarization
3. Thin basal layer
3. Fusion of the oocyte and sperm and formation of
•• The decidua can also be divided into 3 areas
the pro-nucleus
–– Decidua basalis: site of attachment of
POST FERTILIZATION EVENTS placenta

•• Cleavage: Subdivision of the fertilized ovum –– Decidua capsularis: Portion of decidua

into smaller cells between the embryo and uterine cavity

•• 2-cell stage at 30 hours –– Decidua parietalis (or vera): Portion of the

placenta not related to implantation
•• 4-cell stage at 40-50 hours
•• The decidua capsularis and parietalis fuse and
•• Morula (16-cell stage): 72 hours: Cluster of obliterate the decidual space by around 10-12
cells resembling a mulberry weeks of gestation
•• The inner cells of the morula form the inner cell
mass or the embryo proper (Embryoblast)
•• Outer cells: Trophectoderm (future trophoblast)
which later forms the placenta and membranes
•• Blastocyst: 4th-5th day
 PLACENTA

Development of Placenta •• Development of the placenta

•• The human placenta is 1. Formation of chorionic villi

–– Hemochorial (Direct contact of the chorion a. Primary villus

with maternal blood) B. Secondary villus
–– Discoid in shape C. Tertiary villus
–– Deciduate (i.e. it is shed at delivery)
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Obstetric and Gynecology

Structure of the Placenta:

Placenta at Term: •• Placental circulation consists of

•• Fleshy Discoid 1. Uteroplacental circulation (Blood enters from
•• 500g in weight the spiral arterioles; circulates in the intervillous
space and is drained by the uterine veins)
•• Diameter: 15-20 cm
2. Fetoplacental circulation (Oxygenated blood
•• Thickness: 2.5 cm travels to the fetus through the umbilical vein
•• Volume: 500ml and deoxygenated blood flows through 2 umbilical
arteries to the placenta)
•• 2 surfaces: Fetal and Maternal
•• 4/5th of placenta is fetal origin and 1/5th is
maternal origin (decidua basalis and blood in the
intervillous spaces)
•• 15-20 cotyledons on the maternal surface
•• Separation occurs at the spongy layer
 FETAL PHYSIOLOGY

Fetal Hematopoiesis amniotic fluid. Its dark green color is from

biliverdin secreted by the lover.
•• Fetal Hematopoiesis: Demonstrable in the
yolk sac by the 14th day followed by the liver •• Meconium may be passed at term as part of
between 6-10 weeks. normal bowel peristalsis but is also released due
to fetal hypoxia
•• Hematopoiesis in the bone marrow begins at 15-
16 weeks and spleen at 19-20 weeks
Respiratory System
•• At 40 weeks: 75-80% of total Hb is HbF, 20% •• Surfactant production: Produced by type 2
is HbA and 5-10% id HbA2 pneumocytes
•• By 6-12 months of birth, fetal Hb is totally •• The main active component of surfactant is a
replaced by adult Hb lecithin: Dipalmitoyl phosphatidyl choline
•• HbF has higher affinity for O2 due to less •• Fetal cortisol is the natural trigger for
binding of 2,3-diphosphoglycerate as compared surfactant production
with HbA.
•• Begins to be produced at about 24 weeks
•• Thus fetal Hb binds with O2 even at lower
pressures of O2 •• By 34 weeks, adequate surfactant has been
produced
•• HbF is also more resistant to denaturation with
alkaline reagents: Basis of Apt Test •• Both dexamethasone and betamethasone
(maternal administration) can accelerate
•• Ways of differentiating fetal Hb and adult Hb surfactant production
–– Rosette test
–– Apt test (alkaline denaturation test)
Fetal Thyroid
–– First endocrine gland to develop
–– Kleihauer Betke test
–– Develops around the 4th week, is secreting
–– Flow cytometry
T3 and T4 by 11th week
•• Lifespan of fetal RBS: 80 days
Fetal Circulation
Fetal Urinary System Umbilical Vein: Carries oxygenated blood from the
•• Fetal kidneys start producing urine at 12 weeks placenta to the fetus
↓
GIT
Umbilical vein divides into the Ductus Venosus and
•• Fetal swallowing if amniotic fluid appears at 12
the Portal Sinus
weeks, gradually increases to 250ml/ day at
term ↓
•• Fetal bowel contains intestinal secretions, Ductus venosus: Major branch; Traverses the liver
deswuamated fetal cells, lanugo, scalp hair, and enters the IVC directly; i.e. it carries well
vernux and undigested debris from swallowed oxygenated blood directly to the heart;
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Obstetric and Gynecology

↓ as the umbilical arteries.

The IVC contains mixture of oxygenated blood Remember
(ductus venosus) and deoxygenated blood returning
from the liver and lower body: Thus the O2 content •• Oxygenated blood enters the fetus through:
of blood delivered to the fetal heart is less than Umbilical Vein
that leaving the placenta –– Functional closure: Occurs after closure of
↓ umbilical artery

The Right Atrium directs the blood to the Left –– Forms the ligamentum teres
atrium or the Right ventricle depending on the •• Deoxygenated Blood exits the fetus through
oxygen content Umbilical arteries
Well oxygenated blood is preferentially shunted –– Functional closure of umbilical arteries:
to the left side of the heart (through the foramen immediately after birth
ovale) and then to the heart and brain
–– Anatomical closure: 2 – 3months
Less oxygenated blood enters the RA – RV
–– Proximal part form the superior vesical
The deoxygenated blood returning from the brain arteries
and upper body also enters the RA and then the RV.
–– Distal part form the lateral umbilical
Blood in the RV is 15-20% less oxygenated than the ligaments
LV
•• Ductus venosus: Shunts blood from umbilical
↓ vein to IVC
90% blood from the RV is shunted to the descending –– Functional closure 10 – 96h after birth
aorta through the Ductus Arteriosus. Due to high
pulmonary resistance; only 8% blood enters the lungs –– Anatomic closure: 3 -7 days

↓ –– Forms the ligamentum venosum

Blood exits the fetus through the 2 hypogastric •• Ductus arteriosus: Shunts blood from Pulmonary
arteries – these 2 arteries course from the bladder artery to Aorta
along the abdominal wall and into the umbilical cord
–– Functional closure: 12 – 24 h
–– Anatomic closure: 2 – 3 weeks
•• Foramen ovale
–– Functional closure soon after birth
–– Anatomical closure at 1 year
Fetal circulation
 ANATOMICAL AND PHYSIOLOGICAL
CHANGES IN PREGNANCY

Vagina Increased estrogen

•• Hyperemic: Jacquemier/ Chadwick sign: bluish ↓

discoloration of the vagina Lactobacillus acidophilus

Vaginal pH: - Depends on the estrogen levels ↓

Newborn: 5.6 Glycogen → Lactic acid

Children: 6 – 8 ↓

Puberty: 4 Acidic vagina (pH is low)

Pregnancy: 4 •• Increased thick white secretions

Menopause: 7 •• Cytology: Navicular (ovoid) epithelial cells

(Effect of Progesterone)
•• pH: Acidic (3.5-6)

Uterus
Non-Pregnant Pregnant (Term uterus)
Size 7.5 x 5 x 2.5 cm 35 x 25 x 20 cm
Weight 50-70 g 1000g (20 times increase)
Shape Pyriform Globular and spherical
Position Anteverted and Anteflexed Dextrorotation (To the right because of the rectosigmoid on
the left)
Consistency Firm Becomes softer
Capacity 5-10 ml 4000 ml

•• The uterine musculature undergoes both –– 2nd trimester onwards

hypertrophy and hyperplasia
–– Infrequent, Irregular, Painless contractions
•• Middle layer: figure of 8; prevention of PPH
–– Don’t cause cervical dilatation
–– 5-25 mmHg
–– Increase near term
–– ABSENT in Abdominal Pregnancy
•• Formation of lower uterine segment from the
isthmus

•• Uterine vascularity •• Cervix:

–– 10ml/ min at 10 weeks to 500ml/ min at term –– > 2.5 cm

•• Braxton Hicks contractions: –– Firm in consistency; becomes soft near term

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Obstetric and Gynecology

–– Cervical erosion forms Breast

ƒƒ Endocervical columnar epithelium everts •• High Estrogen: Hypertrophy and proliferation
out beyond the squamo-columnar junction of breast ducts
ƒƒ Also seen in (because of ↑ estrogen levels) •• High Estrogen and Progesterone: Proliferation
○○ Young age of alveoli

○○ OCPs •• Montgomery’s tubercles: Hypertrophic

sebaceous glands
Ovaries •• Formation of secondary areola
•• Corpus luteum cyst •• Colostrum production: 3-4 months of pregnancy
–– Max in structure and function at 8 weeks
Skin
–– Responsible for support of pregnancy till 8
weeks •• Chloasma

–– Thereafter the placenta takes over •• Linea Nigra (Hyper pigmented line from
xiphisternum to pubic symphysis)
–– Will show ring of fire sign on Doppler (Also
seen in Unruptured tubal ectopic) •• Striae gravidarum (Reddish striae of present
pregnancy)
•• Striae albicans (Silvery striae of previous
pregnancies)

•• Theca lutein cysts:

–– Molar pregnancy (Complete mole > Partial Hematological Changes
mole) •• ↑ Blood volume (by 40%) Q
–– Due to very high beta hCG levels –– Max at 32-34 weeks Q
–– No treatment required; evacuation of molar –– Higher in multigravida, multiple pregnancy and
pregnancy and once Beta hCG levels come large babies
down, the cysts disappear
•• ↑ Red cell volume (20%) Q
•• This disproportionate increase in plasma and
RBC volume; produces a state of hemodilution
during pregnancy – fall in Hb by about 2g% at
term - physiological anemia
–– ↓ Hb (13.5 g% to 11.5g%)
•• ↓ Hematocrit
•• ↓ RBC count
•• Slight ↓ in MCV, MCH and MCHC
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Anatomical and Physiological Changes In Pregnancy

•• Leukocytes and Immune system Cardiovascular Changes

–– TLC slightly increased (10000-15000) Normal Cardiac Exam findings in Pregnant
–– Neutrophilic leukocytosis; more in labor women –
–– Deviation from cell mediated immune Jugular venous distension
response to humoral and innate responses 1. Mammary souffle
–– ↑ Complement C3 and C4 2. Venous Hum
•• Total Protein 3. Apex Beat deviated to the 4th intercostal space;
2.5 cm outside the midclavicular line
–– Total plasma protein Increases
4. Occasional S3
–– Plasma protein concentration falls (due to
hemodilution) 5. Aortic or Pulmonary Flow murmurs
–– Marked fall in albumin compared to globulin 6. Systolic Ejection murmur in 90% of normal
pregnancy (mid-systolic/ < grade 3)
•• Blood Coagulation Factors
7. Soft diastolic murmur in 20%
–– Pregnancy is a hypercoagulable state
–– Fibrinogen level: raised by 50% (200-400 Normal ECG Changes in Pregnancy –
mg/ dl to 300-600 mg/dl) •• Left axis Deviation may be seen in 15%

–– ESR increased 4-fold (due to increase in •• Deep Q waves

globulin and fibrinogen) •• Low voltage complexes

–– ↓ Platelet count (slight fall) Other CVS Changes in Pregnancy

ƒƒ Gestational thrombocytopenia: due to Cardiac Output ↑ 40%
hemodilution and increased platelet Stroke Volume ↑ 25%
consumption
Heart Rate ↑ 15%
ƒƒ No adverse effect on pregnancy BP Slightly falls (max in 2nd
ƒƒ Usually seen in the 3rd trimester trimester)
CVP No change
•• Increase in plasma levels of Factors: 1, 2, 7, 8,
MAP Slightly increased
9, 10
Vascular resistance ↓
•• Plasma levels of 2, 5 12 – unchanged/ mildly
(pulmonary and
increased
systemic)
•• Factors 11, 13 – slightly decreased (remember Pulmonary capillary ↑
13 is unlucky; also 11) Q wedge pressure
•• Clotting time: unaffected Q •• Hemodynamic changes regress to normal by 42
•• ↓ Anticoagulant Activity days (= 6 weeks) post-partum.

Supine hypotension syndrome:

•• Seen in the 3rd trimester.
•• Pressure of gravid uterus on the IVC in supine
position.
•• C/F: Hypotension, tachycardia and syncope.
•• Especially dangerous during cesarean where
spinal anesthesia causes hypotension.
•• Hence a left lateral tilt needs to be given to
prevent hypotension (A wedge is placed below
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Obstetric and Gynecology

the right hip).

Respiratory System
•• Anatomical Changes
–– Lower ribs flare out.
–– Widening of subcostal angle (680 to 1020).
–– Diaphragm: rises by 4 cm.
•• Functional Changes:
Respiratory Function Definition Change
Respiratory Rate No of breaths/ minute. No change (14 – 16/ min).
Tidal volume Volume of air inspired/ expired in each Increased (500 to 700 ml; + 40%).
respiration.
Inspiratory Reserve Volume Maximum amount of volume of air which No change/ slightly increased.
can be inspired beyond normal tidal volume
Inspiratory capacity Maximum volume of air that can be in- Increased (+10%) .
spired after reaching the end of a normal,
quiet expiration (TV + IRV).
Minute ventilation Amount of air inspired in a minute Increased (by 40%).
Expiratory reserve Volume Maximum amount of air that can be Decreased (by 18%).
(ml) expired from the resting end expiratory
position
Residual Volume (ml) Volume of air in lungs after maximal expi- Decreased (by 20 – 25%).
ration
Functional residual Volume Amount of air remaining in the resting end Decreased (by 22%).
expiratory position
Total Lung Capacity Amount of air in lungs after maximal inspi- Unaffected/ slightly decreased (5%).
ration
Vital Capacity IRV + TV +ERV No change.

Tidal Volume
Inspiratory Capacity
Total Lung Capacity and Vital capacity:
Minute Ventilation Remain Unchanged
Inspiratory Reserve Volume

Remember: TVs Increase our Information and

Capacity every Minute
Expiratory Reserve Volume
Residual volume
Functional residual capacity
 5
Anatomical and Physiological Changes In Pregnancy

Acid Base Balance: vein)

•• Pregnancy is a state of Respiratory Alkalosis •• Bladder -

–– Minimal increase in pH –– Congestion, hypertrophy.

–– Arterial PO2 ↑ –– Edema In the 3rd trimester.

–– Arterial PCO2 ↓ –– Frequency of micturition at 6 – 8 weeks and

then in the 3rd trimester.
–– Plasma HCO3 ↓
–– Stress incontinence due to weakness of
Renal System the urethral sphincter and pressure of the
gravid uterus.
•• Dilatation of the ureters, renal pelvis, calyces
•• Kidneys enlarge in length by 1 cm Gastro-Intestinal System.
•• Renal plasma flow increased •• Diminished muscle tone and motility.
•• GFR increased – reduced plasma levels of serum •• Increased reflux – chemical esophagitis and
creatinine, blood urea nitrogen and uric acid. heartburn.
•• Decreased reabsorption of - •• Constipation.
–– Glucose (physiological glycosuria). •• Liver and Gallbladder.
–– Uric acid. •• Raised ALP
–– Amino acids. •• All other liver enzymes – unchanged
–– Water soluble vitamins. •• Marked atonicity of the gall bladder – stone
formation favored
•• Ureter -
–– Relaxed, dilated (especially> 24 weeks) Metabolic Changes
–– Right > Left (due to dextrorotation of the •• Pregnancy is an anabolic state.
uterus and pressure by the right ovarian
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Obstetric and Gynecology

•• BMR increases by 30% in pregnancy. Thyroid Physiology in Pregnancy

•• Protein metabolism •• Pregnancy is associated with an Increased
–– There is a positive nitrogen balance iodine requirement; RDA: 250 mcg
throughout pregnancy (pregnancy is an •• Increase mean thyroid volume (12 to 15 ml)
anabolic state)
•• TRH: Remains same; crosses the placenta and
–– Fall in blood urea stimulates the fetal pituitary to release TSH
–– Creatinine and uric acid -fall slightly/ •• Fetus: relies on maternal T4 initially; starts its
unchanged own production at 10 – 12 weeks .
–– Amino acids- actively transported across •• Similarity in α-subunits of TSH, FSH, LH and
the placenta HCG
–– 1000g increase in proteins –– Hence HCG has intrinsic thyrotropic activity
•• Carbohydrate metabolism –– So TSH reduces in the 1st trimester:
–– Pregnancy is a diabetogenic state Physiological Hyperthyroidism

–– Insulin levels increased •• Thyroid Binding Globulin (TBG) rises; peaks at

20 weeks
–– Contra-insulin factors also increased
(Estrogen, progesterone, hPL, cortisol, –– Due to increased hepatic production
prolactin, FFA, leptin and TNFα) –– Increased Total T4 and T3 levels
–– Postprandial hyperglycemia, mild fasting –– Free T3 and T4 –unchanged.
hypoglycemia
Trimester TSH Level (mIU/L)
–– Peripheral insulin resistance First 0.1-2.5
–– Glycosuria Second 0.2-3.0
Third 0.3-3.0
 DIAGNOSIS OF PREGNANCY

Diagnosis of Pregnancy: –– Occurs before complete fusion of the decidua

vera with the decidua capsularis.
1st trimester ƒƒ Also called implantation bleed; It may be
•• Symptoms: cyclical and may last till 12 weeks.

Presumptive diagnosis of pregnancy can be made –– Nausea and Vomiting:

based on the following symptoms: ƒƒ Erroneously called morning sickness as it
•• Amenorrhea: Amenorrhea in a woman with can occur at any time
cyclical periods is highly suggestive of ƒƒ 50% are relieved by 14 weeks
pregnancy.
ƒƒ 90% relieved by 22 weeks
•• Placental sign
ƒƒ Severity is gauged by PUQE score
–– Mild bleeding/ spotting.
○○ PUQE Score: Pregnancy Induced
–– Seen around 6 weeks. Quantification of Emesis Score.

Important to Remember in PUKE Score: –– How many times does she vomit in a day

•• PUQE score is a questionnaire score –– How many times does she have retching in a
day
•• 3 questions:
•• Total Score:
–– How many hours in a day is the patient
nauseous –– Mild ≤6
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Obstetric and Gynecology

–– Moderate 7 – 12 ƒƒPromethazine, prochlorperazine, doxylamine

– 1st line
–– Severe ≥ 13
ƒƒ Metoclopramide and ondansetron – 2nd line.
Hyperemesis Gravidarum
•• Hydrocortisone in intractable vomiting
•• MC in 1st pregnancy
•• Nutritional supplementation with Vit B1, B6, B12
•• Recurs in subsequent pregnancies and vitamin C.
•• More common in: •• Thromboprophylaxis with LMWH
–– Young age
Frequency of micturition:
–– Low BMI
–– Appears in 8th – 12th week
–– H/o migraine
–– Disappears by 2nd trimester
–– Family history
–– Recurs in the 3rd trimester
–– Molar pregnancy
–– Due to
–– Multiple pregnancy
ƒƒ Pressure on bladder fundus by the enlarged
•• Complications: Dehydration, ketoacidosis, uterus
electrolyte disturbance, hypoglycemia Wernicke’s
encephalopathy, Korsakoff psychosis, peripheral ƒƒ Bladder mucosa has increased vascularity
neuritis, pontine myelinolysis, gastric ulcer, ƒƒ Increased maternal thirst and polyuria
esophageal tear (Mallory Weiss), jaundice, liver
failure, renal failure. Breast discomfort
•• Wernicke’s encephalopathy: Vit B1 (Thiamine)
deficiency; Triad of ophthalmoplegia, ataxia Fatigue
and delirium
Change in appetite
•• Korsakoff Psychosis: Vit B1 (Thiamine)
deficiency; Psychosis and Amnesia Objective Signs:
•• Management: –– Breast changes:
–– Daily record of vital signs and I/O ƒƒ Evident by 6- 8 weeks
–– Urine ketones and serum electrolytes ƒƒ Nipple and areola are pigmented
–– Hydration ƒƒ Prominent Montgomery tubercles
–– Antiemetics – ƒƒ Colostrum may appear by 12th week.
–– Uterus not palpable P/A
Named Pelvic signs (IMPORTANT) –– Pelvic signs
Sign Where Description Weeks
Jacquemier’s or Vaginal sign Bluish hue of ant vaginal wall 8th week
Chadwick’s sign
Osiander’s sign Vaginal sign Increased pulsation felt through the lateral fornices 6 – 8 weeks
Goodell’s sign Cervical sign Soft cervix 6th week
Piscacek’s sign Uterine sign Asymmetrical uterine enlargement in lateral implantation
Hegar’s sign Uterine sign On bimanual exam, the abdominal and vaginal fingers appose below 6 – 10
the body of the uterus weeks
Palmer’s sign Uterine sign Regular and rhythmic uterine contractions elicited on bimanual 4 – 8 weeks
exam
 3
Diagnosis of Pregnancy

Mnemonic: Diagnosis in the 2nd and 3rd

Jack and Chad wore blue; they were good and soft
Trimesters of Pregnancy:
hearted; Ossy’s Pulse increased and the F (P)armers •• Symptoms:
Hedge could be reached with both hands. –– Persisting amenorrhea
–– Quickening: Perception of fetal movements
Immunological Tests for Diagnosis of
for the first time
Pregnancy:
ƒƒ 18 weeks in primis
–– Based on serum or urinary detection of hCG
by antibodies ƒƒ 16 weeks in multis
–– Abdominal enlargement
–– Immunoassays without radioisotopes:
–– Frequency of micturition reappears in the
ƒƒ Agglutination inhibition tests (urine)
3rd trimester
ƒƒ Direct latex agglutination tests (urine) •• Signs
ƒƒ Two site sandwich – (membrane ELISA –– Chloasma (pigmentation over the forehead
tests -urine & serum) – can detect hCG and cheek) appears at 24 weeks
in serum up to 1-2mIU/ml and as early
–– Breast changes are more prominent
as 5 days before a missed period/ 30-50
mIU/ml for urine samples –– Abdominal examination:
–– Immunoassays with radioisotopes: ƒƒ Linea nigra from 20th week

ƒƒ Radioimmunoassay ƒƒ Striae gravidarum

ƒƒ Immunoradiometric assay ƒƒ Uterine height

ƒƒ Symphysio fundal height: 24 – 36 weeks
Causes of Positive HCG tests in the absence
of pregnancy ƒƒ 18 -20 weeks: External Ballotment

1. Exogenous hCG injection ƒƒ Palpation of fetal parts by 20th week

ƒƒ Auscultation of Fetal heart sound is the
2. Delayed hCG clearance (renal failure)
most conclusive SIGN of pregnancy: By
3. Pituitary hCG(physiological) 20 weeks
4. Neoplasms producing hCG ƒƒ Uterine souffle: soft blowing and systolic
murmur heard low down at the sides
Ultrasonography: On TRANSVAGINAL of the uterus: synchronous with the
SONOGRAPHY (TVS) maternal pulse; due to increased flow in
uterine vessels
–– Intra uterine gestational sac: visible by 5
weeks (For trans abdominal scan: 6 weeks) ƒƒ Fetal souffle: Rush of blood through the
umbilical arteries; synchronous with the
–– Embryo with cardiac activity: by 6 weeks fetal heart sounds.
(For transvaginal scan: 7 weeks)
–– Vaginal signs: Internal Ballotment: 16 – 28
–– Embryo should be visible once MSD is 25 mm; weeks
otherwise, it is anembryonic
•• Sonography
–– Cardiac activity should be seen once the –– Targeted Imaging for Fetal Anomaly (TIFFA)
embryo length is 5 mm is usually done at 18 – 20 weeks
True gestational Sac Pseudo Sac –– For gestational age estimation:
Eccentric Central
ƒƒ CRL (till 14 weeks): Most accurate
Regular, round Irregular determination of gestational age
Double ring sign seen Not seen
ƒƒ The BPD most accurate in 2nd trimester
Intra decidual sign seen Not seen
ƒƒ If dolichocephalic (flattened)/ brachycephalic
Yolk sac and fetal pole seen Not seen (rounded) head: HC most accurate
Peripheral vascularity seen Not seen
ƒƒ AC: Greatest variation for gestational age.
 ANTENATAL CARE

Preconception counseling •• Assess genetic risk: Formation of pedigree

chart, Age, Down syndrome risk
and care
•• Nutrition and supplements: BMI < 18, > 25
•• Screening of risk factors: HTN, DM – pre-
– abnormal, risk of anemia, fetal growth
gestational diabetes (GDM), Epilepsy.
restricted.
•• Immunization status: IgG, Rubella, CRS
•• Stop teratogenic drugs: Substitute with safer
(congenital Rubella syndrome).
drugs.
Positive – doesn’t requires immunization
•• Start preconception folic acid: neural tube
Negative – requires immunization defects.

Recommendation for preconceptional care

Intervention Proven Health Benefit
Folic Acid Supplementation Reduces occurrence of NTDs by 2/3rd.
•• Low Risk: 400 mcg
•• High Risk: 4 mg
Anti-epileptic drugs:
•• NTD – folic acid.
•• BMI >30: folic acid intake.
•• DM (cardiovascular anomalies).
Hepatitis B vaccination for at risk women Prevents transmission of Hepatitis B to the infant.

HIV screening/ Screening of STDs Reduces risk of ectopic pregnancy.

Reduces risk of infertility.
Reduces risk of fetal infection.
Rubella vaccination Protects against CRS, not to conceive pregnancy prior to 1 month.

Optimizing weight Reduces the risk of preterm/ NTD/ cesarean/ DM/ HTN.
Stop smoking Prevents preterm/ FGR/ abortions/ APH.
Reducing alcohol Prevents FAS
2
Obstetrics and Gynecology

Risk Factor Intervention Proven Health Benefit

Anti-Epileptic Change to less Teratogenic (LL) Lowers risk of malformations.
Safer drugs: levetiracetam.
Phenytoin – fetal hydantoin syndrome
(facial cleft, distal digital hypoplasia).
Multi agent – Single agent.
Anti-Hypertensive Avoid ACE-1, ARBs causes fetal renal Lowers risk of congenital malformations
agenesis,Assess Complications
Diabetes HbA1C < 6.5 /Higher HbA1C, higher risk of Reduced congenital anomalies, IUGR,
anomalies abortions
Hypothyroidism TSH < 2.5 in first trimester Decreases infertility, preterm birth and
<3 in 2nd and 3rd trimester neurological prognosis of fetus.

Hyperthyroidism Maintain TSH in low normal range Decreases pregnancy loss, preterm birth,
FGR, maternal CHF, thyroid storm, Neonatal
Grave’s disease

Asthma Inhalational therapy Decreases perinatal mortality, preterm, FGR

SLE ≥ 6 months of quiescence HTN, Preterm, FGR, IUD, neonatal lupus

Higher risk of preeclampsia, FGR, abortion, erythematosus
preterm labor, abruption Quiescent >6 month

Obstetric History and Parity Index

•• Gravida – no. of pregnancy including current •• LMP (First day of last LMP)
pregnancy
•• EDD calculated byNaegele’s Formula
•• Para — > POV
–– Subtract 3 months + 7 days
–– 28 weeks in developing countries
–– Add 9 months + 7 days
–– 24 weeks in developed countries, excluding
–– In IVF Pregnancy: ET (embryo transfer) + 38
the present pregnancy.
weeks (Add 9 months - 7 days)
•• Abortion - <20 weeks or < 500 g, 24-28 weeks
–– In Irregular cycles, add the extra days to
gray area not defined yet.
the EDD.
•• Living – no. of living children
Period of Gestation
Writing Parity Index / writing the obstetric
formula •• Trimesters: 1st (1 to 13th week)/ 2nd (14th to
27th week)/ 3rd (28th week and more)
1. G_P_L_A_
2. P A – B – C – D Pyramid of antenatal care
P A (term)-B (preterm)-C (living kids)-D (no of
abortion)

EDD and POG

 3
Antenatal Care

Schedule of Antenatal Visits (IMPORTANT)

As per MoHFW guidelines: 4 As per WHO guidelines: 8 As per ACOG and what is ideal/ practiced in
visits contact visits most settings: 12-14 visits
First visit – 12 weeks 1st trimester – 1 contact Up- to 28 weeks – every month
Second visit – 14-26 weeks 2nd trimester – 2 contact 28th to 36 weeks – every 2 weeks
Third visit – 28-34 weeks 3rd trimester – 5 contact >36 week –every week
Fourth visit — >36 weeks

Weight gain in pregnancy

Category (BMI) Total Weight Gain Range (kg) Weight gain (kg/week) in the 2nd and 3rd trimester

Underweight (< 18.5) 12-18 0.5

Normal Weight (18.5-24.9) 11-15 0.4
Overweight (25-29.9) 7-11 0.3
Obese (≥ 30) 5-9 0.2

1200mg)
Diet and Supplementation
–– Vitamin A: Requirement increased in lactation
•• Increased calorie requirement in pregnancy (i.e.
300 extra cal/day avg) –– Folic acid: requirement doubled
–– 1st trimester – 0 extra calories required –– Iodine, vitamin D, Thiamine, riboflavin, niacin,
pyridoxine, Vitamin C, vitamin B12, Zinc.
–– 2nd trimester – 350 extra calories required
–– 3rd trimester – 450 extra calories required Diet and supplementations
•• Protein requirement: Calcium Supplementation:
–– ↑ by about 15 g/day (Total: 60 mg/d).
•• Prevents pre-eclampsia, preterm birth, neonatal
–– Iron requirement ↑ by 15 mg/day. mortality
–– Calcium requirement: Doubled (600 mg to •• Improves maternal bone mineral content and
4
Obstetrics and Gynecology

bone development of neonates –– Each tablet containing 60 mg elemental Iron

+ 500 mcg Folic Acid, sugar-coated, red color
•• Improves breast milk concentration of calcium
(2 tab of calcium contains 500 mg + 250 IU –– Single dose of 400 mg albendazole preferably
vitamin D3 twice a day) in the 2nd trimester
•• Recommendation:
Immunization
–– Oral swallowable calcium tablets
•• Td (has replaced TT)
–– Twice a day (total 1g calcium/day)
–– 1st dose: Early in pregnancy
–– Start from 14 weeks of pregnancy
–– 2nd dose: 4 weeks after 1st dose
–– Till six months postpartum
–– Td-Booster
–– Tablet: 500 mg elemental calcium & 250 IU
•• Tdap recommended by ACOG
Vitamin D3
–– 2nd dose of Td should be replaced with Tdap
•• Preconceptionally and 1st trimester: Folic Acid
between 27-36 weeks
Iron supplementation: As per AMB, •• Covid-19 vaccine recommended in pregnancy and
lactation
–– Daily, 1 Iron and Folic Acid tablet starting
from the fourth month of pregnancy, •• Live vaccines are contra-indicated: Exceptions -
continued throughout pregnancy (minimum
–– Yellow fever
180 days during pregnancy) – to be continued
for 180 days, post-partum –– Rabies vaccine.
 IMMUNIZATION IN PREGNANCY

Remember: ƒƒ Tdap: One dose of Td replaced with Tdap

preferably given between 27-36 weeks of
•• All live vaccines except yellow fever are contra- gestation (ACOG Committee 2017)
indicated due to the theoretical risk of fetal
infection and teratogenicity –– Influenza (inactivated): As per ACOG,
seasonal administration is recommended
•• Live vaccines include: measles, mumps, rubella,
varicella, HPV, HZV, varicella BCG, live •• Also remember:
attenuated influenza, oral polio, rotavirus and –– All covid vaccines can be given in pregnancy
oral typhoid.
–– Tell patient not to conceive for 1 month after
•• Vaccines given in pregnancy live vaccine has been taken
–– TT, Td or Tdap –– Rabies vaccine is safe (post exposure
ƒƒ Td has replaced TT (as per MOHFW) prophylaxis)

ƒƒ 1st dose: early in pregnancy •• All vaccines can be given in lactation

ƒƒ 2nd dose: After 4 weeks •• Smallpox vaccine is the only known vaccine to
cause fetal harm.
ƒƒ Booster: if received 2 Td doses in a
pregnancy within the last 3 years

Important Table:
Vaccine During pregnancy
Td Yes
Tdap Yes, Preferred over Td, Ideally between 27 – 36 weeks
Influenza (inactivated) Yes
Influenza (Live attenuated) No, Delay till after delivery
Hepatitis A (Inactivated) Yes
Hepatitis B (Inactivated) Yes
Pneumococcal Polysaccharide (Inactivated) Yes
Meningococcal Quadrivalent Yes
Varicella (Live) No; Postpartum yes
MMR - Mumps, measles, rubella (Live) No; Postpartum yes
HPV Human papilloma virus (inactivated) No Delay till after pregnancy if indicated
Typhoid Vi polysaccharide (inactivated) Yes
Oral (Live) No
Rabies for post exposure prophylaxis (Live) Yes
Yellow Fever (Live) Yes, if you travel to endemic areas.
 ANTENATAL CARE: PRENATAL SCREENING

Screening for antenatal conditions is under 3 •• Pregnancy-specific levels for TSH (IMPORTANT)
main headings –– 1st Trimester - 0.1-2.5 mIU/l
1. Screening for pre-existing conditions –– 2nd Trimester - 0.2-3 mIU/l
2. Screening for pregnancy specific conditions (PRe- –– 3rd Trimester - 0.3-3 mIU/l
eclampais and GDM)
3. Screening for Down Syndrome Screening for Viral Infections and
syphilis
Screening for Anemia •• HIV, HBsAg, HCV
•• Pre-conceptionally
•• Potential for Vertical Transmission
•• At registration and then every trimester.
•• Screening for syphilis (poor perinatal outcome:
•• As per “Anemia Mukt Bharat”; Hb to be checked Remember Kassowitz law for syphilis: improving
at every contact. fetal outcome with each pregnancy)

Screening for Thyroid Disorders Screening for UTI

•• Why is screening essential? •• UTI is common in Pregnancy due to:
–– Hypothyroidism: Increased risk of abortions, –– Dilatation of the ureters and renal pelvis –
FGR, preterm, preeclampsia, neurological stasis of urine
deficits in the newborn.
–– Decreased ureteral peristalsis
–– Indian Thyroid Society recommends
•• Screening every trimester: To look for
screening of TSH levels in all pregnant
asymptomatic bacteriuria
women at the 1st visit (Ideally during pre-
conceptional counseling) •• Risk of progression to cystitis: 40%

•• TSH levels during pregnancy are lower in the •• Risk of progression to pyelonephritis: 25%
1st trimester
2
Obstetrics and Gynecology

Screening (PREDICTION) for Pre-eclampsia

Medical history and MAP Ultrasound markers (High Biochemical markers (Lower
Uterine A Pl) level of PIGF, PAPP-) A

PE risk calculation

Low risk High risk

Routine antenatal Intensive antenatal

care
care

Low dose aspirin

prophylaxis before
16 weeks

Screening for Diabetes in Pregnancy Screening for Down Syndrome

•• Diabetes in pregnancy could be pregestational •• Trisomy 21 (Down syndrome); is the most
(i.e. pre-existing or overt) or gestational (GDM) common non-lethal trisomy
•• Screening and Diagnosis •• Background risk: Based on age
–– IADPSG: –– 25 y: 1 in 5000
ƒƒ Done in the 1st trimester and again between –– 35 y: 1 in 250
24 – 28 weeks
–– 45 y: 1 in 20 Q
ƒƒ In the 1st trimester: for diagnosis of
•• Screening can be done:
Pregestational (overt) DM.
–– 1st trimester: USG, serum analytes
○○ FBS > 126 mg/dl OR
–– 2nd trimester: USG, serum analytes
○○ HbA1C > 6.5%, OR
–– Irrespective of trimester: Cell free DNA/
○○ RBS > 200 mg/ dl.
NIPT (can be done after 9-10 weeks)
ƒƒ Between 24 – 28 weeks: 75g OGTT –
FBS/ 1h/ 2h (92/180/153): Any 1 value 1st Trimester Screening: USG & Serum
abnormal: GDM analyte (dual marker)

India many places use the DIPSI test (one step 1. Ultrasound at 11 – 14 weeks: Features of Down
screening plus diagnostic): irrespective of prandial Syndrome include:
state – 75 g glucose - venous sample after 2 h –– Increased NT: This is the main one
–– > 120 mg/dl: Decreased glucose tolerance –– Absent nasal bone.
–– > 140 mg/dl: GDM –– Abnormal flow in the Ductus venosus.
–– > 200 mg/dl: Overt DM –– Tricuspid Regurgitation.
 3
Antenatal Care: Prenatal Screening

Nuchal Translucency (NT): Most important to 1. NT alone of used: 65% detection rate for Down
know Syndrome

1. Component of first trimester aneuploidy 2. Combined test: NT + Dual marker (beta hCG +
screening PAPP-A): 80% Detection rate

2. Represents maximum thickness of the 3. NT > 3 mm/ > 99th percentile: Significant
subcutaneous translucent area between the skin 2. 1st trimester (11-14 weeks) serum analytes for
and soft tissue overlying the fetal spine at the Down’s syndrome screening are: Beta hCG and
back of the neck. PAPP-A.
3. If NT increased, risk for β hCG PAPP-A
–– Fetal aneuploidy Trisomy 21 (Down) Increased Decreased

–– Various structural anomalies: CVS, hydrops, Trisomy 18 Decreased Decreased

cystic hygroma. (Edward)
Trisomy 13 (Patau) Decreased/ Decreased
4. Measured between 11 weeks – 13 weeks 6 days
Unchanged
(or 11- 14 weeks)
2nd Trimester Screening:
The triple and Quadruple test are done between 15 –
21 weeks. Q
•• Triple test: Free β hCG, unconjugated Estriol
(uE3) and Maternal Serum α-fetoprotein.
•• Quadruple tests are: Free β hCG, unconjugated
Estriol (uE3), Maternal Serum α-fetoprotein.
And Inhibin A.

(IMPORTANT) β hCG AFP uE3 Inhibin A

TRISOMY 21 Increased Decreased Decreased Increased
TRISOMY 18 Decreased Decreased Decreased -
TRISOMY 13 Unchanged/ Increased Decreased -
Decreased

*Easy to remember: B for Big; so in Down’s syndrome; derived primarily from apoptotic trophoblasts.
Beta hCG and InhiBin A: Big/ Increased
•• Done after 9 – 10 weeks
*King Edward Abdicated his throne so all levels are
•• Results in 7 – 10 days
decreased.
•• 99% Detection rate for Down syndrome
NIPT or cell free DNA screening: Salient
•• Limitations:
features:
–– Cost
•• Introduced in 2011
–– The DNA component may not actually reflect
•• It is a screening test (NOT DIAGNOSTIC)
fetal DNA and instead may reflect:
•• In 2020 (Oct), ACOG guidelines state that along
ƒƒ Placental mosaicism
with serum analytes and NT, cell free DNA can
be offered to all women as the initial screening ƒƒ Early demise of an aneuploid twin
modality for Down syndrome. ƒƒ Maternal mosaicism
•• Identification of DNA fragments that are
4
Obstetrics and Gynecology

ƒƒ Occult maternal malignancy •• Most Commonly performed prenatal diagnostic

procedure
–– Limited role in multiple pregnancy
•• Done at 15 – 20 weeks for prenatal diagnosis
–– In 4 – 8%: No result due to low fetal fraction
but can be done later also
of DNA
•• Indications:
Detection Rates of all Screening Tests for
Down Syndrome: –– Diagnosis of fetal genetic disorders (prenatal
diagnosis)
Test Detection Rate
–– Diagnosis of congenital infections
(%)
Maternal age alone 17 – 35 –– Rh alloimmunization (measurement of
NT alone 64 – 70 amniotic fluid bilirubin to determine severity
of fetal anemia)
Dual marker (βHCG + PAPP-A) 51 – 72
Combined (NT + Dual Marker) 80 –– Assessment of fetal lung maturity (Lecithin/
Triple test (βhCG + AFP + uE3) 70
Sphingomyelin ratio and measurement of
amniotic fluid phosphatidylglycerol in the
Quadruple (βhCG + AFP + uE3 + Inhibin 80
amniotic fluid)
A)
Integrated (1st trimester combined & 95 •• Technique:
2nd trimester Quad) –– 20 – 22 -gauge spinal needle
Stepwise sequential (1st trimester 95
–– Ultrasound guidance
double marker; if positive – diagnostic;
if negative: 2nd trimester Quad) –– Needle inserted into amniotic fluid pocket
Stepwise Contingent (1st trimester 90 –– Avoid umbilical cord, fetal parts
double; if positive – diagnostic;
–– Aspirate 10 – 20 ml if sending for fetal
negative – no further test; karyotype/FISH or chromosomal microarray
intermediate – 2nd trimester Quad)
–– Discard initial 1-2 ml (may be contamination
Ultrasound (18 – 20 weeks) 70
with maternal blood)
NIPT (Cell free DNA) 99
–– If Rh D negative: and unsensitized: Give
Anti-D
Prenatal Diagnostic Tests:
•• Complications:
1. Amniocentesis
–– Procedure related loss: 0.1-0.3%
2. Chorionic Villus Sampling
–– Amniotic fluid leakage
3. Fetal blood sampling/ Cordocentesis/ Percutaneous
Umbilical Vein Sampling –– Vaginal spotting

1. Amniocentesis: •• Early amniocentesis

–– 11- 14 weeks
–– Higher procedure related loss, increased
incidence of talipes equinovarus (clubfoot)
–– Not done now
 5
Antenatal Care: Prenatal Screening

2. Chorionic Villus Sampling •• Complications

–– Overall loss rate: higher than amniocentesis
because of background losses
–– Procedure related loss: same as amniocentesis
(0.1 -0.3%)
–– If done < 7 weeks: limb reduction defects &
oro mandibular defects
–– Vaginal spotting.

Cordocentesis:
•• Aspiration of blood from umbilical vein under
•• Done at 10 – 13 weeks.
USG guidance
•• Chorionic villi obtained via transabdominal or
•• Can be done after 18 weeks of gestation
transcervical route
•• In Rh iso-immunized pregnancies, it is done to
•• Advantage: do not have to wait till 15 weeks for
determine the level of fetal anemia and at the
amniocentesis, results quicker
same sitting, intrauterine blood transfusion can
also be performed.
 TERATOGENS

What are Teratogens? •• Fetal period: beyond 8 weeks post-conception:

some organs vulnerable
•• Any agent that causes an abnormality following
fetal exposure during pregnancy
Alcohol
•• Incidence of anomalies: 2-3%
•• Leading cause of preventable developmental
•• In 80% of anomalies, there is no obvious disabilities worldwide.
etiology.
•• Fetal Alcohol Syndrome.

Important Teratogens –– Neurobehavioral impairment.

Teratogens could be: –– Minor facial abnormalities.

•• Medication/chemical
•• Environmental factor
•• Maternal metabolite
•• Infection

Anti-epileptics-
•• Orofacial clefts, NTD (neural tube defects)
and cardiac defects
•• Valproic Acid: Greatest risk: 4-8-fold
•• If exposure occur during the critical •• Topiramate: 4-fold
developmental period; That is the Pre-
implantation period OR “All or None” period •• Carbamazepine and Phenytoin: 3-fold
(the 1st 2 weeks after fertilization). •• Phenobarbital: 2-fold
if exposure happens during this period, either the •• Multiple agents: higher risk (Newer:
fetus survives or dies. Levetiracetam and Lamotrigine: safer)
•• Embryonic period: 2nd- 8th week post- •• Fetal Hydantoin Syndrome:
conception: Period of organogenesis
–– Upturned nose
2
Obstetrics and Gynecology

–– Midfacial hypoplasia ACE-Inhibitors/Angiotensin Receptor

–– Distal digital hypoplasia Blockers
•• ACE-inhibitor fetopathy
•• Renal hypoperfusion – subsequent ischemia and
renal hypoperfusion
•• Oligohydramnios – pulmonary hypoplasia (Potter
sequence)
•• Shift to safer anti-hypertensive
preconceptionally

NSAIDs Anti-Neoplastic Drugs:

•• Important: Indomethacin •• Methotrexate : Craniosynostosis/Cloverleaf
skull
•• If given > 32 weeks: causes premature
constriction of the fetal ductus arteriosus – •• Tamoxifen: Vaginal adenosis.
subsequent pulmonary hypertension
•• Trastuzumab: Renal failure, pulmonary
•• < 32 weeks: Safer hypoplasia and skeletal abnormalities.

Antimicrobial Drugs Retinoid

•• Aminoglycosides- Nephrotoxic and ototoxic •• Isotretinoin embryopathy
•• Nitrofurantoin- Cleft lip in the 1st trimester –– Bilateral microtia/anotia
and Hypo plastic left heart syndrome
–– Flat/depressed nasal bridge
•• Sulfonamides- Neonatal hyperbilirubinemia
–– Neurodevelopmental defects
•• Tetracycline- Yellowish-brown discoloration of
deciduous teeth
 3
Teratogens

Methimazole Q
•• Cutis aplasia

Thalidomide Q
•• Thalidomide tragedy
•• Phocomelia (in pic)

Warfarin
•• Warfarin embryopathy (Di-sala syndrome) –
stippled epiphyses and nasal hypoplasia
•• Doses > 5 mg/day cause embryopathy
•• Results from fetal exposure between the 6th
and 9th weeks
•• Beyond the first trimester – hemorrhage into
fetal structures
•• Switch over to heparin preconceptionally or in
the first trimester
4
Obstetrics and Gynecology

Recreational Drugs
•• Amphetamines: major Teratogens
•• Cocaine: Additional maternal complications
•• Opioid Narcotics: Neonatal abstinence syndrome.
•• Marijuana: Preterm, Fetal growth restriction (FGR).
•• Tobacco/smoking
–– FGR
–– Preterm
–– APH (Antepartum hemorrhage)
–– Spontaneous abortion

Teratogens in Pregnancy:
Teratogen Defect
Antiepileptic Drugs (Na valproate is Facial features, Distal digital hypoplasia (Fetal hydantoin syndrome)
associated with highest risk)
ACE-I and ARBs Fetal renal hypoperfusion

Alcohol Fetal Alcohol Syndrome

Lithium Ebstein’s anomaly
Indomethacin (after 32 weeks) Premature closure of the ductus arteriosus
Methimazole Cutis aplasia
Warfarin Warfarin embryopathy
Thalidomide Phocomelia
Methotrexate Clover leaf skull

Misoprostol Mobius sequency (Facial palsy and limb abnormalities)

Antibiotics that are teratogenic Aminoglycoside: Ototoxic

Tetracyclines: teeth and bone deformities
Chloramphenicol: grey baby syndrome
Retinoic Acid Craniofacial abnormalities, anotia, clefting, NTD,

SSRIs Paroxetine: VSD

>20 weeks: Primary pulmonary HTN
Neonatal behavioral syndrome (jitteriness, irritability, hyper- or hypotonia,
feeding abnormalities, vomiting, hypoglycemia, thermoregulatory instability, and
respiratory abnormalities)
DES Clear cell adenocarcinoma, T-shaped uterus in females, hypospadias and
epididymal cysts, microphallus, undescended tests & hypospadias in males.
 FETAL IMAGING

Imaging in Pregnancy: Safety –– Increased incidence of childhood cancers

•• Most diagnostic radiographic procedures are •• NOAEL (No observed adverse effect level):
associated with minimal fetal risk –– 0.05 Gy; equivalent to >1000 Chest X Rays
•• Ionizing radiation (X ray and CT scan): can (Exposure from 1 chest X ray < 0.0001 Gy)
cause fetal harm by causing structural change •• Increased exposure with CT scans
in DNA – risk of
•• IV contrast agents are category B and can be
–– Abortion given for CT contrast studies
–– Malformations •• USG – safe
–– Fetal growth restriction •• MRI – safe (does not use ionizing radiation); but
Gadolinium in MRI is c/i
USG in Pregnancy
Components of 1st trimester USG Components of 2nd and 3rd trimester USG
Gestational sac size, location and number Fetal number
Embryo & yolk sac identification Cardiac activity
Fetal Cardiac Activity Fetal presentation
Crown – Rump length and estimation of gestational Placental location, appearance and relationship to the internal os
age

Assessment of anatomy appropriate for the first Amniotic Fluid Volume

trimester
Down’s syndrome screening Gestational age assessment & Fetal weight estimation
Chorionicity in multiple pregnancy Fetal anatomical survey
Evaluation of the uterus and adnexa Evaluation of the uterus, adnexa and cervix

1st trimester USG Important points: •• Absence of Cardiac activity at a CRL ≥ 7 mm –

non-viable pregnancy
•• On Trans-Vaginal scan (TVS)
•• FHR:
–– G.sac seen at 5 weeks
–– 110 – 130 bpm at 6 weeks
–– Yolk sac at 5.5 weeks
–– 160 – 170 bpm at 8 weeks
–– Embryo with CA: 6 weeks
•• Yolk Sac:
–– + 1 week for Transabdominal Scan
–– 1st anatomical structure identified within
•• Absence of an embryo at a Mean Sac Diameter
the g sac (5 weeks)
(MSD) ≥ 25 mm – anembryonic pregnancy
–– Undetectable after 10 weeks
2
Obstetrics and Gynecology

–– Large yolk sac: associated with poor True gestational Sac Pseudo Sac
obstetrical outcome
Eccentric Central
•• CRL: most accurate method to establish/ Regular, round Irregular
confirm GA Double ring sign seen Not seen
–– Measured in the Mid – sagittal plane Intra decidual sign seen Not seen
–– Embryo in neutral position Yolk sac and fetal pole seen Not seen
Peripheral vascularity seen Not seen
–– Till 13 weeks: accuracy of 5 – 7 days
•• Anomalies that can be detected at 11 – 14 weeks:
–– 2nd trimester: BPD
–– If dolichocephaly/ brachycephaly; HC better
–– AC: greatest variation

Yolk sac

gestational sac

Fetal pole

–– Acrania/ Anencephaly (MOST IMPORTANT)

–– Encephalocele
•• Double bleb sign: –– Alobar holoprosencephaly
–– Seen in 1st trimester –– Iniencephaly
–– 2 blebs seen –– Exomphalos
ƒƒ Amniotic sac –– Gastroschisis
ƒƒ Yolk sac –– Body-Stalk anomaly
–– Megacystis
–– Missing Limbs
•• 11-14 weeks: Also, Down Syndrome Screening
–– Nuchal Translucency (NT)
–– Absent nasal bone
–– Abnormalities in ductus venosus flow and
–– Tricuspid regurgitation
•• Imaging in multiple pregnancy
 3
Fetal Imaging

Lambda Sign: DCDA Twins Revered T Sign: MCDA Twins

2nd/ 3rd T rimester USG: Important –– Defect in the diaphragm through which
abdominal organs herniate into the thorax.
Points: Q
–– Left sided: 75% cases
•• Amniotic fluid is measured on ultrasound by 2
methods –– Can be detected as early as 14-15 weeks
but some may be undetected till the 3rd
1. Deepest vertical pocket (2 – 8 cm)
trimester
2. Amniotic Fluid Index (8 – 24 cm) – the liquor
–– Always look for associated cardiovascular
in 4 quadrants are measured and added up.
anomalies
•• Fetal anatomical Survey:
–– Amenable to fetal therapy: FETO (Fetal
–– Targeted Imaging For Fetal Anomalies endoscopic tracheal occlusion)
(TIFFA scan) Q
–– Best done 18 – 20 weeks, some anomalies ROLE of MRI in Obstetrics
are detected later especially fetal cardiac •• Advantages:
anomalies.
–– Not hindered by bony interface, maternal
•• Indications for FETAL ECHO obesity, oligohydramnios, engaged fetal head
–– Suspected fetal cardiac anomaly or –– Safety: No ionizing radiation
Extracardiac anomaly
•• Disadvantages:
–– Chromosomal anomaly
–– Time consuming, not portable, cost
–– Fetal arrhythmia
•• Indications:
–– Hydrops
–– Adjunct to USG in fetal anatomic survey
–– Thick NT
–– Placental invasion
–– Prev baby with CHD; Either parent with
–– Maternal pelvic masses
CHD
–– IVF conception Remember
–– Maternal anti Ro/ anti La –– Investigation of choice for placenta previa:
Transabdominal ultrasound
–– Exposure to Lithium/ teratogenic agents
–– Investigation of choice for placenta accreta:
–– Pregestational DM
Ultrasound with color Doppler.
–– Phenylketonuria

•• Congenital Diaphragmatic hernia (on USG):

 ABORTIONS AND RPL

D/d of bleeding in the 1st trimester Chromosomal Abnormalities: Seen in > 50% of all fetuses
Aneuploid (Abnormal Karyotype)
1. Obstetric Causes
•• Autosomal Trisomy: Most Common: 50 – 60%; Trisomy
i. Implantation bleeding (Placental Sign). 16 - Most common.
ii. Abortion (threatened, inevitable, incomplete, •• Monosomy: Monosomy X: 9 – 13%; single most
complete, missed). frequent specific chromosomal anomaly.

iii. Ectopic Pregnancy. •• Triploid: 11 – 12%.

•• Tetraploid: Rare.
iv. Molar pregnancy.
Euploid with chromosomal rearrangements (deletion,
2. Non-Obstetric Cause translocation, inversion): RARE;
i. Cervical erosion. Abort later than aneuploid.

ii. Cervical polyp. 2. Maternal Factors:

iii. Fibroid polyp. a) Infections (5%):

iv. Carcinoma cervix. a. Bacterial: Chlamydia, Neisseria,
Streptococcus agalactiae, Listeria
SPONTANEOUS ABORTION monocytogenes, Group B streptococci,
Syphilis
Definition of Abortion:
b. Viral: Rubella, CMV, HSV, HIV
•• A.k.a. miscarriage
c. Parasitic: Toxoplasma, Malaria
•• Termination of pregnancy < 20 weeks/500 g
(WHO, CDC and NCHS) b) Endocrine (10-15%):
•• OR Termination of pregnancy before the a. Luteal phase defect.
period of viability (usually taken as 28 weeks
b. Overt hypo and hyper-thyroidism.
in developing countries) – More practical
definition. c. Uncontrolled Diabetes mellitus.
•• Incidence: c) Anatomic (wide range 5-30%)
–– 15% of all pregnancies will end up in abortion. a. Mullerian anomalies: septate uterus,
–– 70% are first trimesters. Unicornuate, bicornuate and uterine
didelphys, DES associated anomalies
•• Causes/Etiology
b. Fibroid (submucosal)
1. Fetal Factors:
c. Intrauterine adhesions
Chromosomal abnormalities: MOST COMMON cause
of spontaneous abortion (> 50%) . d. Cervical insufficiency
2
Obstetrics and Gynecology

d) Environmental Factors: c. Cardiac diseases.

a. Cigarette smoking d. SLE, APLA.

b. Alcohol consumption e. Cancer.

c. Excessive caffeine f) Surgical procedures (infrequent

d. X Ray exposure (> 5 rads) association).

e. Teratogenic drugs 3. Paternal Factors:

a. Increased age
e) Medical Disorders (5-10%)
b. Chromosomal abnormalities in the
a. Thrombophilia.
spermatozoa
b. Renal disease.
4. Unexplained (40 – 60%).

Types of Spontaneous Abortion

Threatened Inevitable Incomplete Complete Missed
Bleeding Mild Mild-Heavy Heavy H/o Heavy Minimal
Abdominal pain Mild Moderate Moderate h/o moderate Absent

Uterine size = POG = POG ≤ POG < POG ≤ POG

Cervical Os Closed Open Open Closed Closed
Ultrasound Live fetus Products low Retained bits Empty uterus Dead fetus/
anembryonic
Treatment Conservative Evacuation Evacuation No intervention Evacuation/ Medical
termination.

Role of Anti-D in Abortions Sonographic Findings of:

•• Dose: CRL ≥ 7 mm and no heartbeat.

–– ≥ 12 weeks: 300 mcg MSD ≥ 25 mm and no embryo.

–– < 12 weeks: 50 mcg

MOST COMMONS (IMPORTANT)
•• When to give?
•• Most Common Cause of Spontaneous 1st OR 2nd
–– Ectopic pregnancy Trimester abortion: Chromosomal abnormality
–– Suction Evacuation in the FETUS (54%)

–– Any abortion > 12 weeks •• Most Common Chromosomal abnormality causing

spontaneous abortion: ANEUPLOIDY
–– Threatened abortion; < 12 weeks with heavy
bleeding •• Most common aneuploidy seen in abortions is
TRISOMY (50%)
•• When not to give?
•• Most common Trisomy seen in spontaneous
–– Threatened abortion; mild bleeding < 12 abortions: TRISOMY 16
weeks
•• Single most frequent specific chromosomal
–– Complete abortion < 12 weeks with no abnormality seen is MONOSOMY X (45 XO;
instrumentation Turner syndrome) – 10% of all conceptuses.

Guidelines for EARLY PREGNANCY Septic Abortions

LOSS Diagnosis (Society of •• Any type of abortion with clinical evidence of
Radiologists in Ultrasound; American infection of the uterus and its contents.
College of Radiology)
 3
Abortions and RPL

•• Criteria: •• Immunological Factors

–– Fever with temperature ≥ 100.4⁰ for > 24 h. •• Autoimmune:
–– Purulent vaginal discharge. –– Antiphospholipid Antibody Syndrome
(APLA): High occurrence of abortion without
–– Lower abdominal pain/ tenderness.
treatment (85-90%).
•• Clinical Grading
–– Inhibition of trophoblastic proliferation and
–– Grade 1: Localized to the uterus. function.
–– Grade 2: Pelvic spread. –– Antinuclear antibodies.
–– Grade 3: Generalized peritonitis, septicemia, –– Alloimmune factors.
endotoxic shock
•• Anatomical Causes
•• Treatment: Broad spectrum antibiotics +
–– More common cause of 2nd trimester RPL .
Evacuation
–– Congenital: Mullerian anomalies (Septate,
•• Indications for Laparotomy:
bicornuate and didelphys).
–– Uterine perforation.
–– Cervical insufficiency: Painless recurrent 2nd
–– Suspected intestinal injury. trimester losses.
–– Foreign body in abdomen. –– Asherman Syndrome.
–– Intra-abdominal abscess. –– Uterine Fibroids (submucosal) .
–– Septicemic shock not improving on •• Chromosomal anomalies:
conservative treatment.
–– 1st trimester RPL.

RECURRENT PREGNANCY LOSS –– 2 - 4%

•• Recurrent Pregnancy Loss (RPL) is classically –– Less significant in RPL; most common in
defined as: spontaneous abortions
–– 3 or more recurrent abortions –– Most common: BALANCED TRANSLOCATION
(Risk: 25%)
–– American Society for Reproductive medicine
(2013) now defines RPL as 2 or more failed •• Infections
pregnancies confirmed by USG/HPE.
–– Rare cause of RPL
ƒƒ Primary RPL : is if the woman has never had
–– Bacterial Vaginosis: Important
a live birth
•• Inherited Thrombophilia
ƒƒ Secondary RPL: multiple losses in a patient
with a prior live birth –– Protein C resistance (Factor V Leiden mutation):
Most common cause
•• Chance of successful pregnancy reduces with-
•• Others: deficiencies of Protein C, S,
–– Increasing no of losses.
antithrombin 3, hyperhomocysteinemia and
–– Increasing age. prothrombin gene mutation.
•• UNEXPLAINED: Most Common Cause of RPL
Etiology (40 – 50%)
•• Endocrine abnormalities
If asked:
–– Uncontrolled DM.
1st Trimester RPL: Think of Endocrine and
–– Thyroid abnormalities. Immunological Causes. Genetic causes are Rare.
–– Luteal phase defect (LPD) – Decreased 2nd trimester: Think of Anatomical causes (Cervical
progesterone. insufficiency) – 10 -15%.
–– PCOS, Hyperprolactinemia.
4
Obstetrics and Gynecology

Cervical Insufficiency ƒƒ Cervical tears during a previous delivery .

•• Typically presents as recurrent painless 2nd •• Diagnosis:

trimester loss. –– Classical history of repeated mid-trimester
•• Etiology painless cervical dilatation and delivery of
the conceptus .
–– Congenital:
–– During pregnancy:
ƒƒ Inherited weakness of cervix .
–– Measurement of cervical length: Cervical
ƒƒ Associated with uterine anomalies/ DES
length < 25 mm on Ultrasound & an internal
exposure.
os diameter > 8 mm (Normal cervical length
–– Acquired: Previous cervical trauma: at 14 weeks is 30 -40 mm)
ƒƒ Dilatation and curettage. –– Changes on Ultrasound in the cervix: T, V Y U
(Trust Your Vaginal Ultrasound)
ƒƒ Conization of cervix.
–– Interconceptional period: NOT DONE NOW
ƒƒ Cervical amputation (part of Fothergill
surgery). ƒƒ Passage of Hegar no 8 dilators without
resistance beyond the internal os .
ƒƒ Trachelectomy.

ƒƒ HSG: funnel shaped shadow seen .

 5
Abortions and RPL

•• Management: Cervical Cerclage is Treatment of

Choice.
–– 12 – 14 weeks (Except Lash procedure which
is ALWAYS done pre-pregnancy and trans
abdominal cerclage is preferably done pre-
pregnancy)
–– Indications for doing a cervical cerclage:
Old Terminology New Terminology
Prophylactic/ Elective → History Indicated

Therapeutic/Salvage → Ultrasound indicated

Rescue, emergency, urgent → Examination indicated

(IMPORTANT)
b. Shirodkar cerclage
•• History Indicated means: 3 or more previous
i. Placed during pregnancy (!2-14 weeks)
2nd trimester/ preterm births.
ii. Bladder pushed up
•• USG indicated means-
iii. Closer to internal os
–– H/o 1 or more preterm/ mid-trimester birth
with USG cervical length < 25 mm iv. More physiological than McDonald

ƒƒ Not recommended only for short cervical v. Usually done if previous failed McDonald
length with no h/o preterm/ mid- vi. A tape is inserted circumferentially near the os
trimester birth.
vii. Removed at 37 weeks
ƒƒ Also, not recommended for only funneling
seen with no shortening of cervical length.

Types of Cerclage Procedures

1. Transvaginal.
2. Transabdominal

1. Transvaginal
a. McDonald suture.
i. Purse string
ii. Below the level of the internal os
iii. Placed during pregnancy (12-14 weeks)
iv. Sutures removed at 37 weeks

c. Wurm’s Cerclage
i. 2 sutures taken as shown in figure
ii. Placed during pregnancy at 12-14 weeks
6
Obstetrics and Gynecology

iii. Removed at 37 weeks

d. Lash Cerclage
i. Done PRE-PREGNANCY
ii. A defect in cervix is removed and cervix
reconstructed Contraindications to cerclage (6 A’s)
iii. Delivery is ALWAYS by LSCS •• Any Bleeding (placenta previa)
iv. Sutures not removed •• Any Leaking (PPROM)
•• Any Infection (Chorioamnionitis)
•• Anomalous or dead baby
•• Uterine Activity/ cervix > 4 cm dilated
•• After 28 weeks

Antiphospholipid Antibody Syndrome

•• Commonly presents as RPL
•• Diagnosed based on Sapporo’s Criteria
–– Lab and Clinical criteria
2. Transabdominal: –– At least 1 clinical and 1 lab criteria must be
a. Could be done by laparotomy (1st introduced by present for diagnosis
Benson and Durfee) OR by Laparoscopy
Clinical Criteria
b. Preferably done pre-pregnancy but can also be
done during pregnancy Obstetric
c. Done in cases of failed transvaginal cerclage •• One or more unexplained death of a
procedures. morphologically normal fetus > 10 weeks.
d. Most physiological as it is highest (at the level of OR
the cervix)
•• Severe preeclampsia or placental insufficiency
necessitating delivery before 34 weeks.
OR
•• 3 or more consecutive spontaneous abortions
before 10 weeks.
 7
Abortions and RPL

Vascular •• Anti β2 glycoprotein – IgG or IgM Antibody

•• 1 or more episode of arterial/venous or small •• Reason for pregnancy loss in APLA is mainly
vessel thrombosis in any tissue or organ. by inhibition of trophoblast function and
differentiation leading to placental dysfunction.
Lab Criteria (Present on 2 or more occasions
at least 12 weeks apart) •• Management of APLA
–– Low dose aspirin as soon as pregnancy is
•• Presence of lupus anticoagulant
confirmed
OR
–– Low Molecular Weight Heparin (LMWH) once
•• Medium to high titers of IgG or IgM cardiac activity appears.
anticardiolipin Antibodies
OR

Summary of RPL and treatment (IMPORTANT).

Cause Diagnosis Treatment
Genetic(Balanced translocation) Parental karyotype Genetic Counseling
Endocrine
1.Thyroid dysfunction TFT, Thyroid Abs Treat
2. Diabetes FBS/ PPBS, HBA1C Treat
3. Luteal phase defect Luteal phase < 10 days Micronized progesterone
Progesterone levels < 15 nmol/L on
Day 21, Endometrial biopsy
Micronized Progesterone, continue
4. PCOS Rotterdam Criteria metformin
Anatomical
1. Fibroids (submucosal) USG/HSG/ Hysteroscopy Hysteroscopic myomectomy
2. Uterine anomalies USG (3D)/ MRI/ HSG/ Hystero- Correction of anomaly (like hysteroscopic
laparoscopy septoplasty if septate uterus)

3. Asherman Syndrome HSG/Hysteroscopy Hysteroscopic adhesiolysis

4. Cervical insufficiency History/USG in pregnancy Cervical Cerclage
Immunological
APLA Sapporo’s Criteria (Clinical + Lab) Aspirin as soon as pregnancy is confirmed +
LMWH once cardiac activity is seen.
 ECTOPIC PREGNANCY

•• Most common site for ectopic pregnancy: ƒƒ Highest risk: Progestasert>LNG-IUD >
Fallopian tube IUCD.
•• In the fallopian tube; Most common site is: 2. Evolution of Tubal Ectopic
Ampulla
•• Ampulla > Isthmus > Infundibulum > Interstitial
•• Heterotopic pregnancy: Q
–– Intrauterine + Ectopic
–– Incidence used to very rare (1 in 30000)
but now with ART, incidence is increasing
(1 in 1000)
–– Management: Surgical (Medical i.e.
methotrexate is contra-indicated)
1. Risk Factors
3. Clinical Features
–– H/o Tubal Surgery (e.g., for fertility
restoration or sterilization): HIGHEST RISK •• Classic Triad
(Ref: William’s Obstetrics 25th edition; page
1. Delayed menstruation
no 371)
2. Abdominal pain
–– Prior h/o salpingitis: 6 – 10-fold increased
risk 3. Vaginal Bleeding

–– H/o previous ectopic: 5-fold risk (10 – 15% •• Passage of a decidual cast
chance of repeat ectopic) •• Severe hemoperitoneum: diaphragmatic
–– Peri tubal adhesions irritation – shoulder pain

–– Salpingitis isthmica nodosa •• Pallor, Shock – uterine rupture

–– Congenital tubal anomalies •• Abdominal tenderness

–– Infertility (ART) •• Bimanual exam: cervical motion tenderness

ƒƒ Associated with Atypical implantations and •• Tender boggy mass in the post fornix (collected
heterotopic pregnancies blood)

–– Contraception: Relative numbers increased •• Cullen’s sign: Periumbilical bluish discoloration

with intrauterine devices (Absolute numbers due to intraperitoneal bleeding
decreased) 4. Investigations/ Diagnosis
1. Suspected Ruptured ectopic pregnancy
•• This is an obstetric emergency
•• Usually, clinical diagnosis is sufficient and time
2
Obstetrics and Gynecology

should not be wasted on unnecessary tests if •• Serum βhCG does not have a role in ruptured
there is clinical suspicion of a ruptured ectopic. ectopic pregnancy
•• CBC and a Blood gp/ Rh should be done urgently Suspected Unruptured Ectopic Pregnancy (IMPORTANT)
•• A positive or weakly positive urine pregnancy •• Trans-vaginal Sonography (TVS) will reveal
test
–– An absent intrauterine pregnancy
•• Trans vaginal sonography (TVS) will
–– The presence of a pseudo-sac in the uterine
reveal:
cavity
i. Absence of intrauterine pregnancy
–– The presence of an adnexal mass separate
ii. Pseudo-sac may be seen in the uterine cavity from the ovary
iii. Presence of an adnexal mass (usually ƒƒ Hyperechoic ring surrounding an anechoic
inhomogeneous) separate from the ovary sac- seen in 20%
iv. Evidence of hemoperitoneum ƒƒ Inhomogeneous mass – 60%
–– 50 ml of blood in the cul-de-sac can be seen ƒƒ Obvious gestational sac with a fetal pole
using TVS – 13%
–– TAS is used to estimate the amount of –– On color doppler: “Ring of fire” seen. (D/d –
hemoperitoneum – Free fluid in the Morrison Corpus luteal cyst)
pouch is seen on TAS when there is 400-
700ml of intraperitoneal blood
•• In the absence of TVS and if the diagnosis is
still in doubt: Culdocentesis can be done:
i. Simple technique
ii. Cervix pulled outward and upward (holding
a tenaculum/ vulsellum) on the posterior
cervix.
iii. 18-gauge needle is inserted in the posterior
“Ring of Fire” Sign on
fornix
Color Doppler-TVS
iv. Aspiration of non-clotting blood signifies
hemoperitoneum
5. Serum βhCG levels: (IMPORTANT)
v. A negative Culdocentesis does not rule out a
–– Discriminatory Zone: This is the level of
ruptured ectopic pregnancy
serum βhCG above which an intrauterine
gestational sac should be seen,
ƒƒ 1500 – 2000 IU/L for TVS Q
ƒƒ 5000 – 6000 IU/L for TAS Q
–– So, if serum βhCG levels are more than the
discriminatory zone and still an intrauterine
gestational sac is not seen on ultrasound, it is
called a pregnancy of undetermined location
& the following should be suspected:
ƒƒ Ectopic pregnancy
ƒƒ Failing intrauterine pregnancy
ƒƒ Recent complete abortion

Procedure of Culdocentesis
ƒƒ Early multifetal pregnancy
 3
Ectopic Pregnancy

–– If the serum βhCG is below the discriminatory 6. PREGNANCY OF UNDETERMINED LOCATION:

zone; it is unlikely to visualize anything on
•• Definition: No sign of an intra or extra uterine
the ultrasound. So
pregnancy on ultrasound despite a positive
ƒƒ Serial βhCG levels are done (Rise of more pregnancy test.
than 60% should be seen in 48 hours in an
intrauterine pregnancy)

Positive UPT
Algorithm for PUL/
Suspected Ectopic TVS – No IUP/ EP/ RPOC
“Pregnancy of Unknown Location” D

Asymptomatic Symptomatic

Expectant Surgical Management

Management Laparoscopy/ Laparotomy

Serum βhCG at
0 & 48 h

Falling > 15% Suboptimal (or) Rising (> 60%)

? Failing PUL ? Ectopic Pregnancy ? Intrauterine

Pregnancy

Repeat βhCG every week Serial βhCG until Serial βhCG Repeat TVS
to confirm falling trend when βhCG > 1500 IU/L
> 1500 IU/L
Consider weekly βhCG till
value < 10IU/L Further OR
Early intrauterine
TVS not required 3 measurements showing suboptimal pregnancy identified No
or / plateauing / fluctuating pattern further βhCG required
Repeat USG for viability

Repeat TVS

Ectopic Pregnancy Negative TVS? Early intrauterine

visualized Persisting PUL pregnancy identified No
Consider Medical Mx further βhCG required
Repeat USG for viability
4
Obstetrics and Gynecology

7. Management of Ectopic Pregnancy i. Patient hemodynamically stable

ii. No significant symptoms
iii. Gestational sac size < 3.5 cm
A. Unruptured Ectopic (IMPORTANT)
iv. No visible cardiac activity
1. Expectant Management –
v. Serum βhCG < 5000 IU/L
–– Only for clinically stable asymptomatic women
with an ultrasound diagnosis of ectopic vi. No contraindication to Methotrexate
pregnancy with the following features– (Anemia, liver disease, bleeding disorder,
active pulmonary disease etc.)
ƒƒ Clinically stable with No pain AND
•• Drug used: Methotrexate:
ƒƒ Serum βhCG < 1000 IU/L AND
–– MOA:
ƒƒ Tubal ectopic < 35mm with no visible heartbeat
AND Folic acid antagonist

ƒƒ Able to return for follow up ↓

–– Repeat βhCG levels on days 2, 4 and 7 after Acts by blocking the function of dihydrofolate
the original test reductase

–– If βhCG levels drop ≥ 15% from the previous ↓

values, then repeat weekly till a negative Blocks the conversion of dihydrofolate to
result tetrahydrofolate
–– If values fall < 15%, stay the same or rise ↓
from the previous value, review the condition
and consider shifting to medical/ surgical De novo synthesis of purines and pyrimidines is
management halted

2. Medical Management Arrest of DNA, RNA and protein synthesis

•• Indications: An unruptured ectopic pregnancy ↓

with: Thus, highly effective against proliferating tissue
like trophoblast
–– 2 protocols: Single dose and Multidose

Single Dose Multi Dose

Dosing One dose, repeat if necessary Upto 4 doses until serum βhCG declines by
15%

Medication dose
1. Methotrexate 50 mg/m2 BSA 1 mg/kg on Day 1, 3, 5, 7
2. Leucovorin NA 0.1mg/kg on Day 2,4, 6, 8
Serum βhCG level Day 1 (baseline), Day 4, Day 7 Day 1 (Baseline), Day 3, 5, 7

Indication for additional If serum βhCG does not decline by 15% If serum βhCG level declines< 15%, give
dose from day 4 to day 7 additional dose, repeat serum βhCG in 48h
OR less than 15% decline during weekly and compare with previous value, maximum 4
surveillance doses.
Surveillance Once 15% decline is achieved, then weekly
βhCG until undetectable
 5
Ectopic Pregnancy

Contraindications to Methotrexate (Mtx):

1. Sensitivity to Mtx
2. Tubal rupture
3. Breastfeeding
4. Intrauterine pregnancy
5. Peptic ulcer disease
6. Active pulmonary disease
7. Immunodeficiency
8. Hepatic, renal or hematologic dysfunction

3. Surgical Management in Unruptured Ectopic

Salpingectomy
–– Offer surgical management to:
i. an ectopic pregnancy and significant pain
ii. an ectopic pregnancy with an adnexal
mass of 35 mm or larger
iii. an ectopic pregnancy with a fetal
heartbeat visible on an ultrasound scan
iv. an ectopic pregnancy and a serum hCG
level of 5,000 IU/L or more
–– Laparoscopy is preferred Salpingostomy
i. SALPINGECTOMY: Preferred if:
○○ Extensive tubal involvement/ damage ○○ Salpingotomy (suturing the opened
incision), partial resection and
○○ Recurrent ectopic pregnancy in the
anastomoses and milking the tube are
same tube
not preferred methods.
○○ Completed family
○○ Ectopic at the site of a previous tubal B. Ruptured Ectopic:
sterilization •• Management of shock
ii. SALPINGOSTOMY: (Linear incision on •• Laparotomy/Laparoscopy (if hemodynamically
the antimesenteric border with removal stable) and SALPINGECTOMY – Treatment of
of products of conception) choice.
○○ Consider if a woman has other 8. OTHER ATYPICAL ECTOPIC PREGNANCIES
infertility factors also OR has a
1. Abdominal Ectopic Pregnancy:
contralateral damaged/removed tube
and wants to conceive in the future –– Primary (Primary implantation of the embryo
in the peritoneal cavity)
○○ Risk of Persistent tissue: Inform
women having a salpingostomy that –– Secondary (Usually from the tube; the
up to 1 in 5 women may need further embryo then implants in the peritoneal
treatment. This treatment may include cavity) – More common
methotrexate and/or a salpingectomy. –– Studdiford Criteria is for diagnosis of
○○ For women who have had a Primary abdominal pregnancy
salpingostomy, take 1 serum hCG i. Both tubes and ovaries normal with no
measurement at 7 days after surgery, marks of injury
then weekly till negative.
ii. Utero-peritoneal fistula should not be
seen
6
Obstetrics and Gynecology

iii. The placenta should be attached –– Rubin’s criteria

exclusively to the peritoneal surface
5. Cesarean Scar Pregnancy:
–– Diagnosis: Symptoms & Signs (But these
–– Increasing incidence due to increasing
are usually if the pregnancy continues to an
incidence of cesarean deliveries
advanced gestational age)
–– Medical (M tx) and Surgical Management
ƒƒ Uterine contour not made out
(excision and repair of cesarean scar site/
ƒƒ Braxton-Hicks absent hysteroscopic guided evacuation)
ƒƒ Abdominal parts superficially palpated, 6. Heterotopic Pregnancy:
FHR superficial
–– Both intra and extrauterine pregnancy
ƒƒ On pelvic exam, cervix displaced, presenting
–– Increasing incidence due to ART
part unusually high
9. Summary of management of Ectopic Pregnancy
Investigations:
(Tubal)
–– USG
–– MRI – To confirm diagnosis
History,
•• Treatment: Examination & Ix
–– Laparotomy: Anticipate excessive blood loss,
anticipate difficulty in removing placenta
2. Ovarian Pregnancy Unruptured Ruptured
–– Very rare
–– Risk factors, C/F and management: Similar to
a tubal ectopic. Expectant Medical Surgical
–– Diagnosis: Spiegelberg Criteria
i. The tube on the affected side must be
intact Laparoscopy Laparotomy
ii. The gestation sac must occupy the position of
the ovary
Conservative (Salpingostomy)/ Salpingectomy
iii. The gestation sac in the ovary must be
connected to the uterus by the ovarian
ligament
iv. Definite ovarian tissue must be found in
the sac wall on histopathology
3. Cornual Pregnancy
–– Implantation of fertilized ovum in a
rudimentary horn of a bicornuate uterus.
–– If undiagnosed, it usually ruptures in the
early 2nd trimester (14 – 18 weeks).
–– Treatment: Laparotomy with excision of the
affected rudimentary horn.
4. Cervical Pregnancy:
–– Implantation is in the endocervical canal
(below the internal os)
–– Presents as painless vaginal bleeding
 MOLAR PREGNANCY

Gestational Trophoblastic Disease (GTD): Includes b. Placental site trophoblastic disease

all abnormal trophoblastic proliferation pathologies.
c. Epithelioid trophoblastic tumor
Classified as:
•• Gestational Trophoblastic Neoplasia (GTN):
1. Hydatidiform Mole
Includes all the malignancies I.e.
a. Complete mole
1. Invasive mole
b. Partial mole
2. Choriocarcinoma
c. Invasive mole
3. Placental site trophoblastic disease
2. Non molar trophoblastic
4. Epithelioid trophoblastic tumor
a. Choriocarcinoma

Genetics

Complete Mole: Important Points and undergoes androgenesis (duplication) to

form the gamete which is DIPLOID (46 XX –
•• Completely Paternal Origin
MOST COMMON)
•• The ova is empty/ inactivated
OR
•• 2 ways complete mole happens:
2. 2 sperms (23X & 23 X or 23 X & 23Y)
1. One sperm (23X) fertilizes the empty ova i.e.,dispermy will fertilize the empty ova and
2
Obstetrics and Gynecology

form the gamete which is 46 XX or 46 XY •• Contains both paternal and maternal components
•• 2 sperms (either 23 X or 23 Y) fertilize an ovum
Partial Mole: Important Points (23X) and form a triploid gamete which could be
•• Always triploid. either 69 XXX or 69 XXY

Differences between partial & complete mole

Partial Mole Complete Mole
Karyotype 69 XXX or 69 XXY 46 XX
Clinical Presentation
• Uterine size = POG >POG

• Theca Lutein cyst Rare 25-30%

• Initial hCG levels < 100000 >100000

• Medical complications Less common More common

• Rate of subsequent GTN 1-5% 15-20%

Pathology
• Embryo-fetus Often present Absent

• Amnion, fetal erythrocytes Often present Absent

• Villous edema Focal Diffuse

• Trophoblastic proliferation Focal Diffuse

• Trophoblastic atypia Mild Marked

• P57 KIP2 immunostaining Positive Negative

•• Ethnicity
P57 kip 2 –This is a new technique of immunostaining
used to differentiate between complete and partial •• Prior 1 complete molar pregnancy – 1%
mole. This nuclear protein is maternally expressed and
•• Prior 2 complete moles – 20%
hence will be ABSENT in complete molar pregnancy.

C/F:
Symptoms:
•• Vaginal Bleeding: Most common presentation;
mixed with gelatinous fluid (White currant in
red currant juice)
•• Expulsion of grape like vesicles
•• Lower abdominal pain
•• Hyperemesis gravidarum
•• Thyrotoxic features
•• Breathlessness due to pulmonary embolism
•• Symptoms of preeclampsia
Grape like cluster image of complete mole
Signs
•• Pallor
Risk Factors
•• Extremes of age •• P/A:
 3
Molar Pregnancy

–– Size of the uterus > POG –– Oxytocin 20 U in 1 L RL – continuous infusion

–– Absent fetal parts –– Uterotonic agents (methergine, misoprostol,
carboprost)
–– Absent FHR
–– Karman’s cannula size 10-14
•• Vaginal exam
–– Under USG guidance
–– No Internal Ballotment
–– Gentle curette with blunt end
–– Adnexal masses (theca lutein cyst)
•• Post op
–– Vesicles seen extruding from the os
–– Anti-D
Diagnosis –– Initiate effective contraception
•• Serum β hCG
–– Review HPE
•• Hook effect on urinary hCG
–– Serum β hCG within 48 h of evacuation; then
•• Ultrasound weekly till undetectable.
–– SNOWSTORM APPEARANCE •• Post Evacuation Surveillance
–– Risk of progression to GTN
–– Done by serial measurement of β hCG to
detect persistent/ renewed trophoblastic
proliferation.
–– 2 days post evacuation – Baseline
–– Then weekly till negative (7 weeks for partial;
9 weeks for complete)
–– Then monthly for 6 months
–– Contraception

Risk Factors for progress to GTN

Management: SUCTION & 1. Complete vs Partial
EVACUATION
2. Older Maternal Age
•• Pre-operative:
3. βhCG levels > 100,000
–– Hemogram
4. Uterine size large for gestational age
–– Baseline serum β hCG
5. Theca lutein cysts > 6 cm
–– TSH
6. Slow decline in βhCG levels
–– Blood group & Rh
Important: Q
–– Chest X-Ray RISK of PROGRESS of COMPLETE MOLE TO GTN:15 -
•• Intra-op 20%
RISK OF PROGRESS OF PARTIAL MOLE TO GTN: 1 -
–– Large bore IV Cannula
5%
 ANTEPARTUM

Antepartum Fetal Surveillance tests 5. Contraction Stress Test

•• These are tests that tell us how the fetus is 6. Amniotic Fluid Volume
doing in utero 7. Umbilical Artery Doppler
•• They are especially indicated in all high- 1. Fetal movement count
risk pregnant women and in women who have
crossed their EDD (past dates) but a daily fetal •• 2 main methods
movement count is advised to all women after I. Cardiff count to 10: Count 10 movements; should
37 weeks count till 10 in 12h
II. Daily Fetal movement count: 1h post meal; total
Tests for Antepartum Fetal
movements in a day (Post breakfast + post lunch
Surveillance + post dinner = 12)
1. Fetal movement count 2. Non-Stress Test (NST)
2. Non-Stress Test (± Vibroacoustic stimulation) •• Remember this is different from CTG
3. Biophysical Profile (Cardiotocogram) although the machine used is
the same
4. Modified Biophysical Profile
NST CTG
Done antenatally (> 28 weeks) Done intrapartum
Measurement of only Fetal Heart Rate (FHR) Measures both the FHR and uterine pressure
Test of antepartum fetal surveillance Test of intrapartum fetal surveillance

•• Based on the principle that with fetal movement, •• Reactive NST: 2 or more accelerations in a 20
fetal heart rate increases minute period
•• 4 basic components of an NST or a CTG •• Sometimes the fetus is in sleep cycle and
has to be awakened to elicit movement (and
I. Baseline fetal heart rate (Normal is 110-160
acceleration), this can be achieved through a
bpm)
vibroacoustic stimulator (VAST)
II. Beat to beat variability: 5-25 bpm
III. Accelerations: Increase in the FHR (above
the baseline) by at least 15 bpm lasting for at
least 15 seconds). There should be at least 2
accelerations in a reactive NST (in 20 minutes)
IV. Decelerations: Decrease in the FHR (below
the baseline) by 15 bpm or more lasting for at
least 15 seconds). These should NOT be any
decelerations in a reactive NST.
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Obstetrics and Gynecology

NST machine. Has 3 probes:

1. Fetal heart rate probe
2. Toco probe (For use in CTG to measure uterine
pressure during a contraction)
3. Movement marker: This is a button which the
woman presses when she appreciates a movement.
This would appear as a mark on the graph and
should correspond to an acceleration

VAST: Used to wake the baby up!

3. Biophysical Profile:
•• Has 5 components

Reactive NST

Parameter Normal criteria Score

Non Stress Test Reactive 2
Fetal Breathing movements ≥ 1 episode> 30 seconds 2
Gross body movements ≥ 3 discrete body or limb movements 2
≥ 1 episode of active extension with return of
Fetal muscle tone 2
flexion or opening and closing of hand
Amniotic fluid Single deepest pocket > 2 cm 2

•• What to do depending on score? •• This tells how the fetus will respond to uterine
contractions
–– 8-10: Normal; less risk of fetal asphyxia; can
wait •• NST is done either after nipple stimulation
(This releases oxytocin and can cause mild
–– 6: Suspect asphyxia: If more than 36 weeks:
uterine conractions) OR after oxytocin
Deliver
–– 4: Suspect asphyxia; Deliver •• Not routinely done

–– 2: Strongly suspect asphyxia: Deliver; poor 6. Umbilical Artery Doppler

prognosis •• An umbilical artery with good diastolic flow
4. Modified BPP means a well oxygenated fetus

•• As the BPP takes time (30 mins) to see all •• As the oxygenation decreases it results in
parameters on ultrasound, a quicker way is the i. Reduced flow, f/b
modified BPP.
ii. Absent flow f/b
•• This includes AFI+NST
iii. Reversal of flow
•• AFI is a reflection of chronic fetal compromise
•• Reduced diastolic flow is also reflected as an
•• NST reflects acute changes in the fetus increase in the S/D ration and a decreased
5. Contraction Stress Test Pulsatility Index
 3
Antepartum
 INTRAPARTUM

INTRAPARTUM FETAL MONITORING Electronic fetal monitoring

(IMPORTANT)
Aims of intrapartum fetal surveillance
Two types:
•• Identification of decreased fetal oxygenation
1. External Monitoring: also called Cardiotocogram
•• Timely & effective intervention
(CTG). (If done in the antepartum period: It is
•• Prevention of brain injury called NST)

Methods
1. Intermittent auscultation: usually done in low-risk
women by using the stethoscope or the fetoscope,
fetal heart rate is auscultated
2. Cardiotocography (CTG)
3. Fetal scalp blood for pH
4. Fetal scalp blood for lactate 2. Internal monitoring:
5. Fetal ECG
6. Fetal pulse oximetry

Intermittent Auscultation

CTG – Components

•• 1st Stage:
–– 15 mins in high risk women/ women on oxytocin
–– 30 mins in low risk women
•• 2nd stage: 5 mins
2
Obstetric and Gynecology

•• The above image is of a Cardiotocograph.

•• The graph on top is measuring the fetal heart
rate and the graph below is measuring the
uterine contractions or toco (pressure).
•• The CTG has several components the same as
the NST.

These are:
1. Baseline fetal heart rate: 110-160 beats per minute
•• Fetal heart rate is a continuous wavy line not
2. Beat to Beat Variability: 5-25 beats per minute. like an adult pulse of 72 throughout.
3. Accelerations: These if seen on a CTG are always a •• Fetal heart rate changes every second, that is
good thing reassuring that the baby is fine. called beat to beat variability.
4. Decelerations: This is opposite of an acceleration, •• Variability is a sign of an intact autonomic
that is, the drop in the fetal heart rate by 15 beats nervous system.
per minute or more, lasting for at least 15 seconds.
Accelerations
Baseline Fetal Heart Rate: Normal
110 - 160 bpm
Tachycardia Bradycardia
> 160 beats per minute < 110 beats per minute
Important reasons of Important reasons of fetal
fetal tachycardia bradycardia
1. Fetal distress 1. Acute hypoxic or distressed
2. Maternal fetus
tachycardia 2. If the cord get compressed
3. Maternal fever or for e.g., if the cord gets
sepsis prolapsed out i.e., it come out
4. Chorioamnionitis of the uterus
•• A rise of the fetal heart rate and an increase
i.e., infection of 3. Maternal hypotension: of 15 beats per minute or more lasting for 15
the placenta and which could happen because of seconds or more is called acceleration
membranes excessive blood loss if she has
•• Accelerations reassures that the fetus is doing
5. Fetal arrhythmias or abruption of placenta previa
okay.
certain drugs that the there will be loss of blood
mother is taking and that can lead to fetal
bradycardia Decelerations
4. Arrhythmia

Beat to beat variability

 3
Intrapartum

•• It is a drop in the fetal heart rate of 15 beats

per minute or more lasting for 15 seconds or
more.
•• These are always seen in relation to the uterine
contractions because it helps in telling us the
type of deceleration and its possible causes.

Types of Deceleration
1. Early Deceleration:
•• When decelerations are in symmetry with the Variable Deceleration
uterine contractions, the nadir corresponds to
the peak of the contraction.
•• Early deceleration is seen when the head of the
fetus is compressed in the second stage of the
labor because of head compression
•• Early decelerations, specially in the second
stage of the labor ar normal
2. Late Deceleration:
•• The start, nadir and end of the deceleration
occurs after the start, peak and end of the
contraction
•• These are dangerous as this means that there Late Deceleration
is fetal distress
3. Variable Deceleration:
•• Variables are seen typically when the cord is
getting compressed.
•• Seen in Oligohydramnios.
4. Prolonged Deceleration:
Prolonged deceleration
•• It is a drop in the fetal heart rate by 15 beats
per minute or more lasting for > 2 minutes to <
10 minutes
•• If it is lasting for more than 10 minutes, it
becomes fetal bradycardia
•• It is seen in two classic conditions:
I. Prolapse of the umbilical cord

II. Intrapartum abruption

Sinusoidal pattern (seen in fetal anemia)

Early Deceleration
4
Obstetric and Gynecology

Interpretation
Feature Baseline (bpm) Variability (bpm) Decelerations Accelerations
Reassuring 110-160 (good) > 5 (good) None Present
Non-reassuring (Need to 100-109 < 5 for > 40 to Early deceleration The absence of
increase vigilance) 161-180 < 90 minutes Variable Deceleration accelerations with
•• Hydrate the patient and (mild bradycardia Single prolonged an otherwise normal
check for any abnormal or mild tachycardia) deceleration up to 3 CTG are of uncertain
factors like cephalopelvic minutes significance
disproportion.
•• We give oxygen to the
mother and make her lie in
the left lateral position to
improve the CTG

Abnormal <100 (bradycardia) < 5 for > 90 Atypical variable

(Need to take urgent action >180 (tachycardia) minutes decelerations
and deliver this baby) Sinusoidal Late decelerations
pattern > 10 Single prolonged
Minute deceleration > 3
minutes

Fetal scalp blood pH and lactate levels

Measurements Interpretation
pH Lactate

≥ 7.25 ≤ 4.1 mmol /

7.21-7.24 4.2-4.8 mmol/L Normal

≤ 7.20 (Hypoxic fetus) ≥ 4.9mmol/L (Hypoxic fetus) Borderline

Abnormal
 MATERNAL PELVIS AND FETAL SKULL AND
BASIC DEFINITION

Maternal Pelvis Pelvic Inlet

The Pelvis is divided into 2 parts •• Forms an angle of 550: Angle of inclination

1. False Pelvis •• High inclination: Sacralization of lumbar

vertebrae: Angle increases
•• Formed by the iliac portions of the innominate
bones –– Delayed engagement

•• Supports the growing uterus –– Occipito-posterior position

•• Boundaries –– Difficult descent

a. Posterior: Lumbar vertebrae •• Low inclination: No significance

b. Laterally: Iliac fossa •• Diameters

c. Anteriorly: Anterior abdominal wall –– ANTEROPOSTERIOR:

ƒƒ 3 AP diameters (depending on the anterior
point) – True conjugate, Obstetric
conjugate, and Diagonal conjugate
ƒƒ The diagonal conjugate is what is measured:
12 cm
ƒƒ Subtract 1.5 cm from diagonal conjugate:
Obstetric conjugate: 10.5 cm
ƒƒ True/ Anatomical conjugate: 11cm

2. True Pelvis: ○○ TRANSVERSE DIAMETER: 13cm

•• Actual bony canal through which the fetus ○○ OBLIQUE DIAMETER: Right oblique
passes means from the right sacro-iliac joint
and left oblique means from the left
•• Shallow anteriorly (Pubic symphysis) sacro-iliac joint: 12cm
•• Deep posteriorly (sacrum and coccyx) ○○ SACRO-COTYLOID 9.5 cm (PYP):
•• Divided into inlet, cavity and outlet Midpoint of sacral promontory to ilio-
pubic eminence
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Obstetrics and Gynecology

Sacro-cotyloid
diameter

Pelvic Cavity •• At the level of ischial spine

This has 2 planes •• Very important plane CLINICALLY Q

i. Narrowest part of pelvis
1. Plane of Greatest Dimension:
ii. Internal rotation takes place here
•• At the level of S2/3
iii. Origin of levator ani
•• Circular plane; AP diameter = Transverse
diameter = 12.5 cm iv. Landmark for pudendal block
•• Widest part of pelvis v. When engagement occurs, the head is
felt at 0 station, i.e. at this plane
2. Plane of Least dimension
vi. Deep Transverse Arrest occurs here
•• At the level of S3/4
 3
Maternal Pelvis And Fetal Skull And Basic Definition

Pelvic Outlet –– Anteroposterior: 13 cm (Obstetric i.e till

sacrococcygeal joint)
•• Diamond shape
•• Subpubic angle: Normally wide (850)
•• Anteriorly: pubic arch
•• Waste space of Morris: < 1 cm in an adequate
•• Base of triangle: Transverse diameter: Bi-
pelvis
tuberous diameter: 11 cm
•• Posteriorly: Also remember
–– Anatomically: Tip of coccyx •• Symphysis Pubis: Secondary fibro-cartilaginous
–– Obstetrically: sacro-coccygeal joint joint

•• Diameters •• Sacro-iliac joint: synovial joint

–– Transverse (Bi-tuberous diameter): 11 cm •• Sacrococcygeal joint: synovial hinge joint

The Fetus v. Facilitates molding

Important Landmarks vi. Helps determine flexion (In a well flexed
head, it won’t be felt on PV)
1. Sutures
vii.In the newborn:
•• Sagittal suture: Between 2 parietal bones
1. Depressed in dehydration
•• Coronal suture: Between parietal and frontal
bone 2. Bulging in hydrocephalus

•• Frontal suture: Between 2 frontal bones 3. CSF can be drawn through the lateral
ventricle
•• Lambdoid sutures: Between occipital and
parietal bones 4. Rarely: collection of blood and exchange
transfusion in the neonate
2. Fontanelle
•• Posterior fontanelle
•• Anterior fontanelle (Bregma):
i. Meeting point of 3 suture lines (Sagittal and
i. Meeting point of 4 sutures (Frontal, sagittal 2 lambdoid)
and on either side coronal)
ii. Triangular
ii. Diamond shaped
iii. 1.2 x 1.2 cm
iii. 3 x 3 cm
iv. Becomes bony at term.
iv. Membranous; ossifies at 18 months after
birth
4
Obstetrics and Gynecology

3. Areas
•• VERTEX: Quadrangular area bounded by
i. Bregma and coronal sutures
ii. Parietal bones
iii. Lambdoid sutures
•• BROW (SINCIPUT)
•• FACE
•• OCCIPUT

Diameters of the fetal skull:

TRANSVERSE DIAMETERS
1. Bi-parietal diameter: 9.5 cm (Diameter of
engagement)
2. Super sub parietal diameter: 8.5 cm
(Diameter that engages in asynclitism)
3. Bitemporal diameter: 8 cm

ANTERO-POSTERIOR DIAMETER:
These are the presenting diameters and change
depending on the attitude of flexion or extension of
the head.
 5
Maternal Pelvis And Fetal Skull And Basic Definition

Moulding –– Grade 1: skull bones touch

•• Alteration of fetal head in labor while passing –– Grade 2: overlapping of skull bones but can
through the bony pelvis be separated

•• Reduces diameters by 4mm –– Grade 3: overlapping but can’t be separated;

seen in OBSTRUCTED LABOR
•• Grading

Lie: Relationship of the long axis of the fetus to the long axis of the maternal spine
•• Longitudinal (99.5%)
•• Transverse
6
Obstetrics and Gynecology
•• Oblique 0.5%
Presenting Part:
•• Unstable
The part of the presentation that lies over the
internal os and that is felt through the cervix on
vaginal examination. The presenting part depends on
the attitude of flexion/ extension.

Denominator:
Longitudinal lie Oblique Lie Transverse Lie Arbitrarily chosen bony prominence on the presenting
part which is used to describe position

Presentation: Position:
The part of the fetus which occupies the lower pole Relationship of the denominator to different
of the uterus quadrants of the pelvis
•• Cephalic (96.5%)
Attitude
•• Breech (0.5%)
Relationship of fetal parts to one another
•• Shoulder (0.5%)
•• Flexion
•• Extension

(IMPORTANT)

Cephalic Breech Shoulder

Presentation Attitude Presenting Part Denominator Presenting Diameters

Cephalic Complete Flexion Vertex Occiput Sub Occipito Bregmatic 9.5 cm

Deflexion/ Military Vertex Occiput Occipito-Frontal 11.5 cm

Partial Extension Brow Frontum Vertico mental 14 cm

Complete Extension Face Mentum Sub-mento bregmatic 9.5 cm

 MECHANISM OF LABOR

1. ENGAGEMENT
•• When the largest transverse diameter of
foetus (BPD - 9.5 cm) crosses the pelvic brim

•• Flexion reduces the diameter

•• Occipital frontal diameter is 11.5cm and sub
occipital diameter is 9.5cm
•• In the vertex presentation, the vertex is flexed
2. DESCENT
such that the chin rests on the foetal chest,
•• Descent is a continuous process but is helped allowing the suboccipitobregmatic diameter
by 3 forces of approximately 9.5cm to be the diameter
through the maternal pelvis.
1. Direct myometrial pressure of the fundus
with contractions •• This is the smallest of the diameters to
negotiate the maternal pelvis.
2. Bearing down efforts of maternal abdominal
muscles 4. INTERNAL ROTATION
3. Extension and straightening of the fetal
body
•• Also an essential requirement of descent is
flexion (described next), as this allows the
smallest diameters to traverse the pelvis

•• Internal rotation happens because of uterine

contraction, and levator ani muscles also.
•• The fetal head twists (by 1/8th of a circle in
LOA) so that the sagittal suture of the fetus
3. FLEXION
finds a way to accommodate itself in the
changing0 contours of the pelvis.
2
Obstetrics and Gynecology

5. CROWNING AND EXTENSION 7. EXTERNAL ROTATION

•• During the next contraction, the shoulders,
having reached the pelvic floor, will complete
their rotation from a transverse position to
an anterior-posterior position, i.e. they will
undergo internal rotation which is manifested
by us seeing external rotation of the head.
•• Evidence of this manoeuvre happening inside
can be visualised by seeing the head externally
rotating as the foetus keeps its spine aligned.
•• When the widest diameter of the foetal head
8. DELIVERY OF SHOULDER
successfully negotiates through the narrowest
part of the maternal bony pelvis, the foetal
head is considered to be ‘crowning’.
•• This is clinically evident when the head, visible
at the vulva, no longer retreats between
contractions.
•• Complete delivery of the head is now imminent
and often the woman, who has been pushing, is
encouraged to pant so that the head is born
with control.
•• The occiput slips beneath the suprapubic arch
allowing the head to extend. •• Downward traction by the healthcare
professional will assist the delivery of the
•• The foetal head is now born by extension and
anterior shoulder below the suprapubic arch.
will be facing the maternal back with its occiput
anterior. •• This is followed by upward traction assisting
the delivery of the posterior shoulder.
6. RESTITUTION

Mnemonic
Every – Engagement
Darn – Descent
Fool – Flexion
In – Internal rotation
Egypt – External rotation
Royally – Restitution
•• This is the spontaneous realignment of the
Eats – External rotation
head with the shoulders, i.e. untwisting of the
twisted head, so this will also be by 1/8th of a Raw
circle Eggs – Expulsions
 INDUCTION OF LABOR

•• Initiation of uterine contractions in a quiescent ASSESSMENT BEFORE INDUCTION

uterus by a medical or mechanical method. OF LABOR
•• About 10-15% of all labours are induced. •• Review the indication

INDICATIONS OF INDUCTION OF •• Counsel the patient

LABOR •• Confirm the dates by asking last date of LMP

Maternal Indications– •• USG in first trimester/8-12 weeks
•• PROM. •• Examine the patient
•• Chorioamnionitis.
•• Bishop’s score – favorability of the cervix
•• Pre-eclampsia/eclampsia.
•• Abruptio placentae •• Exclude contra-indications
•• Intrahepatic cholestasis of pregnancy
•• Maternal request.
MODIFIED BISHOP SCORE
•• Post dated pregnancy. Components:
•• GDM.
1. Cervical Dilatation
•• Oligohydramnios.
2. Cervical length/effacement

Fetal Indications 3. Cervical consistency

•• Prolonged pregnancy 4. Cervical Position
•• Fetal growth restriction
5. Station of presenting part.
•• Oligohydramnios
Each component is scored between 0-3
•• Rh iso-immunized pregnancy
•• Fetal demise Mnemonic: BISHOP (IMPORTANT)
B – Bishop.
CONTRA-INDICATIONS TO INDUCTION I – effacement.
OF LABOR S – station.
1. Placenta Previa H – hard or soft.
2. CPD O – os dilatation.
3. Foetal bradycardia P – position of the cervix.
4. Malpresentation
5. Previous scared uterus
6. Any other contraindication to vaginal delivery
2
Obstetrics and Gynecology

Component Score
0 1 2 3
Cervical Dilatation 0 1-2 3-4 5-6
Cervical length (cm) >4 3-4 1-2 <1
Cervical position Posterior Central Anterior
Cervical consistency Firm Medium Soft
Station -3 -2 -1,0 +1,+2

CERVICAL RIPENING: is a part of induction 2. Chorioamnionitis/infection

of labor.

METHODS OF INDUCTION OF
LABOR

Medical methods:
•• Prostaglandins
–– PGE1(misoprostol)
–– PGE2(dinoprostone) – only one indication of
use, induction of labor/cervical ripening
•• Oxytocin
1. PGE1 (misoprostol)
–– Available as a tablet
–– It can be given orally/vaginally/ sublingually
as 25-50 mcg
2. Artificial rupture of membrane:
–– Can causes sudden vigorous contractions
(uterine tachysystole), fetal distress.
2. PGE2 (dinoprostone)
•• Available in the form an intracervical gel OR
•• Vaginal tablet in the name of prostin/propess
•• Preferred when Bishop score is poor; it causes
cervical ripening
3. OXYTOCIN
•• Introduced as IV infusion . •• Ruptured membrane will release prostaglandins
•• 1-2 ml IU/min – gradually increased. •• Advantages:
1. We can see the colour of the amniotic fluid.
Surgical methods:
•• Disadvantages:
1. Sweeping/Stripping of membranes:
1. Cervix needs to be dilated >3cm.
•• This sweeping of the fetal membrane
releases prostaglandins which induces uterine 2. Risk of chorioamnionitis.
contractions.
3. Abruption.
•• Drawbacks:
4. Cord can prolapse outside.
1. PROM
 3
Induction of Labor

2. Foley’s Catheter with/without Extra Amniotic

saline instillation.

Amino Hook

Newer methods:
•• Nitric oxide donors
•• Relaxin
Kocher Forceps
•• Mifepristone
Mechanical methods: •• Buccal oxytocin (patch).
1. Dilators: Laminaria Tents/hygroscopic cervical •• Interleukin-8 .
dilators.
 STAGES OF LABOR AND LABOR
MANAGEMENT

Definition of Normal Labor Stages of Labor

•• Spontaneous 1. Stage 1: From onset of true labor pains to full
dilatation of the cervix
•• Term
2. Stage 2: From full dilatation of the cervix to
•• Cephalic presentation
delivery of the baby
•• Without undue prolongation
3. Stage 3: From delivery of baby to delivery of
•• With minimum aids placenta
•• Without any complications to mom and baby 4. Stage 4: 1 hour of observation following delivery of
placenta

Pain Pathways in Labor

2
Obstetrics and Gynecology

First Stage: The pain is mainly visceral/ T10-L1 6, TNF), infection, vaginal examination, and
separation or rupture of the membranes.
Second stage:
•• Prostaglandins enhance gap junction
•• Visceral pain + somatic pain
(intermembranous gap between two cells
•• Pain is transmitted via S2-S4 through which stimulus flows) formation.

Causes of Onset of Labor 1ST STAGE OF LABOR: WHAT

1. Uterine distension ACTUALLY HAPPENS AND
2. Feto-placental contribution MANAGEMENT OF THIS STAGE
•• Cascade of events activate fetal hypothalamic- •• The first stage is chiefly concerned with the
pituitary-adrenal axis prior to onset of labor → preparation of the birth canal so as to facilitate
increased CRH → increased release of ACTH → expulsion of the fetus in the second stage.
fetal adrenals → increased cortisol secretion •• The main events that occur in the first stage
→ accelerated production of estrogen and are
prostaglandins from the placenta
–– Dilatation and effacement of the cervix and
3. Estrogen:
–– Full formation of lower uterine segment
•• Increases the release of oxytocin from maternal
•• Lower uterine segment:
pituitary
–– It is developed from the isthmus of the
•• Promotes the synthesis of myometrial receptors
(nonpregnant) uterus,
for oxytocin (by 100–200 folds), prostaglandins
and increase in gap junctions in myometrial cells –– This segment is formed maximally during
labor and the peritoneum is loosely attached
•• Accelerates lysosomal disintegration in the
anteriorly.
decidual and amnion cells resulting in increased
prostaglandin (PGF2D) synthesis –– It measures 7.5–10 cm when fully formed and
becomes cylindrical during the second stage
•• Stimulates the synthesis of myometrial
of labor
contractile protein—actomyosin through cAMP
–– This segment has got poor retractile property
•• Increases the excitability of the myometrial
compared to the upper segment.
cell membranes.
–– Clinical significance of the lower uterine
4. Progesterone:
segment
•• It is the alteration in the Estrogen :
ƒƒ Implantation of placenta in lower segment
Progesterone ratio rather than the fall in the
is known as placenta previa
absolute concentration of progesterone, which
is linked with prostaglandin synthesis and labor ƒƒ It is through this segment that cesarean
onset section is performed.
•• So a FUNCTIONAL DEFICIENCY of progesterone ƒƒ Poor decidual reaction in this segment
is responsible for labor onset facilitates morbid adherent placenta
5. Prostaglandins: ƒƒ In obstructed labor, the lower segment is
very much stretched and thinned out and
•• Prostaglandins are the important factors which
ultimately gives way (ruptures) especially
initiate and maintain labor.
in multipara
•• The major sites of synthesis of prostaglandins
ƒƒ Because of poor retractile property, there
are—amnion, chorion, decidual cells and
is chance of postpartum hemorrhage if
myometrium.
placenta is implanted over the area.
•• Synthesis is triggered by—rise in estrogen
level, glucocorticoids, mechanical stretching
in late pregnancy, increase in cytokines (IL–1,
 3
Stages of Labor And Labor Management

•• Management of 1st stage of labor ○○ No cervical dilatation in 2 hours

–– 1st stage of labor is divided into
ƒƒ Latent phase
ƒƒ Active phase
–– The definition of active phase has changed
over the years
–– Initially it was defined as starting at 3 cm
(Friedman curve) so 0-3 cm was latent phase
and 3-10 cm was active phase
Understand this graph: It is very important and
–– This was later changed to 4 cm, I.e. active commonly asked!
labor was defined as starting at 4 cm
–– Now this is taken to be 5 cm (WHO definition WHO Guidelines for Management of 1st Stage of
as per the labor care guide); and 6 cm (as per Labor (2018)
ACOG based on studies by Zhang et al) •• What are the recommendations
–– PROLONGED LATENT PHASE –– Respectful Maternity care
ƒƒ A latent phase > 20h in a primi and > 14 h –– Effective Communication
in a multi
–– Companionship during labor and birth
ƒƒ Management:
–– Continuity of care: This means continued
ƒƒ Expectant management care in the antepartum/ intrapartum and
ƒƒ Rest and analgesic are usually given postpartum period

ƒƒ Prolonged latent phase is not an indication –– Active labor is defined as starting from 5 cm
for cesarean delivery onward

–– DISORDERS OF ACTIVE PHASE –– Duration of latent phase: Varies; should not

go beyond 12h (primi) and 10h (multi)
ƒƒ Protracted (slow) dilatation
–– The rate of cervical dilatation of 1cm/h
○○ Dilatation of < 1.2 cm/h in a multi
should not be followed
○○ Dilatation of < 1 cm/h in a primi
–– Avoid medical intervention to hasten labor
ƒƒ Arrest of dilatation before 5 cm
4
Obstetrics and Gynecology

–– Delay admission if in latent labor relief during labour, depending on a woman’s

preferences.
–– Routine clinical pelvimetry on admission in
labour is not recommended for healthy –– Pain relief for preventing delay and reducing
pregnant women. the use of augmentation in labour is not
recommended.
–– Routine cardiotocography is not recommended
for the assessment of fetal well-being on –– For women at low risk, oral fluid and food
labour admission in healthy pregnant women intake during labour is recommended.
presenting in spontaneous labour.
–– Encouraging the adoption of mobility and an
–– Auscultation using a Doppler ultrasound upright position during labour in women at
device or Pinard fetal stethoscope is low risk is recommended.
recommended for the assessment of fetal
–– Routine vaginal cleansing with chlorhexidine
wellbeing on labour admission.
during labour for the purpose of preventing
–– Routine perineal/pubic shaving prior to giving infectious morbidities is not recommended.
vaginal birth is not recommended.
–– A package of care for active management of
–– The administration of enema for reducing labour for prevention of delay in labour is
the use of labour augmentation is not not recommended.
recommended
–– The use of amniotomy alone for prevention of
–– Digital vaginal examination at intervals of delay in labour is not recommended.
four hours is recommended for routine
–– The use of early amniotomy with early
assessment of active first stage of labour in
oxytocin augmentation for prevention of
low-risk women
delay in labour is not recommended.
–– Continuous cardiotocography is not
–– The use of oxytocin for prevention of delay in
recommended for assessment of fetal well-
labour in women receiving epidural analgesia
being in healthy pregnant women undergoing
is not recommended.
spontaneous labour.
–– The use of antispasmodic agents for
–– Intermittent auscultation of the fetal heart
prevention of delay in labour is not
rate with either a Doppler ultrasound device
recommended.
or Pinard fetal stethoscope is recommended
for healthy pregnant women in labour. –– The use of intravenous fluids with the aim
of shortening the duration of labour is not
–– Epidural analgesia is recommended for
recommended
healthy pregnant women requesting pain
relief during labour, depending on a woman’s In brief, the WHO (2018) says in 1st stage of labor
preferences.
–– Parenteral opioids, such as fentanyl,
RECOMMENDED
diamorphine and pethidine, are recommended •• Respectful maternity care
options for healthy pregnant women •• Effective communication and companionship
requesting pain relief during labour,
depending on a woman’s preferences. •• Continuity of care

–– Relaxation techniques, including progressive •• Definition of active labor: 5 cm

muscle relaxation, breathing, music, •• Delay admission till active labor
mindfulness and other techniques, are
recommended for healthy pregnant women •• PV every 4h to check progress of labor
requesting pain relief during labour, •• FHR checking with doppler/ stethoscope
depending on a woman’s preferences.
•• Pain relief with epidural/ opioid/ manual
–– Manual techniques, such as massage or techniques/ relaxation techniques
application of warm packs, are recommended
•• Encourage mobility
for healthy pregnant women requesting pain
 5
Stages of Labor And Labor Management

•• Fluid and food intake Second stage has two phases:

(1) Propulsive—from full dilatation until head touches
NOT RECOMMENDED the pelvic floor.
•• Routine clinical pelvimetry
(2) Expulsive—since the time mother has irresistible
•• Routine CTG at admission desire to “bear down” and push until the baby is
•• Routine vaginal cleansing with chlorhexidine delivered.
during labour •• In the 2nd stage, one of the main events is
•• The use of amniotomy alone for prevention of descent of the fetal head
delay •• Descent of the fetal head can be checked
•• The use of early amniotomy with early oxytocin abdominally by palpation OR by checking the
augmentation for prevention of delay in labour station on vaginal exam

•• The use of oxytocin for prevention of delay in •• Progressive descent of the head can be usefully
labour in women receiving epidural analgesia assessed abdominally by estimating the number
of “fifths” of the head above the pelvic brim
•• The use of antispasmodic agents for prevention (Crichton).
of delay in labour
•• The 2nd stage is also where we see crowning
•• The use of intravenous fluids with the aim of (when the head is visible without having to
shortening the duration of labour separate the labia
•• Episiotomy (Not routine) is given at crowning
2nd STAGE OF LABOR: WHAT
ACTUALLY HAPPENS AND •• The baby is delivered by “Ritgen maneuver” i.e.,
controlled extension of the head
MANAGEMENT OF THIS STAGE

PROLONGED 2nd STAGE:

•• Mean duration of second stage is 50 minutes for primi and 20 minutes in multipara.
•• Prolonged second stage is diagnosed if the duration exceeds 2 hours in nullipara and 1 hour in a multipara
when no regional anesthesia is used.
•• One hour or more is permitted in both the groups when regional anesthesia is used during labor (ACOG).
•• Disorders of the second stage:
–– Protraction of descent is defined when the descent of the presenting part (station) is at less than 1
cm/h in a nullipara or less than 2 cm/h in a multipara.
–– Arrest of descent is diagnosed when no progress in descent (no change in station) is observed over a
period of at least 2 hours.
6
Obstetrics and Gynecology

•• Causes of protracted or arrest of descent: based on a woman’s preferences and available

options.
–– CPD
–– Malposition (OP) 6. Episiotomy policy

–– Malpresentation (face/ brow) •• Routine or liberal use of episiotomy is

not recommended for women undergoing
–– inadequate uterine contradictions spontaneous vaginal birth.
–– Asynclitism. 7. Fundal pressure
As per WHO guidelines on intrapartum care for •• Application of manual fundal pressure to
a positive birth experience (2018), these are the facilitate childbirth during the second stage of
recommendations in 2nd stage labour is not recommended.
1. Definition and duration of the second stage of In brief in 2nd stage of labor (WHO guidelines 2018)
labour:
•• The second stage is the period of time between Recommended
full cervical dilatation and birth of the baby, •• Duration of 2nd stage in primi – 3h, multi – 2h
during which the woman has an involuntary urge
to bear down, as a result of expulsive uterine •• Birthing position of choice
contractions. •• Encouraged to follow their own urge to push
•• In first labours, birth is usually completed •• Reduce perineal trauma by – hands on guarding/
within 3 hours whereas in subsequent labours, warm compress/ perineal massage
birth is usually completed within 2 hours.
2. Recommended Birth position (for women with or Not recommended
without epidural analgesia) •• Routine episiotomy
•• For women without epidural analgesia, •• Fundal pressure
encouraging the adoption of a birth position of
the individual woman’s choice, including upright 3rd STAGE OF LABOR: WHAT
positions, is recommended.
ACTUALLY HAPPENS AND
3. Method of pushing MANAGEMENT OF THIS STAGE
•• Women in the expulsive phase of the second •• The third stage of labor comprises the phase
stage of labour should be encouraged and of placental separation; its descent to the
supported to follow their own urge to push. lower segment and finally its expulsion with the
4. Method of pushing (for women with epidural membranes.
analgesia) –– PLACENTAL SEPARATION: Mechanism of
•• For women with epidural analgesia in the second separation: There are two ways of separation
stage of labour, delaying pushing for one to of placenta
two hours after full dilatation or until the ƒƒ Central separation (Schultze): Detachment
woman regains the sensory urge to bear down is of placenta from its uterine attachment
recommended in the context where resources starts at the center resulting in opening up
are available for longer stay in second stage and of few uterine sinuses and accumulation of
perinatal hypoxia can be adequately assessed blood behind the placenta (retroplacental
and managed. hematoma). With increasing contraction,
5. Techniques for preventing perineal trauma. more and more detachment occurs
facilitated by weight of the placenta and
•• For women in the second stage of labour, retroplacental blood until whole of the
techniques to reduce perineal trauma and placenta gets detached. (Remember as
facilitate spontaneous birth (including perineal SHINY SCHULZ)
massage, warm compresses and a “hands on”
guarding of the perineum) are recommended, ƒƒ Marginal separation (Mathews-Duncan):
 7
Stages of Labor And Labor Management

Separation starts at the margin as it is AMTSL which essentially emphasized the main
mostly unsupported. With progressive 3 things but with additional information which
uterine contraction, more and more areas was
of the placenta get separated. Marginal
–– Oxytocin is the uterotonic of choice for
separation is found more frequently.
AMTSL (10 IU IM/IV)
(Remember as DIRTY DUNCAN)
–– Do Controlled cord traction only if a skilled
birth attendant is present.
–– Sustained uterine massage is not
recommended for all women who’ve received
uterotonic; instead; postpartum uterine
tone assessment for early identification of
uterine atony is done.
–– Delayed cord clamping (performed after 1 to
3 minutes after birth) is recommended for all
births while initiating simultaneous essential
newborn care (This is not to prevent atonic
PPH but was introduced along with AMTSL
Shiny Schulz Dirty Duncan to ensure it is followed)
•• In 2018, the WHO issued further guidelines
ƒƒ SIGNS of SEPERATION OF PLACENTA on which other uterotonics can be used for
AMTSL. These include:
○○ Sudden gush of fresh blood
–– Oxytocin (10 IU IM/IV)
○○ Apparent lengthening of cord
–– Carbetocin (!00 mcg IM/IV)
○○ Supra-pubic bulge of the contracted
pelvis –– Misoprostol (400 OR 600 mcg PO – to be used
where Skilled birth attendant isn’t available)
○○ Placenta felt in the vagina
–– Ergometrine/methylergometrine (200 mcg
ƒƒ Mechanism of control of bleeding:
IV EXCEPT in hypertensive women))
○○ After placental separation,
–– Oxytocin and ergometrine fixed-dose
innumerable torn sinuses which
combination (5 IU/500 µg, IM)
have free circulation of blood from
uterine and ovarian vessels have to be •• Injectable prostaglandins (carboprost or
obliterated. sulprostone) are not recommended for the
prevention of PPH
○○ The sinuses are obliterated by the
myometrial fibers which act like a •• AMTSL decreases
living ligature –– Incidence of PPH.

Active Management of 3rd Stage of –– Length of third stage of labor.

Labor –– Percentage of third stages of labor lasting
longer than 30 minutes.
•• Described by the WHO in 2007
–– Need for blood transfusion.
•• Involves mainly 3 basic steps.
–– Need for uterotonic drugs to manage PPH
–– Administering a uterotonic
–– Controlled cord traction
–– Uterine massage
•• AMTSL prevents atonic PPH.
•• In 2012, the WHO issued new guidelines for
 PARTOGRAM

PARTOGRAPH
•• A graphical representation of the key events in
labor
•• Early warning system
•• Inexpensive and pragmatic
•• Medico legal document

HISTORY
•• WHO modified partograph is plotted from 4 cm
onwards (i,e, active labor)
•• When cervicograph is plotted, the 1 cm/ h rule
is very important to note i.e. the cervix dilates
in the active phase by 1 cm/ hour which on the
WHO modified partograph is called the Alert
line. This is the minimum rate at which the
patient should be dilating.
–– Anything to the left of the alert line is normal
–– Anything to the right of the alert line is slow
progress; check for reasons
–– The alert line is also called the transfer line
(for women at PHCs, once this is crossed,
the patient needs to be referred)
•• Friedman cervicograph
•• Action line drawn four hours to the right of the
•• First stage of labor can be divided into two alert line. If this line is crossed, then immediate
part: delivery is warranted.
a) Latent: 0-3 cm •• The 1st marking of cervical dilatation is always
b) Active: 3-10cm on the alert line.
ƒƒ Changed to 4cm
WHO NExt Generation Partograph:
ƒƒ Further changed to 5 cm (by WHO in 2018) The WHO Labor Care guide
and 6 cm by ACOG
Components of the LCG
2
Obstetrics and Gynecology

•• Primarily designed to be used for the care of •• Section 2: Supportive care

apparently healthy pregnant women and their
•• Section 3: Care of the baby
babies (i.e., women with low-risk pregnancies)
•• Section 4: Care of the woman
•• Should be initiated when the woman enters the
active phase of the first stage of labor (5 cm •• Section 5: Labor progress
or more cervical dilatation), regardless of her •• Section 6: Medication
parity and membranes status
•• Section 7: Shared decision-making
STRUCTURE OF THE WHO LABOR CARE
GUIDE
•• Section 1: Identifying information and labor
characteristics at admission
Section 1: Identifying information and labor characteristics at admission

Rupture membrane (Date and Time) U – unknown

 3
Partogram

Section 2: Supportive Care

Y = Yes
Companionship N = No
D = Women declines
Y = Yes
Pain relief N = No
D = Women declines to receive pharmacological or non-pharmacological pain relief
Y = Yes
N = No
Oral fluids D = Women declines

Posture SP = Supine
MO = Mobile

Section 3: Care of the baby

N = No
E = Early
FHR deceleration L = Late
V = variable

I = intact membranes
Amniotic fluid C = membranes rupture, clear fluid
M = meconium – stained fluid: record +, ++ and +++ to represent non-significant, medium
and thick meconium respectively
B = blood – stained fluid
Fetal position A = Any occiput anterior position
P = Any occiput posterior position
T = Any occiput transverse position

Caput 0 (None)
+
4
Obstetrics and Gynecology

++
+++ (Marked)
0 (None)
+ (sutures apposed)
Molding ++ ( sutures overlapped but reducible)
+++ (sutures overlapped and not reducible)

Section 4: Women
P – (No proteinuria)
P Trace (Trace of proteinuria)
Urine P1 +
P2 +
P3 +
A – (No acetonuria)
A1 +
Acetone A2 +
A3 +
A4 +

Section 5: Labor Progress

Here there is no alert line or action a. At 5cm, as long as all else is ok, we can wait for
line but after 5cm, time based 6 hours

criteria are there. b. At 6cm, the cut off time is 5h

1. For Eg c. At 7cm, the cut off time is 3h
 5
Partogram

d. At 8cm, the cut off time is 2.5h

e. At 9cm, the cut off time is 2h

Section 6: Medication

•• The labor care guide creates a positive feedback

and decision – making loop, as health personnel
are encouraged to regularly:
Assess → assess the well-being of women and her
baby, and progress of labor
Record → document labor observations
Check reference threshold → compare labor
observation with reference values in the “alert”
column
Plan → decide whether and what interventions
are required, in consultation with the women, and
document accordingly.
 OCCIPITO-POSTERIOR

Definition corresponding to the neck

It is a vertex presentation with the fetal back –– Fetal movement may be detected near the
directed posteriorly. middle line
•• Palpation:
Incidence
–– Fundal grip:
•• 10% at onset of labour.
ƒƒ The breech is felt as a soft, bulky, irregular
•• Right occipito-posterior (ROP) is more common non-ballotable mass.
than left occipito-posterior (LOP) because:
–– Lateral grip:
–– The left oblique diameter is reduced by the
presence of sigmoid colon. ƒƒ The back felt with difficulty in the flank
away from the middle line.
Etiology ƒƒ The limbs are easily felt near, or on both
•• The shape of the pelvis: sides, of the middle line

–– Anthropoid: MC pelvis associated with OP –– First pelvic grip:

–– Android pelvises ƒƒ The head is usually not engaged due to

deflexion
•• Maternal kyphosis: The convexity of the fetal
back fits with the concavity of the lumbar –– Second pelvic grip:
kyphosis. ƒƒ The head is usually deflexed
•• Anterior insertion of the placenta •• Auscultation:
•• Other causes of malpresentations: as –– FHS are heard in the flank away from the
–– Placenta praevia middle line.

–– Pelvic tumors –– In major degree of deflexion, the FHS may

be heard in middle line.
–– Pendulous abdomen (grandmulti)
–– Polyhydramnios Mechanism of Labour
–– Multiple pregnancy There are 4 methods of the mechanism of
–– Deflexed head labor
1. Long Arc Rotation (90%); most favourable
Diagnosis
•• Deflexion is corrected and complete flexion
During pregnancy occurs. The occiput meets the pelvic floor first,
long anterior rotation 3/8 circle (1350) occurs
•• Inspection: bringing the occiput anteriorly and the fetus is
–– Sub-umbilical flattening delivered normally.
–– A groove may be seen below the umbilicus 2. Short Arc Rotation: (10%) face to pubis
2
Obstetrics and Gynecology

–– In marked deflexion, the sinciput meets Images in OP

the pelvic floor first, rotates 1/8 circle
anteriorly and the occiput becomes direct
posterior.
3. Deep transverse arrest (DTA): 1%
•• In mild deflexion, the occiput rotates 1/8 circle
anteriorly and then the head is arrested in the
transverse diameter.
•• This commonly happens in android pelvis
•• DTA is defined as when the sagittal suture is
stuck in the transverse diameter at ‘0’ station
with arrest of labor. The cervix is fully dilated.
There are good uterine contractions but there
is no further descent of head
–– In primigravida, this is usually because of
CPD and cesarean should be done
–– In multigravida: Usually happens because
of a deflexed head and a vacuum can help.
Hence vacuum can be attempted (Rotational
forceps are usually not done now)
4.Persistent occipito-posterior (3%):
•• Sometimes due to deflexion, internal rotation
does not happen and the head stays as such.
•• If this is the case, cesarean should be done.

Factors favoring long anterior rotation

•• Well flexed head
•• Good uterine contractions.
•• Roomy pelvis.
•• Good pelvic floor. Deep Transverse Arrest
•• No premature rupture of membranes.
 FACE AND BROW PRESENTATION

Definition Positions
•• It is a cephalic presentation in which the head
is completely extended.

Incidence
•• About 1:500 labors.

Etiology
•• Anencephaly
•• Loops of the cord around the neck.
•• Tumors of the fetal neck e.g., congenital goiter
•• Hypertonicity of the extensor muscles of the
neck
•• Dolichocephaly
•• Prematurity Mento-Anterior Mento-Posterior

•• Contracted pelvis
•• Pendulous abdomen or marked lateral obliquity Diagnosis
of the uterus.
Antepartum
•• Other causes of malpresentations as
polyhydramnios and placenta praevia. •• The back is difficult to feel.
•• The limbs are felt more prominent in the mento-
anterior position.
•• Second pelvic grip: the occiput is at a higher
level than the sinciput.
•• A groove is felt on the same side as back
•• The FHS are heard below the umbilicus through
the fetal chest wall in mento-anterior position.
•• Ultrasound confirms the diagnosis and
may identify associated fetal anomalies as
anencephaly.

During labour
Vaginal examination (through an open os)shows the
following identifying features for face:
2
Obstetrics and Gynecology

•• supra-orbital ridges, •• Flexion: is the movement by which the head is

delivered in mento-anterior position when the
•• The malar processes,
submental region hinges below the symphysis.
•• The nose (rubbery and saddle shaped),
•• Restitution.
•• The mouth with hard areolar ridges.
•• External rotation
•• The chin.
•• Expulsion of the remaining body
Late in labour, the face becomes edematous so it can
** Remember the main difference is just interchange
be misdiagnosed as a buttock (breech presentation)
flexion with extension and extension with flexion in
where the two cheeks are mistaken with buttocks
mechanism of labor with OA
and the mouth with anus and the malar processes
with the ischial tuberosities. The following points can **Engagement is delayed because:
differentiate in-between:
•• The biparietal diameter does not pass the plane
Face Presentation Frank Breech of pelvic inlet until the chin is below the level of
The fetal mouth and The anus is on the same line the ischial spines and the face begins to distend
malar processes form the with the ischial tuberosities. the perineum.
apexes of a triangle. •• Moulding does not occur as in vertex
The gum is felt hard No hard object through the presentation.
through the mouth anus.
The examining finger may The anus does not suck Mento-posterior position
be sucked by the fetal the finger. There may be
•• Long anterior rotation 3/8 circle (2/3 of cases):
mouth during vaginal meconium on the finger
examination. –– So the head is delivered as mento-anterior.
•• In about 1/3 of cases one of the following may
occur:
–– Deep transverse arrest of the face: when
the chin rotates 1/8 circle anteriorly.
–– Persistent mento-posterior: when no rotation
occurs.
–– Direct mento-posterior: When the chin
rotates 1/8 circle posteriorly.
In the last 3 conditions no further progress occurs
and labour is obstructed.
Direct mento-posterior DOES NOT HAVE A
MECHANISM OF LABOR because:
Mechanism of Labour
•• As the length of the sacrum is 10 cm and that
Remember of neck is only 5 cm, the shoulders enter the
pelvis and become impacted while the head still
•• Transverse diameter is the BPD: 9.5cm
in the pelvis, thus the labour is obstructed.
•• AP diameter is the Sub mento bregmatic
diameter: 9.5 cm Management of Labour
Mento-anterior position
Mento-anterior
•• Engagement (delayed)
•• Spontaneous delivery usually occurs.
•• Descent
•• Forceps delivery may be indicated in prolonged
•• Extension 2nd stage.
•• Internal rotation of chin 1/8 circle anteriorly. •• Vacuum CANNOT be applied
 3
Face and Brow Presentation

•• Episiotomy is necessary because of over neck

distension of the vulva.
•• Dolichocephaly
•• The face may appear edematous and congested
•• Prematurity

Mento-posterior: •• Contracted pelvis

•• Wait for long anterior rotation of the mentum •• Pendulous abdomen or marked lateral obliquity
of the uterus.
•• Failure of long anterior rotation: Deliver by
CESAREAN •• Other causes of malpresentations as
polyhydramnios and placenta praevia
BROW PRESENTATION
Diagnosis
Definition
It is a cephalic presentation in which the head During pregnancy:
is midway between flexion and extension: Partial •• Cephalic presentation
Extension.
•• Similar to face, a groove may be felt on the
same side as the back
•• The occiput and sinciput may be felt at the
same level.
•• Ultrasonography may be helpful.

During labour:
•• In addition to the previous findings, vaginal
examination reveals the following features:
–– Frontal bones,
–– Supra-orbital ridges, and
–– Root of the nose is felt but not the chin.

Mechanism of Labour
Incidence
•• Persistent brow:
About 1:1000 labour. –– The engagement diameter is the mento-
Etiology vertical 13.5 cm which is longer than any
diameter of the inlet so there is no mechanism
•• Anencephaly of labour and labour is obstructed.
•• Loops of the cord around the neck. –– If however flexion or complete extension
•• Tumors of the fetal neck e.g., congenital goiter happen, the fetus may deliver vaginally

•• Hypertonicity of the extensor muscles of the Management

•• If persistent brow: cesarean section is done
 BREECH PRESENTATION

Definition •• Short cord

•• It is a longitudinal lie in which the buttocks is •• Uterine and pelvic tumors

the presenting part with or without the lower •• Placenta praevia
limbs.
Types
Incidence
•• Complete breech (Flexed Breech):
•• 3.5% of term pregnancies
–– Both knees and hips are flexed.
•• 25% of pre-term pregnancies
–– More common in multipara.
Etiology •• Frank breech (Extended Breech):
•• Prematurity –– Flexed hips where the knees are extended
•• Multiple pregnancy –– More common in primigravida.
•• Poly-and oligohydramnios •• Footling presentation:
•• Hydrocephalus. –– The hip and knee joints are extended
•• Intrauterine fetal death. –– More common in preterm singleton breeches.
•• Bicornuate and septate uterus •• Knee presentation:
–– The hip is extended, and the knee is flexed

Lie: Longitudinal lie

Presentation: Podalic
Presenting part: Breech
Denominator: Sacrum
2
Obstetrics and Gynecology

Positions Mechanism of Labour

•• Left sacro-anterior
Delivery of the buttocks
•• Right sacro-anterior
•• The engagement diameter is the bi-trochanteric
•• Right sacro-posterior diameter 10 cm which enters the pelvis in one of
•• Left sacro-posterior the oblique diameters.

•• Left and right sacro- transverse •• The anterior buttock meets the pelvic floor
first, so it rotates 1/8 circle anteriorly.
•• Direct sacro-anterior and posterior
•• The anterior buttock hinges below the symphysis
Diagnosis and the posterior buttock is delivered first by
lateral flexion of the spines followed by the
Palpation (Grips) anterior buttock.
•• Fundal grip: the head is felt as a smooth, hard, •• External rotation occurs so that the sacrum
round ballotable mass comes anteriorly.
•• Lateral grips: back on 1 side/ limbs on the other
side Delivery of the shoulders
•• Pelvic grips: the breech is felt as a smooth, soft •• The shoulders enter the same oblique diameter
mass continuous with the back. with the biacromial diameter 12 cm (between
the acromial processes of the scapulae).
Ultrasonography: •• The anterior shoulder meets the pelvic floor
•• It is used for the following: first, rotates 1/8 circle anteriorly, hinges under
the symphysis, then the posterior shoulder
–– To confirm the diagnosis. is delivered first followed by the anterior
–– To detect the type of breech. shoulder.
–– To detect gestational age and fetal weight
Delivery of the after-coming head
–– To exclude hyperextension of the head.
•• The head enters the pelvis in the opposite
–– To exclude congenital anomalies. oblique diameter.
–– Diagnosis of unsuspected twins. •• The occiput rotates 1/8 circle anteriorly, in
–– Placental localization case of sacro- anterior position and 3/8 circle
anteriorly in case of sacro- posterior position.
–– Uterine anomalies sometimes can be made out
•• Rarely, the occiput rotates posteriorly, and this
should be prevented by the obstetrician.
During Labour
In addition to the previous findings, vaginal examination The head is delivered by movement of
reveals.
flexion in:
•• The 3 bony landmarks of breech namely 2 ischial
•• Direct occipito-posterior (face to pubis)
tuberosities and tip of the sacrum.
•• Face mento-anterior
•• The feet are felt beside the buttocks in
complete breech. •• The after coming head in breech presentation

•• Fresh meconium may be found on the examining The head is delivered by extension in normal labour
fingers. only i.e. occipito - anterior positions.

•• Male genitalia may be felt.

Management of Breech Presentation
•• The main thing to decide is whether she can
deliver vaginally (Assisted breech delivery) or
by cesarean
 3
Breech Presentation

•• Assisted breech delivery is associated with –– Dead fetus

increased risk of birth injuries and the after
–– Distressed fetus
coming head can get stuck
–– Denied consent
•• Hence it is important to see
(**Previous scar on the uterus is a Relative contra-
–– Can we turn the baby (External cephalic
indication for ECV)
version)
•• Complications of ECV:
–– IF ECV not possible; Are factors favourable
for assisted breech delivery or cesarean –– Abruption
(Zatuchni Andros scoring) –– Rupture of membranes   

External Cephalic Version –– Preterm labour.  

•• It regains its importance after an increased –– Fetal distress.

rate of caesarean sections nowadays –– Cord presentation or prolapse   
•• Timing: ideally at 36 weeks –– Entangling of the cord around the fetus.
•• Version is not done earlier because: –– Isoimmunization in Rh-negative mothers due
–– Return to breech presentation is liable to to feto-maternal transfusion.
occur.
Caesarean Section
–– If labour occurs the fetus will have a lesser
chance for survival. Indications:
•• Version is difficult after 37th weeks due to: •• Primi breech
–– Larger fetal size. •• Complicated breech (Breech with any other
–– Relatively less liquor obstetric complications)

•• Success rate: 50-70%. •• Large fetus i.e., > 3.75 kg estimated by

ultrasound
•• Causes of failure:
•• Preterm fetus
–– Large fetus
•• Footling or complete breech: as the presenting
–– Oligo- or polyhydramnios irregular part is not well fitting with the lower
–– Short umbilical cord uterine segment leading to increased incidence
of cord prolapse
–– Uterine anomalies as bicornuate or septate
uterus. •• Hyperextended head (Star-gazing fetus):
diagnosed by ultrasound
–– Irritable uterus
•• Contracted pelvis: of any degree.
–– Obesity
–– Rigid abdominal wall Vaginal Delivery
–– Frank breech because the legs act as a splint Prerequisites:
–– Anterior placenta •• Frank breech
•• Absolute Contraindications of ECV: •• Estimated fetal weight not more than 3.75 kg
–– Placenta Previa •• Gestational age: 36-42 weeks
–– Contracted Pelvis •• Flexed head
–– Multiple Pregnancy •• Adequate pelvis
–– Hyperextended head •• Normal progress of labour by using the
–– Uterine Anomaly Partogram
4
Obstetrics and Gynecology

•• Uncomplicated pregnancy uterine contractions and relax in between

until the perineum is distended by the
•• Multiparas
buttocks. (climbing the perineum)
•• An experienced obstetrician
–– An episiotomy is indicated done
However, caesarean section should only be done if the
–– The legs are hooked out but without traction.
premature fetus has a reasonable chance of post -
natal survival. –– When the umbilicus appears, a loop of the cord
is hooked to prevent traction or compression
Zatuchni Andros Scoring: As shown below. This
of the cord and detect its pulsation.
helps determine patients who are favourable for
assisted breech delivery. A score of 0-4: Cesarean is –– The fetus is covered with warm towel to
recommended prevent premature stimulation of respiration.
0 1 2 •• Delivery of the shoulders:

Parity Primi Multi –– Gentle steady downward traction is applied

to the fetal pelvic girdle during uterine
Gestational Age ≥ 39 weeks 38 weeks < 37 weeks contractions with gradual rotation of the
fetus to bring the shoulders in the antero-
EFW > 3.5 3-3.5 <3 posterior diameter of the pelvis.
Previous breech 0 1 ≥2 –– When the anterior scapula appears below
the symphysis, both arms are delivered by
Cervical Dilatation ≤2 3 ≥4 hooking the index finger at the elbow and
sweep the forearm across the chest of the
Station ≥ -3 -2 ≤ -1
fetus
–– The back is rotated anteriorly.
Management of Vaginal Breech
–– If the shoulders are arrested/ shoulders lie
Delivery
above the head, Lovset maneuver is done
First stage: as other malpresentations.
Second stage: The fetus may be delivered by one of
the following methods:
1. Spontaneous breech delivery:
•• This is rarely occurring in multipara with
adequate pelvis, strong uterine contractions,
and a small sized baby like in small preterm
babies
•• The baby is delivered spontaneously without
any assistance
2. Assisted breech delivery:
•• This is the method of delivery in far majority
of cases.
•• The assistance is indicated for delivery of the
shoulders and after-coming head and the infant
is allowed to be delivered up to the umbilicus
spontaneously.
•• Delivery of the buttocks:
–– The golden rule is to “Keep your hands off”
–– The patient is asked to bear down during
Lovset Maneuver
 5
Breech Presentation

•• Delivery of the after-coming head: It is

delivered by one of the following methods:
–– Mauriceau-Smellie-Veit method:
ƒƒ Two fingers of the left hand, (as
originally described) or better on the
malar eminencies (the maxillae) to avoid
dislocation of the jaw.
ƒƒ The index and ring finger of the right
hand are placed on each shoulder while
the middle finger is pressing against
the occiput to promote flexion and
act as a splint for the neck, preventing
hyperextension and hence cervical spine
injury.
ƒƒ Traction is given downwards and backwards
till the nape of the fetus appears; the
body is lifted towards the mother’s •• Forceps:
abdomen.
–– Piper’s forceps is more suitable for
aftercoming head
–– It is applied from the ventral aspect of the
fetus.
–– Traction is applied downwards and backwards
till the nape appears, then downwards and
forwards to deliver the head by flexion.
–– Forceps delivery has the following advantages:
–– It promotes flexion of the head.
–– Traction is applied on the head and not on the
neck.
–– It prevents sudden compression and
decompression of the head.

•• Burns - Marshall’s method: –– It protects the head from compression by

pelvic bones or rigid perineum.
–– The fetus is left hanging so that its weight
exerts gentle downwards and backwards
traction.
–– When the nape appears, grasp the feet, and
lift the body towards the mother’s abdomen.

3. Breech extraction:
•• This is complete delivery of the breech by
assistance
•• The only indication for Total breech extraction
is in 2nd of twin (if transverse lie and if an
6
Obstetrics and Gynecology

external version has failed) ƒƒ Intracranial haemorrhage: is the

commonest cause of death due to sudden
•• It is done under General Anesthesia
compression and decompression of the
head as there is no gradual moulding of
Complications of Breech Delivery the head.
•• Maternal:
ƒƒ Fracture dislocation of the cervical spines
–– Prolonged labour with maternal distress.
ƒƒ Asphyxia due to:
–– Obstructed labour with its sequelae may
ƒƒ Rupture of an abdominal organ: from rough
occur as in impacted breech with extended
manipulations avoided by grasping the
legs.
fetus from its hips only.
–– Laceration especially perineal.
–– Non-fatal injuries:
–– Postpartum haemorrhage due to prolonged
ƒƒ Fracture femur, humerus or clavicle.
labour and lacerations.
ƒƒ Dislocation of joints or lower jaw.
–– Puerperal sepsis.
ƒƒ Injury to the external genitalia.
•• Fetal:
ƒƒ Brachial plexus injury.
–– Fetal mortality:
ƒƒ Lacerations to the sternomastoid muscles.
ƒƒ Is about 4% in multipara and 8% in
primigravida which may be due to:
 TRANSVERSE LIE AND CORD PROLAPSE

Transverse Lie
Definition
•• The longitudinal axis of the fetus is perpendicular
to that of the mother

Incidence
•• 0.5% by the time labour commences.
•• Scapulo-anterior are more common than
Etiology scapulo-posterior as the concavity of the front
•• Maternal: of the fetus tends to fit with the convexity of
the maternal spines.
–– Contracted pelvis
–– Lax abdominal wall Diagnosis
–– Uterine causes bicornuate, subseptate and Antepartum
fibroid uterus.
•• Inspection:
–– Pelvic masses as ovarian tumors
–– The abdomen is broader from side to side
•• Fetal causes:
•• Palpation:
–– Multiple pregnancy.
•• Uterine height < POG
–– Polyhydramnios.
•• Fundal grip: The fundus feels empty.
–– Placenta praevia.
•• Lateral grip: The head is felt on one side while
–– Prematurity. the breech one the other.
–– Intrauterine fetal death. –– First pelvic grip: Empty lower uterine
segment.
Positions •• Auscultation:
•• The scapula is the denominator
–– FHS are best heard on one side of the
–– Left scapulo-anterior. umbilicus towards the feetal head.
–– Right scapulo-anterior. •• Ultrasound:
–– Right scapulo-posterior. –– Confirms the diagnosis and may identify
–– Left scapulo-posterior. the cause as multiple pregnancy or placenta
praevia.

Intrapartum
In addition to the previous findings, vaginal examination
reveals:
2
Obstetrics and Gynecology

•• The presenting part is high. •• Similar to ECV done for breech (READ in
CHAPTER ON BREECH)
•• Membranes are bulging.
•• Premature rupture of membranes with prolapsed Internal podalic version
arm or cord is common. (Neglected shoulder) •• It is ONLY indicated in the 2nd twin of
•• When the cervix is sufficiently dilated transverse lie if External version fails.
particularly after rupture of the membranes, •• It is followed by breech extraction.
the scapula, acromion, clavicle, ribs and axilla
can be felt. (Grid iron feel of ribs) Caesarean section
•• It is the best and safest method of management
Mechanism of Labour in nearly all cases of persistent transverse or
•• As a rule no mechanism of labour should be oblique lie even if the baby is dead.
anticipated in transverse lie and labour is
•• As rupture of membranes carries the risk of
obstructed.
cord prolapse, an elective caesarean section
If a patient is allowed to progress in labour with a should be planned before labour commences.
neglected or unrecognized transverse lie, one of the
following may occur: Neglected (Impacted) shoulder
•• Impaction with obstructed labor
Clinical picture (impending rupture uterus)
–– This is the usual and most common outcome.
•• Exhaustion and distress of the mother.
–– The lower uterine segment thins and
•• Shoulder is impacted maybe with prolapsed arm
ultimately ruptures.
and / or cord.
•• Spontaneous rectification / version
•• Membranes have ruptured since a time.
–– Rarely the fetal lie may be corrected by the
•• Liquor is drained.
splinting effect of the contracted uterine
muscles so that it turns and becomes a •• The uterus is tonically contracted.
longitudinal lie with cephalic presentation
•• The fetus is severely distressed or dead.
(rectification)
–– Rarely, by similar process the breech may Management
come to present. (version) •• Caesarean section is the safest procedure even
•• Spontaneous expulsion if the baby is dead.

–– Very rarely, if the fetus is very small or dead •• Sometimes a classical or low vertical incision in
and macerated, the shoulder may be forced the uterus facilitates extraction of the fetus
through the pelvis followed by the head and as a breech in such a condition.
trunk. This is corpora conduplicata (doubling
of the fetus on itself) CORD PROLAPSE
•• Spontaneous evolution:
Definitions
–– Very rarely, the head is retained above the
pelvic brim, the neck greatly elongates, the Cord Presentation:
breech descends followed by the trunk and
the after -coming head, i.e., spontaneous •• A loop of the cord is below the presenting part
version occurs in the pelvic cavity. with intact membranes

Cord Prolapse:
Management
•• A loop of the cord is below the presenting part
External cephalic version with ruptured membranes.
•• Preferably done between 36 and 37 weeks •• This is an OBSTETRIC EMERGENCY as the
cord can
 3
Transverse Lie and Cord Prolapse

•• get compressed between the presenting part preferably within 15 mins. While preparing
and pelvic wall the theatre minimize the risk to the fetus
by relieving pressure off the cord. This can
•• Vasospasm of umbilical vessel
be done by
leading to acute fetal distress and fetal hypoxia and
Putting the patient in Trendelenburg position,
eventually fetal death.
–– Manual displacement of the presenting part
Incidence: higher up
•• 1:200. –– Filling the bladder
–– All 4s position
Etiology
Remember: NEVER touch the cord! This will cause
•• Fetal causes: vasospasm
–– Malpresentations: e.g., transverse lie (MOST •• Fully dilated cervix: the fetus should be
COMMON), oblique lie, complete or footling delivered immediately. Instrumental delivery
breech, can be attempted here.
–– Prematurity. •• Dead fetus:
–– Anencephaly. –– Spontaneous delivery is allowed.
–– Polyhydramnios.
–– Multiple pregnancy.
•• Maternal causes:
–– Contracted pelvis.   
–– Pelvic tumors.

Predisposing factors:
•• Placenta praevia.
•• Long cord.   
•• Sudden rupture of membranes in polyhydramnios.

Diagnosis
•• The cord may be seen lying outside the introitus
or felt on vaginal examination
•• Ultrasound: occasionally can diagnose cord
presentation.

Management
Cord presentation
•• Caesarean section

Cord prolapse
Management depends upon the fetal state:
•• Living fetus:
–– Partially dilated cervix: Immediate caesarean
section is indicated. This is a CATEGORY
1 cesarean (baby should be out in 30 mins;
 CPD & OBSTRUCTED LABOR

Cephalo-Pelvic •• In dorsal position with slightly flexed and

separated thighs, the obstetrician pushes the
Disproportion head into the pelvis with the left hand and keeps
•• This means there is a disproportion in the fetal the right index and middle fingers on pubic
head and pelvis. symphysis to see the degree of overlapping, if
any.
•• It could be due to a
•• Interpretation
–– Contracted pelvis
–– If head is pushed easily into the pelvis with
–– Large baby (Macrosomia)
no overlapping of parietal bone on the pubic
•• Contracted pelvis symphysis: Normal inlet (No disproportion)
–– Assessment: Clinical pelvimetry is done –– Slight pushing of head into pelvis with
usually after 37 weeks or in labor. Parts of a slight overlapping of parietal bone on pubic
clinical pelvimetry are symphysis: Moderate disproportion
ƒƒ Sacrum: using 2 fingers of the hand, the –– Inability to push the head into pelvis with
length, breadth and curvature of the complete overlapping of parietal bone over
sacrum from above downward and side to pubic symphysis: Severe disproportion
side.
ƒƒ Diagonal conjugate measurement Degrees of Disproportion
ƒƒ Sacro-coccygeal joint mobility 1. Severe degree contracted pelvis: Obstetric
conjugate < 7.5 cm
ƒƒ Sacrosciatic notch: should admit 2 fingers
2. Moderate degree: Obstetric conjugate between
ƒƒ Ischial spines should not be prominent 7.5 to 9.5 cm
ƒƒ Sidewalls should be parallel (not converging) 3. Borderline pelvis: Obstetric conjugate measures
ƒƒ Subpubic arch: should be obtuse (> 90 )0 between 9.5 to 10 cm

ƒƒ Transverse diameter of the outlet: 4

knuckles should enter Obstructed Labor
–– Assessment of CPD by abdominal methods
DEFINITION:
•• Obstructed labor is one where despite good
uterine contractions, the progressive descent
of the presenting part is arrested due to
mechanical obstruction.
•• This may result either due to factors in the
fetus or in the birth canal or both, so that
further progress is almost impossible without
assistance.
2
Obstetrics and Gynecology

CAUSES: EFFECTS ON THE FETUS

•• Fault in the passage: a. Asphyxia results from tonic uterine contraction
that interferes with the uteroplacental
1. Bony: Cephalopelvic disproportion and
circulation or due to cord prolapse
contracted pelvis are the common causes.
b. Acidosis due to fetal hypoxia and maternal
2. Soft tissue obstructions:
acidosis
a. Cervical or broad ligament fibroid
c. Intracranial hemorrhage is due to moulding of
b. impacted ovarian tumor the head leading to tentorial tear or due to
c. Nongravid horn of a bicornuate uterus traumatic delivery
below the presenting part. d. Infection.
3. Fault in the passenger: All these lead to increased perinatal loss.
a. Transverse lie
CLINICAL FEATURES
b. Brow presentation
•• Maternal exhaustion and dehydration
c. Congenital malformations of the fetus—
hydrocephalus (commonest), fetal ascites •• Abdominal examination

d. Big baby –– Upper segment is tonically contracted with

no relaxation The wall becomes thicker
e. Occipito-posterior position
–– Lower segment becomes distended and
f. Compound presentation thinned out
g. Locked twins –– Fetal parts not easily felt
h. Mento-posterior –– Round ligaments taut and tender

EFFECTS ON THE MOTHER –– Bandl’s ring is felt (Retraction ring)

•• Immediate: –– Fetal heart rate absent

a. Exhaustion •• Vaginal exam

b. Dehydration –– Vagina feels hot and dry

c. Metabolic acidosis –– Cervix hangs loosely like a curtain

d. Genital sepsis –– Caput +++

e. Rupture of the uterus which may be –– Moulding +++

spontaneous in multipara –– Head feels jammed in the pelvis
f. Postpartum hemorrhage and shock may
be due to isolated or combined effects of
atonic uterus or genital tract trauma.
All these lead to an increased maternal morbidity and
mortality.
•• Remote:
a. Genitourinary fistula (Due to bladder
necrosis)
b. Rectovaginal fistula
c. Secondary amenorrhea following
hysterectomy due to rupture or due to
Sheehan’s syndrome.
 3
CPD & Obstructed Labor

Bandl Ring

PREVENTION: TREATMENT:
•• Antenatal detection of the risk factors likely to •• Cesarean Section must be done even for a dead
produce prolonged labor (big baby, small women, baby
malpresentation and position)
•• In modern obstetrics there is almost NO role
•• Intra-partum: Continuous vigilance, use of for destructive surgeries.
partograph and timely intervention of a
•• Remember: Urinary catheter is kept for 2-3
prolonged labor due to mechanical factors can
weeks. This is to prevent a Vesico vaginal fistula
prevent obstructed labor.
as prolonged obstructed labor causes necrosis
of the bladder. So to enable healing, continuous
drainage is required and hence the catheter is
kept prolonged.
 SHOULDER DYSTOCIA

Definition: –– Maternal:

•• The term shoulder dystocia is defined to as ƒƒ PPH

when the shoulders get stuck after delivery of ƒƒ Cervical laceration
the head. If the duration of delivery of shoulder
is > 1 min after delivery of the head, it is called ƒƒ Vaginal tear
as shoulder dystocia. ƒƒ Perineal tear (3rd and 4th degree)
•• Shoulder dystocia occurs when either the ƒƒ Rupture of uterus, bladder, sacroiliac joint
anterior or the posterior (rare) fetal shoulder dislocation and morbidity.
impacts on the maternal symphysis or on the
sacral promontory respectively. •• Prevention of shoulder dystocia is not possible
accurately even with antenatal ultrasonographic
•• Overall incidence varies between 0.2% and 1%. assessment.

Risk factors: Diagnosis:

–– Previous shoulder dystocia –– Recoil of the head back against the perineum
–– Macrosomia (> 4.5 kg) (turtleneck sign)

–– Diabetes –– Inadequate spontaneous restitution

–– Obesity (BMI > 30 kg/m2)

Management principles:
–– Induced labor
–– Prolonged first stage or second stage of
labor
–– Secondary arrest of labor
–– Post-maturity
–– Multiparity
–– Anencephaly
–– Instrumental delivery

Complications:
–– Fetal:
ƒƒ Asphyxia
ƒƒ Erb (C5,6), Klumpke palsy (C8-T1) Shoulder Dystocia Maneuvers
ƒƒ Humerus fractures, clavicle or 1. McRoberts maneuver:
sternomastoid hematoma during delivery •• This is the immediate STEP when asked a
ƒƒ Perinatal morbidity and mortality are high. question about shoulder dystocia management
2
Obstetrics and Gynecology

•• Hyperflexion of mother’s legs onto the abdomen Rubin and Woods maneuver are rotational
during childbirth maneuvers
•• This widens the pelvis and flattens the lumbar
spine.
2. Suprapubic pressure:
•• Directional (45° downward) pressure to
the maternal abdomen just above the pubic
symphysis.
•• This pressure should be applied to the posterior
aspect of the anterior shoulder, pushing toward
the opposite side from where the attendant is
positioned.
•• Suprapubic pressure is often used concomitantly
with the McRoberts maneuver.

The McRobert and Suprapubic pressure go

hand in hand Rubin

3. Rubin II or posterior pressure on the anterior

shoulder, which would bring the fetus in an oblique
position with head somewhat towards the vagina Wood Corkscrew

4. Woods’ screw maneuver: 1800 rotation of posterior 1. Gaskin maneuver involves moving the mother to an
shoulder all fours position with the back arched, widening
the pelvic outlet.
2. Zavinelli’s maneuver: which involves pushing the
fetal head back in with performing a cesarean
section. or internal cephalic replacement followed
by Cesarean section.
3. Intentional fetal clavicular fracture, which
 3
Shoulder Dystocia

reduces the diameter of the shoulder girdle that Prevention of Shoulder Dystocia
requires to pass through the birth canal.
•• The ACOG says that data is insufficient to
4. Maternal symphysiotomy, which makes the opening determine whether women with GDM whose
of the birth canal laxer by breaking the connective fetuses have an USG estimated wight ≥ 4500g
tissue between the two pubes bones facilitating should undergo an elective LSCS to reduce the
the passage of the shoulders. risk of birth trauma (2019)
5. Abdominal rescue, described by O’Shaughnessy. •• The ACOG says, prophylactic LSCS should be
where a hysterotomy facilitates vaginal delivery of considered in diabetic women with an estimated
the impacted shoulder fetal weight ≥ 4500g
 INJURIES TO THE BIRTH CANAL

PERINEAL TEARS
•• Classification of Perineal Tears

RCOG classification of Perineal Tears: –– Prolonged 2nd stage

2007 –– Precipitate labor
•• First degree: Injury to perineal skin only. –– Shoulder dystocia
•• Second degree: Injury to perineum involving –– Instrumental delivery
perineal muscles but not involving the anal
–– Big baby
sphincter.
–– Occipito posterior position
•• Third degree: Injury to perineum involving the
anal sphincter complex: –– Assisted breech delivery
3a: Less than 50% of EAS thickness torn –– Scarred perineum
3b: More than 50% of EAS thickness torn
PREVENTION:
3c: Both EAS and IAS torn.
–– Proper conduct in the second stage of labor
•• Fourth degree: Injury to perineum involving the taking due care of the perineum when it is
anal sphincter complex (EAS and IAS) ans anal likely to be damaged is essential
epithelium.
ƒƒ Perineal support
•• 3rd and 4th degree tears are called as OASIS
ƒƒ Modified Ritgen maneuver
(Obstetric Anal Sphincter Injuries)
ƒƒ Perineal massage
Risk Factors for OASIS ƒƒ Warm compress
–– Primi
ƒƒ Episiotomy (Restrictive)
 1
Injuries to the Birth Canal

For repair of EAS either an overlapping

or end-to-end approximation method can
be used with similar outcome.

Modified Ritgen
Maneuver

MANAGEMENT:
End to end technique
–– Recent tear should be repaired immediately
following the delivery of the placenta.
–– This reduces the chance of infection and
minimizes the blood loss.
–– In cases of delay beyond 24 hours, the repair
is to be withheld.
–– Antibiotics should be started to prevent
infection.
–– The complete tear should be repaired after 3
months if delayed beyond 24 hours.
–– In case of any doubt to grade of 3rd degree
tear, it is advisable to classify to the higher Overlap technique
degree rather than lower degree.
ƒƒ IAS repair is done by interrupted suture.
–– Repair of complete perineal (4th degree tear)
ƒƒ Repair of perineal muscle is done by
ƒƒ Preferably under anesthesia with good interrupted sutures
exposure to the area and light
ƒƒ The vaginal wall and the perineal skin are
ƒƒ Antiseptic cleaning of the local area is apposed by interrupted sutures.
done.
ƒƒ The rectal and anal mucosa is first sutured AFTERCARE:
from above downward ƒƒ A low residual diet is given from third day
ƒƒ No. “3-0” vicryl or 3-0 PDS, atraumatic onward
needle, interrupted stitches with knots ƒƒ Stool softeners like lactulose
inside the lumen are used.
ƒƒ Broad-spectrum antibiotics
ƒƒ The rectal muscles including the pararectal
fascia are then sutured by interrupted ƒƒ The woman is advised physiotherapy and
sutures using the same suture material pelvic floor exercises and she is reviewed
again 6–12 weeks postpartum.
ƒƒ The torn ends of the sphincter ani externus
(EAS) are then exposed by Allis’s tissue ƒƒ In case of persistent incontinence of flatus
forceps. and feces, endoanal USG and anorectal
manometry should be considered to
ƒƒ The sphincter is then reconstructed with a detect any residual defects (20–30%).
figure of eight stitch, and it is supported Consultation with a colorectal surgeon
by another layer of interrupted sutures. may be needed.
2
Obstetrics and Gynecology

PLAN FOR FUTURE DELIVERY: entire cervix is seen and tear is identified.

ƒƒ All women need to have institutional ƒƒ The margins of the torn cervix are grasped
delivery following repair of obstetric by the sponge holding forceps.
sphincter injury. ƒƒ The first suture is placed just above the
ƒƒ Vaginal delivery may be allowed in a apex using polyglactin (vicryl) or chromic
selected case with or without episiotomy. catgut No. “0” taking whole thickness of
the cervix.
ƒƒ Women having symptoms or with abnormal
endoanal USG and/or manometry should ƒƒ The rest of the tear is repaired by similar
be delivered by elective cesarean birth. sutures.
ƒƒ Mattress suture is preferable as it
COLPORRHEXIS: prevents rolling in of the edges.
•• Rupture of the vault of the vagina is called
colporrhexis.
•• It may be primary where only the vault is
involved or secondary when associated with
cervical tear (common).
•• It is said to be complete when the peritoneum
is opened up
•• Treatment—If the tear is limited to the vault
close to the cervix, the repair is done from
below. If, however, the cervical tear extends
high up into the lower segment or major branches
of uterine vessels are damaged, laparotomy is
to be done simultaneously with resuscitative
measures. Evacuation of hematoma and arterial
ligation may be needed.

PELVIC HEMATOMA
CERVICAL TEARS
•• Collection of blood anywhere in the area
•• It is the commonest cause of traumatic
between the pelvic peritoneum and the perineal
postpartum hemorrhage.
skin is called pelvic hematoma.
•• Left lateral tear is the most common.
•• ANATOMICAL TYPES:
•• TREATMENT:
–– Infralevator hematoma—common (aka vulval
–– Deep cervical tear associated with bleeding hematoma)
should be
–– Supralevator hematoma—rare (aka Broad
–– Repair should be done under anesthesia, in ligament hematoma)
lithotomy position with a good light.
•• INFRALEVATOR HEMATOMA:
–– Procedures:
–– Presents as persistent, severe pain on the
ƒƒ The tear is first identified by “walking the perineal region.
cervix” with 2 sponge holding forceps,
–– There may be even retention of urine.
clockwise.
–– Signs:
ƒƒ The area between 2 forceps is examined
and if no tear, the 1st sponge holder is ƒƒ Patient may be in shock.
removed and placed a few cm away from ƒƒ Local examination reveals a tense swelling
the 2nd sponge holding forceps and the at the vulva which becomes dusky and
area between these 2 forceps is now purple in color and tender to touch
examined and so on and so forth till the
 3
Injuries to the Birth Canal

–– Treatment: ○○ Blood transfusion may be required

ƒƒ Small hematoma; not increasing in size:
Pressure packing, ice packing and careful
observation
ƒƒ Large hematoma/ painful/ patient in shock:
○○ Requires evacuation under anesthesia
○○ Hematoma Is evacuated by making an
incision on the most prominent part OR
if it is a hematoma in the episiotomy,
the episiotomy is reopened and
explored
○○ The clots are evacuated, if a bleeding
vessel is identified, it is ligated, but
•• SUPRALEVATOR HEMATOMA (Broad ligament
many times the vessel isn’t identifiable
hematoma)
so the main aim is to OBLITERATE the
EMPTY SPACE with sutures –– Should be suspected in a woman post delivery
who goes into shock with no visible external
○○ A drain can be kept in situ
bleeding with the uterus well contracted
–– Can be confirmed by an ultrasound
–– Treatment: Laparotomy and Exploration
–– Many times an obstetric hysterectomy OR an
internal iliac artery ligation or both may be
required to be done.
 3rd STAGE COMPLICATIONS INCLUDING PPH

3rd Stage complications including VII.

PPH, Uterine Inversion and Retained •• This leads to the development of disseminated
Placenta intravascular coagulation.

3rd Stage of Labor: •• Incidence and Risk Factors

–– Older maternal age
•• Defined as from delivery of baby till delivery
of placenta –– Precipitate (Quick) labor
•• It is important as several complications are –– Hydramnios
anticipated and PPH can be prevented in this
–– Meconium-stained amnionic fluid
stage by Active Management of 3rd stage of
Labor. (Discussed in chapter on Management of –– Post-term pregnancy
Labor) –– Labor induction or augmentation
•• In this we will discuss the following –– Cesarean, forceps, or vacuum delivery
1. Amniotic Fluid Embolism –– Perineal tears
2. Post partum Haemorrhage –– Placental abruption or previa
3. Uterine Inversion –– Eclampsia
4. Retained Placenta •• Diagnosis

1. Amniotic Fluid Embolism –– Classic triad of

•• This syndrome usually is caused by intravenous 1. Abrupt hemodynamic compromise

embolization of meconium laden amnionic fluid. 2. Respiratory compromise
•• It results in rapid cardiorespiratory collapse 3. DIC
and profound consumptive coagulopathy (DIC)
–– Diagnostic Criteria of AFE
•• However, during normal delivery, amnionic fluid
1. Clinical onset during labor or within 30
can enters maternal circulation through venous
minutes of placental delivery
channels at the placental implantation site or
small lacerations. 2. Abrupt onset of cardiorespiratory arrest,
or both hypotension and respiratory
•• This leads to abnormal activation of
compromise
proinflammatory mediator systems, similar to
the systemic inflammatory response syndrome 3. Overt Disseminated intravascular
(SIRS), and causes initial, transient pulmonary coagulopathy
vasoconstriction and hypertension
4. No fever ≥38°C
•• Women who survive beyond these first phases
•• Management:
invariably a consumptive coagulopathy as,
material from the fetal compartment that –– Immediate high-quality cardiopulmonary
contains tissue factor then activates factor resuscitation and advanced cardiac life
2
Obstetrics and Gynecology

support must be initiated without delay •• Infection (Chorioamnionitis)

–– ICU Care •• Anesthesia: Depth of anesthesia and the
anesthetic agents (ether, halothane) may cause
–– Management of DIC
atonicity
•• AFE is associated with HIGH MATERNAL
•• Initiation or augmentation of delivery by
MORTALITY
oxytocin
“Remember the classical history of AFE is sudden
•• Uterine malformation
collapse (usually postpartum; sometimes intra-
partum); followed by bleeding PV (because of DIC). •• Mismanaged third stage of labor
This is important to remember and differentiate from
•• Precipitate labor
PPH where there will be bleeding followed by collapse”
•• Other risk factors like Elderly, obesity,
2. Post-Partum Haemorrhage: This is a previous h/o PPH, drugs like ritodrine, MgSO4
very very important topic and Nifedipine

Definition Management of PPH

•• The American College of Obstetricians and Zero-hour checklist
Gynecologists (2019a) defines postpartum
hemorrhage as cumulative blood loss >1000 mL •• Once a woman has been assessed to have PPH, call
or blood loss accompanied by signs and symptoms the Emergency Response Team (ERT) for help
of hypovolemia •• Initial resuscitation with ABCDE (Airway,
•• Earlier definitions were > 500ml blood loss Breathing, Circulation, Disability, Exposure)
following a vaginal delivery and > 1000ml blood approach is to be done
loss following a cesarean section •• IV access with two wide bore cannula #14/16
PPH Can be of 2 types •• Blood sample for investigations to be collected
and adequate blood and blood products to be
A. Primary PPH: Haemorrhage within the first 24h of arranged
delivery. This can be further classified as
•• Catheterization is mandatory.
1. 3rd STAGE PPH or 3rd Stage PPH (PPH in the 3rd
stage of labor i.e., before placental delivery) •• The vitals- Shock Index must be recorded

2. TRUE PPH Obstetric shock index

B. Secondary PPH: Haemorrhage after 24h and within Defined as HR/SBP
the puerperal period
Has been used as an early marker of compromise in
Causes of Primary PPH (4Ts) Causes of Secondary PPH various shock in non pregnant population
Tone (Atonic Uterus): Most Retained bits of placenta For pregnant population, normal SI ranges from 0.7 -
common cause (most common cause) 0.9; SI
Trauma (Traumatic PPH) Endometritis
≥ 1 predicts adverse clinical outcome
Thrombin (Coagulopathy) Infected polyp
Tissue (Retained placenta) Placental polyp HR/SBP (Normal 0.7 – 0.9)
Choriocarcinoma •• Quick history and rapid initial assessment

Risk Factors for Atonic PPH Clinical and Pharmacological

•• Grand multipara Management
•• Overdistension of the uterus (multiple •• Ensure the cause by palpating the uterus for
pregnancy, hydramnios and big baby) atony.

•• Malnutrition and anemia •• In cases of uterine atony, the primary response

is to do uterine massage, bimanual uterine
 3
3rd Stage Complications Including PPH

compression, aortic compression, and administer •• Evaluate for blood coagulation abnormalities.
uterotonics.
•• If patient is still bleeding and goes in refractory
•• Tranexamic acid injection: 1gm IV to be given PPH then, uterine balloon tamponade to be done
immediately (within 3 hours of PPH) and repeat and NASG (Non pneumatic anti shock garment)
another 1 gm IV after 30 minutes if PPH to be placed.
persists.
•• In cases of lower level health facilities, transfer
•• If the uterus has contracted, inspect for and appropriate referral to be done.
genital tract trauma. If detected, appropriate
•• In level II and level III settings, if women is
intervention should be taken.
still bleeding, she can be taken for surgical
compression sutures, uterine artery ligation
(stepwise devascularization), uterine artery

Clinical and pharmacological management of PPH (modified flowchart)

embolization, and hysterectomy.

4
Obstetrics and Gynecology

Carbetocin is recommended by WHO only for prevention of PPH

•• Initial management is zero-hour checklist f/b •• In refractory PPH, before surgical management
or while transferring a patient, mechanical
•• If the cause of PPH is determined to be due
methods can be instituted. These include
to an atonic uterus, then medical (uterotonics)
management and uterine massage is instituted. –– Bi-manual compression
•• If bleeding persists, then surgical management –– Uterine balloon tamponade
is instituted.
–– Aortic compression
–– Non Pneumatic Anti Shock Garment (NASG)
 5
3rd Stage Complications Including PPH

1. Bimanual Compression •• Balloon tamponade provides pressure and stops

the bleeding. It can be used while awaiting
surgical management/ referring a patient or can
many times stop the bleeding completely.
•• Inflation is with 200-500 ml saline
•• Kept for 4 – 6 hours

3. Aortic Compression

•• Insert one gloved hand into the vagina and push

up against the body of the uterus.
•• Place the other hand above the uterine fundus
on the abdomen and compress the uterus against
the hand in the vagina.
•• Successful external external aortic compression
•• To be effective bimanual uterine compression is achieved when the femoral pulse ceases
has to be maintained effectively for 8–10 mins and when blood pressure in the lower limit is
till the blood clots in the uterine vessels. unrecordable;
•• In a number of women this is all that is needed. •• It may be of benefit as a temporary measure
in the management of postpartum hemorrhage
•• In the others it is a temporary measure in the
whilst resuscitation and other management
management of PPH caused by uterine atony
plans are made.
after vaginal delivery
•• Internal aortic compression can also be used
2. Uterine balloon tamponade as a temporary measure to control severe
postpartum hemorrhage due to placenta
percreta during cesarean section.

4. Non-Pneumatic Anti Shock Garment

(NASG)

•• A Sengstaken tube, Rüsch balloon, Bakri balloon •• The best method of keeping a woman stable
and even an inflated condom or glove can be while transferring her is to use a non-inflatable
used anti-shock garment (NASG) if available.
6
Obstetrics and Gynecology

•• This may stop bleeding in many cases. Surgical Management of PPH:

•• How it works: It is a lower body compression 1. Uterine Compression Sutures:
device. The NASG is a simple neoprene and
•• These work by apposition of the uterine walls
Velcro device made of articulated segments
to each other. The most common type of suture
that are wrapped tightly around the legs, pelvis
is B-Lynch suture (aka vertical brace sutures)
and abdomen. It can be used to treat shock,
resuscitate, stabilize and prevent further •• Before attempting a compression suture, always
bleeding in women with obstetric hemorrhage. compress the uterus with both hands and see if
bleeding stops.
•• Only if bleeding stops, should compression
sutures be put. This tell us that the procedure
will be effective.

Other type of compression sutures:

 7
3rd Stage Complications Including PPH

Hayman Suture: These are preferred if a patient had a vaginal delivery

Cho’s Square sutures

Internal Iliac Artery Ligation
2. Devascularization. •• For internal iliac ligation, adequate exposure is
•• This involves systemic ligation of vessels in the obtained by opening the peritoneum over the
following order common iliac artery and dissecting down to the
bifurcation of the external and internal iliac
1. b/l uterine arteries
arteries
2. b/l uterine-ovarian artery anastomoses
•• Branches distal to the external iliac arteries
3. b/l internal iliac arteries (Anterior division) are palpated to verify pulsations at or below the
inguinal area.
•• Ligation of the internal iliac artery at a point
5 cm distal to the common iliac bifurcation will
usually avoid the internal iliac artery’s posterior
division branches
•• The most important mechanism of action with
internal iliac artery ligation is an 85% reduction
in pulse pressure in those arteries distal to the
8
Obstetrics and Gynecology

ligation Uterine Inversion

•• The basis of internal iliac artery ligation: This •• It is an extremely rare but a life-threatening
converts an arterial pressure system into one complication in 3rdstage in which the uterus is
with pressures approaching those in the venous turned inside out partially or completely.
circulation. This creates vessels more amenable
•• The incidence is about 1 in 20,000 deliveries.
to hemostasis via pressure and clot formation.
Even bilateral internal iliac artery ligation •• The obstetric inversion is almost always an
does not appear to interfere with subsequent acute one and usually complete.
reproduction
•• TYPES:
3. Obstetric Hysterectomy
–– First degree: There is dimpling of the fundus,
•• This is as a last resort when nothing else works which still remains above the level of internal
os
Uterine Artery Embolization –– Second degree—The fundus passes through
•• This modality is now used for many causes of the cervix but lies inside the vagina
intractable hemorrhage when surgical access is –– Third degree (complete)—The endometrium
difficult. Its use has increased remarkably in with or without the attached placenta is
the past decade visible outside the vulva.

Secondary PPH Classification

•• Bleeding after 24h, within the puerperium

•• CAUSES:
–– Retained bits of cotyledon or membranes
(most common)
–– Infection (endometritis)
–– Coagulation abnormalities
–– Other rare causes are
ƒƒ Chorionepithelioma RISK FACTORS

ƒƒ Carcinoma cervix •• Fundal attachment of the placenta

ƒƒ Placental polyp •• Short cord

ƒƒ Infected fibroid or fibroid polyp and •• During Manual removal of placenta

puerperal inversion of uterus •• Placenta accreta weakness of uterine wall at
•• DIAGNOSIS: the placental site are often associated.

–– Ultrasonography is useful in detecting the •• Mismanagement of third stage of labor. (Pulling

bits of placenta inside the uterine cavity. the cord before placental separation, fundal
pressure while the uterus is relaxed, faulty
•• MANAGEMENT technique in manual removal)
–– To assess the amount of blood loss and to
replace it COMPLICATIONS

–– To find out the cause and to take appropriate 1. Shock; of neurogenic origin due to
steps to rectify it. a. Tension on the nerves due to stretching of the
ƒƒ Retained bits of placenta: Dilatation and infundibulopelvic ligament
Evacuation b. Pressure on the ovaries as they are dragged with
ƒƒ Endometritis: Broad spectrum antibiotics the fundus through the cervical ring and
 9
3rd Stage Complications Including PPH

c. Peritoneal irritation –– To apply counter support by the other hand

placed on the abdomen.
2. Hemorrhage
–– After replacement, the hand should remain
3. If left uncared for, it may lead to a chronic
inside the uterus until the uterus becomes
inversion
contracted by oxytocin
DIAGNOSIS: Clinical –– The placenta (if still attached) is to be
•• It is an acute presentation usually identified at removed manually only after the uterus
the time of placental delivery becomes contracted.

•• Classically the scenario will be “A red velvety Other methods

mass at the introitus is seen and the uterus is
•• Replacement of the uterus using hydrostatic
not palpable P/A or palpated much below the
method (O’Sullivan’s) under general anesthesia.
umbilicus; and the patient will be in shock. On
The hydrostatic method is quite effective and
vaginal exam, a boggy mass will be felt.”
less shock producing. The inverted uterus is
replaced by the vagina. Warm sterile fluid (up
to 5 liters) is gradually instilled into the vagina
through a douche nozzle. The vaginal orifice
is blocked by operator’s palms supplemented
by labial apposition around the palm by an
assistant. The water distends the vagina and
the increased intravaginal pressure leads to
replacement of the uterus.
•• If this also fails, then Laparotomy is done
–– The typical laparotomy appearance of an
inverted uterus is called the flowerpot
PREVENTION: appearance
•• Do not deliver the placenta till sign of separation –– On laparotomy, using allis forceps, the
are seen inversion is corrected (Huntington
•• Avoid Crede’s method of placental delivery procedure)
–– Sometimes an incision on the cervix is needed
MANAGEMENT:
to help correct the inversion (Haultain
•• Call for extra help technique)
•• Before the shock develops, urgent manual
replacement is done. The basic principal is the
part that comes out first is replaced last.
•• If immediate replacement fails or the patient
is referred), then the cervix usually starts
contracting so replacement is best done under
GA
•• Principal steps:
–– The patient is under general anesthesia
–– To replace that part first, which is inverted
last with the placenta attached to the
uterus by steady firm pressure exerted by
the fingers.
 HYPERTENSION IN PREGNANCY

Terminology and Classification: Updated classification Delta Hypertension

of hypertensive disorders in pregnancy (ACOG 2013)
•• BP which may be less than 140/90 but is higher
– 4 disorders
than the baseline range for that woman during
1. Pre-eclampsia and eclampsia syndrome pregnancy and is associated with all her features
2. Chronic Hypertension of any etiology (Woman who of preeclampsia
has HTN and conceives OR HTN which develops in
pregnancy but persists after 12 weeks postpartum) Preeclampsia/ Eclampsia
3. Pre-eclampsia superimposed on chronic •• Preeclampsia is defined as BP > 140/ 90 mmHg
hypertension with proteinuria

4. Gestational hypertension (BP ≥ 140/90 mmHg for –– > 1 + or

the first time after mid pregnancy; no proteinuria; –– ≥ 300 mg/ 24h sample or
Resolves by 12 weeks; sometimes known as transient
hypertension) –– urine protein creatinine ratio ≥ 0.3; seen > 20
weeks
•• In pre-eclampsia; the 2nd wave of spiral
remodeling is diminished/ absent leading to
reduced blood flow to the feto-placental unit

•• Severe preeclampsia: Indicators

–– BP: Systolic ≥ 160 mmHg; Diastolic ≥ 110 mmHg
–– Proteinuria: No longer a marker for severity
–– Imminent eclampsia symptoms: Vomiting, headache, blurring of vision
–– Upper abdominal pain (stretching of Glisson’s capsule)
2
Obstetrics and Gynecology

–– Eclampsia Pathophysiology
–– Elevated serum transaminases •• Kidney:
–– Elevated Creatinine –– Glomerular Endotheliosis
–– Thrombocytopenia (< 100000/ µL) –– Glomerular enlargement
–– Fetal growth restriction –– Hyaline, foam cells with ‘pouting’ of glomeruli
–– Pulmonary edema and fat in glomerular cells

–– Presentation at an early gestational age –– Deposition of IgM fibrin and thrombi in the
glomerular capillaries
–– Oliguria
–– Thickened epithelial tuft with vacuoles
Risk Factors –– Swelling of mesangial cells
High Risk Factors Moderate Risk Factors –– Moderate to gross ballooning of loops
Autoimmune ds (SLE, APLA Primi/ pregnancy
•• Hepatic
etc.) interval > 10 y
–– Subcapsular haemorrhage/ subcapsular
Chronic HTN Age> 40
hematoma - stretching of Glisson’s capsule
DM BMI> 35kg/ m2
– epigastric pain
Earlier h/o preeclampsia Multiple Pregnancy
–– HELLP syndrome
CKD Family h/o preeclampsia
PREVENTION OF PREECLAMPSIA: Any 1 high risk •• Brain
factor/ 2 or more moderate risk factor: start Low –– Cerebral edema
dose aspirin 75 – 150 mg before 16 weeks; No other
–– Cerebral haemorrhage
modality/ medication has been proven beneficial in
preeclampsia –– PRES (Posterior reversible encephalopathy
syndrome) –
Other predictors of preeclampsia: ƒƒ Associated with pre-eclampsia (also seen in
•• Biophysical markers: Raised PI in the uterine sepsis, autoimmune diseases and immune
Artery (11 – 14 weeks); notching of uterine suppression)
Artery waveform (mid trimester). ƒƒ PRES is rare clinic-radiological diagnosis.
•• Biochemical markers: Symptoms include headache, seizures
Markers Decreased Markers Increased and visual loss invoking early brain MRI
to reveal typical pattern of bilateral
•• PP13 •• SFlt 1 hyperintensities (FLAIR imaging),
•• VEGF •• SEng predominantly in the parieto-occipital
region
•• PAPPA •• Cell free DNA
•• Visual Disturbances
•• PlGF
–– Hypertensive retinopathy
•• Roll over test: 28- 32 weeks: BP is measured –– Rarely: retinal detachment
with patient on her side first and then she is
Not
asked to roll on her back and BP is checked Complications:
again -an increase of 20mmHg in diastolic BP
done •• Maternal – Eclampsia, HELLP (Hemolysis,
from lateral to supine position is a positive
now! Elevated Liver Enzymes, Low Platelet Count),
test – 30% of such women will develop pre-
Pulmonary Edema, ARF, DIC, PRES (posterior
eclampsia in the future.
reversible encephalopathy), occipital blindness
•• Angiotensin II sensitivity test: Rise in BP (amaurosis) in eclampsia, RD in preeclampsia
with Angiotensin II infusion.
•• Fetal – Fetal growth restriction, Intra uterine
demise, iatrogenic prematurity
 3
Hypertension In Pregnancy

•• Placental: Abruption Placentae h apart IM) for lung maturity if < 34 weeks
•• Anti-hypertensives:
Management:
–– DOC: Labetalol (Max oral dose 2400mg/d);
•• Definitive treatment is delivery
can be given IV in emergencies (Max IV dose
•• Mild preeclampsia: Termination at 37 weeks is 220 mg)
•• Severe preeclampsia –– Alpha methyl dopa: Greatest safety data
available, 48 h for onset of action
–– Admit; Consider prophylactic MgSO4
–– Nifedipine: CCB, short acting, oral (S/l is c/i)
–– Start anti-hypertensives
used in emergencies
–– Terminate at 37 weeks or SOS if
•• Hydralazine: for emergencies, IV
ƒƒ Persistent severe HTN
•• Diuretics: only if pul edema
ƒƒ Eclampsia, HELLP, pulmonary edema, ARF,
•• Beta blockers: long term use causes Growth
DIC
restriction, not preferred
ƒƒ Fetal compromise
•• ACE inhibitors and ARB – Absolute c/I in
ƒƒ Abruption pregnancy as they cause fetal renal anomalies.
ƒƒ Pre-viable fetus
–– Steroids (Betamethasone 12 mg 2 doses 24
4
Obstetrics and Gynecology

Management:
Confirm Diagnosis of Pre-eclampsia

Mild pre-eclampsia Severe pre-eclampsia

Rest Admit

Day Care Unit •• Investigations

•• BP 4 hourly
th
•• Start anti-hypertensives
•• KFT, LFT if diastolic BP > 100 mmHg

•• Platelet count
•• 24h urine protein
•• BP under control •• Persistent severe HTN
•• Fundoscopy
•• No other indications •• Eclampsia
•• Fetal well-being
of termination
•• HELLP syndrome
–– DFMC
•• Pul edema/ ARF/ DIC
–– NST
Terminate at 34 weeks •• Fetal compromise
–– BPP
•• Abruption
–– Modified BPP
•• Pre-viable fetus (early onset
–– Doppler of umbilical artery
< 24 weeks)

Complete control; Not severe

•• MgSO4 for eclampsia prophylaxis
•• IV Labetalol
Continue pregnancy till 37 weeks
•• Termination of Pregnancy
(induction/ Cesarean if cervix
Induction of labor/ cesarean for unfavorable or obstetric
obstetric indication indication)
•• Usually in such situations, like
abruption/ eclampsia/ HELLP,
there is not enough time to
even give steroids for fetal lung
maturity

ECLAMPSIA puerperal sepsis and obstetric hemorrhage

•• Generalized tonic-clinic seizures in a woman •• Stages:

with preeclampsia 1. Premonitory stage
•• Seizures in pregnancy - is always eclampsia 2. The tonic stage
unless proven otherwise
3. The clonic stage
•• Maternal mortality is 4 – 6% (3 most common
causes of maternal mortality in India – Eclampsia, 4. The stage of coma
 5
Hypertension In Pregnancy

•• Prevention: –– Hemolysis (H)

–– Eclampsia is preventable ƒƒ Bilirubin > 1.2 mg/dl
–– Appropriate management of pre-eclampsia ƒƒ LDH > 600 IU/ L
and inj MgSO4 is used for prevention
ƒƒ Absent plasma haptoglobin
•• Treatment – Stabilize the patient + MgSO4
ƒƒ Schistocytes in the blood smear
(DOC) + Control of HTN + Termination of
pregnancy –– Elevated Liver Enzymes (EL)

•• MgSO4: ƒƒ AST/ ALT > 40 IU/l

–– Preferred regime is Pritchard’s regime: –– Low Platelet (LP)

–– 4 g of MgSO4 as a 20% solution @ 1g/ min ƒƒ Platelet < 150 x 103

+ 10 g of 50% MgSO4 (5 g in each buttock) •• Mississippi Classification of HELLP syndrome:
f/b maintenance dose of 5 g 50% MgSO4 on Based on Platelet count: Remember the most
alternate buttocks every 4 h till 24 h after severe is Class 1 and least severe is Class 3
delivery/ last convulsion; whichever is later.
–– Class 1: Platelet count < 50,000
–– If 20% not available, convert 50% to 20% by
adding 1.5 times distilled water (1ml of 50% –– Class 2: Platelet count 50,000 – 100,000
MgSO4 contains 0.5g MgSO4) i.e. to 8ml of –– Class 3: Platelet count: 100,000 – 150,000
50% MgSO4 + 12ml of distilled water
•• Tennessee Classification:
–– Check – RR, urine output and DTR before
administering MgSO4 (Risk of toxicity) –– True/ Complete HELLP

–– 1st to disappear in Mg toxicity: DTR ƒƒ Platelets < 100,000

–– Other regimes – Zuspan (Continuous IV ƒƒ AST > 70 IU/l

regime); higher risk of Mg toxicity if Mg ƒƒ LDH> 600 IU/L
levels unchecked
–– Partial or incomplete HELLP
–– Antidote to MgSO4 is Calcium gluconate
ƒƒ Severe preeclampsia with HE/ LP/ HEL/
•• Cut short 2nd stage, avoid methyl-ergometrine ELLP/ HLP
in 3rd stage and avoid fluid overload
•• Management

HELLP Syndrome –– Termination of pregnancy

•• Form of severe pre-eclampsia –– Inj Dexamethasone 10 mg IV 12th hourly also

has been found to increase platelet counts in
•• Characterized by
come studies
–– Prophylactic MgSO4 for prevention of
eclampsia
 DIABETES IN PREGNANCY

GESTATIONAL DIABETES pregnancy.

MELLITUS •• > 20 weeks.

Remember:
What is Diabetes in Pregnancy?
•• GDM is NOT TERATOGENIC.
There are two types of diabetes:
•• OVERT DIABETES is TERATOGENIC (i.e.
1. Pregestational Diabetes: Pre-existing Diabetes women with pregestational diabetes, are at
(Overt diabetes) an increased risk of the fetus developing
2. Gestational Diabetes Mellitus (GDM): GDM occurs anomalies).
after 20 weeks of pregnancy and it’s specific to
pregnancy . Risk factors
Previous pregnancy. Present Pregnancy.
Maternal glucose homeostasis — H/o GDM Age > 30 years
Pregnancy is a diabetogenic state H/o big baby Polyhydramnios
Family history of GDM Preeclampsia
•• This means that pregnancy itself is predisposed
to developing diabetes. Bad obstetric history BMI ≥ 30
•• More glucose is made available to the fetus H/o foetal anomaly Recurrent UTI/vaginitis
because of certain placental hormones for e.g.
Estrogen, Progesterone, CRH and Prolactin. H/o PCOS Multiple pregnancy
These are anti-insulinogenic
Screening and diagnosis of diabetes in
pregnancy
Screening:
•• Universal Screening.
•• Recommended by the International Association
of Diabetes and Pregnancy Study Group.
(IADPSG)
•• 2-Stage process.
1st trimester
HbA1C/ FPG/ Random

•• There is increased lipolysis and increased free

fatty acids in the body 24 – 28 weeks

•• Glucose intolerance of variable severity with 75 g OGTT

onset or 1st identified during the present
2
Obstetrics and Gynecology

Screening and Diagnosis of GDM by 2 step tests:

DIPSI •• 1st screening test then diagnostic test.
75g OGTT (2 h sample after 75g glucose; fasting not •• These are not done now and have been replaced
required) by 1 step testing by IADPSG and DIPSI.
1. >140 = GDM •• In 2 step screening 50 g Oral glucose challenge
2. >126 = Impaired Glucose tolerance test (OGCT) is done f/b a OGTT in those with
GCT > 140 mg/dl .
3. >200 = overt diabetes
It should be done between 24-28 weeks.

Diagnostic Test
Type & glucose values Glucose load Fasting (mg/dl) One hour (mg/dl) Two hour (mg/dl) Three hour (mg/dl)
ACOG 100 g 95 180 155 140
WHO 2013 for GDM 75 g 92-125 180 152 - 199
IADPSG 2010 75 g 92 180 153
DIPSI 2010 75 g ≥ 140

Effect of Diabetes on Pregnancy Pre-gestational:

GDM: •• Increased risk of congenital anomalies-

•• Infection (UTI and vulvovaginal candidiasis) –– MC anomaly is congenital heart disease esp VSD.

•• It can increase the incidence of pre-eclampsia –– Most characteristic anomaly is sacral agenesis
(mermaid syndrome).
•• Polyhydramnios
–– Thus higher the HBA1C, the more the risk of
•• Macrosomia anomalies
•• IUD •• Increased incidence of abortions.
•• Shoulder dystocia •• Foetal growth restrictions (IUGR)

Neonatal Complications: Based on Pedersen Hypothesis

 3
Diabetes In Pregnancy

Neonatal Effects (Pederson Diagnosis & Treatment of GDM

hypothesis)
•• Hypoxia
•• RDS (respiratory distress syndrome)
•• Hyperbilirubinemia
•• Low calcium / low magnesium
•• NEC / RVT
•• HOCM
•• Macrosomia
Diet
•• Shoulder dystocia
•• Medical nutrition therapy
•• Hypoglycaemia
•• Advise her to take 3 big meals + 3 small meals
Objectives of Treatment •• Low glycaemic index and a high fibre intake
•• Good glycaemic control AP and IP
Exercise
•• Antepartum foetal surveillance
•• Upper body exercises
•• Intrapartum management .
•• Exercise will increase insulin uptake and
Antepartum decrease insulin resistance

•• Good glycaemic control •• Diet + exercise should be advised for women

with normal sugar
•• Identifying complications
•• Repeat sugar profile after 1-2 weeks
Investigation
OHA
Maternal investigations:
Metformin: Glyburide:
•• Sugar profile (pre-meal and post-meal) •• Biguanide •• Sulfonylurea
•• HTN •• 2500 max a day •• Increases insulin
•• Increases insulin uptake production
•• Urine routine and urine culture (every trimester)
•• Doesn’t cause •• 2.5 g per day max
•• In overt diabetes patients, check for ketosis hypoglycemia •• Causes Hypoglycemia
•• KFT
Insulin
•• Fundus examination
•• Short-acting and medium-acting insulin should
For foetus: be given 20 minutes before a meal – 2/3rd in
the morning and 1/3rd in the evening
•• Pre gestational-MSAFP (16- 18 weeks)
•• TIFFA (18 -20 weeks) Goals (IMPORTANT).
•• Foetal echo •• Fasting: < 95g/dl
•• Ultrasound – to look for macrosomia (GDM) •• Pre-meal: < 100g/dl
•• FGR •• 1 hour postprandial: < 140 g/dl
•• 2 hours postprandial: < 120 g/dl
•• 0200-0600 > 60 g/dl
•• Mean: 100g/dl
4
Obstetrics and Gynecology

•• HbA1C: < 6 •• Anticipate shoulder dystocia, PPH, macrosomia

•• Higher incidence of caesarean delivery
Obstetric Management
RCOG/NICE: Insulin Management for Labor
Induction / Cesarean
•• Advise pregnant women with type 1 or type
2 diabetes without complications to deliver •• Give evening insulin dose
between 37 weeks and 39 weeks •• Withhold morning dose
•• Advise women with gestational diabetes to give •• Infuse IV normal saline at 100-125 ml/h
birth no later than 41 weeks
•• Regular insulin is infused at 1-1.25 U/h, if
glucose levels > 100 mg/dl
Obstetric Management
•• Avoid past dates •• Measure glucose levels hourly

•• Avoid beta-mimetic drugs for tocolysis that •• With active labor OR if glucose levels < 70 mg/
causes hyperglycemia dl, change from IV saline to 5% Dextrose.

GDM Pre-gestational Diabetes

Diagnosed during pregnancy Present before pregnancy
Requires OGTT for diagnosis Can be diagnosed on the basis of raised HbA1C or a raised FBG/ RBS
in the 1st trimester
Maternal and perinatal mortality more in the Congenital anomalies and spontaneous abortions if uncontrolled in the
latter half of pregnancy. 1st trimester
Ketosis is uncommon Ketosis is more common.

No end organ complications. Diabetic nephropathy retinopathy can be present; Preeclampsia and
IUGR more common in such scenarios.
Diet and exercise are sufficient in majority If on metformin, it is continued
Insulin may be additionally required

OHAs are useful Insulin is usually required

PP screening required after 6 weeks

Prone for Type 2 DM, metabolic syndrome
 ANEMIA IN PREGNANCY

•• WHO Definition: < 11g. Effects of Anaemia on Pregnancy

•• CDC Maternal:
Definition: •• Preterm birth
1st and 3rd trimester: < 11g. •• Preeclampsia
•• 2nd trimester: < 10g %. •• Cardiac failure
•• FOGSI: <11g%. •• Infections
•• Atonic PPH
Severity of Anemia
•• Puerperal sepsis
According to Anaemia Mukt Bharat campaign,
•• Pelvic vein thrombosis
•• Mild – 10-10.9 g%
•• Moderate – 7-9 g% Foetal:
•• Severe – <7 g % •• Foetal growth restriction
•• Premature birth
Physiological Anemia of Pregnancy
•• Foetal anemia
Physiological hemodilution –
•• Poor cognitive functioning
•• Blood volume increases significantly.
•• Red cell increases but not as much as the blood Evaluation
volume so there is physiological hemodilution. •• At every doctor’s visit, Hb is checked
•• Hb falls by 2 g% (maximum in the second
trimester). Diagnosis of Iron Deficiency Anemia
(IMPORTANT)
Iron Deficiency Anemia 1. Serum ferritin <30 (Normal: 15-300 mcg/L): 1st
•• Most common type of anemia in pregnancy. abnormal test in IDA and is unaffected by recent
iron intake
•• India – low bioavailability of iron in diet.
2. Serum Iron <30 mcg/dl (Normal: 60-120)
•• Iron requirement in pregnancy – 4 mg/day –
absorption <10%. 3. TIBC >400 mcg/dl (Normal: 300-350)
•• So, 40-60 mg/day iron is required in your diet. 4. Transferrin Saturation < 10%
•• Hence, supplementation required. 5. Serum transferrin receptor: Increased in IDA
6. Raised free erythrocyte protoporphyrin (FEP > 50)
7. Reticulocyte count increased
8. Hematocrit reduced
2
Obstetrics and Gynecology

9. Blood indices 6 INTERVENTIONS

a. MCV ↓ 1. Prophylactic iron and folic acid supplementation
b. MCH ↓ 2. Deworming
c. MCHC ↓ 3. Intensified year – round behavior change
communication campaign (solid body, smart mind)
10. Red cell distribution width >14 in IDA (reduced in including ensuring delayed cord clamping in newborns
thalassemia)
4. Testing of anemia using digital methods and
points of care treatment
Prevention of IDA
5. Mandatory provision of iron and folic acid
•• Dietary modifications – iron-rich diet fortified foods in government – funded health
•• Food fortification – Fe programme
6. Addressing non – nutritional causes of anemia
•• Deworming – Tab Albendazole 400 after first trimester
in endemic pockets, with special focus on malaria,
•• Iron supplementation in pregnancy haemoglobinopathies and fluorosis.

Anemia Mukt Bharat Campaign Prophylaxis in Pregnancy

•• 2018 •• Red colour tablet, sugar coated
•• Aim: Reduce anemia by 3% per year •• 60 mg of elemental iron and 500 mg of folic acid
•• This is called 6 x 6 x 6 strategy •• Start it at 14 weeks &continue for 180 days in
pregnancy
•• Continue 180 days postpartum

Other beneficiaries under Anemia Mukt

Bharat:
•• Pink colour – given to children of age 5-9 years
•• Blue colour – given to adolescents
•• Red colour – given to pregnant women
•• Syrup – given to children less than 5 years

Deworming
•• Tab Albendazole 400 mg after first trimester
•• Preferably in 2nd trimester

Testing and treating Mild and

Moderate Anemia
•• Haemoglobin checked at every contact visit
•• If mild anemia – 10-10.9g% OR moderate anemia
– 7-9.9 g%: Give 2 tablets of iron.
•• If patient presents late in pregnancy or is
 3
Anemia In Pregnancy

unable to tolerate oral iron: Parenteral iron – •• If patient presents late in the third trimester
iron carboxymaltose (FeCM). with severe anemia or Hb is less than 5 g%:
ADMIT
Severe anemia
•• Hb < 7g%: Iron carboxymaltose

Intra – Partum Management

1st stage 2nd stage 3rd stage
•• Sedation; lie in left lateral position •• Avoid prolonged bearing down •• AMTSL
•• Pain relief •• Avoid methergine in severe anemia
•• Oxygen ready •• Watch for signs of failure
•• Antibiotic prophylaxis after membrane rupture
•• Avoid overloading with intravenous fluids; encourage oral
hydration
•• Strict asepsis
•• Arrange and transfuse packed cells if required.
 INFECTION IN PREGNANCY

HIV in Pregnancy •• Low CD4 count

•• 0.3% prevalence in pregnancy •• Concomitant infection

•• 30% vertical transmission rate without •• STD

treatment (from mother to child) •• History of PROM
•• Operative vaginal delivery

Fetal Factors:
•• Invasive fetal monitoring
•• Preterm infants
•• Invasive procedures

Preconception counseling:
•• Explaining the mother about risk of vertical
transmission, HAART and other reproductive
procedures
•• Safe sexual practices (HIV discordant couples)
•• Ensure Immunization is complete

Diagnosis:
•• Routine antenatal testing
Human immunodeficiency
•• Opt out approach (NACO)
virus
•• ELISA – screening test
Vertical transmission: •• Confirmation by Western blot/Immunofluorescence
•• Antepartum: 20%
Antepartum management:
•• Intrapartum: 50-60%
•• Multidisciplinary
•• Postpartum (breastfeeding): 30%
•• Investigations: Hemogram, LFT, serological
test for certain infections like CMV, STD,
HAART reduces this risk to 1-2%
tuberculosis, CD4 count every trimester all
Risk Factors for Vertical Transmission: women pregnant
•• Counseling regarding risk of vertical
Maternal Factors: (IMPORTANT).
transmission (30%)
•• High viremia
•• Termination of pregnancy can be offered
2
Obstetrics and Gynecology

•• Nutritional advice Rubella in pregnancy

•• Avoid invasive testing like CVS/ amniocentesis •• Rubella infection in the 1st trimester: 90%
•• Start Antiretroviral Therapy (ART) and this is have a significant risk for abortion and severe
to be continued life long congenital malformations
•• Transmission: Nasopharyngeal secretions
Antiretroviral therapy in Pregnancy
As per NACO: Diagnosis:
•• IgM rubella will be positive for 6 weeks after
•• Lamivudine (3TC) + Tenofovir (TDF) + Efavirenz
acute infections
(EFV)
•• IgG avidity will be high in the women with
•• If a woman is already on ART, prefer to continue
recent rubella infection
the same regime
•• Amniocentesis- NAAT
•• 3TC + TDF + EFV during labor will reduce risk of
vertical transmission to 1-2%
Fetal Effects:
Intrapartum Management: •• Teratogenic

•• WHO and NACO (2013): Cesarean ONLY to be •• Congenital rubella syndrome

done for obstetric indication. –– Highest risk (90%) in first trimester
•• But Elective LSCS reduces the transmission –– Reduces to 25% in the third trimester
by half (but this is not feasible in low resource
countries)
•• Avoid vacuum / forceps
•• Elective LSCS at 38 weeks recommended by
RCOG/ ACOG unless low viral load
•• Factors increasing risk of transmission:
–– Long rupture of membrane to the delivery
interval
–– Invasive fetal monitoring
–– Operative vaginal delivery
•• Universal precautions
•• Delayed cord clamping

Postpartum management:
•• Breastfeeding increases transmission by 30%
•• NACO: Exclusive feeding for 6 months
Congenital Rubella Syndrome:
•• Mix feeding should not be done Triad of: CARDIAC (PDA) + CONGENITAL
CATARACT + SENSORINEURAL HEARING
ART to the neonate: LOSS

•• Nevirapine: 2 mg/kg from birth for 6 weeks Other features:

OR •• Purpura
•• Zidovudine: 4 mg/kg twice a day •• Hepatosplenomegaly
•• Encephalitis
 3
Infection In Pregnancy

•• Developmental delay •• No role of VZIG once rash has appeared

•• Radiolucent bone disease
Delivery in woman with chicken pox
Management & Prevention: •• Preferably avoid delivery for at least one
week after rash develop
•• Termination of pregnancy, if the infection in
the first trimester •• High risk of neonatal infection and high rate of
mortality (30%)
•• Prevention: preconception testing (IgG rubella)
•• If delivery can’t be delayed, give VZIG to
–– IgG rubella negative: Rubella vaccine
neonate
(4 weeks) can be given postnatally or
preconceptionally
–– Do not conceive for at least 1 month after
Herpes in Pregnancy
receiving the vaccine •• Infection may be primary or recurrent
•• Presents as painful genital vesicular lesions
Varicella in Pregnancy •• Trans-placental transmission: Rare
(Chicken pox)
•• Transmission during delivery: up to 50%
2 scenarios: •• Increased risk of fetal infection in primary
•• Contact with an infected person genital HSV

•• Infection with chickenpox •• Acyclovir reduces HSV shedding

•• Cesarean section indicated in active primary
Contact with an infected person: genital HSV
•• Risk of congenital varicella syndrome – fetal
growth restriction, microphthalmia / skin CMV
lesions and limb hypoplasia •• Trans-placental spread
•• Maximum risk: 13-20 weeks •• Fetal damage at all gestational ages
•• Ask for history of chickenpox •• Intracranial calcifications / periventricular
–– If history of chicken-pox: No need to worry calcifications

–– If no history of chicken pox or unsure history:

Get IgG varicella done Parvovirus
ƒƒ If IgG varicella positive: she is immune •• Trans-placental infection

ƒƒ If IgG varicella negative: she is susceptible •• Fetal anemia, hydrops and death

•• If the pregnant woman is not immune: Give

VZIG as soon as possible Syphilis in Pregnancy
•• Immunoglobulin has to be given within 10 days •• Vertical Transmission: Congenital Syphilis
of contact with infected person. / Hutchinson triad (Interstitial Keratitis/
Hearing loss/ Peg teeth)
Infection with chickenpox •• Kassowitz Law – gradually improving fetal
•• Avoid contact with susceptible individuals till outcomes in congenital syphilis
rash crust •• VDRL: may be false positive
•• Symptomatic treatment, hygiene •• USG: FGR, hepatomegaly, fetal anemia, hydrops,
•• Oral acyclovir, in severe cases IV acyclovir can placentomegaly
be given
4
Obstetrics and Gynecology

•• Treatment: Benzathene penicillin 2.4 million u syncytiotrophoblasts necrosis.

•• Screening VDRL at the time of booking •• Breastfeeding safe

Covid-19 in Pregnancy Management:

•• Supporting respiratory function
•• Caused by SARS-CoV-2 virus
•• Managing comorbid conditions
•• Severity higher in pregnancy
•• Monoclonal antibodies
•• ICU admission
•• Dexamethasone
•• Invasive ventilation
•• IV Remdesivir
•• Death
•• Anticoagulants should be given
•• Higher preterm rate
•• Cesarean NOT indicated
•• High fetal growth restriction and fetal death
•• Cord clamping should be done
Fetal infection (not teratogenic)
Prevention: Covid vaccines are safe in
•• Rare (3%)
pregnancy and lactation.
•• HPE of placenta: inflammation and
 LIVER DISORDER IN PREGNANCY

Acute fatty liver of pregnancy Lab Features •• Raised bilirubin

•• Most common cause of acute liver failure in •• Raised AST /ALT
pregnancy . •• Raised creatinine

•• Soft yellow greasy looking liver •• Raised urea

•• Raised ammonia
•• Histopathology – classic micro vesicular
•• Raised coagulopathy
steatosis
•• Raised TLC
•• 1 in 10,000
•• Hypoglycaemia
•• Male fetus, Multiple Pregnancy. USG Ascites / small liver.
•• 3rd trimester > 28 weeks. HPE Micro vesicular steatosis.

•• Associations preeclampsia
Management
•• Pregnancy has to be terminated
•• Supportive care
•• Correction of coagulopathy
•• High mortality rate for mother or foetus

IHCP (intrahepatic cholestasis of

pregnancy)
1. A.k.a. recurrent jaundice of pregnancy/ cholestatic
heptoses/ icterus gravidarum
2. Diagnosis:
•• 3rd trimester of pregnancy
•• Pruritus in the palm and the soles
Swansea Criteria for AFLP Diagnosis (At least 6 of •• Icteric (bilirubin level raised but very less)
these to be present)
Diagnosis
Clinical Features •• Pain
•• Vomiting
•• Serum bile acids is the investigation of choice
(>10: diagnostic for IHCP).
•• Encephalopathy
•• Polydipsia / polyuria •• Values above > 100 are known to be associated
with fetus death.
•• As the bile acid concentration rises, they cause
cardiac arrhythmia in the foetus (cardio toxic) .
2
OBG

•• Raised AST and ALT level •• Sexual transmission

Treatment •• Vertical transmission (rarely also through

breast milk)
•• UDCA 300 mg BD /TDS
Vertical Transmission
•• Dexamethasone
•• 10% risk in the 1st trimester; 90% in the 3rd
•• Induced delivery– 38 weeks
trimester
•• Recurrence: 25-50%
•• HBV is not teratogenic.
•• OCPs – There is chance of pruritus because of
•• Carrier neonate – cirrhosis/ hepatic cancer
oestrogen
later on in life
•• Foetal distress meconium amniotic fluid
•• Higher risk if HBeAg and HBsAg positive
•• Foetal death
Clinical Features
•• Terminate patients at 38 weeks of pregnancy
•• Flu-like illness – fever, malaise, anorexia, nausea
HELLP Syndrome and vomiting

•• Haemolysis +elevated liver enzymes + low •• Jaundice (rare)

platelet count •• 90% women will clear the infection
•• seen in severe preeclampsia •• 1% will develop fulminant hepatic failure
•• Commonly occur in the 3rd trimester •• 5-10% will have chronic infection/10% will have
•• Lab evaluation: LDH increases / PBS / increased cirrhosis
ALT and AST level
Diagnosis
•• Low platelets < 150000
•• Serological testing of HBsAg
•• Treatment: delivery
•• Screened for Hepatitis B
Viral hepatitis in pregnancy •• HBeAg denotes high infectivity
•• Most common cause of jaundice in pregnancy •• Ab to Hepatitis B Core Ag
•• Hepatitis B – increase risk of vertical •• HBV DNA titer (if it is high, there is increased
transmission risk of vertical transmission)
•• Hepatitis E – causes fulminant hepatic failure •• Liver enzymes elevated in acute infection
•• ALT /AST > 1000
Hepatitis B in pregnancy
Management
•• Pre-conceptional counseling: Screening and
immunization (active and passive with Hb IG in
12 hours within birth)
•• Tenofovir (Drug of choice in pregnancy)
•• No contraindication to vaginal delivery

Vaccination

All infants born to HBsAg positive mothers:

Active and passive immunization within 12
hours of birth.
Transmission
•• Parenteral transmission
RENAL AND URINARY TRACT IN PREGNANCY

Renal Changes in Pregnancy Cystitis

•• Infection of lower urinary tract system present
mainly with dysuria, urgency and frequency
•• It is also treated based on antibiotic sensitivity
•• Fever will not be present

Treatment Regimes for UTI in

pregnancy
Oral antibiotics:

UTI in pregnancy •• Nitrofurantoin 100 mg QID

•• Common in women because of short urethra and •• Ampicillin 500mg QID

proximity of urethra to the anal canal •• Amoxicillin 500mg TDS
•• Common in pregnancy due to stasis of urine •• Cephalexin 250 mg TDS
–– Effect of progesterone •• Oral Fosfomycin 3g sachet with a glass of water
–– PRessure of gravid uterus single dose

•• Most common organism – E. coli (90%) Treatment is based on urine culture

•• 3 main types - Asymptomatic bacteriuria, sensitivity report
cystitis and pyelonephritis

Asymptomatic bacteriuria
•• Women is not symptomatic but urine culture
shows significant bacteriuria (more than 105
CFU)
•• Incidence: 5 %, if there is no treatment, 25%
will develop symptomatic infection
•• Urine culture is done for all pregnant women in
every trimester Acute pyelonephritis (IMPORTANT).
•• Treatment is based on the culture report, •• Involves the upper urinary tract.
whatever antibiotic is sensitive
•• C/F: Lumbar pain, fever, chills, nausea, vomiting,
•• Always repeat the urine culture 2 weeks after myalgia, malaise, costo-vertebral angle
completion of treatment tenderness (Right > Left)
2
OBG

Complications in pregnancy 2. Septic abortion

1. Hemolytic anemia Causes in 2nd and 3rd trimester:

2. Thrombocytopenia 1. Preeclampsia

3. Renal failure 2. AFLP

4. ARDS 3. HELLP syndrome

5. Endotoxic shock 4. Abruption

6. Abortions, preterm labour 5. PPH

7. FGR 6. Post-partum haemorrhage

8. Foetal demise 7. Amniotic fluid embolism

Management of acute pyelonephritis 8. Puerperal sepsis

(IMPORTANT)
CKD in Pregnancy
•• Main-stay of treatment: adequate hydration,
•• Mild <1.5 creatinine
urine output should be more than 50 ml
•• Moderate: 1.5-3 creatinine
•• Blood and urine culture
•• Severe >3 creatinine
•• Broad spectrum antibiotics (cephalosporin)
•• Afebrile – switch to oral antibiotics Risks of CKD in pregnancy
•• Afebrile for > 24 hours – discharge and continue •• Preeclampsia
antibiotics for 7 to 10 days
•• Anaemia
•• Repeat urine culture 2 weeks after treatment
•• Foetal growth restriction
Acute kidney injury in pregnancy •• Preterm labor
Causes in 1st trimester: •• Abruption.
1. It can be caused due to severe dehydration in
women who have hyperemesis gravidarum
 HEART DISEASE IN PREGNANCY

Physiological changes of Symptoms

the heart in pregnancy Progressive dyspnea or orthopnea
Cardiac Output + 40% Nocturnal cough
Stroke Volume + 25 %
Hemoptysis
Heart Rate + 15%
Syncope
Blood Pressure Slightly decreased
Systemic vascular resistance -20% Chest pain
Pulmonary vascular resistance -35% Clinical findings
Central venous pressure No change Cyanosis
Pulmonary capillary wedge Slightly increased Clubbing of fingers
pressure
Persistent neck vein distention
Systolic murmur grade 3/6 or greater
Diastolic murmur
Cardiomegaly
Persistent arrhythmia
Persistent split second sound
Criteria for pulmonary hypertension
Abnormal Findings indicative of Heart Disease in Preg-
nancy

•• 3 important classifications of severity of heart

disease in pregnancy

Physiological Findings in Pregnancy

2
Obstetrics and Gynecology

1. NYHAS Classification
Class I. Uncompromised—no limitation 01 physical octivity
These women do not have symptoms of cardiac insufficiency, nor do they experience anginal pain
Class II. Slight (imitation of physical activity
These women are comfortable at rest, but if ordinary physical activity is undertaken, discomfort results in the form of
excessive fatigue, palpitation, dyspnea, or anginal pain
Class III. Marked limitation of physical activity
These women are comfortable at rest, but less than ordinary activity causes discomfort by excessive fatigue,
palpitation, dyspnea, or anginal pain
Class IV. Severely compromised-inability to perform any physico/ activity without discomfort
Symptoms of cardiac insufficiency or angina may develop even at rest, and if any physical activity is undertaken,
discomfort is increased
2. WHO Risk Classification of cardiovascular disease and Pregnancy with Management Recommendation (In this
remember the ABSOULTE CONTRA-INDICATIONS TO PREGNANCY)
 3
Heart Disease In Pregnancy

3. CARPREG 2 Risk Predictors •• Antenatal Management

CARPREG Il Risk predictors –– More frequent visits
Predictor Points –– Correct anemia
Prior cardiac events or arrhythmias 3
–– Check for asymptomatic bacteruria
Baseline NYHA 3—4 or cyanosis 3
Mechanical valve 3 –– Early diagnosis of preeclampsia (Inj
benzathine penicillin)
Systemic ventricular dysfunction LVEF <5 % 2
High-risk valve disease or left ventricular 2 –– Admit is
outflow tract obstruction (aortic valve area ƒƒ NYHA 3 or 4 at diagnosis
<1.5 cm2, subaortic gradient >30, or moderate
ƒƒ NYHA 2 at 32-34 weeks
to severe mitral regurgitation, mitral stenosis
2.0 cm2) ƒƒ NYHA 1 weeks prior to EDD
Pulmonary hypertension, RVSP >49 mmHg 2 •• Intrapartum Management
High-risk aortopathy 2
–– Avoid fluid overload
Coronary artery disease 2
–– O2
No prior cardiac intervention 1
Late pregnancy assessment 1 –– Pain relief: epidural analgesia preferred
(Except in Eisenmenger/ aortic stenosis and
In CARPREG 2 scoring: the risk or a primary cardiac
hypertrophic cardiomyopathy)
event in pregnancy
–– Watch for signs of cardiac failure
•• If the score is 1: Risk of a cardiac event is 5%
–– Infective Endocarditis prophylaxis in labor:
•• If the score is 2: Risk of a cardiac event is 10%
ƒƒ Not recommended for either vaginal
•• If the score is 3, Risk of a cardiac event is 15%
delivery or cesarean in the absence of
•• If the score is 4, Risk of a cardiac event is 22% infection
•• If the score is > 4, risk of a cardiac event is ƒƒ Recommended in
40%
○○ Women with prosthetic heart valves
Remember: ○○ Past h/o bacterial endocarditis
•• MC heart disease in pregnancy: Rheumatic heart ○○ Patient with congenital heart disease
disease with
•• MC time when patient can have cardiac failure ♦♦ Unrepaired congenital heart
–– Antepartum: 32-34 weeks disease

–– Intrapartum (during labor) ♦♦ Completely repaired congenital

heart ds with prosthetic device
–– Immediate postpartum (sudden redistribution
of blood in the uterus back to systemic ♦♦ Repaired heart ds with residual
circulation) defects at the site adjacent to the
prosthetic patch or device
•• Effects of heart disease on the fetus
○○ Cardiac transplant recipient with
–– Abortions valve regurgitation due to structurally
–– Prematurity abnormal valve

–– FGR ƒƒ Drugs for IE prophylaxis

–– Fetal death ○○ IV: Ampicillin (2g) or cefazolin (!g) or

ceftriaxone (1g) 30-60 mins before
–– 5-10% risk of congenital heart disease if procedure OR
either parent has a congenital heart disease
○○ Oral: Amoxicillin: 2g
4
Obstetrics and Gynecology

•• 2nd stage of labor Peri Partum Cardiomyopathy

–– Cut short 2nd stage of labor with forceps or •• Development of cardiac failure in the last month
vacuum of pregnancy or within 5 months of delivery
•• 3rd stage of labor •• Absence of an identifiable heart disease prior
–– AMTSL to the last month of pregnancy

–– Avoid fluid overload •• LV systolic dysfunction on ECHO

–– Post partum vigilance •• Treatment is bed rest, digoxin and diuretics

•• Usually seen in older, obese women with HTN
•• High morbidity and mortality
•• Recurrence in subsequent pregnancies
 EPILEPSY IN PREGNANCY

Effect of pregnancy on –– Abortions

epilepsy –– Preeclampsia

•• 20% - Increased frequency of seizures: –– Abruptions

–– Reduced absorption of Anti-epileptic Drugs –– Preterm labor

(AEDs). •• Congenital Anomalies
ƒƒ Increased renal plasma flow •• Increased risk of Postpartum depression
ƒƒ Decreased gastric motility
ƒƒ Vomiting in pregnancy Preconception counseling -
–– During labour, increased pain and –– Folic acid to prevent neural tube defect (3
hyperventilation during labour months prior to conception) at a dose of 4mg
/day
•• 20% - Reduced frequency
–– Anti-epileptic drugs should be Adjusted to:
Lowest no of drugs with lowest possible dose
Effect of Epilepsy on
Pregnancy
Teratogenicity
•• Increased risk

Drug Abnormalities
Na Valproate Highest incidence of abnormalities (20%) causes NTD, cardiac anomalies,
clefting

Phenytoin Foetal hydantoin syndrome (facial defect + distal digital hypoplasia)

Phenobarbital Foetal hydantoin syndrome

Carbamazepine Foetal hydantoin syndrome

Lamotrigine Cleft lip and cleft palate

Topiramate Least risk of congenital anomalies

Levetiracetam Least risk of congenital anomalies

2
Obstetrics and Gynecology

–– Foetal echo
•• Intrapartum management
–– Good hydration and pain management
–– Epidural analgesics

Managing an Acute seizure

episode in pregnancy
•• Benzodiazepines (first line drug of choice) e.g.
lorazepam/ diazepam
•• IV phenytoin (In refractory cases)
•• Left lateral tilt
•• Oxygen
Fetal hydantoin syndrome
•• Continuous electronic foetal heart rate
Upturned nose Distant digital hypoplasia monitoring

Management
Drug interaction
•• Folic Acid (preconceptionally, 4mg /day) 3
months prior •• Anti-Epileptic Drugs (Enzyme inducers) reduce
OCP efficacy (induce CYP P450)
•• Detecting foetal malformations
•• Avoid OCPs with Lamotrigine. Lamotrigine
–– MS AFP at 16 - 18 weeks clearance is increased in the presence of
–– Targeted Imaging For Fetal Anomaly (level 2) Estrogen-containing oral contraceptives
at 18-22 weeks leading to increased seizure frequency
 THYROID DISORDERS IN PREGNANCY

Physiology of thyroid in 2. Subfertility

pregnancy 3. High abortion rate

1. TSH levels change throughout pregnancy 4. IUGR

•• In the first trimester, TSH level reduces 5. Preterm baby

causing: physiological hyperthyroidism
•• It happens because the alpha subunits of hCG Treatment:
and TSH are similar, it stimulates thyroxine •• Thyroxine; Aim to keep the TSH levels in these
production and it gives negative feedback and ranges
TSH production will reduce (Cross stimulation
by hCG) –– In first trimester: 2.5 u/ml
2. TBG increased –– 2nd & 3rd trimester: 3 u/ml
3. Total T3 and T4 levels also increased in pregnancy
that’s why,always measure free T3 and T4 levels Autoimmune thyroid disease
4. Maternal thyroxine is important for fetal brain •• Most common cause of thyroid hypofunction
development. It crosses the placenta before <12
•• TPO-Abs and TG Abs
weeks and reaches to foetus
•• Increased risk of:
5. Fetal thyroxine production starts at 12 weeks
6. Increased requirement of iodine – 250 mg/day 1. Preeclampsia

7. Thyroid gland also increases in size – 12-15 ml 2. IUGR

3. Abruption
Hyperthyroidism
4. Preterm labour
•• 1%
•• Grave’s disease most common in pregnancy Post-partum thyroiditis
•• PTU: hepatotoxicity (propylthyrouracil – drug •• It happens within 12 months of delivery
of choice)
•• It could manifest as hyperthyroidism or
•• Methimazole/carbimazole can also be given
hypothyroidism or both
–– Methimazole embryopathy: choanal atresia +
cutis aplasia is seen •• It is common in overt DM
•• Radioactive I: completely contradicted –avoid •• Usually the course is such that in initial stage,
pregnancy for 6 months after radio ablative there is hyperthyroidism which lasts for few
therapy months and treated with beta blockers ; This
is followed by a stage of hypothyroidism which
Hypothyroidism in could be prolonged for many months, treatment
pregnancy –thyroxine.

Complications:
1. Higher incidence of preeclampsia
 Rh negative pregnancy and Rh iso-
immunization

Basics: The Abs will go and attack the fetal red cells –
hemolysis – fetal anemia – hydrops– death
•• When Rh neg mother with Rh positive father is
Prevention of Rh iso-immunization:
carrying a Rh positive fetus in the first pregnancy
and develops Abs against the D Antigen (Allo
•• 90% of iso-immunization happens during delivery
immunization).
•• 0.1 ml of blood can induce an antibody response
•• If 2nd pregnancy also the fetus is Rh positive –
•• Other inciting events:

Pregnancy Loss Procedures Others

Spontaneous abortion Chorionic villous sampling Delivery

Induced abortion Amniocentesis Abdominal trauma
Molar pregnancy Cordocentesis Antepartum haemorrhage
Ectopic pregnancy Evacuation of molar preg- Unexplained vaginal bleed-
nancy ing in pregnancy
Suction evacuation of prod- Manual removal of placenta
ucts of conception
External cephalic version

•• Any woman who comes for her 1st prenatal DNA can be offered to determine fetal
visit – Blood group and Rh status. Rh status. But this is optional and most
of the time it is not done so directly ICT
–– If Rh negative, husbands blood group and Rh
is done.
status determined
–– Zygosity and cfDNA is not routinely done but
–– If husband is Rh negative: Fetus will be Rh
can be offered.
negative so nothing to worry and routine
prenatal care given –– If Rh neg and husband Rh positive – ICT is
done.
–– If husband is Rh positive, then depending on
the zygosity, the fetus can be Rh negative –– ICT is repeated monthly
or Rh positive.
–– Prophylaxis (Given in women who are ICT
ƒƒ If husband is homozygous for the D antigen negative)
(DD); the fetus is definitely Rh positive
ƒƒ Anti D (300 mcg IM) given at 28 weeks (If
and ICT is done (indirect Coomb’s Test)
ICT is negative)
ƒƒ If husband is heterozygous for the D
ƒƒ Repeated within 72 h after delivery if
antigen (Dd), there is a 50% chance that
baby is Rh positive
the fetus is Rh positive. Hence cell free
2
Obstetrics and Gynecology

ƒƒ 300 mcg neutralizes 30 ml of fetal blood peaks at a wavelength of 450 nm). This
(15 ml of fetal red cells) value is then plotted on Liley’s graph. (>
27 weeks) or Queenans graph (< 27 weeks)
ƒƒ Avoid past dates; Avoid methylergometrine
ƒƒ Zone 1 & lower level of zone 2: Repeat
ƒƒ Delivery is the cause of 90% of feto
Amniocentesis after 2 weeks
maternal haemorrhage (FMH)
ƒƒ Upper zone 2: Cordocentesis and Intra-
ƒƒ Also given after inciting events (When
uterine transfusion if Hct < 30%
feto maternal haemorrhage can happen)
ƒƒ Zone 3: cordocentesis and Intra-uterine
○○ Spontaneous/ induced abortion/ MTP/
transfusion
fetal demise at any gestation
○○ Ectopic pregnancy, Molar pregnancy
○○ Selective fetal reduction/
Amniocentesis/ Chorionic villous
sampling
○○ External cephalic version
○○ Manual removal of placenta
○○ Abruptio Placentae/ Abdominal trauma
–– FMH > 30 ml: Determine fetal cells in maternal
blood by:
ƒƒ Qualitatitive test: Rosette test
ƒƒ Quantitative test:
○○ Kleihauer- Betke test (Acid elution
test) – adult RBS appear as ghost cells
○○ Best test: Flow cytometry Liley’s Curve

•• Management of an already sensitized pregnancy

(i.e., ICT positive)
–– Check ICT monthly till 24 weeks and weekly
thereafter till critical titers are reached
–– Critical titre is > 1: 16
–– Once critical titer is reached - Check Peak
systolic velocity of Middle cerebral artery
(PSV of MCA)
–– If PSV of MCA > 1.5 MoM – Cordocentesis
and check fetal Hematocrit (Hct)
–– If Hct of fetal blood is < 30% - Intra
uterine transfusion with O negative blood
is transfused
–– Earlier, amniotic fluid spectrophotometry
was done to determine the level of bilirubin
in the amniotic fluid (indirectly assessing
anemia) by spectrophotometry (bilirubin Normal MCA Doppler
 3
Rh Negative Pregnancy and Rh Iso-Immunization

•• Cord blood at delivery for

–– Hb %
–– ABO & Rh
–– Hematocrit
–– Direct Coomb’s test (DCT)
–– Bilirubin
Progressive worsening and earlier onset in subsequent
pregnancies; monitoring should start earlier and
critical titers aren’t required to start MCA PSV
monitoring

Hydrops Fetalis
•• Excessive accumulation of serous fluid
Increased flow in MCA (Redistribution) •• USG Diagnosis: 2 or more fetal effusions OR 1
effusion + anasarca

Intrauterine transfusion, •• Usually accompanied with skin edema and

placentomegaly
•• Done if Hct < 30% (Once Hct < 15%; there is
evidence of hydrops) –– USG – clinically significant edema: > 5 mm

•• Fetus is injected with a muscle relaxant –– USG - > 4 cm in 2nd trimester/> 6 cm in the
3rd trimester
•• Cordocentesis is done i.e. blood is aspirated
from umbilical vein •• 2 causes:

•• Hematocrit is checked and the decision for –– Immune (Rh iso-immunization) – 10%
intra-uterine transfusion taken –– Non – Immune – 90%
•• Red cells transfused are
–– Freshly donated Non-Immune Hydrops
–– O neg •• 90%

–– CMV neg •• Etiology:

–– 80% PCV –– Aneuploidy (20%) – MC: 45 XO (Turner

Syndrome)
–– Irradiated
–– Cardiovascular (15%)
–– Leukocyte poor
–– Infections (15%) –Most common – Parvovirus
•• EFW x 0.02 for each 10% rise in Hct desired
B19
(Target Hct is 40 - 50%)
–– High mortality rate; 40% liveborn – only 50%
Planning Delivery of an Rh iso-immunized pregnancy
survive
•• Delivery at 34 weeks (Fetal lung maturity) or
earlier
4
Obstetrics and Gynecology

Causes of non-immune hydrops

CARDIOVASCULAR
•• Arrythmia
•• Myocardiopathy
•• Structural malformations (Ebstein anomaly, premature closure of the foramen ovale)
•• Vascular obstruction
•• Vascular malformation and hemangioma

•• Genetic
•• Skeletal dysplasia and myopathies
•• Metabolic diseases (Gaucher, GM!, gangliosidosis, mucopolysaccharidosis)
•• Autosomal disease (Noonan, Prune belly, Fanconi)
•• Chromosomal abnormalities (Turner, trisomy 21, 13, 18)

Congenital Infections
•• Virus (parvo B19, CMV, rubella, varicella, RSV, herpes)
•• Toxoplasmosis
•• Syphilis
•• Chagas ds

Hematologic
•• Non immune anemia
•• Alpha thalassemia

Placental
•• Twin to twin transfusion syndrome

Miscellaneous
•• Respiratory (tumor, adenomatoid ds, pul sequestration)
•• Genitourinary (obstructive uropathy, cyst, dysplasia)
•• GIT (duodenal/ jejunal atresia, anal imperforation, peritonitis)
•• CNS (encephalocele, intracranial haemorrhage)
•• Tumor (sacrococcygeal teratoma, neuroblastoma, hepatoblastoma)
•• Multiple causes (more than 1 cause)

Idiopathic
 Antepartum Haemorrhage

Antepartum haemorrhage is defined as bleeding from •• Etiology:

the genital tract after the period of viability till
–– Dropping down theory i.e., implantation occurs
delivery.
in the lower uterine segment
–– Defective decidua resulting in spreading
Causes: of the villi to a larger area in search of
1. Placental (70%) nourishment
a. Placenta Previa –– Large surface area of the placenta
b. Abruptio Placenta
High Risk Factors
c. Vasa Previa (Cause of Fetal blood loss)
•• Multiparity
2. Extraplacental (Local Causes) (5%)
•• Age > 35 y
a. Cervical polyp
•• Asian women
b. Cervical erosion
•• H/o ART
c. Cervical malignancy
•• Previous scar on the uterus (cesarean,
d. Local trauma myomectomy)
3. Indeterminate (25%) •• Prior D & C
•• Prior placenta previa
PLACENTA PREVIA
•• Multiple pregnancy
Definition: When the placenta is implanted partially
or completely in the lower uterine segment. •• Placental abnormalities like bilobed placenta,
succenturiate lobe
•• Accounts for about 1/3rd of all cases of APH
•• Smoking
•• 80% found in multipara

Types of Placenta previa

Older Classification (Browne’s classification)

Type 1 Lower edge of placenta enters the lower segment; away from os

Type 2 The placenta reaches the margin of the os; doesn’t cover it

Type 3 The placenta covers the internal os partially (when fully dilated doesn’t cover)

Type 4 The placenta completely covers the os

2
Obstetrics and Gynecology

Type 1 Type 2 Type 3 Type 4

Minor degree (Type 1 & type 2 ant) Major degree (Type 2 post, type 3 & 4)

Newer Classification (based on Transvaginal ƒƒ Soft, relaxed (if not in labor), non-tender
Sonography -TVS); By ACOG
ƒƒ Uterine height = POG or less than POG if
1. True Placenta Previa: Placenta covers the internal IUGR (commonly associated with placenta
os previa)
2. Low lying placenta: Placenta lies within 2 cm of the ƒƒ Malpresentations common (35% incidence
internal os but does not cover it. of malpresentations in placenta previa)

Dangerous placenta previa: Type 2 posterior ƒƒ Floating head in cephalic presentation

placenta previa. Why? ƒƒ Stallworthy sign (fetal bradycardia
•• Because the placenta which is overlying the on pushing the head down): seen
sacral promontory decreases the AP diameter characteristically in type 2 posterior
of the inlet – No engagement placenta previa.

•• Cord compression and cord prolapse can occur –– L/E and P/S: done to rule out local causes;
blood is usually bright red.
•• Excessive compression of the placenta by
the fetal head if vaginal delivery is allowed –
Stallworthy’s sign – fetal bradycardia on pushing
Investigations:
the head down (As it causes compression on the •• Ultrasound
placenta). Not a reliable sign.
–– Modality of choice
–– Preliminary investigation of choice:
Clinical Features Transabdominal ultrasound (TAS)
•• Symptoms: Bleeding
–– Transvaginal ultrasound: More accurate; done
–– SUDDEN, PAINLESS, RECURRENT, if any doubt on TAS; Safe
APPARENTLY CAUSELESS
•• MRI
–– 1st bleeding is called warning haemorrhage
–– Useful in some situations
–– 80% of all women with placenta previa bleed
–– More useful in morbidly adherent placenta
before onset of labor
•• Signs:
Complications:
–– Pallor: proportionate to blood loss
1. Maternal
–– P/A:
a. Excessive bleeding leading to shock. But this is
 3
Antepartum Haemorrhage

more common in abruption 2. Fetal

b. Malpresentations a. Prematurity
c. Preterm labor (Iatrogenic and spontaneous) b. Fetal growth restriction
d. Prolonged hospitalization c. Congenital malformations
e. Operative delivery d. Malpresentations
f. Anemia e. Intrauterine fetal demise
g. PPH f. Increased perinatal mortality

Management

Components of Expectant Management •• Type 1 and type 2 a: Can consider vaginal

(MacAfee & Johnson) delivery – Double Set-up – not done now. Can
be performed if inconclusive USG/ USG not
•• Bed rest available and patient is stable.
•• Hb and Blood group
Problems anticipated in Cesarean Delivery
•• Hematinics/ Blood transfusion
•• Lower segment cesarean delivery: usually done.;
•• Avoid tocolysis Classical if adherent placenta.
•• Inj Anti-D for Rh negative women •• Dilated vessels on the lower segment need to
•• Corticosteroids for fetal lung maturity (< 34 be ligated
weeks): Inj Betamethasone 12 mg 2 doses 24 •• If placenta anterior; try avoiding the placenta;
h apart if cut through; delivery needs to be quick
Definitive Management: Delivery •• Placental bed bleeding: Sutures in the placental
bed
•• Cesarean delivery done for almost all placenta
previa •• Anticipate atonic PPH
4
Obstetrics and Gynecology

Abruptio Placentae •• Trauma including abdominal wall trauma. Also

iatrogenic procedures like
Definition: Premature separation of a normally
implanted placenta –– External cephalic version
–– Amniocentesis
Types:
•• Sudden uterine decompression:
1. Revealed: Most common type
–– PPROM/ PROM
2. Concealed: Thromboplastin pushed into the inter-
–– Delivery of 1st twin
villous spaces: DIC More common
–– ARM
3. Mixed
–– Short cord
–– Placental anomalies like circumvallate
placenta
–– Folic acid deficiency
–– APLA and other Thrombophilias
–– Smoking, cocaine
–– Placenta implanted over a septum or a
leiomyoma

Complications of Abruption (more common in

concealed abruption)

Etiopathogenesis Maternal
•• Rupture of a decidual spiral artery -Haemorrhage •• Hemorrhagic shock
into the decidua basalis – the decidua then splits
•• Acute renal failure
– decidual hematoma – expands – separation &
compression of the adjacent placenta •• Disseminated intravascular coagulation
•• Postpartum hemorrhage
Risk Factors
•• Maternal mortality
•• General – Increased age, grand multipara, poor
nutritional state, smoking
Fetal
•• Previous h/o abruption
•• Prematurity
•• Hypertension in pregnancy (preeclampsia,
•• Fetal asphyxia
gestational HTN, chronic HTN)
•• Fetal death

Clinical Features •• Perinatal mortality

Parameter Revealed Abruption Concealed Abruption

Symptoms Pain + Bleeding Pain + very slight/ nil bleeding
Bleeding Dark color continuous Spotting
General condition In proportion to visible blood loss Out of proportion to visible blood loss
Pallor Related with blood loss Severe
Uterine height = POG >POG
Uterine feel Normal; contractions + if in labor Tense and tender
Fetal parts Felt easily Not easily felt
DIC Less common More common
 5
Antepartum Haemorrhage

Clinical Classification (Page •• Severe concealed abruption

Classification) •• Intravasation of blood into uterine musculature
Grade 0: Asymptomatic; detected by seeing •• Diagnosed on laparotomy
retroplacental clot after delivery
•• Dark bluish/ wine colored uterus; cornua
Grade 1: Vaginal bleeding mild; uterine tenderness
•• Not an indication for hysterectomy
minimal or absent, FHR – good
Grade 2: Vaginal bleeding: mild – moderate, Uterine
tenderness +; No maternal shock; Fetal distress/
death
Grade 3: Bleeding: moderate/ severe; Marked
uterine tenderness; fetal death +; maternal shock/
DIC/ ARF +

Diagnosis:
•• Mainly clinical
•• Ultrasound: helpful in ruling out placenta previa
and in concealed abruption

VASA PREVIA
•• Fetal blood loss (NOT maternal)
•• Seen in succenturiate placenta/ velamentous
insertion
•• High fetal mortality due to exsanguination
•• Detection of nucleated RBCs (singer’s alkali
denaturation test) OR fetal hemoglobin (Apt
test) is diagnostic
•• Often associated with sinusoidal FHR tracing
Management: •• Management: Elective cesarean
•• Emergency measures •• Question asked: CTG in vasa previa: sinusoidal
•• Immediate Delivery is the rule pattern of FHR

•• If fetal distress/maternal shock – expedite

(Cesarean delivery unless patient in advanced
labor)
•• If no fetal distress or fetal demise has already
occurred OR no maternal distress: Induce/
Augment (ARM ± Oxytocin)

Couvelaire Uterus
•• Uteroplacental apoplexy
 MULTIPLE PREGNANCY

Risk Factors –– If the split has happened in <72 hour:

Diamniotic Dichorionic.
•• Race
–– If the splitting happens on 3rd to 8th day:
•• Heredity Monochorionic Diamniotic.
•• High Parity –– If the splitting happened on 8th to 12th day:
•• Increasing age > 35 – high age means higher Monochorionic Monoamniotic.
FSH level and more than one follicle recruited –– If the split happened after the 13th day:
•• Iatrogenic: Artificial Reproductive Techniques Conjoined twin.
(IVF)
Diagnosis and Chorionicity
Incidence •• Determination of Chorionicity: Sonography
•• Hellin’s rule: 1 in 80 (n-1)
(n is the number of fetus) –– No. of placentas
–– Incidence of twin pregnancy: 1 in 80 –– Presence and thickness of the intervening
–– Incidence of triplets: 1 in 802 membrane

–– Incidence of quadruplets: 1 in 803 –– Fetal gender

Classification of Twin
Pregnancy
Two main types:
1. Monozygotic: One sperm fertilises one ova and
then embryo is formed which gets split into two
foetuses
2. Dizygotic: One sperm fertilises one ova and other Reverse T (MCDA)
sperm fertilises other ova and two seperate
embryo formed

Chorionicity:
•• Dizygotic twins – sperm fertilises two separate
ova to form a separate embryo – these type of
twins are always diamniotic and dichorionic
•• Monozygotic – a single sperm fertilises single
ova, then embryo gets split into two embryos
Lambda sign or twin peak sign – thicker formation,
(IMPORTANT) 4-layered (DCDA)
2
Obstetrics and Gynecology

Complications
Maternal Fetal
Hyperemesis Spontaneous abortion

Anemia Congenital malformations

APH Fetal growth restriction / discordancy

Preterm Preterm

PPROM Fetal Death

Pre-eclampsia Unique complications

Increased operative delivery

PPH

Vanishing Twin & Fetus Twin to Twin Transfusion

Papyraceous Syndrome (TTTS)
•• Vanishing twin – Fetal demise of 1 twin in •• Monochorionic diamniotic twins
early pregnancy; spotting may be present, no
•• Because of vascular anastomosis, one twin
significant effect on other twin.
becomes donor twin & starts donating its blood
•• Foetus papyraceus – Greek word for paper- to the recipient twin
like, foetus demise in the second trimester.
•• As a result, donor twin become anaemic
(oligohydramnios) and recipient twin becomes
polycythemic(polyhydramnios)
•• Both twin will go in cardiac failure and death
will happen
•• Severity is based on Quintero Classification
(Stage 1 to 5)

Discordant Twins (foetal

growth restriction for one
twin)
Diagnosis:
1. HC > 5%
2. AC ≥ 20mm
3. EFW > 25% if the estimated foetal weight
is varying more than 25%, then it is called
Treatment of Twin to twin transfusion
discordant twin.
syndrome
•• Best way to treat: and do laser ablation
•• Septostomy
 3
Multiple Pregnancy

•• Amnio-reduction, or removal of the excess fluid Conjoined Twins

done
•• Selective feticide

Twin Reversed – Arterial –

Perfusion Sequence (TRAP)

•• Joined at head, called craniopagus

•• Thoracopagus (most common)
•• Ischiopagus
•• Aka Acardiac Twin
•• Always delivered by caesarean
•• Donor twin will give blood to the acardiac twin
•• Donor twin becomes anaemic and eventually
leads to cardiac failure and fetal death
Management of Twin
Pregnancy
Treatment: •• Antepartum

•• Ablating or cutting of blood supply –– Anticipate complications

–– ANC visits more often
Monoamniotic Twin –– Diagnose chorionicity (11-14 weeks)
Pregnancy –– Delivery
ƒƒ DCDA: Delivery at 38 weeks
ƒƒ Uncomplicated MCDA: 34-37 weeks
ƒƒ MCMA twins: 32-34 weeks (high risk of
cord entanglement)

Confirm presentation at
term
•• Cephalic – Cephalic (most common).
•• High complication rate •• Cephalic – Non-cephalic .
•• Cord entanglement •• Non-cephalic – cephalic/no- cephalic .
•• This type of pregnancy is delivered at 34 weeks First twin non-cephalic is direct indication of
by cesarean method caesarean delivery
4
Obstetrics and Gynecology

Indications for Elective

LSCS in Multiple Pregnancy
1. First fetus non-cephalic (breach / lie transverse)
2. Triplets and above – caesarean
3. Conjoined Twins – obstructed labour
4. Monoamniotic twins (Risk of cord entanglement,
so LSCS done at 34-weeks)
5. Discordant twins (severe)

Multifetal Pregnancy
Reduction & Selective Fetal
Termination •• KCl is injected intracardiac of foetus by
ultrasound guidance at 11-14 weeks
•• Smallest foetus should be terminated
•• Selective foetus termination: is when an
anomalous fetus is terminated.
 VAGINAL BIRTH AFTER CESAREAN (VBAC)

Risks following a cesarean What are we worried about?

section Ruptured uterus)
•• Cesarean scar pregnancy
•• Placenta previa (implantation of a placenta in Risk of rupture
the lower uterine segment) 1. Type of Previous scar : Depends on type of scar;
•• Placenta accreta syndromes (PAS) least with a lower segment scar
•• Rupture uterus (previous uterine scars) •• Lower segment scar (Kerrs incision): 0.2-1.5% .
•• Retained placenta •• Upper segment (classical cesarean) scar (4-9
%).
•• Postpartum haemorrhage
•• T-shaped or J-shaped incision (4-9 %).

Vaginal Birth After Cesarean (Vbac) Upper segment

Suturing Better apposition Poor apposition, thicker

Healing in puerperium Better Imperfect due to contraction/

retraction of upper segment

Stretching of wound Along the scar Perpendicular to the scar

Scar rupture rates 0.2-1.5% 4-9%

Timing of rupture Intrapartum during labor Antepartum and Intrapartum

166
Obstetrics and Gynecology

2. Interdelivery interval
•• More the number of previous cesareans, higher
the risk of rupture .
•• ideal Interconceptional period: 18 months → <
18 months risk of rupture is high
3. Indication for previous LSCS
•• Recurrent indication (like contracted pelvis) is
a c/i to TOLAC
4. Factors in the Present Pregnancy: Factors not
favorable for a TOLAC
1. Multiple pregnancy
•• Look for impending signs of rupture
2. Macrosomia
–– Fetal bradycardia
3. Over distended uterus
–– Maternal tachycardia
4. Spontaneous v/s induced labor
–– Scar tenderness
Assessment of risk of rupture •• Prostaglandins are contraindicated in previous
•• History: Past and Present cesarean

•• During pregnancy: Ultrasound assessment of •• Oxytocin has to be carefully used.

thickness of scar: 3.5 mm
Management of Scar Dehiscence
Counseling is done: Depending on all the above
factors, the patient is counseled regarding
•• Trial of labor after cesarean (TOLAC) – 60% of
patients undergoing TOLAC wil have a vaginal
birth after cesarean (VBAC)
•• Elective repeat cesarean delivery (ERCD)

Contra-indication to TOLAC
•• Previous classical cesarean/J-shape or T-shape
•• Two or more previous cesarean
•• Interconceptional period < 18 months
•• Obstetric risk factor like preeclampsia
•• Placenta previa Immediate cesarean section

•• Multiple pregnancy
Management of ruptured uterus
•• CPD
The signs of ruptured uterus (This is a more acute
presentation than scar dehiscence) so the patient will
TOLAC Management in Labor– be in shock.
2 important definitions:
1. Cessation of contractions.
Scar dehiscence (incomplete rupture) – Myometrium
2. Fetal heart will become absent; you will not be
has given way but overlying peritoneum is intact.
able to auscultate because the fetus dies almost
Scar rupture – complete give way of the scar. instantaneously or within minutes
3. You will find easily palpable fetal parts. On
 167
Vaginal Birth After Cesarean (Vbac)

abdominal examination, you normally find smooth 6. Hematuria is typically seen if the bladder also
contour of the uterus but if the uterus ruptures, ruptures. Many times, when the lower segment
it will be lying in a corner and the fetus will be all ruptures the bladder also ruptures.
in the abdominal cavity
4. Mother will be in shock, hypotension and Management of Rupture:
tachycardia.
•• An emergency laparotomy needs to be done.
5. On vaginal examination, we find Loss of Station.
•• Repair or remove the uterus. If repair of uterus
So on examination, the fetal head is somewhere
is possible, then a tubal ligation is recommended
high that it may not be even felt. This is called a
because once the uterus has ruptured, the
loss of station. The head recedes back , It goes up
woman is at much higher risk of getting it
because the fetus is not in the uterus but is in the
ruptured at the time of next pregnancy.
abdominal cavity.
 Fetal Growth
Disorders

Fetal Growth 1500 – 2500g

Pathophysiology 2. Very Low Birth Weight: 1000 -1500 g

Fetal growth can be divided into 3 phases: 3. Extremely Low Birth Weight: 500 – 1000g

1. Phase of Hyperplasia: Upto 16 weeks Small for Gestational Age: Weight < 10th percentile
for that gestational age. These include:
2. Phase of Hyperplasia AND Hypertrophy: 16 – 32
weeks 1. Constitutionally small (these fetuses are not
pathologically growth restricted but are small
3. Phase of Hypertrophy: > 32 weeks
because of biological factors – i.e. they are
Fetal Growth Restriction (FGR)/ Intra-Uterine genetically small)
Growth Restriction (IUGR)
2. Fetal Growth Restriction (FGR): Failure to reach
the true growth potential;
Definitions:
Low Birth Weight:
1. Low Birth Weight: Neonates who a weigh between

Types of FGR
Symmetrical (20%) Asymmetrical (80%)

Insult occurs early on (during phase of Insult occurs later on (phase of

hyperplasia) hypertrophy)
Uniformly small Head larger than abdomen
Etiology: Genetic disease or infection Etiology: Utero-placental insufficiency
(intrinsic to fetus) (Extrinsic to fetus)
Total Cell no: Less Total cell no: Normal
Cell Size: Normal Cell size: Smaller
HC: AC - Normal HC: AC – Increased
FL: AC – Normal FL: AC – Increased
Ponderal Index (Birth weight/ Crown heel Ponderal Index (Birth weight/ Crown
length3) - Normal heel length3) – Low
Neonatal course: Poorer Prognosis Neonatal course: Prognosis better
2
Obstetrics and Gynecology

Etiology of FGR
Risk Factors
Major: Minor:
•• Maternal age > 40 y •• Maternal age > 35
•• Smoker •• BMI < 20
•• Cocaine abuse •• Nulliparity
•• Previous SGA •• IVF conception
•• Chronic HTN •• BMI > 25
•• Diabetes with vascular involvement •• Dietary deficiency
•• Renal impairment •• Pregnancy interval < 6 months/ > 60 months
•• APLA •• Previous h/o preeclampsia
•• Threatened abortion
•• PAPP-A < 0.4 MoM
•• Fetal echogenic bowel on 20 weeks scan

If 3 or more minor risk factor or 1 major risk factor

Assess at 20 - 24 weeks: Uterine artery Doppler

Serial assessment of fetal size and umbilical artery doppler from 28 weeks

Diagnosis & Evaluation of •• AC: most sensitive parameter to detect FGR

FGR •• HC/AC ratio: Normal in symmetric FGR,
Increased in asymmetric FGR
1. History
Normal HC/AC ratio:
•• Risk Factors
> 1 at less than 32 weeks
•• Maternal weight gain
1 at 32 – 34 weeks
2. Examination
> 34 weeks: < 1
•• Palpation of uterine height. Not a sensitive
parameter. •• FL/AC ratio: Normal in symmetrical FGR;
•• Symphysio-fundal height measurement and Increased in asymmetrical FGR
charting. Disparity of > 2-3 cm: FGR. Not a Normal FL/AC ratio: 22 after 21 weeks
sensitive parameter.
An FL/AC ratio > 23.5: FGR
•• Measurement of abdominal girth: stationary/
falling values •• Amniotic Fluid Volume: AFI < 5 (oligohydramnios):
3. Ultrasound associated with FGR due to utero-placental
insufficiency
•• Measuring BPD, HC, FL, AC
•• Anatomical survey: to look for associated
congenital anomalies
 3
Fetal Growth Disorders – Notes

4. Doppler Parameters
•• Uterine artery doppler:
i. Raised Pulsatility Index (PI)
ii. Persistence of diastolic notch after 24 weeks

Reversal of end diastolic Flow

***Umbilical Artery Doppler: Primary

Diagnostic Tool for Fetal Surveillance
•• Middle Cerebral Artery (MCA): Redistribution
of blood flow leading to increased diastolic flow
in the MCA and decreased Pulsatility Index (PI)
Normal uterine A Doppler in the 2nd trimester

Persistence of Uterine A diastolic notch

Normal MCA Doppler
•• Umbilical Artery
i. Initially: Decreased end diastolic velocity:
Increased Pulsatility Index (PI) and
increasing S/D Ratio
ii. Later: Absent end diastolic flow
iii. Last: Reversal of end diastolic flow

Increased flow in MCA (Redistribution)

•• Cerebro-Placental Ratio:
Reduced diastolic Flow
–– Calculated by dividing the PI of the MCA by
the PI of the Umbilical Artery
ƒƒ Middle Cerebral Artery PI
–– C/P Ratio =
ƒƒ Umbilical Artery PI
–– C/P Ratio > 1: Normal
Absent end diastolic Flow
4
Obstetrics and Gynecology

–– C/P Ratio < 1: IUGR

•• Venous Doppler
–– Ductus Venosus flow: Reversal of ‘a’ wave
–– Umbilical vein: Presence of Pulsatility. LAST vessel to be affected on Doppler

Management of Fetal Growth Restriction

History (Risk Factors)/ Examination (Uterine height/SFH)

Ultrasound: Fetal Biometry < 10th percentile/ Serial growth measurements indicative of FGR

Umbilical Artery Doppler

Normal PI/ RI Increased (Reduced End Diastolic Flow) Absent/ Reversed

End Diastolic Flow

Twice weekly Doppler & Weekly Biometry

Repeat Ultrasound and
Doppler 2 - Weekly Plan Delivery if > 34 weeks
If < 34 weeks:
Corticosteroids and then
plan delivery
Plan Delivery at 37 weeks
(Plan Delivery > 34 weeks if static growth > 3 weeks)
Plan Delivery at 37 weeks
 Preterm Labor

•• Defined as birth before 37 weeks

•• Lower limit to call it preterm: threshold of viability: different in different countries (usually taken as 24
weeks in Western countries; 28 weeks in developing countries)
•• New classification:

•• Preterm birth is a direct cause of about 28 – 35 % of all neonatal deaths

•• Preterm birth causes > 50% of all neonatal deaths (including indirect causes)

Organ/ System Short-term Problems Long-term Problems

Pulmonary RDS, apnea of prematurity, Bronchopulmonary dysplasia, reactive airway ds,
bronchopulmonary dysplasia asthma

GI/ Nutritional Hyperbilirubinemia, feeding intolerance, Failure to thrive, short bowel syndrome,
NEC, growth failure cholestasis

Immunological Hospital acquired infection, immune RSV infection, bronchiolitis

deficiency, perinatal infection

CNS Intraventricular Hemorrhage, Cerebral palsy, Cerebral atrophy,

Periventricular leukomalacia neurodevelopmental delay, hearing loss
2
Obstetrics and Gynecology

Organ/ System Short-term Problems Long-term Problems

Ophthalmological Retinopathy of Prematurity Blindness, RD, myopia, strabismus

CVS Hypotension, PDA, Pulmonary HTN Pulmonary HTN, adult HTN

Renal Acid base disturbance, electrolyte Adult HTN

disturbance

Hematological Anemia

Endocrine Hypoglycemia, cortisol deficiency, Impaired glucose regulation, increased insulin

transient hypothyroidism resistance

Direct causes •• Congenital Mullerian anomalies

1. Spontaneous preterm labor •• Lifestyle factors (smoking)
a. Overdistended uterus (polyhydramnios, multiple •• Young age, old age
pregnancy)
•• Poverty, malnutrition, Vitamin C deficiency
b. Maternal – Fetal Stress (nutrition, diabetes,
psychological etc.) •• Short stature

c. Cervical dysfunction (congenital/ acquired •• Interval between pregnancies (both reduced

following conization/ amputation/ cervical and increased)
trauma •• Bacterial vaginosis (spontaneous abortion,
d. Intrauterine Infection PPROM, chorioamnionitis and Preterm labor)

e. Placental Abruption •• Periodontal disease (chronic anaerobic

inflammation of the gums)
f. Mullerian Anomalies
•• Depression, anxiety
2. Preterm Pre-labor Rupture of Membranes (PPROM)
•• Hard labour/ severe physical exertion
a. Intrauterine infection
•• Genetic Factors
b. Oxidative stress induced DNA damage
c. Premature cellular senescence Diagnosis:
3. Medically indicated or iatrogenic –– Regular uterine contractions before 37
a. Maternal: Pre-eclampsia, Eclampsia, APH, GDM weeks associated with cervical change (> 1
cm or > 80% effaced)
b. Fetal: IUGR, Oligohydrmanios, Rh isoimmunization
–– Symptoms: pelvic pressure, menstrual like
4. Due to multiple pregnancy: several reasons cramps, vaginal discharge, lower back pain
including:
a. Overdistension Prediction:
b. Increased cortisol levels (Activation of the –– Home ambulatory uterine monitoring
placental - fetal endocrine axis) (HAUM)
c. Medical reasons (higher incidence of pre- –– Biochemical markers:
eclampsia, FGR etc.)
1. Fetal fibronectin (fFN)

Contributory Factors ○○ Glycoprotein

•• h/o Threatened abortion ○○ Produced by – fetal amnion cells

•• h/o Previous preterm birth ○○ High conc in amniotic fluid

 3
Preterm Labor

○○ Found in cervico-vaginal secretions < If at risk of having preterm labor; what

22 weeks & > 37 weeks should be done?
○○ fFN > 50 ng/ml: Predictor of preterm 1. Progesterone:
labor
–– 17 α hydroxyprogesterone caproate
○○ Not recommended routinely by ACOG OR micronized progesterone (Vaginal
2. Insulin Like Growth Factor Binding administered)
Protein (IGFBP -1; Actim Partus) –– 16 – 24 weeks till 34 weeks
○○ Qualitative immunochromatographic 2. Cervical Cerclage is recommended If both history
test designed to detect phosphorylated and short cervix are there
IGFBP-1 (insulin-like growth factor
binding protein-1) in cervical –– H/o prior preterm birth/ mid-trimester loss
secretions during pregnancy with short cervix & < 24 weeks

○○ Protein made by the cells lining the Preterm Labor: Management

uterus.
1. Bed rest
○○ When delivery is imminent, small
amounts of phosphorylated IGFBP-1 2. In-utero transfer
leak into the cervix. 3. Hydration
3. Placental alpha macroglobulin – 1 4. Corticosteroid therapy
(PAMG-1; PartoSure)
•• Accelerates fetal lung maturity (Increases
○○ Qualitative immunochromatographic surfactant production)
test designed to detect placental
•• Given in women who are 24 – 34 weeks;
alpha microglobulin-1 (PAMG-1) in
anticipated to deliver within 7 days
vaginal secretions during pregnancy
•• Some role in late preterm also; can be considered
○○ Protein released from the lining of
in up to 366/7
the uterus into the amniotic cavity
throughout pregnancy. •• Advantages of corticosteroids: They lower the
rates of
○○ It is found in very high concentrations
in amniotic fluid and in very low –– Perinatal death
concentrations in normal vaginal
–– Neonatal death
discharge.
–– RDS
○○ Strong correlation between the
presence of PAMG-1 in cervicovaginal –– Intraventricular haemorrhage
discharge and imminent delivery –– Necrotizing enterocolitis
•• Cervical Length Measurement: –– Need for mechanical ventilation
–– Transvaginal sonography •• Two 12-mg doses of betamethasone given
< 25 mm between 16 - 24 weeks: Predictor for intramuscularly 24 hours apart OR
preterm birth
•• Four 6-mg doses of dexamethasone administered
intramuscularly every 12 hours
•• Both reduce RDS equally
•• ? Additional benefit of betamethasone in
reducing the incidence of IVH and NEC
•• No benefit of repeated doses
•• Rescue dose may be considered in < 34 weeks
and anticipated delivery within 7 days with last
4
Obstetrics and Gynecology

received dose > 14 days ago (ACOG)

5. Role of Tocolysis

Only 2 indications: < 34 weeks and

1. In-utero transfer

2. Corticosteroid coverage

Group MOA Doses S/e & Precautions

CCB (Nifedipine) – FIRST Blocks the entry of Oral 20 mg stat f/b 10 Hypotension, flushing, headache,
LINE calcium in the cell mg 4 – 6 hourly until nausea
contractions stop
Betamimetics (Terbutaline, β2 receptor Ritodrine: IV infusion Maternal: headache, palpitation,
ritodrine, isoxsuprine) stimulation causes Terbutaline: s/c 0.25 mg tachycardia, hypotension, pulmonary
smooth muscle edema, hyperglycemia, hypokalemia
relaxation C/i: DM, cardiac disease
Magnesium Sulphate Competitive inhibition Loading dose 4 – 6 g Flushing, headache
to Ca ions f/b IV infusion 1-2 g/h, Monitoring required (Mg toxicity)
continue till 12 h after
contractions stop
Indomethacin Reduces intracellular 50 mg PO/PR f/b 25 mg 6 c/I > 32weeks (premature closure of
free Ca ions hourly for 48 h ductus arteriosus)
Oligohydramnios, Neonatal pulmonary
HTN
Atosiban Oxytocin receptor IV infusion 300 mcg/ min Expensive,
antagonist less side effects overall
Safe in Diabetes, heart disease
Nitric Oxide donors (GTN) Smooth muscle Transdermal patch Headache, hypotension
relaxant

6. Role of antibiotics of 1 g per hour until the birth or for 24 hours

(whichever is sooner).
•• No use in Preterm labor with intact membranes
•• Useful where there is evidence of infection Tests for Pulmonary
7. Neuroprotection Maturity
•• MgSO4
Amniocentesis and examination of amniotic fluid:
•• Reduces incidence of cerebral palsy and
L/S Ratio: L/S Ratio ≥ 2: Pulmonary maturity
neurodevelopmental delay
Shake test/ Bubble Test (Clément’s)
•• Offer IV MGSO4 for neuroprotection of the
baby to women between 24+0 and 29+6 weeks Foam Stability Test (> 47: Pulmonary maturity)
who are Presence of phosphatidyl glycerol
–– In established preterm labour or Saturated phosphatidylcholine ≥ 500 ng/ml
–– having a planned preterm birth within 24 Fluorescence polarization
hours.
Amniotic fluid Optical Density
•• Consider IV MGSO4 for neuroprotection of the
baby for women between 30+0 and 33+6 weeks Lamellar body count > 30000/ μL
•• 4 g intravenous bolus of magnesium sulfate over Orange colored cells on Nile blue sulfate
15 minutes, followed by an intravenous infusion
Increased turbidity
 5
Preterm Labor

Preterm Pre-labor Rupture of –– Premature cell senescence

Membranes (PPROM) –– Increased degradation of amniotic membrane
collagens by proteases
•• Diagnosis:
ƒƒ This leads to decreased tensile strength
–– H/o leaking
of the membrane and increased friability
–– P/S: Pooling of amniotic fluid (surest test)
•• Risks:
ƒƒ pH of amniotic fluid: 7 – 7.5 (Nitrazine
–– In term PROM – labor starts in 80 – 90%
paper turns BLUE)
within 24 h
ƒƒ Ferning pattern on microscopy
–– Increased risk of ascending infection if
ƒƒ Nile blue sulfate: orange blue coloration PPROM > 24 h: Chorioamnionitis
ƒƒ Specific amnionic fluid proteins: Amnisure, –– Placental abruption
ROM plus (IGFBP1 + αFP)
–– Dry labor
–– Ultrasound: Oligohydramnios
–– Neonatal sepsis
•• Etiology:
–– Early PPROM: Potter’s sequence (Early inset
–– Infection/ inflammation leading to: oligohydramnios leading to abnormal facies,
limb anomalies and pulmonary hypoplasia)
ƒƒ Release of IL-1β, TNF-α, leukocyte
activation and proliferations –– Increased perinatal mortality
–– Release of matrix metalloproteinases •• Management

Plan delivery
> 34 weeks
Group B streptococcal prophylaxis

Corticosteroid can be considered

Expectant management

Group B streptococcal prophylaxis

32 – 33 weeks
Corticosteroid therapy

Antimicrobials

Expectant management

Group B streptococcal prophylaxis

24 – 32 weeks
Corticosteroid therapy

Antimicrobials

MgSO4 for neuroprotection

Expectant management or PPROM:

•• Maternal Markers
–– Temperature 6th hourly
–– PR 6th hourly
–– Palpation for tenderness
6
Obstetrics and Gynecology

–– TLC, CRP (thrice a week) morbidity in infants in the USA

–– Weekly High vaginal swab, urine RM & CS •• As per ACOG: Universal rectovaginal screening
for GBS at 35 – 37 weeks (Not done in India)
•• Fetal Markers
•• Intrapartum antibiotic prophylaxis for carriers
–– Non-Stress Test
or for those with GBS bacteriuria or h/o
–– Amniotic Fluid Assessment previous infant with GBS disease
•• Intrapartum antibiotic prophylaxis also for:
Chorioamnionitis:
–– Carriers (on rectovaginal swab testing)
•• Intra-amnionic infection and inflammation;
–– GBS bacteruria
seen once membranes have ruptured (Following
PPROM or PROM) –– Previous infant with GBS ds
•• Maternal temp > 390C – ESSENTIAL –– Delivery < 37 weeks (I.e. preterm delivery)
•• Other features: –– Amniotic membrane rupture > 18h
–– Maternal tachycardia –– Intrapartum temp > 100.4
–– Fetal tachycardia –– Intrapartum NAAT positive for GBS
–– Maternal leukocytosis •• Recommended antibiotic:
–– Uterine tenderness –– DOC: Penicillin G 5million units IV initial then
2.5 million units 4 hourly till delivery
–– Foul smelling discharge
–– Alternate: Ampicillin
•• Treatment: Immediate delivery, broad
spectrum antibiotics –– If penicillin allergy: Cefazolin or Clindamycin
or Vancomycin
Group B Streptococcus Infection &
Prophylaxis
•• Streptococcus agalactiae: Group B organism
that colonizes GIT & GUT in 10 – 25% of
pregnant women
•• Leading infectious cause of mortality and
 Disorders of Amniotic Fluid Volume

Functions of Amniotic •• Color: Early pregnancy it is colorless; straw

colored near term
Fluid:
•• Abnormal Colors
1. Helps in lung development
–– Green – Meconium (Fetal distress/ hypoxia)
2. Helps in GIT development
–– Red: Abruption
3. Physical space for movement and neuromuscular-
skeletal development –– Tobacco: Intra-uterine Death
4. Protects against umbilical cord compression –– Golden color: Fetal hemolysis (Rh iso-
immunized pregnancy)
5. Protects fetus against trauma
–– 1st half of pregnancy: composition is identical
6. Bacteriostatic properties
to a transudate of plasma; altered later once
7. Maintains temperature the main component becomes fetal urine.
8. Negligible nutritive value –– Faintly alkaline
9. Diagnostic & Therapeutic value –– Low specific gravity (1.010)
•• Amniocentesis for prenatal diagnosis –– Hypotonic at term; Osmolarity: 250mOsm/l
at term (Decreases with increasing age)
•• Amniocentesis for polyhydramnios
–– Contains lanugo, exfoliated squamous
•• Amniocentesis for determining fetal lung
epithelial, vernix caseosa etc.
maturity (lecithin sphingomyelin ratio)
•• Amniocentesis for severity of anemia in Rh iso-
immunized pregnancy (measuring bilirubin in
Dynamics and Formation/
amniotic fluid) Circulation of Amniotic
•• Measurement of AFI is an indirect sign of fetal Fluid
well-being (component of Biophysical profile •• Early in pregnancy, the amniotic cavity is filled
and modified biophysical profile) with fluid that is similar in composition to the
•• Artificial rupture of membranes – induction and ECF.
augmentation of labor •• During the first half of pregnancy, transfer
•• Color of liquor – can be helpful in diagnosis. of water and other molecules takes place
across the amnion (trans membranous), across
1. Deep yellow/ golden color: Fetal anemia the fetal vessels on the placental surface
2. Green (meconium stained): fetal distress or (intramembranous) and across the fetal skin
post-maturity (transcutaneous).

3. Red: Abruption •• Fetal urine production: starts at 8 – 11 weeks

but becomes a major component of the amniotic
fluid till the 2nd trimester.
Appearance & Composition of
•• Fetal skin keratinizes by 22 – 25 weeks: water
Amniotic fluid:
2
Obstetrics and Gynecology

transport across fetal skin reduces after this. accounts for significant intramembranous
fluid transfer across fetal vessels on the
•• In advanced gestation: 4 major pathways:
placental surface (400ml/day)
1. Fetal urine (1l/ day at term).
3. Respiratory tract: 350 ml/ day produced by
2. Fetal urine/ amniotic fluid osmolality (260 secretions; half immediately swallowed
mosm/l) < maternal and fetal plasma (280
4. Major mechanism for amnionic fluid
mosm/l). It is hypotonic; this hypotonicity
resorption: fetal swallowing (500-1000 ml/d)

Volume of Amniotic Fluid & 1. Amniotic Fluid Index (AFI)

its Measurement •• The ultrasound transducer is held perpendicular

to the floor and parallel to the long axis of the
Average volume versus gestational age
woman
•• 20 weeks - 400 ml
•• The uterus is divided into 4 equal quadrants – rt
•• 28 weeks - 800 - 1000 ml and left upper and lower quadrants
•• 34-36 weeks - 000 – 1500 ml (peak) •• The AFI is the sum of the single deepest pocket
from each quadrant.
•• 40 weeks - 800ml (declines)
•• So, the unit of measurement is mm/ cm
•• After 40 weeks: declines 150 ml/week
•• Normal value: 5 – 25 (ACOG)
•• 42 weeks - 400 ml
•• The intra-observer variability is 1cm that means
if the same person measures the AFI again he
Measurement:
or she would measure it with a difference of ≤
•• Correct quantitative measurement is done only 1 cm.
in research settings using dye-dilution method,
•• The inter -observer variation is 2 cm, this
•• In clinical settings - We do semiquantitative means if 2 different people were to measure it,
measurement by ultrasound. This is done by 2 the difference would be ≤ 2 cm.
methods:
1. Amniotic Fluid Index (AFI)
2. Single deepest vertical pocket
measurement
 3
Disorders of Amniotic Fluid Volume

2. Fetal Anomalies
•• Causing impaired swallowing
–– CNS – Anencephaly, Hydranencephaly,
Holoprosencephaly
–– Craniofacial – Cleft palate, micrognathia
•• Causing Obstruction to Swallowing:
–– Cystic hygroma
–– Congenital high airway obstruction sequence
(CHAOS)
•• GI Obstruction
–– Esophageal atresia
–– Tracheo-esophageal fistula
–– Duodenal atresia
•• Neurological
–– Myotonic dystrophy
•• High output cardiac failure
–– Ebstein’s anomaly (Seen in Lithium intake)
–– Tetralogy of Fallot
–– Cardiomyopathy

2. Single Deepest Pocket •• Metabolic:

•• Or Maximal vertical pocket –– Baarter Syndrome

•• The ultrasound probe is held perpendicular to 3. Placental

the floor and parallel to the long axis of the –– Chorioangioma
woman.
–– Circumvallate placenta
•• The largest vertical pocket of fluid is identified
and measured. 4. Along with fetal hydrops

•• Unit of measurement: cm/ mm –– Immune hydrops (Rh isoimmunization)

•• The single deepest pocket of liquor is considered –– Non-immune hydrops e.g. associated with
normal if between 2 - 8 cm CMV, toxoplasmosis, syphilis and parvovirus)

•• More useful in 2nd trimester assessment of 5. Diabetes mellitus: Fetal hyperglycemia causes
amniotic fluid and in multiple gestation. fetal osmotic diuresis
6. Multifetal gestation: Twin to twin transfusion
POLYHYDRAMNIOS syndrome

Important Clinical Features in Polyhydramnios

Definition: •• Symptoms: Discomfort
•• AFI > 25 cm or > 95th percentile for that
•• Signs:
gestational age
–– Pedal edema
Etiology: –– P/A
1. Idiopathic: Most Common (66%) ƒƒ Inspection: Overdistension, umbilicus
4
Obstetrics and Gynecology

everted, stretched shiny skin •• Fetal renal anomalies:

ƒƒ Palpation: ƒƒ B/l renal agenesis
•• Fetal parts not felt easily ƒƒ B/l multicystic dysplastic kidneys
•• Ballotability easy to elicit ƒƒ Infantile form of Autosomal recessive
polycystic kidney disease
•• Fluid thrill
•• Obstruction to the Renal outflow tract
•• Auscultation:
–– Posterior urethral valve (keyhole sign)
–– FHR faint
–– Urethral atresia/ stenosis
Management: –– Megacystis microcolon intestinal
hypoperistalsis syndrome
•• Evaluation – to determine the cause
–– Sirenomelia
•• Supportive management
•• Loss of Amniotic fluid
•• IF < 37 weeks:
–– PPROM
–– Amnioreduction by amniocentesis
•• Others
–– NSAIDs before 32 weeks: Indomethacin
or Sulindac; not given > 32 weeks as there –– Twin to twin transfusion syndrome
is risk of premature closure of the ductus
•• Idiopathic
arteriosus
•• Clinical Features
•• IF> 37 weeks:
–– Lag in sequential fundal height measurements
–– Plan delivery
–– Fetal parts not easily palpable
–– Check the lie and presentation
–– Uterus: gripped over fetal parts
–– Amniocentesis to reduce the liquor followed
by Induction of Labor (Stabilizing induction) –– Little Ballotment

–– ARM is always done in a controlled manner •• Management:

–– Early onset oligohydramnios:
OLIGOHYDRAMNIOS ƒƒ Poor prognosis due to Potter’s sequence
•• Definition: AFI < 5 cm or AFI < 5 centile for
th (Pulmonary hypoplasia, limb anomalies and
that gestational age craniofacial anomalies due to compression)

•• Etiology: –– If remote from term, expectant management

with an aim to prolong pregnancy with close
–– Decreased urine production
fetal monitoring
ƒƒ Uteroplacental insufficiency –
–– If term:
preeclampsia, FGR
ƒƒ Termination is planned especially if
ƒƒ Placental maturity (post term)
associated complications (IUGR,
ƒƒ Medication: preeclampsia)
○○ ACE-I/ ARBs ƒƒ Continuous intrapartum fetal monitoring
○○ NSAIDs
 Placenta Accreta Syndromes (PAS)/
Morbidly Adherent Placenta

Normal Placentation Placenta Accreta Placenta Increta Placenta Percreta

Definition:
–– Risk of accreta in placenta previa with 1
•• When the placenta is firmly adhered to the cesarean: 10%Risk of accreta with previa
uterine wall due to partial/total absence of the and 2 cesareans: 40%
decidua basalis and fibrinoid layer (Nitabuch
layer) –– Risk of accreta with previa and 3 or more
cesareans: 60%

Types
Diagnosis:
1. Placenta Accreta: Chorionic villi are ATTACHED
to the myometrium USG:
2. Placenta Increta: Chorionic villi INVADE the •• Loss of normal hypoechoic retroplacental
myometrium myometrial zone
3. Placenta Percreta: Chorionic villi PERFORATE the •• Thinning and disruption of the uterine serosa-
myometrium bladder interface
•• Focal exophytic masses invading the bladder
Etiology:
•• Placenta previa Color Flow Doppler:
•• Previous cesarean or any uterine scar –– Hypervascularity of serosa-bladder interface

•• Previous dilatation & curettage USG with Color Flow Doppler: Investigation of
choice for adherent placenta
•• Previous MRP
MRI: If Diagnosis is doubtful; especially useful in
•• Previous accreta
2
Obstetrics and Gynecology

posterior placenta •• Consider prophylactic uterine artery

catheterization for embolization if needed
HPE: •• Baby delivered by classical incision/ avoiding
the placenta
•• Absence of decidua basalis
•• No attempt at removing the placenta as this can
•• Absence of Nitabuch’s fibrinoid layer
incite torrential haemorrhage.
•• Varying degree of penetration of the villi into
•• Proceed with hysterectomy
the myometrium or till the serosal layer
•• Conservative treatment includes retaining the
placenta I.e., leaving it in situ; close the uterine
Management
incision:
•• Multidisciplinary team
–– Done rarely if uterus wants to be conserved.
•• Anticipate massive haemorrhage
–– Complications: Sepsis/ DIC, pulmonary
•• Cesarean planned 34 – 37 weeks embolism, AVM
•• Hysterectomy is the usual plan after delivering –– 20 - 60% will eventually require a subsequent
the baby by a classical cesarean. hysterectomy
•• Skin incision: infra-umbilical longitudinal –– Inj Methotrexate has been tried; no benefit
•• Consider prophylactic ureteric catheterization documented
 Post – Term Pregnancy

Definition: –– Favorability of cervix

•• > 42 weeks/ 294 days

Complications
•• Aka prolonged pregnancy
•• Post-maturity syndrome: The features used to MATERNAL:
describe a neonate born after 42 weeks •• Increased operative delivery
•• Postdated pregnancy: Terminology used to
describe > 280 days in some books. Also FETAL:
synonymously used with post-term pregnancy
•• Oligohydramnios & Cord Compression
by some authors
•• Fetal distress and hypoxia

Etiology •• Meconium aspiration

•• Wrong Dates •• Macrosomia

•• Genetic Factors
NEONATAL
•• Past h/o post term pregnancy
•• Post-maturity syndrome
•• Congenital fetal malformations disrupting the
–– Meconium aspiration syndrome
fetal HPA axis and adrenal hypoplasia
–– Hypoglycemia, Hyperbilirubinemia,
•• Placental factors:
Polycythemia
–– Placental sulfatase deficiency
–– Low Apgar Score, Increased NICU Admissions
–– Placental CRH deficiency
–– HIE, Neonatal seizures
•• Idiopathic

Diagnosis:
•• Dating is very Important
–– Date of LMP
–– Regularity of previous cycles
–– Early USG with CRL
•• On Examination:
–– Uterine height
–– Size of the fetus
–– Feel of the fetal skull
–– Assessment of liquor
2
Obstetrics and Gynecology

POST MATURITY SYNDROME •• If Oligohydramnios/ evidence of Fetal distress:

Induction of Labor
•• Patchy peeling and wrinkled skin (palms, soles)
•• If uncomplicated (i.e., no additional risk factor
•• Meconium staining
and no oligohydramnios or fetal distress):
•• Long nails can wait with continued antepartum fetal
•• Scalp hair surveillance.

•• Thin body, reduced s/c fat •• Induction of Labor:

•• Well-developed creases on palms and soles –– Complications

•• Open-eyed, alert, worried apprehensive look –– At 42 weeks

–– Most centers in India plan induction between
Management 40 – 406/7

•• After 40 weeks: Initiate Antepartum Fetal

monitoring

Gestational Age of 41 weeks (accurate dating)

Discuss risks and benefits of labor induction. Patient may choose induction or expectant management

Expectant Management

Antenatal monitoring

NO
Labor Induction NST Reactive, AFI normal

YES

42 weeks gestation complete

 PUERPERIUM: NORMAL AND ABNORMAL

•• Definition of Puerperium: 6 weeks post delivery •• It is composed of sloughed off decidua, blood,
period during which maternal anatomical and necrotic debris and secretions of the cervix
physiological changes and pelvic organs return and vagina
to the non-pregnant state
•• Types
•• Fourth Trimester of the Pregnancy: The 1st 3
1. Lochia RUBRA:
months after delivery is now called as the 4th
trimester a. Red
b. First 3-4 days
Changes in the puerperium
2. Lochia serosa
1. Uterus:
a. Yellowish – brownish
•• Undergoes involution (0.5 inch or 1 finger
b. 5 – 9 days
breadth per day)
c. Contains less red cells, more leucocytes
•• Immediately after delivery: Uterus is at the
necrotic decidua, cervical mucus and some
lower border of the umbilicus (20 weeks)
bacteria
•• Day 1: 1 finger breadth below the umbilicus
3. Lochia alba
•• Day 2: 2 finger breadths below the umbilicus
a. White discharge
•• At the end of 2 weeks: No longer palpable
b. Lasts for 10-28 days
abdominally (It becomes a pelvic organ)
c. Mainly has leukocytes, decidual cells,
•• At the end of 6-8 weeks: Pre-pregnant sized
cervical mucous, epithelial cells and
uterus
bacteria
•• Causes of sub-involution
3. Ovarian Function
○○ Retained placenta
•• In Non lactating women: Menstruation may
○○ Endometritis (puerperal sepsis) resume in about 40% by the 6th week and in 80%
○○ Anemia by the 14th week of delivery.

○○ Fibroid uterus •• In lactating women:

○○ h/o overdistended uterus (multiple i. Exclusively lactating: Lactational amenorrhoea

pregnancy/ polyhydramnios) will be there

○○ Not breastfeeding (no release of ii. Prolactin inhibits release of LH and inhibits
oxytocin) the ovarian response to FSH

2. Lochia Contraception in the puerperium

•• Vaginal discharge following delivery is called •• Combined oral contraceptive pills
lochia
•• Can be given > 3 weeks in non-breast feeding
•• Lasts for 3-6 weeks (BF) moms (preferably after 6 weeks)
2
Obstetrics and Gynecology

–– in BF mothers > 6 months Puerperal Pyrexia Abnormal

•• Progesterone only Pills •• Temperature elevation of 380 or more after 24h
–– Can be given in BF and non-BF moms of delivery recorded on 2 occasions 24h apart,
(preferably > 6 weeks in BF) usually within 10 days after delivery.

•• DMPA (injectable depot Medroxy progesterone •• Causes of Puerperal Pyrexia

acetate) ○○ Puerperal sepsis (infection of the
–– Any time after delivery in non-BF moms uterus)

–– > 6 weeks in BF moms ○○ Post surgical wound infection

•• LNG IUD (Mirena) ○○ Mastitis

–– < 48h or > 4- 6 weeks in BF or non-BF moms ○○ UTI

(Preferably > 6 weeks in BF moms) ○○ Pulmonary infections, ARDS
•• Cu IUD
Puerperal Sepsis
–– < 48h of > 4- 6 weeks in BF or non-BF moms
•• Infection of the female genital tract at any time
between delivery till 42 days of puerperium
Lactation
•• 4 phases of lactation •• 2 or more of the following features

○○ Mammogenesis (preparation of the ○○ Pelvic pain

breast for lactation) ○○ Fever
○○ Significant ductal and alveolar growth ○○ Abnormal vaginal discharge
in pregnancy
○○ Abnormal smell
○○ But milk production does not happen
○○ Foul smelling discharge
despite high levels of prolactin and
hPL because of the inhibitory effect ○○ Subinvolution
of progesterone and estrogen
•• Predisposing factors
•• Lactogenesis (production of milk)
○○ Anemia
○○ Prolactin is secreted from the anterior
○○ Malnutrition
pituitary in response to suckling
○○ PPROM
○○ Prolactin acts on the milk secreting
cells of the alveoli to stimulate the ○○ PROM
synthesis of milk ○○ Diabetes
•• Galactokinesis (milk discharge) ○○ UTI
○○ Also called as milk ejection or let down ○○ Repeated vaginal exams
○○ Mediated by oxytocin ○○ PPH
○○ Oxytocin binds to myo-epithelial cells ○○ Operative delivery
causing their contraction to expel milk
into ducts ○○ Handling by untrained dais

•• Galactopoiesis (Maintenance of milk production) ○○ Intra uterine manipulation (eg Manual

removal of placenta)
○○ Suckling is essential for successful
and effective lactation ○○ Twin delivery

○○ Prolactin is the MOST IMPOTANT ○○ Prolonged or obstructed labor

galactopoietic hormone •• Etiology: MC organism: E Coli
ƒƒ Puerperium •• Treatment:
 3
Puerperium: Normal and Abnormal

○○ Antibiotics: Broad spectrum coverage evert the nipples

(Ampicillin + Metronidazole +
•• Acute Mastitis
Gentamycin); changed as per culture
sensitivity ○○ MC organism is Staphylococcus aureus

○○ Surgical treatment may be required ○○ Presents as high grade fever,

constitutional symptoms with a swollen,
♦♦ Debridement of an infected
red, tender breast
episiotomy/ cesarean wound
○○ Treatment is
♦♦ Evacuation of retained products
♦♦ Analgesia
♦♦ Laparotomy or colpotomy if there
is a pelvic abscess ♦♦ Anti-pyrectics
♦♦ Hydration
Breast Complications in the Puerperium
♦♦ Feed from the unaffected breast
•• Insufficient lactation
♦♦ Emptying the affected breast
○○ Pharmacological galactagogues include:
domperidone or metoclopromide ♦♦ Send milk for culture sensitivity

•• Failed lactation: This could be because ♦♦ Antibiotics: Dicloxacillin/

of Erythromycin

○○ Preterm baby •• Breast Abscess

○○ Improper suckling ○○ Surgical drainage needs to be done

with broad spectrum antibiotics
○○ Nipple confusion
○○ A deep radial incision is made
○○ Inverted nipple
○○ Anxiety/ depression Psychiatric Disorders in the Puerperium
○○ Endogenous suppression of prolactin
by drugs (methylergometrine,
cabergoline, bromocriptine)
•• Breast Engorgement
○○ Use proper brassiere (Support)
○○ Timely and regular breastfeeding (2-3
hourly) or emptying the breast
○○ Analgesia for pain
○○ Cold packs
○○ Inj Oxytocin 10U IM will result in milk
let down and relief in engorgement
•• Cracked nipple: Usually due to improper latching
○○ The hind milk can be applied to the
cracked nipples
○○ Application of emollients or lanolin
cream also helps
•• Retracted Nipple
○○ Should be detected antenatally so
timely correction can be done
○○ Inverted syringe technique is used to
4
Obstetrics and Gynecology

Postpartum Blues Postpartum Depression Postpartum Psychosis

Incidence 35-70% 10-15% 0.1%

Time of onset 2-4 days PP 2 weeks-12 months PP 2-3 days PP

Duration Resolves within 10 days 13-14 months Variable

Symptoms Insomnia, tearfulness, Irritability, labile mood, Mania and/ or mixed affective
fatigue, irritability, poor difficulty falling asleep, sad state, agitation, delusions,
concentration mood, phobias, anxiety disorganized behavior,
infanticide

Risk Factors Very common Adverse delivery experience, Past/ho psychosis, H/o bipolar
Still birth, H/o depression, or family H/o bipolar ds
adverse childhood experience,
recent life events, lack of
social support

Treatment Self limiting CBT + Antidepressants In patient, Pharmacotherapy

 DRUGS IN OBSTETRICS

1. Folic Acid –– Low dose: 0.5mg per day – 3 months post-

conceptually, 1st trimester.
2. Iron
–– High dose: 5mg per day (or 4 mg n some
3. Calcium
books)– advised for high risk group women Q
4. Progesterones in Pregnancy
1. Previous history of neural tube defect (Reduces the
5. Tocolytics (CCB, Atosiban, MgSO4, Beta agonists, incidence of NTDs by 70%)
Indomethacin)
2. Known folic acid deficiency
6. Anti-hypertensives (Alpha methyldopa, Labetalol,
3. Women on anti-epileptic drugs
CCB, Hydralazine)
4. Women with diabetes (diabetes is teratogen)
7. MgSO4
5. Obese females
8. Oxytocin
6. Women with hemoglobinopathies
9. PGs
10. Methylergometrine IRON
11. Tranexamic Acid

FOLIC ACID

•• Can be given in oral and parenteral form.

•• Started from 14 weeks of pregnancy.
•• Available as a tablet. •• As per Anemia Mukt Bharat Program of India,
iron can be started in all pregnant females
•• Importance:
as prophylaxis and for treatment of anemic
1. Reduces incidence of neural tube defect – females.
advised to take pre-conceptually (3 months
•• Give it for 6 months antenatally (14 weeks
before conception)
till delivery) and give 6 months in postpartum
2. Decreases anemia period to replenish stores.
3. Decreases chance of abruptio placenta •• 180 days antenatally and 180 days in postpartum
•• Dose: period.
2
Obstetrics and Gynecology

•• Iron capsule is red in color (sugar coated) and •• Forms:

contains ferrous sulfate 60 mg and folic acid
1. Micronized Progesterone (natural form)
0.5mg.
2. Hydroxyprogesterone caproate (parenteral
•• As per Anemia Mukt Bharat Program 400 mg of
form)
Albendazole tablet given for deworming, after
first trimester – helps in preventing Anemia. •• Indications:

•• However for treatment of iron deficiency 1. History of previous miscarriage/bleeding in

anemia in pregnancy, iron can be started in any early pregnancy
trimester 2. Prevention of preterm birth

CALCIUM •• Progesterone keeps cervical length maintained.

•• Useful when history of mid trimester loss,
recurrent abortion, threatened abortion.

TOCOLYTICS

•• Started at 14 weeks
•• Adequate intake of calcium intake during
pregnancy and lactation
1. Reduce incidence of preterm labor
2. Improves bone mineral density in mother and
newborn Calcium Channel Blockers
3. Reduces maternal and neonatal morbidity •• Uterine relaxants

4. Reduces chance of pre-eclampsia (not proven) – •• Indications:

only definitive strategy to decrease chance of 1. Preterm labor < 34 weeks – Tocolytic is given
pre-eclampsia is low dose aspirin. to stop contraction of uterus < 34 weeks
•• Recommended dose of calcium – 1000 mg per Pregnancy, so that we get time to give
day steroids for fetal lung maturity.

○○ 1 capsule have 500 mg of calcium + 250 2. In utero referral of pregnant mother to

IU of Vit D3 tertiary center if she lives far away in a rural
area – given to avoid delivery during referral.
PROGESTERONES IN PREGNANCY •• Examples: calcium channel blockers are DOC as
tocolytics
•• First line drugs, E.g. Nifedipine – it acts by
blocking entry of calcium into cells and prevent
contractions
•• Dose: 10-20 mg, 3-6 hourly till contractions
stops.
•• Side effects:
•• Hypotension, headache, nausea, flushing.
•• Avoid giving it with beta mimetic and magnesium
 3
Drugs in Obstetrics

sulfate. •• Given per orally or per rectally < 32 weeks

•• Not given > 32 Weeks because it can cause
MgSO4 premature closure of ductus arteriosus, leading
to pulmonary hypertension.
•• Dose: 50mg PO/PR – 25mg 6 hourly for 48 hours

ATOSIBAN

•• Given in:
1. Treatment of eclampsia
2. Prophylaxis of eclampsia in females with
severe pre-eclampsia
3. Tocolytic drug •• Oxytocin receptors antagonist
4. Neuroprotective in very preterm fetuses < •• Competitive antagonist that blocks oxytocin
32week receptors
•• When we anticipate a delivery case in less than •• Dose: IV Infusion of 300 mcg/min
24 hours, MgSO4 is given as a neuroprotective
agent. •• Very Safe drug

•• MOA: Acts by competitive inhibition of Ca

•• Dose: 1g per hour IV infusion till the •• Indications:
contractions stops.
1. In diabetic females in need of tocolysis when
•• C/I: Myasthenia gravis and Renal impairment other tocolytics are contraindicated. Beta
(MgSO4 is excreted by kidney, so it will lead to mimetic are contraindicated in diabetics
magnesium toxicity) because it causes hyperglycemia.
•• S/E: Flushing, headache 2. In females with cardiovascular diseases the
safest tocolytic is Atosiban.
•• Do not give with CCB and magnesium sulfate.
•• Major drawback: Very costly
INDOMETHACIN
BETA AGONIST

•• E.g. Isoxsuprine (Duvadilan), Terbutaline

4
Obstetrics and Gynecology

•• MOA: Activation of intracellular enzymes that

reduce Ca
•• S/E:
1. Hypotension
2. Hypoglycemia
3. Hypokalemia
4. Hyperglycemia (so, contraindicated in
diabetic females)
5. Headache
6. Tachycardia
7. Palpitations
8. In severe case, pulmonary edema (so,
contraindicated in women with cardiovascular
diseases)
•• C/I
1. Diabetic female
2. Female with cardiovascular diseases

Group MOA Doses S/e & Precautions

CCB (Nifedipine) – Blocks the entry of Oral 20 mg stat f/b 10 Hypotension, flushing,
FIRST LINE calcium in the cell mg 4 – 6 hourly until headache, nausea
contractions stop

Betamimetics β2 receptor Ritodrine: IV infusion Maternal: headache,

(Terbutaline, stimulation causes Terbutaline: s/c 0.25 palpitation, tachycardia,
ritodrine, smooth muscle mg hypotension, pulmonary edema,
isoxsuprine) relaxation hyperglycemia, hypokalemia
C/i: DM, cardiac disease
Magnesium Sulphate Competitive Loading dose 4 – 6 g Flushing, headache
inhibition to Ca ions f/b IV infusion 1-2 g/h, Monitoring required (Mg
continue till 12 h after toxicity)
contractions stop
Indomethacin Reduces 50 mg PO/PR f/b 25 c/I > 32weeks (premature
intracellular free mg 6 hourly for 48 h closure of ductus arteriosus)
Ca ions Oligohydramnios, Neonatal
pulmonary HTN

Atosiban Oxytocin receptor IV infusion 300 mcg/ Expensive,

antagonist min less side effects overall
Safe in Diabetes, heart disease

Nitric Oxide donors Smooth muscle Transdermal patch Headache, hypotension

(GTN) relaxant
 5
Drugs in Obstetrics

ANTIHYPERTENSIVE •• No longer DOC for hypertension in pregnancy –

replaced by Labetalol
•• Has a very good safety profile
•• Dose: 250 mg BD; max 2g/day
•• MOA: Centrally acting alpha agonist .
•• S/E: Postural hypotension, hemolytic anemia,
sedation, PP depression
•• C/I: Hepatic disorders, CCF, depression

CALCIUM CHANNEL BLOCKER

•• Contraindicated Antihypertensives in pregnancy
are:
1. Angiotensin Receptor Blocker
2. Ace Inhibitor – because it can cause
fetal renal agenesis, severe early onset
oligohydramnios.
3. Diuretics – Can be given in case of pulmonary
edema
•• Antihypertensive DOC in pregnancy – •• 5-10 mg TID (max 60-120 mg/day)
LABETALOL Q
HYDRALAZINE
–– Oral or parenteral (emergency) routes
→ MOA: combined alpha plus beta blocker Q
•• Dose:
–– Oral tablet : 100 mg BD ; max is 2400 mg per
day
–– IV infusion (in hypertensive emergency/
eclampsia): Start with 20 mg IV; check after
20 mins, if still high then give 40mg IV, then
80mg IV; then again 80mg (max 220mg)
•• S/E: headache, tremors, congestive cardiac
failure
•• C/I: asthmatics and congestive cardiac failure
Q

ALPHA METHYLDOPA
•• Useful in Hypertensive emergency like eclampsia
or severe pre-eclampsia
•• If IV Labetalol does not work, then IV
Hydralazine is used in Hypertensive emergencies.
•• It is a Vasodilator
•• Dose: 100mg OD in 4 divided doses
•• More commonly used in Hypertensive
emergencies: 5-10 mg IV every 15-20 mins
6
Obstetrics and Gynecology

•• S/e: hypotension, tachycardia, arrhythmia, each ampoule has 2 ml of fluid.

palpitation, lupus like syndrome, neonatal
○○ So, we take 4 ampoules of MgSO4 – (1g
thrombocytopenia.
+ 1g + 1g + 1g ) 4g in 8 ml (2ml + 2ml +
2ml + 2ml) of solution: This is 4g of
MAGNESIUM SULPHATE 50% MgSO4 and this has to be diluted
to make it 20%
○○ How to convert 50% of MgSO4 to 20%
MgSO4:
–– Add 12 ml of distilled water and dilute it,
so we get 20 ml of solution with 4g and it
contains 20% MgSO4.
–– This is given slow IV 1g per ml, so entire 20
ml should go in 4 min.
•• Intramuscular loading dose:
–– 10 g MgSO4, so take 10 ampoules with 1g
Uses: MgSO4 in each ampoule.

1. Eclampsia –– Each ampoule has 2ml fluid, so 20 ml solution.

2. In severe pre-eclampsia to prevent eclampsia –– 10 g 50% MgSO4 in 20 ml solution.

3. Tocolytic agent –– We don’t need to dilute when giving IM

solution
4. Neuroprotective agent in preterm labor
•• Pritchard regime maintenance dose:
SEIZURE MANAGEMENT –– 5g IM (50% MgSO4) 4th hourly
•• Any seizure in pregnancy unless proven –– 5 ampoules of MgSO4 used (10ml)
otherwise is eclampsia.
Before giving maintenance dose, always check for
Regimen used in India for Eclampsia (IV plus IM magnesium toxicity signs – check all every 4 hours
regime): Pritchard Regime (IMPORTANT)
1. Deep tendon reflexes – first to be lost in magnesium
toxicity – if reflexes are lost, magnesium levels are
very high
2. Check respiratory rate – excess magnesium leads to
respiratory depression
3. Urine output (>30 ml/hr) – urine output is reduced
•• Maintenance dose given till 24 hours after last because of renal failure due to eclampsia and
seizure or delivery, whichever is later. preeclampsia, so if urine output is less, it means
magnesium is not excreted properly and is piling up
•• Zuspan Regimen is a complete IV regime used
in the body
where good infusion set and perfect monitoring
is present because in infusion, risk of toxicity –– DTRs are lost at a serum magnesium level of
is more, so good monitoring is required – 4g IV 9 mg/dL (7 mEq/L)
loading dose + 1g/hr IV infusion as maintenance –– Respiratory depression occurs at 12 mg/dL
– clinical monitoring of Mg toxicity is very (10 mEq/L)
important.
–– Cardiac arrest occurs at 30 mg/dL (25
•• Pritchard Regimen: Loading Dose (14g): How to mEq/L)
prepare the loading dose:
○○ Each ampoule contains 1g MgSO4 and
 7
Drugs in Obstetrics

OXYTOCIN –– Injection form: 5 units in 1 ml

–– Synthetic oxytocin – 5 U/ml
–– Synthetic oxytocin stable at room temp:
Carbetocin (Heat stable, so does not require
cold chain) – kept in 2-8° Celsius - useful
in poor resource settings where cold chain
maintenance is difficult.
–– Syntometrine (5U oxytocin + 0.5mg
ergometrine)
–– Nasal oxytocin
–– Desamino oxytocin: buccal use
•• WHO has proposed drugs for AMTSL:
1. Oxytocin
2. Carbetocin
3. Syntometrine
4. Methylergometrine
5. PG E2

•• In 1950, Du Vigneaud was awarded the Nobel •• Indications for use of oxytocin
Prize in Medicine for discovering the structure –– Antepartum:
of oxytocin
–– 1st & 2nd trimester: Suction evacuation of
•• Nonapeptide molar pregnancy, 2nd trimester abortion.
•• Secreted by posterior pituitary. –– 3rd trimester: Induction of labor,
•• MOA: Augmentation of labor

–– Binds to oxytocin receptors on the ƒƒ Intrapartum:

myometrium cell membrane –– AMTSL
–– Calcium ions released –– Management of atonic PPH
–– Increased contractions –– Retained placenta
–– More oxytocin receptors near term ○○ Postpartum:
–– Also causes a vasodilatory effect – fall in BP –– Breast engorgement
–– ADH effect – water intoxication in large •• Routes of Administration:
doses.
–– For Induction of labor and augmentation of
•• Available preparations: labor:
–– Controlled IV infusion
ƒƒ Low dose regime: 1-2 mIU/min and increase
by 1-2 mIU/min every 20 mins
ƒƒ High dose regime: 4-6 mIU/ min, increase
by 4-6 mIU/ min every 20 mins
ƒƒ Maximum dose: 40-50 mIU/ min
ƒƒ For AMTSL: 10 U IM/ IV
○○ For Management of Atonic PPH: 10-40
U in 1 L of crystalloid solution IV
8
Obstetrics and Gynecology

•• For infusion, we dilute oxytocin with normal CARBETOCIN

saline or ringer lactate.
•• End point for oxytocin is good contractions.
•• Definition of good contraction: 4-5 Contractions
lasting for 40 to 45 seconds in 10 minutes.
•• Dangers of oxytocin:
○○ Maternal:
–– Uterine tachysystole: > 5 uterine contractions
in 10 Min
–– Uterine hyperstimulation: > 5 contractions in •• Long-acting synthetic analogue of oxytocin
10 min plus fetal distress
•• Stable at room Temperature
–– Uterine rupture: Due to excessive
•• WHO recommends its use ONLY in prevention
contractions in primigravida, uterine inertia
of atonic PPH (Not treatment)
occurs and in multiracial, uterine rupture
occurs (Grand multipara) •• Dose: 100 mcg (1ml) IV or IM bolus slowly over
1 minute
–– Water intoxication.
–– Hypotension. PROSTAGLANDINS IN OBSTETRICS
○○ Fetal: AND GYNECOLOGY
–– Fetal distress: due to hyper stimulation •• 3 prostaglandins:
(>5 contractions in 10 minutes) which leads –– PGE1
to uteroplacental insufficiency and fetal
distress. –– PGE2

–– Neonatal hyperbilirubinemia: Due to –– PGF2 ALPHA

vasopressin-like effect of oxytocin swelling •• Increased biosynthesis of PGs is a prerequisite
of RBC occurs leading to destruction of fetal for labor
RBC and neonatal hyperbilirubinemia.
–– Decidua: main source of PGF2α
•• Contraindications to oxytocin:
–– Amnion: main source of PGE2
–– Grand-multipara
–– Myometrium: main source of PGI2
–– Contracted pelvis (prostacyclin)
–– H/o classical cesarean •• PGs promote myometrial contractility
–– H/o 2 or more LSCS irrespective of gestational age

–– Malpresentation •• They are uterotonics that work in the 1st

trimester also unlike oxytocin which works
–– Obstructed labor more in the 3rd trimester because receptors on
–– Fetal distress myometrial cells are more in the 3rd trimester
and during labor.
–– Hypovolemia
•• Preparations:
1. Prostaglandin E1 (Misoprostol) tablet
2. Prostaglandin E2 (Dinoprostone) gel /vaginal
insert /tablet
3. Prostaglandin F2 α (Carboprost) Injection IM
or intramyometrial
 9
Drugs in Obstetrics

Prostaglandin E1 (misoprostol): 4. Fetal distress (meconium aspiration syndromes)

Prostaglandin E2 (dinoprostone):

○○ Uses: Cervical ripening and induction

–– Rapidly absorbed of labor
–– Primarily, it was used for peptic ulcer ○○ Available as:
–– Available as a tablet 1. Intracervical gel between external and
–– Routes of administration: oral, any mucosal internal os (most common route)
route like vaginal/rectal/sublingual/buccal
–– Different doses in micrograms present
–– Uses:

Gynecology:
1. Prior to procedures that require cervical
dilatation 1. Tablet form
2. Endometrial biopsy
3. Hysteroscopy
4. Fractional curettage
5. Dilatation and curettage

Obstetrics:
1. 1st trimester: Medical TOP, Surgical TOP
(suction and evacuation), Prior to evacuation of
molar pregnancy
2. 2nd trimester: TOP 2. Propress (vaginal pessary)
3. 3rd trimester: Induction of labor
4. Post-partum: AMTSL, Management of atonic
PPH.
–– Risks:
1. Uterine tachysystole
2. Uterine hyperstimulation
3. Uterine rupture
10
Obstetrics and Gynecology

15 methyl analogue of PGF 2 alpha (Carboprost or CONTRAINDICATION Q

prostadin):
1. Hypertension in pregnancy
2. Cardiovascular diseases
3. Rh negative female (when given to contract
uterus and once the baby is delivered due to
vasospasm, some fetal blood is sucked back
in maternal blood leading to fetomaternal
hemorrhage)
•• Contains 250 mcg
4. Twin pregnancy
•• IM/ Intra-myometrial use
5. Severe anemia because due to increase of
•• Use: Management of atonic PPH afterload, cardiac failure may occur
•• Dose: 250 mcg every 15 minutes for 8 doses
TRANEXAMIC ACID (ANTI
•• Contra-indication: Bronchial Asthma, cardiac
FIBRINOLYTIC)
arrhythmia.
•• Never given IV

METHYL ERGOMETRINE
(METHERGINE)
•• Mainly used for AMTSL, Prophylaxis and
treatment of PPH (at the delivery of anterior
shoulder)
•• Given as injection and tablets

•• Coagulation of blood
•• IV Tranexamic Acid given within 3 hours of
birth in PPH – Very effective
•• Used in all cases of PPH, approved by WHO
•• Dose: 1 g in 10ml IV
•• Second dose of 1g IV if bleeding continues
after 30 minutes

•• Uterotonic & Vaso-constrictor

•• Dose: 0.25mg intravenous
 OPERATIVE OBSTETRICS

EPISIOTOMY Median Episiotomy Medio-Lateral Episiotomy

•• A deliberate incision given on the posterior Advantages: Advantages:
vaginal wall and the perineum to aid in delivery • Less bleeding • Less risk of extension
of the fetus during the 2nd stage of labor • Less pain (lower incidence of 3rd and
•• It is the most common obstetric operation • Better healing 4th degree perineal tears)
performed • Better anatomic • Can be extended if
result required
•• Given at the time of crowning
• Less dyspareunia
•• Routine episiotomy is NOT to be given. Only
• Less wound
Restrictive use of episiotomy to be done
dehiscence
•• Some indications for an episiotomy are Disadvantage Disadvantage
○○ Rigid perineum (Common in primis) • Can extend to form • More bleeding
○○ Macrosomia a 3rd or 4th degree • More pain
perineal tear • Apposition of wound not
○○ Face to pubis deliver (Occipito-
• Cannot be extended perfect
posterior)
• More dyspareunia
○○ Shoulder dystocia
• More risk of wound
○○ Assisted breech delivery dehiscence

○○ Instrumental delivery
•• Past h/o perineal surgery
•• Types of episiotomy (As shown)
•• Structures cut in an episiotomy: From inside
○○ Mediolateral (most common)
out:
○○ Median
○○ Vaginal Mucosa
○○ Lateral
○○ Muscle
○○ J-shaped
♦♦ Superficial and deep transverse
perinei
♦♦ Bulbospongiosus
♦♦ Part of levator ani
○○ Perineal skin
•• An episiotomy is given with an episiotomy
scissors which looks like this:

•
2
Obstetrics and Gynecology

○○ Aftercoming head of breech

•• Parts of the forceps:
○○ It has 2 blades
○○ Each blade is fenestrated for a better
grip
○○ There are 2 curves
♦♦ Pelvic curve which conforms to the
pelvic curves
♦♦ Cephalic curve which conforms to
the fetal head

Suturing of episiotomy
•• With rapidly absorbable sutures (polyglactin or
chromic catgut); so sutures dissolve and ARE
NOT removed
•• Done under local anesthesia which is infiltrated
at the time of giving the episiotomy
•• First repair the mucosa (After locating the
angle): usually sutured as continuous interlocking
sutures
•• Muscle is sutured with intermittent simple
sutures. It is important to note to not leave any
dead space in this layer otherwise hematoma
can form
•• Skin: Interrupted mattress sutures or
subcuticular sutures are taken

INSTRUMENTAL DELIVERIES
Indications of Instrumental Delivery
•• Types of Forceps
1. Prolonged 2nd stage of labor
○○ Traction Forceps
2. Fetal distress
♦♦ Short: Wrigley (Outlet), Simpson
3. To cut short the 2nd stage of labor forceps
a. Preeclampsia/ eclampsia ♦♦ Long: Simpson long forceps, Das
b. Heart disease in pregnancy forceps, Neville Barnes, Haig
Ferguson
c. Severe anemia
♦♦ Axis Traction

FORCEPS ○○ Rotational Forceps

•• An instrument designed to assist in the ♦♦ Kielland’s forceps

extraction of the fetal head ♦♦ Barton’s forceps
•• IT can be used in ○○ Special forceps
○○ Cephalic presentation (OA and OP) ♦♦ Piper forceps (Aftercoming head in
○○ Mento anterior breech)
 3
Operative obstetrics

•• Classification of Forceps (ACOG) ○○ Always do a phantom application, i.e.

practice applying the blades outside so
you know which is left and right blades
○○ Hold left blade in left hand in a pen
like fashion and with your right hand
guide it inside
○○ Ask the assistant to hold it
○○ Similarly apply right blade holding in
right hand
○○ The blades should lock if correctly
applied
○○ Apply traction
•• The most important forceps that you should ♦♦ In outlet forceps: Upwards and
know is the OUTLET FORCEPS as it is most forwards
commonly used
♦♦ In low forceps: Along curve of
•• This is how the outlet or Wrigley Forceps looks pelvis: First downwards and
like backwards, then horizontal, then
upwards and forward

•• Also remember Advantages of Forceps over

Vacuum
○○ Can be applied in certain situations in
•• Pre-requisites of applying a FORCEPS (Also which vacuum can’t be used like
applies to vacuum)
♦♦ Face presentation
F: Fully dilated cervix
♦♦ Aftercoming head of breech (piper
O: Occipito anterior / occipito posterior forceps)
R: Ruptured membranes ♦♦ Intrauterine death
C: Consent/ CPD ruled out ♦♦ Preterm
E: Empty bladder/ Episiotomy ○○ Forceps causes less fetal trauma
P: Position of head must be known/ Pediatrician should ○○ Preferred when you don’t want the
be available patient to bear down (for e.g. when
S: Sagittal suture should be in AP diameter we cut short 2nd stage for severe
(preferably): This is for OUTLET forceps as outlet preeclampsia/ heart disease) as
forceps does not cause rotation. Vacuum causes forceps does not require additional
auto-rotation on traction so in vacuum, placement of bearing down by the mother.
sagittal suture isn’t important. •• Disadvantages of Forceps
•• Application of forceps ○○ More maternal trauma:
4
Obstetrics and Gynecology

♦♦ Vaginal and cervical lacerations ○○ The center of the cup should be placed
over the sagittal suture as close to
♦♦ Extension of episiotomy and 3rd and
the posterior fontanelle as possible
4th degree tears
(FLEXION POINT)
♦♦ Vulvar hematoma
○○ The Flexion point is a point 3 cm
♦♦ Colporrhexis anterior to the post fontanellae
♦♦ Rupture uterus ○○ Traction at this point causes flexion
○○ PPH (traumatic and atonic) of the head

○○ Requires more skill than vacuum ○○ Creation of the vacuum

○○ Does NOT have function of rotation ♦♦ First feel all around the cup to see
(unlike vacuum) that no maternal tissue is stuck in
the cup
VACUUM (Ventousse) ♦♦ Cup is connected to the suction
•• It is an instrumental traction device that is machine and vacuum till 0.8 kg/cm2
used to deliver the baby is created.

•• Indications: Similar to forceps but CANNOT be ○○ Traction

used in ♦♦ Traction is applied at right angles
i. Dead fetus (As the chignon will not form) to the cup

ii. In very preterm fetuses (Increased risk of ♦♦ Traction is applied intermittently

intracranial hemorrhage) with uterine contraction

iii. Aftercoming head of breech ♦♦ Direction of traction: Along the

pelvic curve (First downwards then
iv. Face presentation horizontal then upwards)
•• Instrument
i. Suction machine
ii. Suction cups (metal cup and silastic cup)
*But now we also have available the “Kiwi omni-cup”
which is a handheld apparatus which has both the
suction machine and cup together

•• Pre-requisites for Forceps: Similar for forceps

but remember rotation need not be complete as
on traction with a vacuum, rotation will happen
by itself
•• Application of Vacuum
–– Application of the cup
ƒƒ The cup is lubricated and introduced into
the vagina
 5
Operative obstetrics

•• Cup Pop Off ♦♦ Abnormal labor

ƒƒ Detachment of the cup due to technical ♦♦ Failed induction
failure or incorrect placement
♦♦ Prolonged or arrested labor
ƒƒ Reassess after 1 pop off
♦♦ Obstructed labor
ƒƒ Abandon if
•• Antepartum haemorrhage (Placenta previa and
○○ 3 pop offs Abruptio placenta – to be individualized)
○○ 3 pulls over 3 contractions without •• Complications in Pregnancy where vaginal
descent delivery may not be an option (This depends on
each case like preeclampsia or eclampsia with
○○ > 30 mins without delivery
poor Bishops or Bad obstetric history or IVF
•• Advantages of Vacuum conception)
○○ Less skill required •• Previous 3rd or 4th degree perineal tear
○○ Causes auto-rotation so can be applied •• Infections in pregnancy:
in a head which is not OA (Can be
ƒƒ HIV
applied in ROT and LOT)
ƒƒ Active genital herpes
○○ Less maternal trauma
•• On Maternal Request
•• Disadvantages of vacuum
○○ Fetal
○○ Requires electricity
ƒƒ Fetal Distress
○○ Causes fetal trauma (cephalhematoma,
scalp abrasions, sub galeal hematoma, ƒƒ Malpresentations and Malpositions
intracranial hemorrhage, retinal
♦♦ Mentoposterior
hemorrhage, sub-conjunctival
haemorrhage) ♦♦ Brow

○○ Requires maternal effort so forceps ♦♦ Transverse Lie

is preferred when you don’t want the ♦♦ Oblique lie
mother to bear down or she cant bear
down (Eclampsia, heart ds etc) ♦♦ Unstable lie

○○ Cannot be used in ♦♦ Breech presentation (If

unfavorable for an assisted breec
♦♦ Face delivery)
♦♦ Breech for aftercoming head ♦♦ Persistent Occipito posterior
♦♦ Preterm ♦♦ Deep transverse Arrest
♦♦ Dead fetus ♦♦ Fetal macrosomia (> 4.5Kg)

CESAREAN DELIVERY ♦♦ Multiple pregnancy

•• Defined as the birth of a fetus through an ♦♦ 1st twin non cephalic

incision in the abdominal wall and uterine wall ♦♦ Triplets and above
•• Indications for a cesarean delivery ♦♦ Monoamniotic Monochorionic twins)
○○ Maternal ♦♦ Conjoined twins
♦♦ Contracted pelvis ♦♦ Certain fetal anomalies like
♦♦ Previous scar on the uterus hydrocephalus
(previous cesarean/, myomectomy/ ♦♦ Cord prolapse
hysterotomy/ metroplasty)
•• Types of Cesareans
6
Obstetrics and Gynecology

○○ Depending on timing:
♦♦ Emergency
♦♦ Elective
○○ Depending on the type of incision on
the uterus
♦♦ Lower segment cesarean section
(LSCS): This is a transverse incision
in the lower uterine segment. This is
the most common type of cesarean,
done in > 99% of cases
Anesthesia:
♦♦ Upper Segment cesarean section
•• Regional in the form of spinal or epidural is
(Classical cesarean): Done in very
preferred
few cases. The indications are
important to know •• Steps of a cesarean section (Please read these
alongwith seeing the video on the app for better
○○ Placenta Accrete Syndromes
understanding!)
○○ Large fibroid in the anterior lower
–– Bladder cathetrization is done prior to
segment
starting. This is essential as an empty
○○ Adhesions in the lower uterine segment bladder is required to approach the lower
○○ Cervical cancer uterine segment. A full bladder obscures
the lower uterine segment and can lead to
○○ Sometimes in placenta previa with inadvertent injury to the bladder.
the baby in transverse lie, a classical
cesarean may help –– Painting and draping

♦♦ Lower segment vertical incision –– Skin incision

♦♦ J shaped incision •• Preferred: Pfannenstiel (Transverse curvilinear

incision 2 finger breadths above the pubic
♦♦ Inverted T incision symphysis)
•• Vertical midline

Transverse skin Incision Vertical skin Incision

Cosmetic Appeal More Less
Post operative pain Less More
Wound dehiscence Less More
Incisional hernia Less More
Access to upper abdomen Less access Good access

–– After incision skin, the next layer is identified as it is a loose fold of peritoneum
subcutaneous tissue attached to the uterus; it is incised and cut
–– Then the rectus sheath is incised transversely transversely and the Doyen retractor is
placed in such a way that the bladder stays
–– Then the 2 bellies of the rectus abdominus away
are separated
–– Now the lower uterine segment appears and
–– The parietal peritoneum is incised and the a transverse incision is made (Kerr’s incision)
Doyen retractor is placed inside (This helps
keep the bladder away) –– The amniotic sac is ruptured and baby is
delivered
–– The uterovesical fold of peritoneum is
 7
Operative obstetrics

–– The cord is clamped (Delayed cord clamping ƒƒ PPH

and other steps of AMTSL) are followed
ƒƒ Anesthetic complications
–– The placenta is delivered
ƒƒ Infections
–– The uterine incision is closed in 1 or 2 layers
ƒƒ Wound sepsis
using polyglactin suture (Vicryl) after holding
the angles of the uterus with Allis or Green ƒƒ Hematoma
Armytage forceps ƒƒ Thrombo-embolism
–– The parietal peritoneum may or may not be ƒƒ Paralytic ileus
closed
ƒƒ Intestinal complications
–– The rectus sheath is the most important
structure closed ƒƒ ARDS

–– Skin is sutured –– Late

–– Vaginal cleansing is done ƒƒ Secondary PPH

•• Post op care ƒƒ Incisional hernia

–– NPO for about 6 hours ƒƒ Scar endometriosis

–– Check vital signs and urine output ƒƒ VVF

–– IV fluids ƒƒ Subsequent pregnancies

–– Antibiotics are continued (1st dose is given at •• Cesarean scar ectopic

the time of the skin incision) •• Scar rupture
–– Analgesics •• Repeat cesarean section
–– Urinary catheter is usually removed after •• Placenta previa
24h or till the patient is ambulatory
•• Placenta accreta
•• Complications
•• Auditing of deliveries (including both normal and
–– Immediate cesarean deliveries) by Robson Classification
 INSTRUMENTS IN OBSTETRICS

1. Sim’s Speculum 2. Cusco Speculum

•• Double blade •• Duck Billed speculum

•• Used along with an anterior vaginal wall •• Self-retaining (has a lock)
retractor to
•• Uses
–– Visualize the cervix and vagina
–– To visualize the cervix
–– Aid in diagnostic and operative procedures
like –– In a few procedures (As it has limited space)
like
ƒƒ Cervical biopsy
ƒƒ Colposcopy
ƒƒ IUD insertion and removal
ƒƒ Removal of an intra-uterine device
ƒƒ D & C
ƒƒ Cervical biopsy
ƒƒ Dilatation and evacuation
•• Advantages:
ƒƒ Cervical cerclage
–– Self-retaining so doesn’t require assistance
ƒƒ Cervical tear repair
•• Disadvantages:
ƒƒ Gyn surgeries like vaginal hysterectomy
–– Less space; cannot introduce more than 1
•• Central groove: drainage of secretions instrument inside so only a few procedures
•• Advantage can be done

–– Lot of space
3. Anterior Vaginal Wall Retractor
–– Does not obscure vaginal walls
•• Used along with a Sim speculum to retract the
•• Disadvantages: anterior vaginal wall
–– Requires assistance
2
Obstetrics and Gynecology

•• Similar to Vulsullum; the only difference is that

this is straight and has single tooth

6. Uterine Sound

4. Vulsullum

•• To gauge the direction and length of the uterus.

•• It has gradations
•• Where resistance is felt is the utero-cervical
length
•• Should not be used in a pregnant uterus for the
risk of perforation
•• This is a long, curved instrument used to hold
the cervix Angle of Anteversion:
•• It has a toothed end •• It is a forward angle formed by the long axis
of the vagina and cervix at the level of the
•• Usually, the anterior lip of cervix is held
external os
•• A pregnant cervix is preferably held by a sponge
•• Measures about 90°
holding forceps
•• Sometimes the posterior lip of cervix is held if Angle of Anteflexion
access to the POD is needed •• It is a forward angle formed by the long axis
–– Culdocentesis of uterus and that of the cervix at the level of
the internal os
–– Drainage of pelvic abscess
•• Measures 125 - 170°
•• Instead of a vulsellum, a tenaculum can be used
(single toothed)

5. Tenaculum
 3
Instruments in obstetrics

7. Hegar Dilators procedures or suction and evacuation procedures

in
–– Missed abortion
–– Incomplete abortion
–– Inevitable abortion
–– Surgical MTP till 12 weeks
–– Evacuation of molar pregnancy
•• After creating a vacuum manually, it is attached
to the Karman cannula and the loaded apparatus
is introduced into the uterus
•• The size of the Karman cannula is the POG in
•• These are graduated metal dilators increasing weeks
in size from smallest to largest
•• Using rotatory and back and forth movements,
•• The smallest is 1 mm in diameter and the largest the products
14 mm
•• They are used to dilate the cervix prior to any 9. Ovum Forceps
procedure requiring a dilated cervix
•• Cervical dilatation is done
–– Pharmacologically by PGE1 (misoprostol)
–– Mechanically (Hegar dilators)
•• In a dilatation and evacuation done for a
surgical MTP, the cervix is dilated to the period
of gestation; so if the patient is 8 weeks, the
cervix is dilated to Hegars no 8.

8. Manual Vacuum Aspirator and Karman •• It is a long instrument used to evacuate

Cannula products of conception in
–– Missed abortion
–– Incomplete abortion
–– Inevitable abortion
–– Surgical MTP till 12 weeks
–– Evacuation of molar pregnancy
•• Imp features of this instrument
–– End is oval or egg shaped
–– There is no lock; this is to prevent inadvertent
injury to the uterus in case uterine tissue
gets caught in the jaws

•• • A Manual Vacuum Aspirator (MVA) is a large

syringe which has a 60 ml cannula with a double
valve system and a plunger
•• • It is used in dilatation and evacuation
4
Obstetrics and Gynecology

10. Uterine Curette •• Metzenbaum scissors

•• Doyens retractor
•• Green Armytage forceps
•• Needle holder
•• Dissecting forceps
All the above are common surgical instruments but 2
of these are almost exclusively used in a cesarean and
are important to identify
1. Green Armytage forceps: This is used to hold the
•• This is an instrument which is used to curette angles and edges of the cesarean scar if there is
the endometrium excessive bleeding. Normally the edges are held
with an allis forceps but in case of heavy bleeding,
•• It is used following a suction evacuation after a Green Armytage forceps is better as it is less
suctioning out the products or after removing traumatic and has a wider surface area.
them with an ovum forceps to ensure everything
has been removed
•• It is also used in gyn procedures like a dilatation
and curettage to get an endometrial biopsy
•• It has 2 ends
–– Blunt: used in obstetric procedures
–– Sharp: Used in gyn procedures
•• Procedure is complete if
–– Grating on all 4 walls
–– Presence of air bubbles 2. Doyen Retractor: This is a specially shaped
–– No bleeding retractor that keeps the bladder away from the
uterine incision (lower segment cesarean section)
Instruments used in a Dilatation and thereby preventing bladder injury
Evacuation
•• Speculum (Preferably Sim)
•• Anterior vaginal wall retractor
•• Sponge holding forceps/ Vulsullum to hold the
cervix
•• Hegar dilators to dilate the cervix
•• Manual vacuum aspirator OR Electrical suction
apparatus with Karman cannula OR ovum forceps
to evacuate the products
•• Uterine curette

Instruments used in a cesarean section

•• BP handle and blade
•• Allis forceps
•• Artery forceps
 5
Instruments in obstetrics

Other important Obstetric •• Episiotomy should NOT be given routinely;

rather restrictively in conditions like
Instruments:
•• Episiotomy Scissors –– Macrosomia
–– Assisted breech delivery
–– Use of instrumental delivery
–– Shoulder dystocia
–– Rigid perineum
•• The layers cut in an episiotomy from inside out
are
–– Vaginal mucosa
–– Muscle (superficial and deep transverse
perinei, Bulbospongiosus and part of levator
ani)
•• This is a scissors that is characteristically
angulated in the middle and very easy to identify –– Perineal skin

•• The inside blade is guided by 2 fingers so as to •• An episiotomy is a type of 2nd degree perineal
avoid inadvertent injury to the fetus tear
 PREVENTIVE AND SOCIAL OBSTETRICS

Maternal Mortality
•• A maternal death is defined as death of a
woman while pregnant or within 42 days of
termination of a pregnancy irrespective of the
site or duration of the pregnancy from any
cause related to or aggravated by pregnancy
or its management but not from accidental or
incidental causes
•• Maternal deaths can be
–– Direct
–– Indirect
•• Direct maternal death:
–– Deaths resulting from direct complications
of pregnancy, labor or puerperium
–– Most common direct causes of maternal
deaths in India
ƒƒ Obstetric haemorrhage
ƒƒ Hypertensive disorders
ƒƒ Puerperal sepsis
Maternal Mortality Ratio
ƒƒ Abortion related
•• Defined as the number of maternal deaths per
ƒƒ Prolonged and obstructed labor 100,000 live births
•• Indirect causes: •• India’s MMR has improved to 103 in 2017-
–– Deaths from previous existing diseases that 19, from 113 in 2016-18
developed or worsened in pregnancy •• Seven Indian states have very high maternal
–– These account for about 35% of all maternal mortality (> 130). These are Rajasthan, Uttar
deaths Pradesh, Madhya Pradesh, Chhattisgarh, Bihar,
Odisha and Assam
–– Common cause include
•• India has committed itself to the latest UN
ƒƒ Anemia target for the Sustainable Development Goals
ƒƒ Heart disease (SDGs) for MMR at 70 per 1,00,000 live births
by 2030
ƒƒ Thromboembolism
•• As per National Health Policy 2017, the target
for MMR is 100 per 1,00,000 live births by 2020
2
Obstetrics and Gynecology

Maternal Mortality Rate •• Features are

•• The maternal mortality rate is the number of –– 100% centrally sponsored scheme
maternal deaths in a population divided by the –– Integrates cash benefits to mothers and to
number of women of reproductive age ASHA workers

Perinatal Mortality
•• Death of a fetus during the perinatal period
(from 28 weeks of age or > 1000g birth weight
in the first week of life
•• The current PNMR is 26/ 1000 births Low Performing States (LPS) are: UP, Uttarakhand,
•• Causes of Perinatal mortality Bihar, Jharkhand, MP, Chhatisgarh, Assam, Rajasthan,
Orissa, J & K
–– Prematurity
–– Infections
–– Birth asphyxia
–– Congenital anomalies
–– Fetal growth restriction
–– Birth trauma
–– RDS
–– Metabolic problems
–– Miscellaneous 3. Janani Shishu Suraksha Karyakram (JSSK)
Important Health Programmes in India which aim to •• Launched in June 2011
improve maternal and perinatal health
•• Entitles all women delivering in public health
1. Reproductive and Child Health Program (RCH) institutions to free and no expens delivery
including cesarean sections
•• We are currently in RCH – II (started in 2003)
•• This includes
•• Aim is to reduce maternal and child morbidity
with an emphasis on rural healthcare –– Free and cashless delivery
•• Major strategies –– Free cesarean delivery
•• Essential Obstetric care: –– Free drugs and consumables
–– Institutional delivery –– Free diagnostics
–– Skilled attendance at delivery –– Free diet
–– Permitting ANMS to use life saving drugs –– Free provision of blood
and to carry out emergency life saving
–– Exemption from user charges
interventions
–– Free transport to and from home
•• Emergency Obstetric Care
–– Operationalizing FRUs
–– Operationalizing PHCs and CHCs

–– Strengthening referral systems

2. Janani Suraksha Yojana (JSY) April 2005

•• Focus is to encourage delivery at health
institutions
 3
Preventive and social obstetrics

4. Pradhan Mantri Surakshit Matritiva Abhiyan methodology is used to drive and sustain
change in the cycles
•• Launched in 2016
–– Real time partograph generation, usage of
•• To ensure quality antenatal care to pregnant
safe birth checklist and strengthening
women on the 9th of every month
documentation practices
–– Presence of birth companion , RMC and
enhancing patient satisfaction
–– Assessment, triage and timely management
of complications including strengthening of
referral protocols
–– Management of labor as per protocols,
AMTSL and rational use of oxytocin
–– Essential and emergency newborn care,
management of birth asphyxia, timely
5. MAA (Mother’s Absolute Affection) Program initiation of breast feeding and Kangaroo
mother care
•• Countrywide intensified breast-feeding
promotion campaign –– Infection prevention including biomedical
waste management
•• Launched on 5th August 2016

7. VandeMataram Scheme

6. LaQshya •• Voluntary scheme wherein private doctors

volunteer themselves to provide safe
•• LaQshya stands for Labor room Quality motherhood services
Improvement Initiative
•• The enrolled doctors will display the
•• It is an approach to standardize care in labor “Vandemataram logo” at their clinic
rooms throughout the country
•• Iron, folic acid, tetanus etc. will be provided
•• Launched in 2017 by the District Medical Officers for free
•• Main points distribution to beneficiaries

ƒƒ To reduce maternal mortality and morbidity

due to labor complications
ƒƒ To improve quality of care
ƒƒ To provide Respectful Maternity Care
(RMC
ƒƒ Quality Improvement Cycles (QI) are the
fulcrum of LAQshya. There are 6 defined
cycles and a PDCA (Plan-Do-Check-Act)
4
Obstetrics and Gynecology

8. National Rural Health Mission Extended (NRHM) +

National Urban Health Mission (NUHM) = National
Health Mission (NHM): of which, ASHA is a key
component
 Unit 14
Physiology of Menstruation
 PHYSIOLOGY OF MENSTRUATION

•• Menstruation: The visible manifestation –– At puberty, some 400,000 primary oocytes

of cyclic physiologic uterine bleeding due are left behind, the rest become atretic.
to shedding of the endometrium following
–– During the entire reproductive period, some
invisible interplay of hormones mainly through
400 are likely to ovulate.
hypothalamo-pituitaryovarian axis.
–– The primary oocyte remains in diplotene
•• For menstruation to occur
phase until shortly before ovulation unless it
–– The HPO axis must be intact undergoes atresia.

–– The Outflow tract must be functional –– It is the midcycle LH surge that initiates the
resumption of meiosis-1.
•• OOGENESIS
–– The primary oocyte undergoes first meiotic
–– The germ cells migrate from the endoderm division giving rise to secondary oocyte and
of the yolk sac in the region of hindgut. one polar body.
–– From there, they migrate into the genital –– The two are of unequal size, the secondary
ridge (between 5 and 6 weeks of gestation) oocyte contains haploid number of chromosomes
–– A peptide, called, telopheron directs this (23, X) but nearly all the cytoplasm.
anatomic migration. –– The small polar body also contains haploid
–– The germ cells undergo rapid mitotic division number of chromosome (23, X) but with scanty
and by 20 weeks, the number reaches about cytoplasm.
7 million. –– The formation of secondary oocyte occurs
–– Some enter into the prophase of first meiotic with full maturation of Graafian follicle just
division and are called primary oocytes. prior to ovulation.

–– These are surrounded by flat cells from the –– The secondary oocyte immediately begins
stroma (pre-granulosa cells) and are called the second meiotic division but stops at
primordial follicles. metaphase.

–– The primary oocytes continue to grow through –– The secondary oocyte completes the second
various stages of prophase (leptotene, meiotic division only after fertilization by a
zygotene, pachytene and diplotene) and sperm in the fallopian tube.
ultimately reach to the stage of diplotene or –– The division results in the formation of the
else become atretic. two unequal daughter cells each possessing
–– Primary oocytes are then arrested in the 23 chromosomes (23, X).
diplotene stage of prophase of first meiotic –– The larger one is called the ovum (female
division, until ovulation. pronucleus) and the smaller one is the second
–– Total number of oocytes at 20 weeks of polar body. I
intrauterine life is about 6–7 million. –– In the absence of fertilization, the secondary
–– At birth, the total number of primordial oocyte, does not complete the second meiotic
follicles is estimated to be about 2 million. division and degenerates as such.
2
Obstetrics and Gynecology

–– The arrested meiotic division of the oocyte

prior to ovulation is probably due to oocyte
maturation inhibition (OMI) factor present
in the follicular fluid. OMI is secreted by
the granulosa cells.

MENSTRUAL CYCLE PHYSIOLOGY: Can be described

as
1. Ovarian Cycle
2. Endometrial Cycle

OVARIAN CYCLE
•• The ovarian cycle consists of:
–– Recruitment of groups of follicles
–– Selection of dominant follicle and its
maturation
–– Ovulation
–– Corpus luteum formation

–– Demise of the corpus luteum.

Endometrium in different phases of the

menstrual cycle

MORPHOLOGY OF THE OOCYTE: The morphological

features of the primary oocyte just prior to ovulation
are as follows:
•• It measures about 130 microns
•• The radially arranged granulosa cells surrounding
Development of Graafian follicle
the oocyte is called corona radiata.
•• The oocyte is surrounded by an outer envelope
called zona pellucida, a glycoprotein layer,
secreted by the growing oocyte
•• The cytoplasm, also called vitellus contains
nutritive yolk granules and is limited by a
definite membrane called vitelline membrane.
•• The space between the vitelline membrane and
the zona pellucida is called perivitelline space.
•• The spherical nucleus is located near the center
of the cytoplasm. The nucleolus is large with
sparsely distributed chromatin. A Mature Graafian Follicle
 3
Physiology of Menstruation

in LH surge from the anterior pituitary (positive

feedback effect). Effective LH surge persists for
about 24 hours.
2. FSH rise: Preovulatory rise of 17-α-hydroxy
progesterone facilitates the positive feedback
action of estrogen to induce FSH surge → increase
in plasminogen activator → plasminogen → plasmin
→ helps lysis of the wall of the follicle.
ƒƒ Following ovulation, the follicle is changed
to corpus luteum.
ƒƒ The ovum is picked up into the fallopian
tube and undergoes either degeneration
or further maturation, if fertilization
occurs.
Approximate time interval of events in menstrual
2-cell 2-gonadotropin theory
cycle prior to ovulation
•• 2-cell 2-gonadotropin theory:
–– According to this, LH stimulates theca cells
to produce androgens and FSH stimulates
granulosa cells to produce estrogens from
androgens

Ovulation:
•• The dominant follicle, shortly before ovulation
reaches the surface of the ovary. Corpus Luteum
•• The cumulus becomes detached from the wall, •• After ovulation, the ruptured Graafian follicle
so that the ovum with the surrounding cells develops into corpus luteum.
(corona radiata) floats freely in the liquor •• The color of the corpus luteum at this stage is
folliculi. greyish yellow due to presence of lipids
•• The oocyte completes the first meiotic division •• Progesterone is the predominant hormone
with extrusion of the first polar body which is secreted by the corpus luteum to support the
pushed to the perivitelline space. endometrium of the luteal phase.
•• The follicular wall near the ovarian surface •• Progesterone along with estrogen from corpus
becomes thinner. luteum maintain the growth of the fertilized
•• The stigma develops as a conical projection ovum.
which penetrates the outer surface layer of the
ovary and persists for a while (30–120 seconds) ENDOMETRIAL CYCLE
as a thin membrane.
•• The endometrium is the lining epithelium of the
•• The cumulus escapes out of the follicle by a slow uterine cavity above the level of internal os.
oozing process, taking about 60–120 seconds
•• It consists of surface epithelium, glands,
along with varying amount of follicular fluid.
stroma and blood vessels.
•• The stigma is soon closed by a plug of plasma.
•• Two distinct divisions are established— basal
•• Why does ovulation occur? Possible explanations zone (stratum basalis) and the superficial
are: functional zone.
1. LH surge: Sustained peak level of estrogen for •• Basal Zone
24–48 hours in the late follicular phase results
–– It is about one-third of the total depth of
4
Obstetrics and Gynecology

the endometrium and lies in contact with the

myometrium.
–– The zone is uninfluenced by hormone and as
such, no cyclic changes are observed.
–– After shedding of the superficial part during
menstruation, the regeneration of all the
components occurs from this zone.
–– It measures about 1 mm.
•• Functional Zone:
–– This zone is under the influence of fluctuating
cyclic ovarian hormones, estrogen and
progesterone.
•• The changes in different components during an
ovulatory cycle has been traditionally divided
into four stages
1. Regenerative phase
2. Proliferative phase
3. Secretory phase
4. Menstruation Physiology of Puberty
Definition:
•• It is the period of gradual development
of secondary sexual characters. There
are profound biological, morphological, and
psychological changes that lead to full sexual
maturity and eventually fertility.
•• Morphological changes as described by Tanner
and Marshall, five important physical changes
are evident during puberty. These are
–– Breast
–– Pubic hair growth
–– Axillary hair growth
–– Growth in height
–– Onset of menstruation.
•• The most common order is beginning of the
growth spurt → breast budding (thelarche)
Endometrium in different phases of the menstrual → pubic and axillary hair growth (adrenarche)
cycle → peak growth in height → menstruation
(menarche).
•• All these changes are usually completed between
the age of 10 and 16 years.
•• Important controlling factors for onset of
puberty are
–– Genetic
 5
Physiology of Menstruation

–– Nutrition and body weight COMMON DISORDERS OF PUBERTY

–– Psychologic state •• Precocious puberty
–– Social and cultural background •• Delayed puberty (Discussed under primary
–– Exposure to light and others. amenorrhoea)

Precocious Puberty
ENDOCRINOLOGY IN PUBERTY
•• Definition: The term precocious puberty is
•• The levels of gonadal steroids and gonadotropins
reserved for girls who exhibit any secondary
are low until the age of 6–8 years.
sex characteristics before the age of 8 or
•• This is mainly due to the negative feedback menstruate before the age of 10.
effect of estrogen to the hypothalamic pituitary
Causes of precocious puberty
system (Gonadostat).
•• The gonadostat remains very sensitive (6–15
times) to the negative feedback effect, even
though the level of estradiol is very low (10 pg/
ml) during that time.
•• As puberty approaches this negative feedback
effect of estrogen is gradually lost
•• This results in pulsatile gonadotropin secretion
(first during the night then by the day time).
•• Increased amplitude and frequency of GnRH →
↑ secretion of FSH and LH → ovarian follicular
development → ↑ estrogen.
•• Gonadal estrogen is responsible for the
development of uterus, vagina, vulva and also
the breasts
•• Leptin, a peptide, secreted in the adipose
tissue is also involved in pubertal changes and
menarche

Tanner stages of pubertal development in girls

6
Obstetrics and Gynecology

•• Mccune-Albright syndrome is characterized by Treatment of Precocious Puberty

–– sexual precocity •• The treatment depends upon the cause.
–– Multiple cystic bone lesions (polyostotic –– Any exogenous estrogen therapy or its
fibrous dysplasia) inadvertent intake should be stopped
–– Café-au-lait spots on the skin. –– Cortisone therapy for adrenal hyperplasia
and surgery to remove the adrenal or ovarian
tumor eliminate the excess source of either
androgen or estrogen.
–– Any intracranial tumor requires neurosurgery
or radiotherapy. Primary hypothyroidism
needs thyroid replacement therapy.
•• Constitutional precocious puberty:
–– GnRH agonist therapy:
–– Arrests the pubertal precocity and growth
velocity significantly.
––
–– GnRH agonist therapy is the drug of choice
Café Au Lait spots in McCune Albright Syndrome
in cases with GnRH dependent precocious
Evaluation of Precocious Puberty puberty.
–– The agonists suppress the premature
activation of hypothalamic-pituitary axis due
to down regulation and thereby diminished
estrogen secretion.
–– Therapy should be started as soon as the
diagnosis is established.
–– GnRH agonist therapy suppresses FSH,
LH secretion, reverses the ovarian cycle,
establishes amenorrhea, causes regression
of breast, pubic hair changes, and other
secondary sexual characteristics.
–– This drug should be continued till the median
age of puberty (around 11 years)
–– Dose:
•• Buserelin nasal spray 100 mg daily. It can slow
down the process of skeletal maturation.
•• Depot forms (goserelin or leuprolide) once a
month can be used Dose is adjusted to maintain
the serum estradiol below 10 pg/mL
 PRIMARY AMENORRHEA

DEFINITION (IMPORTANT). These girls should be evaluated for possible

outflow tract obstruction.
•• In the absence of 20 sexual characters: 13
years.
•• In the presence of 20 sexual characters: 15
years.
•• Absence of 20 sexual characters means: No
exposure to estrogen .
•• If by the age of 13 years, if no menses have
occurred and there is a complete absence
of secondary sexual characteristics such as
breast development, evaluation for primary •• Cryptomenorrhea is a condition in which
amenorrhea should begin. menstruation occurs but is not visible due to
•• In addition, some girls with secondary sexual obstruction of the outflow tract resulting in
characteristics may present before age 15 either hematometra (blood collection within
years with amenorrhea and cyclic pelvic pain. the uterus) or hematocolpos (blood collection
within vagina). In the long term, it may result in
endometriosis, urinary retention and infertility.

Compartment Defect Disorders/syndromes

Utero-vaginal agenesis (MRKH syndrome)

Imperforate hymen
Compartment 1
Transverse vaginal septum
Androgen Insensitivity Syndrome (AIS) (46 XY)

Gonadal Dysgenesis
Turner Syndrome (45XO)
Compartment 2 Pure gonadal dysgenesis (46XX)
Swyer Syndrome (46 XY)
Resistant ovary syndrome (Savage syndrome) (46XX)
Neoplasia
Compartment 3 Prolactinoma/hyperprolactinemia (secondary amenorrhea)
Problem in Pituitary Empty Sella syndrome
Congenital panhypopituitarism
Isolated FSH deficiency
Kallmann Syndrome (anosmia)
Compartment 4
Anorexia nervosa
Problem in hypothalamus
Extreme stress/exercise
2
Obstetrics and Gynecology

UTERO-VAGINAL AGENESIS/MRKH
SYNDROME
•• Mayer-Rokitansky-Küster-Hauser (MRKH)
syndrome, also known as Müllerian agenesis.
•• 2nd most common cause of 10 amenorrhea (Most
common cause is Turner -45XO)
•• 46XX
•• External genitalia female but small blind vagina
(length is 1-2 cm) .
Imperforate hymen
•• Rudimentary/absent uterus; Normal
ovaries;estrogen will be produced and secondary
characters will be present
•• FSH/LH – normal (USG examination – uterus is
absent)
•• Estrogen – normal
•• Associated renal anomalies (15-30%)/10 %
skeletal anomalies.
•• Management:
–– Sexual: Vaginoplasty (by vaginal dilators OR
surgical - McIndoe repair)
–– Fertility: Gestational surrogacy, uterine ANDROGEN INSENSITIVITY
transplant, adoption. SYNDROME/TESTICULAR
FEMINISATION SYNDROME
IMPERFORATE HYMEN Q
•• X-linked recessive/primary amenorrhea
•• Presents as cryptomenorrhea
•• Abnormality in the androgen receptor
•• Normal 20 sexual characters
–– Wolffian structures don’t develop
•• H/o cyclical abdominal pain/cyclical
dysmenorrhea –– Mullerian structures regress (AMH)

•• If hematocolpos/hematometra is significant •• 46 XY

–– Abdominal mass •• External genitalia – female

–– Urinary retention •• Breast will be developed (But absent pubic and

axillary hair) Q
•• Local examination: Bluish bulge with intact
hymen. •• Peripheral conversion of androgens to Estrogen:
Breast development
•• On P/R: swelling (hematocolpos) felt along
length of vagina anteriorly •• Androgen insensitivity syndrome is a condition
that affects sexual development before birth
•• Treatment: Cruciate incision . and during puberty.
•• People with this condition are genetically male,
with one X chromosome and one Y chromosome in
each cell.
•• Because their bodies are unable to respond to
certain male sex hormones (called androgens),
they may have mostly female external sex
characteristics Q
 3
Primary Amenorrhoea

•• FSH: moderately ↑; serum testosterone – SWYER SYNDROME:

normal
•• 46 XY gonadal dysgenesis
•• Management:
•• Uterus is present; absent secondary sexual
–– Gonadectomy at puberty characters
–– Sexual: Vaginoplasty •• Gonads are present (gonadectomy needs to be
–– Fertility: Counsel for adoption done)

PARTIAL ANDROGEN KALLMANN SYNDROME

INSENSITIVITY SYNDROME (46 •• Hypogonadotropic hypogonadism with anosmia.
XY/FEATURES OF VIRILIZATION) •• Associated cleft lip/palate, cerebellar ataxia
(CLITOROMEGALY) and nerve deafness.
•• Partial androgen insensitivity syndrome (PAIS) •• Primary amenorrhea is the rule
is a genetic condition that affects the sexual
•• The ovaries are usually small
development of a male fetus.
•• FSH/ LH – low; Estrogen – low
•• During pregnancy, male foetuses with PAIS are
unable to properly respond to male sex hormones •• Management: HRT with exogenous estrogen and
(androgens), this affects the development of progestin/gonadotropin.
the genitals. Evaluation of Primary Amenorrhoea (These 2
•• The appearance of the genitals may vary from flowcharts are very useful in solving questions)
person to person.
•• Some males have an unusually small penis
(microphallus), undescended testes, hypospadias
(urethra located on the underside of the penis),
and/or bifid scrotum (scrotum split in two).
•• Breast is developed but the uterus is absent.

GONADAL DYSGENESIS
•• Abnormal development of the gonads (streak
gonads)
•• Absent 20 sexual development
•• Estrogen ↓
•• FSH/ LH ↑
•• Karyotype abnormalities: Common (Turner
syndrome (45 XO) – Most common in primary
amenorrhea
•• Management:
–– In XY karyotype: Gonadectomy (SWYER
syndrome)
–– Estrogen replacement/ hormone replacement
therapy
 SECONDARY AMENORRHEA

DEFINITION of progesterone for 5 to 7 days: She will either

bleed or doesn’t bleed
•• Secondary amenorrhea refers to the absence
of three or more periods by someone who has –– → If she bleeds: diagnosis is anovulation (MC
had regular periods in the past. cause is PCOS)

•• Pregnancy is the most common cause of –– → If she doesn’t bleed: give oestrogen and
secondary amenorrhea progesterone challenge test
–– She will bleed or doesn’t bleed
CAUSES
–– If she bleeds: think of deficient estrogen
•• Uterine (compartment 1) and progesterone; the cause could be ovarian
–– Asherman syndrome or hypothalamic.

–– Genital tuberculosis –– Do FSH test

•• Ovary (Compartment 2) –– If FSH is low, it is hypothalamic or pituitary

cause like Sheehan syndrome
–– Premature ovarian failure.
–– If FSH is high, think of ovarian cause
–– Genetic (Turner mosaic, fragile X
(Premature ovarian failure)
permutation).
•• If she is not bleeding, think about uterine cause
–– Post surgery.
like Asherman Syndrome and do hysteroscopic
–– Post Radiotherapy adhesiolysis
–– PCOS.
PREMATURE OVARIAN FAILURE
•• Pituitary (compartment 3)
•• Ovarian Failure < 40 years of age
•• Hypothalamus (compartment 4)
•• Etiology:
–– → Sheehan syndrome.
–– Genetic (Fragile x chromosome) / Turner
mosaic
EVALUATION
–– Autoimmune
•• Rule out Pregnancy
–– Infections
•• Rule out Hypothyroidism
–– Iatrogenic
•• Progesterone Challenge Test
–– Metabolic
•• Estrogen-Progesterone Challenge Test
–– Environmental
EVALUATION OF SECONDARY
AMENORRHEA (IMPORTANT). DIAGNOSIS
•• Do UPT and thyroid profile test •• Raised FSH

•• Progesterone challenge test: Give oral tablets •• Low Estradiol

2
Obstetrics and Gynecology

•• Ovarian Biopsy •• Presentation:

•• Karyotype (Younger Patients)/Turner mosaic –– FSH will decrease
•• Autoimmune (ANA) –– LH will decrease
–– Prolactin will decrease
TREATMENT
–– TSH and GH will decrease
•• Hormone replacement therapy (oestrogen +
progesterone) till age of 45 to 50 years •• Treatment: Gonadotropins

SHEEHAN SYNDROME Q PSEUDOCYESIS

•• Postpartum hypopituitarism caused by necrosis •• Secondary Amenorrhea + Symptoms of
of the pituitary gland. Pregnancy

•• It is usually the result of severe hypotension or •• Alterations in LH Pulse Frequency

shock caused by massive haemorrhage during or •• Increased Androgens
after delivery.
•• Raised Prolactin
•• Patients have varying degrees of anterior
pituitary hormone deficiency.
 PCOS

•• Genetic (CYP21 gene mutation)

ASSOCIATIONS
•• Metabolic syndrome
•• 3 out of 5 characteristics should be present
Criteria
Abdominal Obesity>88cm

Hypertriglyceridemia>150 mg/dl
Low HDL<40
BP>130/80
Fasting glucose>100

DIAGNOSIS Hair-an Syndrome

Rotterdam criteria says 2 out of 3 following ○○ Acanthosis nigricans
characteristics should be present:
○○ Hyperandrogenism
1. Anovulation/oligo ovulation
○○ Insulin resistance
2. Hyperandrogenism (Clinical: acne, hirsutism;
Biochemical: raised testosterone, DHEAS levels)
3. Polycystic morphology on USG, one or both ovaries
showing small follicles on the periphery of the
ovary.
–– Older definition – size of follicle should be
2-9mm, ≥12 follicles/ovarian volume>10ccm3
–– According to ESHRE, >20 follicles should be
present instead of 12.
–– Necklace-like pattern on USG
According to Rotterdam criteria above, there should
CLINICAL FEATURES OF PCOS
be presence of 2/3 characteristics
•• High BMI
ETIOLOGY •• Delayed cycle
•• Insulin resistance •• Acne
•• Altered LH/FSH ratio •• Hirsutism
•• Low grade systemic inflammation •• Infertility
2
Obstetrics and Gynecology

FERRIMAN GALLWEY SCORING OF MANAGEMENT

HIRSUTISM Q •• Lifestyle modification
•• If score is more than 8 then, hirsutism will be •• Diet
diagnosed
•• Exercise
•• 9 areas (score: 1 to 4)
•• Treatment of menstrual disorder – progesterone
–– 0 = no hirsutism (D15-D25)
–– 1 = mild –– Medroxyprogesterone acetate/
–– 2 = moderate norethisterone acetate

–– 3 = complete light coverage –– Combined oral contraceptive pills (E+P).

Progesterone component of OCPs should
–– 4 = heavy coverage preferably be an anti androgen like
–– Drospirenone (progesterone) spironolactone
derivatives
–– Cyproterone acetate (antiandrogenic)
Women having PCOS with anovulation should bleed
at least 4 times a year to prevent endometrial
hyperplasia.

TREATMENT OF HIRSUTISM
•• Depilation (shaving, anti-hair creams)
•• Epilatory methods (waxing/threading)
•• Medication:
–– Topicals (eflornithine)
–– Oral (antiandrogen-containing
pills like cyproterone acetate and
drospirenone,spironolactone)
–– Flutamide (androgen receptor antagonist)

–– Finasteride (5-alpha reductase inhibitor)

TREATMENT OF INFERTILITY
•• Ovulation induction drugs:
1. Letrozole (DOC in PCOS for ovulation
induction)
–– Aromatase inhibitors – promotes mono
follicular development, endometrial
thinning, maintain endometrial thickness
1. Clomiphene citrate (Anti-estrogen) –
promotes multifollicular development so
that, multiple pregnancy can occur; decrease
the endometrium thickness
2. Gonadotropin (inj. of FSH, hMG) – to resume
ovulation
 3
PCOS

LAPAROSCOPIC OVARIAN DRILLING –– Energy used– 40 watt

•• Small holes are made in follicles to resume –– 4 drills should be done in each ovary
ovulation in women who are not responding to –– Depth of 4mm for 4 seconds
drugs
•• Advantage: induce the resumption of ovulation
in more than 50% females
•• Disadvantages: invasive procedure, can cause
adhesion,
•• Rule of 4:
 MULLERIAN ANOMALIES

EMBRYOLOGY •• 20 weeks: Dissolution of the uterine septum

•• At 7 weeks of fetal life: Differentiation of •• Unfused cephalad portion: Fallopian tube

Mullerian and Wolffian ducts begins •• Vagina: Upper 2/3rd: Fused Mullerian ducts;
•• AMH (marker of ovarian reserve), Testosterone: Lower 1/3rd: Urogenital sinus
Regression of the Mullerian duct
•• Lack of AMH, testosterone: Mullerian ducts
persist
•• 10 weeks: distal ends fuse: Uterovaginal canal
inserts into the urogenital sinus

Indifferent Structure Female Male

Genital Ridge Ovary Testis

Primordial Germ Cells Ova Spermatozoa

Sex Cords Granulosa cells Seminiferous tubules, Sertoli cells

Gubernaculum Utero-ovarian and round ligaments Gubernaculum testis

Mesonephric ducts Gartner duct (cyst) Epididymis, ductus deferens, ejaculatory

duct
Paramesonephric Uterus, fallopian tubes, upper vagina Prostatic utricle, appendix of testis
ducts (mullerian duct)
Urogenital sinus Bladder, urethra, vagina, para urethral Bladder, urethra, prostatic utricle,
glands, Bartholin glands and lesser prostate glands, bulbo-urethral glands
vestibular glands
Genital tubercle Clitoris Glans penis

Urogenital folds Labia minora Floor of penile urethra

Labioscrotal swellings Labia majora Scrotum

2
Obstetrics and Gynecology

MULLERIAN ANOMALIES
CLASSIFICATION
1. AFS 1998

2. ESHRE

3. ASRM Müllerian Anomalies Classification 2021:

MULLERIAN AGENESIS
This is actually a app which is a tool and gives
detailed information about the anomalies •• Complete (MRKH syndrome)

•• Mullerian agenesis •• Partial

•• Cervical agenesis •• Characterized by: Absent uterus, absent cervix,

absent fallopian tube, partial vagina.
•• Unicornuate uterus
•• Presents with primary amenorrhea in presence
•• Uterus didelphys
of secondary sexual characters and in the
•• Bicornuate uterus absence of uterus.
•• Septate uterus •• On examination, there is a blind vagina.
•• Longitudinal vaginal septum •• PIR examination: uterus absent but ovaries will
be present
•• Transverse vaginal septum (obstructive system)
•• Treatment:
•• Complex anomalies
1. Sexual function: by creating a neovagina
 3
Mullerian Anomalies

(vaginoplasty)/ Vaginal dilators. Type A1 a Type Type A2 Type B

2. Fertility: Surrogacy/ Uterine transplant/ Communicating A1b Non No cavity No Horn
Adoption communicating
10% 22% 33% 35%
CREATING A FUNCTIONAL VAGINA
•• Frank Dilators/Ingram dilators: Done when a
UTERINE DIDELPHYS
woman plans sexual activity/ marriage
•• McIndoeVaginoplasty: dissecting the space
between the urethra and rectum and then
placing grafts to ensure its patency

UNICORNUATE UTERUS

•• When there is complete separation of two

uterine horns
•• No communication between horn
•• Good reproductive performance
•• Malpresentation is common
•• Endometriosis may be seen (rare) in OHVIRA
syndrome (Obstructed hemivagina + Ipsilateral
renal agenesis)

•• Poor reproductive outcomes BICORNUATE UTERUS

•• Increased risk of preterm labour
•• Majority have a with rudimentary horn
•• Horn can further cause complications/ectopic
and hematometra
•• Diagnosis:
–– Non-invasive methods:
ƒƒ HSG (hysterosalpingogram)
ƒƒ 3D ultrasound

ƒƒ MRI (Investigation of choice)

–– Invasive methods:
ƒƒ Hystero-laparoscopy
4
Obstetrics and Gynecology

•• On HSG: •• Hysteroscopic septoplasty is the treatment of

choice.
–– Angle between uterine horns is obtuse >1050

–– If angle is < 75°, it’s septate uterus ARCUATE UTERUS

•• Bicornuate uterus is associated with
–– mid trimester loss commonly due to cervical
insufficiency
–– Preterm labor
–– Malpresentations
•• Metroplasty can be done. It is a surgical
procedure where both the horns are joined
together laparoscopically or via laparotomy

SEPTATE UTERUS •• No reproductive effect on women

•• No clinical significant

DES-INDUCED REPRODUCTIVE
TRACT ABNORMALITIES

•• Most common mullerian anomaly

•• Usually associated with bad obstetric history
•• Associated with: Infertility, abortions, mid
trimester losses, preterm labor, malpresentation
and foetal growth restriction are common

•• DES – Given to women who have recurrent

abortion (1960s)
•• Increased risk of
–– T-shaped uterus
–– Clear cell adenocarcinoma of cervix and
vagina

–– In males: hypospadias,

Image showing hysteroscopic view of a septum

 5
Mullerian Anomalies

TRANSVERSE VAGINAL SEPTUM Q LONGITUDINAL VAGINAL SEPTUM

•• No obstruction
•• Dyspareunia, difficult delivery
•• Complete or Partial
•• Many times diagnosed during labor in second
•• It could be low, mid, and high
stage
•• In complete TVS: Primary amenorrhea with
•• Treatment: cut the septum
cyclical dysmenorrhea (Cryptomenorrhea)
OHVIRA SYNDROME - Uterine Didelphys with
•• O/e: Blind vagina
Obstructed hemivagina + ipsilateral renal agenesis
•• On ultrasound, hematocolpos and hematometra
•• Treatment: Resect the septum
 BASICS AND EVALUATION OF FEMALE
INFERTILITY

Subfertility •• If everything is alright, with reasonable

frequency of sexual intercourse, around 85% of
•• Subfertility (Earlier Known as Infertility)
couples will conceive within 1 year.
•• 10-15% of all couples
•• Types: Evaluation Q
1. Primary subfertility: never conceived •• Evaluation is done after 1 year of trying to
conceive
2. Secondary subfertility: Conceived earlier and may/
may not have resulted in the live birth. May have a •• After 6 Months, in Women > 35 Years of age/
previous history of miscarriage, ectopic pregnancy, Menstrual Irregularity
molar pregnancy, stillbirth or preterm delivery.
Cause of infertility
•• Fecundability: The probability of a woman
becoming pregnant •• Male infertility: 30 - 35% Q

•• Fecundity: Probability of having a live birth •• Female infertility: 40% Q

○○ Ovarian pathology
Fecundability ○○ Tubal cause
•• Probability that in 1 month or 1 menstrual cycle,
○○ Uterine cause
a couple will conceive if they have regular sexual
intercourse without any contraception is 20- ○○ Any other cause
25% •• Both male and female- causes about 10-15% of
•• In 3 months, it reaches 50% all cases of infertility
•• In 6 months, it reaches 75% •• Unexplained infertility (when nothing wrong is
found in basic evaluation)- causes about 10-15%
•• In 1 year, it reaches 80-85%
of all cases of infertility.
Male Factor Infertility
Pre-Testicular Causes Testicular Causes Post-Testicular Causes
Hypothalamic/pituitary gland 1. Testicular failure: it can be Vasectomy
problems like Kallman’s syndrome, genetic like Klinefelter syndrome, CBAVD
hypogonadotropic hypogonadism Down syndrome, Y- chromosome Young’s syndrome
Pituitary lesions like tumor, granuloma microdeletions Erectile dysfunction
or history of radiation 2. History of radio/chemotherapy
Diabetes mellitus 3. History of Orchitis
Hypothyroidism 4. Alcohol/drugs
Obesity
2
Obstetrics and Gynecology

Female Factor Infertility

Ovarian Causes Tubal Causes Uterine Causes Others
Anovulation (PCOS) Adhesions Mullerian Anomalies Vaginal Causes
Hyperthyroidism Pelvic Inflammatory Disease Fibroids Cervical factor
Hyperprolactinemia Genital Tuberculosis Polyps Peritoneal Factors

Evaluation
Evaluation Initial Evaluation
Ovulation History and Physical Examination
Basal Body Temperature charting
Ovulation Predictor Kits (urinary LH)

Uterus Ultrasonography (Trans vaginal scan)

Fallopian Tubes Hysterosalpingography

Male Semen Analysis

Repeat Semen Analysis If Indicated Post-Coital Test (Not Routine)

Ovarian Reserve
Tests for Ovarian Reserve Q
When the fetus is in the uterus at 20 weeks, there
are 7-8 million follicles; these gradually decline.
(IMPORTANT).
•• When a female is born, there are 1 million eggs Biochemical tests
•• At puberty, there are 40000 eggs •• FSH: D2/3: Increased in poor ovarian reserve

•• At age of 40, there are 25000 eggs •• Estradiol: Day 2: Increased in poor ovarian
reserve
•• At menopause, there are 1000 eggs
•• Inhibin B: Reduced in poor ovarian reserve
•• AMH: Reduced in poor ovarian reserve

Ultrasound
Clomiphene Citrate Challenge Test

AMH
•• Produced by the granulosa cells of the pre-
antral and small antral follicles (2-6 mm)
•• Low AMH means
○○ Poor response to ovulation induction
○○ Low Oocyte Yield
○○ Low Embryo Quality
 3
Basics and evaluation of female infertility

Antral follicle count dip

3. Cervical mucus study

•• Trans vaginal scan

•• At the time of ovulation, cervical mucus is thin
•• Done at Day 2 or 3 and stretchy
•• Poor ovarian reserve < 4-6 •• It is thin and viscous at the time of luteal phase
•• >10 is a good count 4. Hormonal Studies
•• Mid Luteal Progesterone: Peak on Day 21 (> 10
Clomiphene Citrate Challenge Test ng/ml)
•• FSH measured Before and After CC
5. Endometrial Biopsy (Secretory phase of the cycle
•• Day 3 – FSH level measurement → the at day 21)
Clomiphene citrate is given from day 5 to day 9
•• Done in the premenstrual phase
→ repeat FSH at day 9
•• If proliferative endometrium: Anovulation
•• If FSH is high, then it is an indicator of poor
ovarian reserve •• Ovulation: Sub-nucleolar vacuolation Q
•• If endometrial biopsy shows a lag of 2-3 days:
Tests of Ovulation Corpus luteal deficiency
1. History
•• Regularity of Menstrual Cycle
•• Mittelschmerz/ovulation is painful
•• Dysmenorrhoea
•• Premenstrual Syndrome because progesterone
is high
2. Basal body temperature
•• Just prior to ovulation, there is a drop in
temperature by 0.25, then it rises by 0.5 deg C

6. Ultrasound

Basal body temperature chart with implantation

4
Obstetrics and Gynecology

Cause of Tubal Factor Infertility

Proliferative Endometrium 1. Adhesions

•• Trans vaginal scan 2. Salpingitis
•• Trilaminar endometrium or triple layer 3. Genital tuberculosis
endometrium is seen in the proliferative phase. 4. Endometriosis
•• In the secretory phase, the endometrium
becomes homogeneous. Hysterosalpingography (HSG)
•• Visualization of the uterine cavity and fallopian
tube after injecting a radio-opaque dye in the
uterine cavity
•• 9thor 10thDay of the cycle.
•• Procedure:
1. Sub mucosal fibrosis
2. Endometrial fibrosis
3. IU Adhesions

This is the ovary showing a dominant follicles, just

about to ovulate (18-20 mm)
7. Laparoscopy
•• If performed mid-cycle, a large follicle may be
seen

Leech Wilkinson Cannula

Test for Tubule Patency

1. Hysterosalpingogram (HSG)
2. Laparoscopic chromotubation (Gold standard test)

3. Sonosalpingography
 5
Basics and evaluation of female infertility

SubMucosal Fibroid

HSG

Asherman’s syndrome (moth eaten/flea bitten)

Sonosalpingography

Right cornual block due to tubal spasm

•• Procedure:
–– Under ultrasound scanning, an injection of
about 200 ml physiological saline is pushed
into the uterine cavity is accomplished via
Distal Tubal Block/may be fimbrial block
Foley catheter.
–– An inflated bulb of the catheter prevents
leakage of fluid outside the uterine cavity.
6
Obstetrics and Gynecology

Laparoscopic chromotubation –– USG contrast media with galactose micro

particles is infused in the uterine cavity
–– Flow of Medium Observed on USG

Management of Tubule Occlusion

•• Proximal Tubal Occlusion: hysteroscopic re-
cannulation / ART
•• Distal Tubal Obstruction – fimbrioplasty / ART
•• Hydrosalpinx – ART (clipping of the tubes has
to be done prior to IVF.

Uterine causes
1. Fibroids
2. Endometrial polyps
3. Mullerian anomalies

4. Asherman syndrome

Diagnosis of uterine causes

•• USG (trans vaginal scan)
•• HSG (delineates the uterine cavity)
•• Hysteroscopy: endometrial polyps/Intrauterine
•• Spill of methylene blue indicates tubal patency adhesion/ Septate uterus
•• Advantage: Other pathologies can also be •• MRI – mullerian anomalies/fibroids
visualized and treated

Other Tests of tubal patency

•• Hysteroscopic cannulation and falloposcopy.
•• Hystero – Salpingo – Contrast – Salpingography
(HYCOSY)
 MALE INFERTILITY

•• Male infertility accounts for about 30% of all

infertility

•• Causes of male infertility

Common Causes of Male Infertility

•• Evaluation of male infertility Parameter WHO 2010 WHO 2020

criteria
–– The single most important investigation is
Semen Analysis Volume ≥ 1.5 ml ≥ 1.4 ml

–– The WHO has defined semen analysis Sperm ≥ 15 million/ml ≥ 16 million/ml

parameters which were recently revised in concentration
2020. These are important to know. Sperm motility Total motility: Total motility:
40% 42%
≥ 32% ≥ 30%
progressive progressive
Morphology ≥ 4% ≥ 4%
(strict criteria)
Viability ≥ 58% alive ≥ 54%
2
Obstetrics and Gynecology

Normozoospermia: All sperm parameters are in the

normal range Other investigations:
Oligospermia: Low sperm count •• Serum FSH, LH, testosterone, prolactin, and
Moderate: 5-15 million/ml TSH:
Severe: < 5 million –– Testicular dysfunction causes rise in FSH and
Azoospermia: No sperm in semen
LH.
Hypospermia: Decreased semen volume (< 1.5 ml) –– Low level of FSH and LH suggest hypogonadotropic
hypogonadism
Hyperspermia: (Excessive semen volume > 5.5 ml)
Aspermia: No semen –– Leydig cell dysfunction causes low testosterone
and high LH level.
Asthenospermia: Abnormal motility
Teratospermia: Abnormal morphology –– Elevated prolactin due to pituitary adenoma
Oligo-astheno-teratozoospermia (OATS): Reduced may cause impotency
number, motility and morphology
 3
Male Infertility

•• Fructose content in the seminal fluid: Its ○○ hMG or pure FSH (75–150 IU) is
absence suggests congenital absence of seminal added to hCG when there is no sperm
vesicle or portion of the ductal system or both. in the ejaculate with hCG alone.
•• Testicular biopsy: ○○ Dopamine agonist (cabergoline) is
–– Done to differentiate primary testicular given in hyperprolactinemia to restore
failure from obstruction as a cause of Semen normal prolactin and testosterone
analysis level.
–– The biopsy material is to be sent in Bouin’s
solution and not in normal saline. ○○ This improves libido, potency, and
fertility.
–– Testicular tissues may be cryopreserved for
future use in IVF/ICSI ○○ Pulsatile GnRH therapy in infertile
•• Transrectal ultrasound (TRUS): male with GnRH deficiency (Kallmann’s
syndrome) is effective.
–– Done to visualize the seminal vesicles,
prostate, and ejaculatory ducts obstruction. ○○ Clomiphene citrate 25 mg orally daily
for 3 months is given increases serum
•• Karyotype analysis: level of FSH, LH and testosterone
–– This can be done in cases with azoospermia
or severe oligospermia and raised FSH. ƒƒ IVF with ICSI may be done in cases with
Klinefelter’s syndrome (XXY) is the most severe oligospermia
common.
ƒƒ Retrograde ejaculation: phenylephrine
–– Micro deletions of the long arm of Y (α-adrenergic agonist) is used to improve
chromosome can also cause severe seminal the tone of internal urethral sphincter.
abnormalities Sperm may be recovered from the
•• Immunological tests: sperm agglutinating and neutralized urine. Processed spermatozoa
could be used for lUI.
sperm immobilizing antibodies
ƒƒ Teratospermia, asthenospermia: Donor
•• Treatment of Male infertility
insemination (AID) is the option
ƒƒ The treatment of male is indicated in
ƒƒ Genetic abnormality: artificial insemination
ƒƒ Oligospermia with donor sperm (AID) is the option as
ƒƒ Azoospermia no other treatment is available.

ƒƒ Low volume ejaculate ƒƒ When the patient is found to be azoospermic

and yet testicular biopsy shows normal
ƒƒ Impotency. spermatogenesis, obstruction of vas must
–– Management is often difficult and be suspected. This can be corrected by
unsatisfactory. microsurgery—vasoepididymostomy or
vasovasostomy.
–– To improve spermatogenesis the following
measures may be helpful ƒƒ After vaso-vasostomy patency is obtained
in about 80 percent of cases and
○○ General care: Improvement of general
pregnancy rate is about 50 percent.
health, reduction of weight in obese,
avoidance of alcohol and heavy smoking ƒƒ Surgery for varicocele for improvement of
are of help fertility is not helpful.

○○ In hypogonadotropic hypogonadism, ƒƒ Hydrocele is corrected by surgery.

the disorders of spermatogenesis can ƒƒ Orchidopexy in undescended testes should
be treated with the following therapy be done between 2–3 years of age to have
with varying success adequate spermatogenesis in later life.
○○ hCG 5000 IU intramuscularly once ƒƒ Impotency: Psychosexual treatment may
or twice a week is given to stimulate be of help. Hyperprolactinemia needs
endogenous testosterone production further investigation and. For erectile
4
Obstetrics and Gynecology

dysfunction sildenafil (25–100 mg) or

tadalafil (10–20 mg) is currently advised.
A single dose (depending on response)
is given orally one hour before sexual
activity. In unresponsive cases, IUI can
be done.
ƒƒ ART for Male Infertility: Prospect of male
infertility has improved significantly
with the advent of ART. IUI, TESE,
PESA, MESA and intracytoplasmic sperm
injection (ICSl) are now the treatment
available for infertile males.

Sperm Retrieval Techniques

 TREATMENT OF INFERTILITY

Treatment of Infertility
Evaluation of Initial Evaluation Further Tests

•• Mid luteal progesterone levels

•• History and Examination
•• Ultrasound for follicular imaging
Ovulation •• Basal Body Temperature
•• Endometrial biopsy
•• Urine LH kits
•• Hormonal profile
•• MRI
Uterine Factor •• Ultrasound •• SIS
•• Hysteroscopy
•• Laparoscopy with chromo
Tubal Factor •• HSG
tubation
•• Genetic evaluation
•• History and Examination •• Hormonal study
Male
•• Semen analysis •• Ultrasound
•• Testicular biopsy

TREATMENT OF ANOVULATION –– Anti estrogenic effect on endometrium

•• Ovulation Induction: The use of medicines to –– S/e: Hot flushes, multiple pregnancy, OHSS,
stimulate ovulation in women who are anovulatory ovarian cancer
•• Superovulation/ Ovulation enhancement: Use of –– Clomiphene resistance: No ovulation even
medicines to promote follicular development in after 3 cycles of max dose
women who are otherwise ovulating
–– Clomiphene failure: No pregnancy in 3-6
•• Controlled ovarian hyperstimulation (COH): Use cycles
of medications to stimulate follicles for the
2. Letrozole
purpose of egg harvesting and oocyte retrieval
in ART –– Inhibit aromatase enzyme; thereby limiting
estrogen production
Drugs used in Ovulation Induction –– Less chances of multiple pregnancy and
1. Clomiphene Citrate OHSS
–– Anti estrogen (SERM) –– Less t ½; so, no prolonged anti-estrogenic
effects
–– Stimulates HPO axis – increased FSH –
follicular growth –– DOC for Ovulation Induction in PCOS
–– Starting dose: 50mg D2-6; max 150mg –– 2.5 mg D2-D6 (max: 5mg)
–– 80% ovulation rate; 40% pregnancy rate 3. Gonadotropins
2
Obstetrics and Gynecology

–– In clomiphene resistance –– All submucosal fibroids

–– In COH in ART cycles –– All intramural fibroids that are > 5 cm in size
or those that are distorting the cavity
–– Available as
–– Also remember that type 0 and type 1 fibroids
1. hMG
can be removed by hysteroscopy
2. Purified FSH/ recombinant FSH
–– For other types of fibroids, laparoscopic
1. Laparoscopic Ovarian Drilling myomectomy is preferred
ƒƒ Can be done in clomiphene resistant cases 3. Asherman Syndrome
ƒƒ Advantages: 50% ovulation rate, low risk •• These are intra-uterine adhesions
of multiple pregnancy and can diagnose/
•• They usually follow a history of sharp curettage
treat other conditions
•• Symptoms are hypomenorrhea, secondary
ƒƒ Disadvantages: Invasive, adhesions,
amenorrhoea and secondary infertility
decreased ovarian reserve
•• Diagnosis is by
–– HSG: space filling defect is seen (moth eaten
appearance)
–– Hysteroscopy
•• Treatment: Hysteroscopic adhesiolysis

TREATMENT OF UTERINE FACTOR

INFERTILITY
1. Endometrial Polyps
•• Hysteroscopic polypectomy should be done

Asherman syndrome on
HSG
4. Septate uterus
•• This is the most common mullerian anomaly
•• It causes subfertility, abortions, preterm labor,
malpresentations
•• It is diagnosed on
–– HSG (angle between 2 cornua < 750)
–– 3D USG
–– MRI
–– Hysteroscopy
Hysteroscopic appearance of an endometrial polyp
•• Treatment: Hysteroscopic septal resection
2. Leiomyomas
•• Leiomyomas that need to be removed in
infertility are
 3
Treatment of infertility

2. Distal Tubal Obstruction

•• Fimbrioplasty
•• Adhesiolysis
•• Salpingostomy/ Neo salpingostomy

HSG: Septate uterus

HSG showing hydrosalpinx
3. Hydrosalpinx
•• IVF
•• Prior to IVF: Salpingectomy/ clipping of the
tubes as this reduces the amount of toxins
entering and harming the embryo

Hysteroscopy: Septate uterus

TREATMENT OF TUBAL FACTOR

INFERTILITY HSG showing hydrosalpinx
1. Proximal Tubal Occlusion:
Artificial Reproductive Techniques
•• Fluoroscopic recannulation
•• These include all the clinical and laboratory
•• Hysteroscopic cannulation techniques to achieve pregnancy
•• Microsurgical tubal anastomoses •• Indications
–– Tubal block
–– Endometriosis
–– Male infertility
–– Poor ovarian reserve

–– Unexplained infertility

Steps in IVF-ET (In vitro Fertilization-

Embryo Transfer)
•• Controlled ovarian hyperstimulation
•• Monitoring of ovarian follicles by TVS, estradiol

HSG showing b/l distal tubal block

4
Obstetrics and Gynecology

levels COMPLICATIONS OF ART

•• Ovulation trigger 1. Ovarian Hyperstimulation Syndrome
•• Ovum pick up done 36h after trigger 2. Multiple Pregnancy
•• Sperm preparation 3. Ectopic Pregnancy
•• Fertilization; checking after 20h (2 pro-nuclei) 4. Heterotopic Pregnancy
•• Embryo Transfer (48 – 72h or Day 5) 5. Congenital Malformations (doubtful association)
•• Luteal phase support 6. Risk of cancer following fertility treatment
(Theoretical risk of ovarian cancer if too many
ICSI (Intra – Cytoplasmic Sperm Injection)
cycles of ovulation induction are given)
•• A single mature sperm is injected into a mature 7. Pregnancy complications
oocyte
8. Psychological stress
•• 40-60% success rates
OVARIAN HYPERSTIMULATION SYNDROME
•• Useful in male infertility and IVF-ET failures
(OHSS)
GESTATIONAL SURROGACY •• OHSS is characterized by multiple follicular
•• A woman without a functional uterus development and ovarian enlargement following
(developmental or hysterectomy), can have her hCG stimulation.
genetic offspring with the help of ART. •• It occurs mostly in IVF due to controlled
•• Embryos are transferred to the uterus of ovarian hyperstimulation (COH) but can also
another woman who is willing to carry the happen with simple ovulation induction
pregnancy on behalf of the infertile couple. •• The clinical features appear about 3–6 days
after the ovulating dose of hCG is administered.
PREIMPLANTATION GENETIC DIAGNOSIS
(PGD) •• It is an iatrogenic and potentially a life-
threatening complication of COH
•• Can be performed on polar bodies removed from
oocytes before fertilization. •• Risk factors for OHSS are:

•• It can also be done by blastomere biopsy or Yound age (< 35 years)

biopsy from the tropho - ectoderm
low body mass index - asthenci habitus
•• Genetic screening can avoid transferring polycystic ovary syndrome
embryos with aneuploidy and autosomal
history of atopy or allergies
recessive or autosomal dominant gene mutation
High serum estradiol
CRYOPRESERVATION previous episode of ovarian hyperstimulation
syndrome
Restoration of reproductive function of a woman
Mutiple follicles
or a man undergoing chemotherapy or radiotherapy
is possible these days with the help of cryobiology. Higher or repeated doses of exogenous human
Cryopreservation of ovarian tissue or auto- Chorionic gonadotropin
transplantation may allow natural pregnancy later on. Gonadotropin - releasing hormone against protocol
•• Cryopreservation of spermatozoa Pregnancy
•• Cryopreservation of unfertilized oocytes
•• Pathophysiology:
•• Cryopreservation of embryos: This helps in
preserving extra embryos formed at IVF/ ICSI –– Increased capillary permeability leads to
and reduces the risk of OHSS leakage of fluid from the peritoneal and
ovarian surfaces.
•• Cryopreservation of ovarian tissue
–– Variety of chemical mediators like cytokines,
 5
Treatment of infertility

vascular epidermal growth factor (VEGF), •• To withhold ovulatory dose of hCG in susceptible
prorenin, renin and nitric oxide (NO) system cases and to cancel the cycle or to delay the
are thought to be stimulated with hCG dose of hCG injection (coasting)
administration.
•• Cryopreservation of oocytes or embryos for
•• Clinical Presentation (and Classification future use
depending on severity)
•• Aspiration of immature oocytes and in vitro
maturation (IVM)
•• Progesterone should be used for luteal phase
support instead of hCG
•• Cabergoline and albumin have a role in reducing
the incidence of OHSS in those at high risk

Management:
•• The management of OHSS is mainly supportive.
•• Severe cases are to be admitted
•• To monitor complete hemogram, LFTs, RFTs,
electrolytes, coagulation profile, ECG and urine
output.
•• Chest X-ray (shielding the pelvis)
•• Monitoring of O2 saturation is needed when
there is respiratory compromise.
•• TVS is to be done to assess ovarian volume and
ascites
•• Oral fluid is continued to prevent
hemoconcentration and to maintain renal
perfusion.
•• Normal saline 150 ml/ hr IV is given when
hematocrit is >45 percent
•• To relieve respiratory distress, abdominal
paracentesis may be done under USG guidance.
•• Human albumin (50 ml of 25%) may be
Ultrasound image of ovaries in OHSS administered to correct hypovolemia

Prevention •• Pain is controlled with paracetamol or pethidine

•• Use of GnRH antagonists (instead of GnRH •• Intensive care management is needed for
agonists) for down regulation specific complications like renal failure

•• Low starting dose of gonadotropins in high-risk •• Anticoagulation may be required

women •• Surgery is rarely indicated
•• Metformin cotreatment during gonadotropin
stimulation in women with PCOS or at high risk
of OHSS
•• Close monitoring of the superovulation cycles
using TVS and serum estradiol estimation
•• Replacing hCG with leuprolide as a maturation
trigger
 MENOPAUSE

Definition fornices

•• Menopause: Means permanent cessation of •• Vagina: pale and dry, dyspareunia

menstruation at the end of reproductive life •• Vulva: atrophic
due to loss of ovarian follicular activity.
•• Urethra: urethral prolapse, caruncle can form
•• It is the point of time when last and final
menstruation occurs. •• Ligaments of the uterus: weak

•• The clinical diagnosis is confirmed following •• Breasts: deposition of fat; large, reduced
stoppage of menstruation (amenorrhea) for glandular tissue
twelve consecutive months without any other •• Weight gain
pathology.
•• Wrinkling of skin
•• It is a retrospective diagnosis
•• Greying of hair, increased facial hirsutism
•• Perimenopause: Period around menopause (40–
55 years). •• Bones and joints: osteoarthritis, osteopenia,
osteoporosis, increased fracture risk
•• Climacteric: Period of time during which a
woman passes from the reproductive to the Physiological Changes of Menopause
nonreproductive stage. This phase covers 5–10
years on either side of menopause.
•• The age of menopause ranges between 45–55
years, average being 50 years.

Endocrinology of Menopause
•• Fall in serum estradiol to 10–20 pg/mL after
menopause.
•• This decreases the negative feedback effect
on hypothalamic-pituitary axis resulting in
increase in FSH.
•• An FSH > 20 is diagnostic of menopause

•• LH also increases

Anatomical Changes in Menopause

•• Ovaries shrink and become atrophic; size < 2 ml
•• Atrophy of fallopian tubes
•• Uterus: small, atrophic, thin endometrium •• The important symptoms and the health
•• Cervix: shrinks, becomes flush with vaginal concerns of menopause are:
2
Obstetrics and Gynecology

–– Vasomotor symptoms •• Anxiety

–– Urogenital atrophy •• Irritability
–– Osteoporosis and fracture 2. Cognitive Dysfunction
–– Cardiovascular disease •• Poor concentration
–– Cerebrovascular disease •• Poor memory
–– Psychological changes •• Tiredness
–– Skin and Hair •• Lack of motivation
–– Sexual dysfunction 3. Sexual dysfunction
–– Dementia and cognitive decline •• Dyspareunia
•• Vaginal dryness
A. IMMEDIATE SYMPTOMS
•• Decreased libido
1. Vasomotor symptoms
•• Urinary symptoms
•• The characteristic symptom of menopause is a
“hot flush”. •• Urinary incontinence
•• Hot flush is characterized by sudden feeling of •• Dysuria and frequency
heat followed by profuse sweating.
•• Frequent UTI
•• Also - palpitation, fatigue and weakness.
•• Weight gain
•• Hot flush coincides with GnRH pulse secretion
with increase in serum LH level. B. DELAYED SYMPTOMS
•• It may last for 1–10 minutes and may be at times
A. BONE HEALTH: OSTEOPENIA and
unbearable.
OSTEOPOROSIS
•• Seen in 10% women in the menopausal transition
•• Bone strength is determined by BMD (grams of
and up to 50-80% after menopause
mineral per unit area and volume of bone)
•• They are most severe in the 1st 2-3 years
•• Till 35y, there is positive bone balance
•• Gradually reduce by 5 years
•• After 35, there is gradual decrease by 0.4%
•• Due to peripheral vasodilatation and rise in skin each year increasing to 2-5% per year in the
temp first 5-10 years after menopause and then 1%
•• Dysfunction in hypothalamus regulatory nuclei per year thereafter
due to E withdrawal •• Loss in trabecular bone is more than cortical
bone
Treatment:
–– Nonpharmacological treatment: Lifestyle
modification
–– Clonidine (alpha adrenergic agonist)
–– Phytoestrogens
–– Soy proteins
–– Hormone Replacement Therapy

2. Mood Disorders
•• Mood swings
•• Depression
 3
Menopause

RISK FACTORS OF OSTEOPOROSIS •• Z score of -2.0 or lowers: Osteoporosis

•• Early menopause –– Severe Osteoporosis: At or below -2.5 with 1

or more fracture
•• > 65y
•• Family h/o osteoporosis and fracture femur
neck in mother/ grandmother
•• Past history of non traumatic fracture
•• Race (Asian > Caucasian > African)
•• Low BMD at a younger age
•• Low BMI
•• Sedentary lifestyle
•• Surgical menopause
•• Radiation menopause
•• Thyrotoxicosis
•• DM
•• Drugs: Steroids, GnRH therapy, Sedative How the DEXA scan report looks like
drugs, Danazol, Long term heparin, long term •• FRAX Scoring is an online assessment tool to
anti-convulsant assess the risk of fracture
•• Alcohol
•• Smoking
•• Primary hyperparathyroidism
•• Excessive caffeine

•• Malabsorption

Diagnosing Osteoporosis
•• DEXA Scan: Dual Energy Xray Absorptiometry
scan
•• of lumbar vertebra: Why lumbar vertebrae?
Because it contains mainly trabecular bone
which is less dense than cortical bone and easily
detects early bone loss
•• Neck of femur and greater trochanter can also
be done to assess degree of OP and risk of #
neck of femur
•• T-Score: It measures in SD, the variance of an
individuals BMD from that expected by a person
of same sex at peak bone mass (25-30 years)
–– Normal: +2.5 to -1.0
–– Osteopenia: -1.0 to -2.5
•• Calcium and Vitamin D supplementation
–– Osteoporosis: At or below -2.5Z-Score: SD
between patients BMD and average bone –– Calcium supplementation: 1200mg/ day
mass of a person of same age and weight –– Vitamin D:
4
Obstetrics and Gynecology

ƒƒ Low risk: 600 IU/ day Treatment of issues in the Post Menopausal Woman

ƒƒ High risk: 800 IU/ day 1. Calcium and Vitamin D Supplementation

a. Vitamin D:
B. CARDIOVASCULAR CHANGES
(i). Low risk: 600 IU/ day
•• 2-6-fold increases in developing atherosclerotic
CV disease (ii). High risk/ > 70 years: 800 IU/ day

•• Hypoestrogenism: ↑ LDL ↓ HDL, remodeling of b. Calcium supplementation (1000-1200 mg/day)

coronary arteries, vasoconstriction 1. Hormone Replacement Therapy
•• Other risk factors may superimpose like HTN, •• HRT should be given for treatment of vasomotor
DM, obesity, dyslipidemia symptoms, vaginal atrophy and prevention and
•• Dietary modification, Estrogen therapy and treatment of OP
statins can reduce this risk •• Lowest effective dose for shortest period of
•• Hormone Replacement Therapy is NOT given to time
reduce the risk of Cardio vascular Disease •• With yearly evaluation, can give for 5 years
C.CNS EFFECTS •• Foe bone protection: Prefer bone specific
agents
•• Dementia
•• Local estrogen creams and pessaries can be
•• Alzheimer’s
safely used for urogenital atrophy
•• Stroke
•• Do not give for prevention of CHD

EVALUATION OF A POST
HRT Routes
MENOPAUSAL WOMAN
1. Oral
BLOOD Work
•• Estrogen + Progesterone (Is she has a uterus)
1. Full Blood Count
•• Estrogen alone (In a hysterectomized woman as
2. Blood sugars there is no risk of endometrial hyperplasia or
3. Lipid Profile carcinoma)
4. FSH levels •• HRT can be given as
5. Serum Calcium, phosphate and vitamin D –– Cyclical regime (in women who are peri-
Imaging menopausal) so they get their period at a
regular interval
•• Pelvic Ultrasound
–– Continuous: in those women who have
•• DEXA Scan attained menopause so that they don’t bleed
**Also sometimes asked in the exam is the maturation in between
index which is basically done on microscopic •• Commonly available estrogen is
examination of vaginal cells on a smear. This isn’t done
ƒƒ Conjugated equine estrogen (Premarin) –
routinely now but is sometimes aske din the exam.
Age Maturation Index (PB/I/S)
At Birth (up to 10 days) 0/95/5
Childhood (10 days to puberty) 8/20/0 (Shift to left)
Menstrual Cycle (Reproductive Period) 0/40/60 (Estrogen Exposure)
Follicular Phase (Estrogen dominance) 0/70/30 (Progesterone Dominance)
Secretory Phase (Prog dominance)
Post partum 100/0/0
Menopausal 0/100/0 and later 100/0/0
 5
Menopause

0.625mg/ day ○○ Bone protection

ƒƒ Estradiol (0.5mg – 1mg/day) •• Advantages
•• Commonly used Progesterones are ○○ Endometrial protective
ƒƒ Medroxy Progesterone Acetate: 2.5-5mg/ ○○ Cardioprotective
day
○○ Breast protective
ƒƒ Dydrogesterone
2. Raloxifene (SERM)
ƒƒ Micronized progesterone
•• Bone Protective: Prophylaxis and treatment of
ƒƒ Drosperinone OP
ƒƒ LNG-IUD (Mirena) •• Breast and Endometrial friendly
2. Transdermal Route •• Cardioprotective
3. Vaginal gel •• Increases risk of Thrombosis
4. Vaginal Estrogen ring •• Dose: 60mg OD
5. Subdermal estradiol implants •• Disadvantages: Worsens hot flushes so not
given in women with hot flushes. Mainly used for
6. Intranasal Estrogen
prevention and treatment of Osteoporosis

Absolute Contra-indications to HRT Treatment of Osteoporosis

•• Undiagnosed AUB •• 1st Line agents: Bisphosphonates: Alendronate,
•• Breast Cancer Risendronate, Zoledronic acid

•• Estrogen dependent neoplasia •• Other Drugs: Denosumab, Raloxifene, Calcitonin

•• DVT •• Patients with very high fracture risk/ failed

bisphosphonates: Teriparatide
•• Arterial thrombosis
•• All patients: Ca + Vitamin D
•• Hepatic disease
•• HRT: Not recommended
•• Pregnancy
•• Known allergy Bisphosphonates
•• Decrease bone resorption
Side Effects of HRT
•• High affinity for calcium and bind to calcium
•• DVT hydroxyapatite in bone
•• Coronary artery disease •• Oral except Zolendronate
•• Stroke •• Poor bioavailability, taken on empty stomach
•• Vaginal bleeding •• Upper GI inflammation, ulceration and bleed
•• Breast cancer •• Rare: Osteonecrosis of jawbone, atypical femur
•• Endometrial cancer fractures

1. Tibolone
•• Synthetic Steroid
•• Weak E, P and Androgenic action
•• 2.5mg OD
•• Indications
○○ Vasomotor
 VAGINAL DISCHARGE

NORMAL VAGINAL DISCHARGE •• Aka Hemophilus vaginitis, anaerobic vaginitis,

nonspecific vaginitis
•• Colourless/white
•• Most common cause of vaginal discharge in
•• Contains secretions from the vulvar glands, reproductive age group
vaginal glands, vaginal transudate and secretions
from the cervix, endometrium and fallopian •• Alteration in the normal vaginal flora
tubes –– Decrease in Doderlein’s bacilli/pH>4.5
•• pH: 3.5-4.5 in reproductive age – acidic due to –– Overgrowth of aerobic and anaerobic
estrogen bacteria
•• Normal flora: Lactobacilli, Streptococci, •• C/F:
Staphylococci
–– Homogenous white discharge
•• On microscopy: desquamated epithelial cells,
WBCs and Lactobacilli –– Minimal itching
•• Diagnosis: Amsel’s Criteria (3 out of 4)
VAGINAL pH 1. Type of discharge: Thin, homogenous, white that
•• Vaginal pH: Depends on the estrogen levels coats the vaginal walls
(estrogen will reduce, alkaline pH– estrogen
2. pH: Alkaline
converts glycogen to lactic acid and makes pH
acidic in the presence of bacteria lactobacillus) 3. Presence of clue cells on smear (bacteria that line
the vag epithelial cell giving it a stippled or rough
–– New born: 5.6 due to maternal estrogen
appearance)
–– Children: 6-8 – alkaline pH
4. Whiff test: On adding KOH to discharge: fishy
–– Puberty: 4 odor
–– Pregnancy: 3.5-4
–– Reproductive age group: 3.5-4.5

–– Menopause: 7

VAGINITIS
•• Infections and Inflammation of the vagina. 3
main infections
–– Bacterial Vaginosis
–– Trichomonas vaginitis
–– Candidiasis

BACTERIAL VAGINOSIS (BV)

2
Obstetrics and Gynecology

–– Smear: Clean background with inflammatory

cells and clue cells, fuzzy-looking cells and
stippled appearance

•• Symptoms:
•• BV in Pregnancy is associated with: –– Greenish yellowish discharge
1. Abortions (1st and 2nd trimester) –– Dysuria
2. Preterm labor –– Dyspareunia
3. PPROM and PROM •• Signs:
•• Treatment: –– Strawberry vagina
–– Recommended Regime: –– Strawberry cervix
–– Metronidazole 2g single dose –– Greenish yellowish discharge
–– OR •• Diagnosis:
–– Metronidazole gel (0.75%) 5g – single –– Wet mount: flagellated organism
application vaginally x 5 days
–– Pap smear
–– OR
–– Diamond media: culture sensitivity
–– Clindamycin cream (2%) 5g – single application
vaginally x 7 days –– NAAT (nucleic acid amplification test) for
Trichomonas DNA
ƒƒ Alternate Regime:
–– Test for other STDs
–– Tinidazole 2g once daily for 2 days OR
secnidazole 2g •• Treatment:

–– Clindamycin vaginal pessary 100mg ODat –– Single dose of 2g oral Metronidazole/

bedtime for 3 days Tinidazole/Secnidazole

–– OR –– OR

–– Clindamycin 300mg orally BD for 7 days –– Metronidazole oral 500mg twice a day x 7
days
TRICHOMONAS VAGINITIS •• Precautions:
•• Etiology: –– Avoid alcohol up to 48 h – Disulfiram-like
–– Flagellated organism reaction

–– Exists as a trophozoite –– Treat the partner

–– Anaerobic protozoa CANDIDA VAGINITIS

–– Coexists with BV/ occurs in alkaline media •• Candida albicans: 85% cases
•• Other species: C. glabrata, C. tropicalis, C.
kansasii
 3
Vaginal discharge

•• Risk Factors: –– Clotrimazole vaginal tablet (100mg x 7

days/200 mg x 3 days/500 mg single dose)
–– Diabetes mellitus
–– OR
–– Pregnancy
–– Miconazole/Nystatin/Tioconazole
–– Broad spectrum antibiotics
•• Recurrent vulvovaginal candidiasis:
–– Combined oral contraceptive pills
–– 4 or more episodes/year
–– Immunosuppression
–– Fluconazole: weekly suppressive regime for 6
–– Malignancies
months
•• Symptoms:
–– OR
–– Thick curdy discharge
–– Itraconazole 200mg OD for 3 days followed
–– Intense pruritus by 200 mg orally monthly for 6 months.
–– Vulvar pain
–– Superficial dyspareunia
–– Dysuria
•• Signs:
–– Vulvar erythema and edema
–– Excoriation on the vulva
–– Discharge
•• Diagnosis:
–– Curdy white discharge
–– Smear on KOH: hyphae
–– pH: < 4.5
–– Culture on Nickerson or Sabouraud’s media

•• Treatment:
–– Single dose Fluconazole 150mg
–– OR
–– Itraconazole 200mg BD x 1day
–– OR
 PELVIC INFLAMMATORY DISEASES (PID)

•• Infection and inflammation of the upper genital 7. Pain and discomfort in the right hypochondrium
tract. (Fitz-Hugh-Curtis syndrome)
•• Includes: •• Signs:
–– Endometritis 1. Temp > 38⁰C
–– Infections of fallopian tube (salpingitis) 2. Vaginal/cervical discharge
–– Infections of ovaries (oophoritis) 3. Uterine, cervical & forniceal tenderness
–– Tubo-ovarian abscesses 4. Bimanual examination reveals a large tubo-
ovarian mass
–– Peritonitis
ORGANISM: It occurs due to ascending infection
from the cervix and vagina
INVESTIGATIONS
•• Clinical diagnosis:
•• STD – Chlamydia, N. Gonorrhoeae
–– Blood: CRP, TLC
•• Can be enteric organisms – E. coli, proteus,
bacteroides –– Imaging: hydrosalpinx – retort shape,
hypoechoic, black
•• Exogenous – iatrogenic (after surgical
procedure)

RISK FACTORS
•• Young age
•• Multiple sexual partners
•• STI
•• History of blood per vaginal
•• History of PID
•• Surgical instrumentation, douching
–– Culture: HVS, cervical
•• Smoking
–– Diagnostic laparoscopy
CLINICAL FEATURES –– Culdocentesis via a needle in pouch of douglas
1. Constitutional symptoms
2. primary symptom
3. Abnormal uterine bleed (polymenorrhea)
4. Dyspareunia
5. Dysuria
6. Abnormal vaginal discharge
2
Obstetrics and Gynecology

Diagnostic laparoscopic view of tubo- superimposed tubal occlusion or tubo-ovarian

ovarian abscesses complex
–– Stage IV: Ruptured tubo-ovarian abscess
Fitz-Hugh Curtis Syndrome –– Stage V: Tubercular salpingitis
•• Violin string appearance seen
GRADING OF PID
•• Clinical system:
–– Grade I: Disease limited to the adnexa.
–– Grade II: PID with an inflammatory mass.
–– Grade III:Ruptured tubo-ovarian abscess.
•• Operative system:
•• Perihepatic adhesions.
–– Mild: Erythema and edema of the adnexa
•• Seen in chronic PID.
–– Moderate: Purulent exudate from fallopian
•• Called fitz-hugh-curtis syndrome tubes
•• Commonly seen during ectopic pregnancy testing –– Severe:Pyosalpinx, inflammatory complex,
•• Clinical Diagnostic criteria of PID (CDC 2015): TOA

–– Minimum Criteria:
TREATMENT OF ACUTE PID –
ƒƒ Adnexal tenderness OUTPATIENT
ƒƒ Cervical motion tenderness •• Ceftriaxone 250mg IM single dose + Doxycycline
ƒƒ Uterine tenderness 100mg BD x 14 days +/- Metronidazole 500 mg
BD for 14 days
–– Additional Criteria:
OR
ƒƒ Oral temperature
•• Cefoxitin 2g IM single dose and probenecid 1g
ƒƒ Cervical discharge/cervical friability orally + Doxycycline 100mg BD x 14 days +/-
ƒƒ WBCs on microscopy of vaginal fluid Metronidazole 500 mg BD for 14 days
ƒƒ Elevated ESR; Elevated CRP
INDICATIONS FOR
ƒƒ Lab documentation of cervical infection HOSPITALIZATION IN PID
with N. gonorrhea or C.trachomatis
H. Hospitalized in:
•• Definitive Criteria:
O. Out-patient management failure
–– Endometrial biopsy with HPE of endometritis
S. Severe illness
–– TVS/MRI – thick, fluid-filled tubes ± free
pelvic fluid or tubo-ovarian complex P. Pregnancy/peritonitis

–– Doppler studies suggesting pelvic infection I. Inability to tolerate OPD management

(e.g., tubal hyperemia) T. Temperature > 38⁰C
–– Laparoscopic findings consistent with PID A. Adolescent/abscess
L. Look for other causes (that is if other surgical
STAGING OF PID causes suspected)
•• Clinical Stages of Acute PID:
–– Stage I: Acute salpingitis w/o peritonitis
–– Stage II: Acute salpingitis with peritonitis
–– Stage III: Acute salpingitis with
 3
Pelvic Inflammatory Diseases (PID)

TREATMENT OF ACUTE PID – IN •• No response to medical treatment in tubo-

ovarian abscess
PATIENT
•• Recommended Regime A: •• Pyo-peritoneum

–– Cefotetan 2 g IV every 12 hours •• Rupture of tubo-ovarian abscess

OR SYNDROMIC MANAGEMENT
Cefoxitin 2g IV every 6 hours + Doxycycline OF SEXUALLY TRANSMITTED
100mg orally/IV every 12 hours INFECTIONS
•• Recommended Regime B: •• KIT 1 (gray):
–– Clindamycin 900mg IV every 8 hours + –– Azithromycin 1g single dose + Cefixime 400
Gentamicin loading dose IV/IM followed by mg single dose
a maintenance dose (1.5mg/kg) every 8 hours
–– For urethral discharge, Ano-rectal discharge,
•• Alternate regime: Cervicitis Syndromes
–– Ampicillin/sulbactam 3 g IV every 6 hours +
Doxycycline 100mg orally or IV every 12h Mnemonic:
Grey discharge 1st treated with cervical antibiotic
INDICATIONS FOR SURGICAL
•• KIT 2 (Green):
MANAGEMENT
–– Secnidazole 1g BID dose + Fluconazole 150
•• Large tubo-ovarian abscess
mg single dose
–– For Vaginal Discharge Syndrome
To (2) Green Fields She Vows

•• KIT 3 (white):
–– Inj. Benzathine penicillin 2.4 MU (1) + Tab Azithromycin 1g single dose + Disposable syringe 10ml with
21-gauge needle (1) + Sterile water 10ml (1)
4
Obstetrics and Gynecology

–– For genital ulcer disease- non-herpetic –– For Genital ulcer disease – herpetic (GUD)
syndrome syndrome

3 White Girls Are Broke 5th Girl Has Red Accents

•• Kit 4 (blue): •• KIT 6 (yellow):

–– Doxycycline 100mg BD for 15 days + –– Cefixime 400 mg single dose + Metronidazole

Azithromycin 1g single dose 400mg BD for 14 days + Doxycycline 100mg
BD for 14 days
–– For genital ulcer disease – non-herpetic
syndrome –– For Lower abdominal pain syndrome

–– For those who are allergic to penicillin 6 Yellow Doors Make Cats Playful

4th Girl Dresses As Blue •• KIT 7 (black):

•• KIT 5 (red): –– Doxycycline 100mg BD for 21 days +

Azithromycin 1g single dose
–– Acyclovir 400 mg orally TID for 7 days
–– For Inguinal Bubo Syndrome
7 Black bags Are Dropped.
 Fibroids (Leiomyoma)

•• Also called uterine leiomyoma, myoma or

fibromyoma
•• Fibroids are the commonest benign tumor of
the uterus (20% of women at age 30 have them)
•• Also the commonest benign solid tumor in women
•• Upto 50% are asymptomatic

Risk Factors
•• Nulliparity
•• Hyper estrogenic states
•• Obesity
•• Black race
Types: 3 basic types of fibroids FIGO Classification of
1. Subserous (on the outer surface of uterus) Fibroids:
2. Intramural: Most common type: Within the •• FIGO has further classified fibroids into
myometrium several types based on their location

3. Submucous (in the endometrial cavity): Least

common type
2
Obstetrics and Gynecology

Cervical Fibroids •• It is formed by liquefaction of the areas with

hyaline changes.
•• Can be anterior, posterior or midline
•• The cystic spaces are lined by irregular ragged
•• Anterior cervical fibroids can present with walls.
urinary retention
3. Fatty degeneration
•• Posterior cervical fibroids can present with
constipation 4. Calcific degeneration

•• A large cervical midline cervical fibroid as a •• Usually involves the subserous fibroids with
typical appearance of a “lantern on St Paul’s small pedicle or myomas of postmenopausal
cathedral” as the small uterus appears as the women.
lantern as shown below •• When the whole of the fibroid is converted into
a calcified mass, it is called “womb stone”
5. Red degeneration (carneous degeneration)
IMPORTANT
•• Occurs in a large fibroid mainly during second
half of pregnancy and puerperium.
•• The cause is not known but is probably due to
thrombosis and infarction
•• The typical presentation is severe abdominal
pain esp in the 2nd trimester of pregnancy
•• Treatment is symptomatic with analgesics and
hydration
•• TLC is raised but the etiology is not infective
•• Surgery is NOT done for red degeneration
•• Can also happen in the puerperium and in women
on combined OCPS
6. Atrophy: Atrophic changes occur following
menopause due to loss of support from estrogen.
7. Necrosis: Circulatory inadequacy may lead to
central necrosis of the tumor. This is present
in submucous polyp or pedunculated subserous
fibroid.
8. Infection: The infection gains access to the tumor
core through the thinned and sloughed surface
epithelium of the submucous fibroid. This usually
happens following delivery or abortion.
9. Vascular changes: Dilatation of the vessels
Degenerations in Fibroids (telangiectasis) or dilatation of the lymphatic
1. Hyaline degeneration: channels (lymphangiectasis) inside the myoma may
•• Most common occur

•• The feel becomes soft elastic in contrast to the 10. Sarcomatous changes: IMPORTANT
firm feel of the tumor. –– Sarcomatous change may occur in less than
2. Cystic degeneration 0.1% of all fibroids

•• Usually occurs following menopause –– The usual type is leiomyosarcoma.

 3
Fibroids (Leiomyoma)

–– Recurrence of fibroid polyp, sudden •• Metrorrhagia

enlargement of fibroid or fibroid along with
–– Seen in submucous fibroids when the surface
postmenopausal bleeding raises the suspicion
sloughs off
2. Dysmenorrhoea
Clinical Features of
–– The congestive variety may be due to
Fibroids
associated pelvic congestion or endometriosis
Symptoms –– Spasmodic type is associated with extrusion
of polyp and its expulsion from the uterine
1. AUB
cavity.
•• Menorrhagia. This is due to
3. Infertility. Seen in
–– Increased surface area of the endometrium
–– Submucosal fibroids
–– Interference with normal uterine
–– Large intramural fibroids distorting the
contractility
endometrial cavity
–– Congestion and dilatation of the subjacent
–– Fibroids obstructing the cornua (ostia of
endometrial venous plexuses
fallopian tubes)
–– Endometrial hyperplasia due to hyper-
4. Lower Abdominal Pain
estrogenism
5. Lower Abdominal Heaviness/ Mass Abdomen
–– Pelvic congestion
6. Pressure symptoms
–– Role of prostanoids—imbalance of
thromboxane (TXA2 ) and prostacyclin (PGI2 7. Pregnancy related
) with relative deficiency of TXA2

Pregnancy and Fibroids

Q1. What do fibroids do to pregnancy? Q2. What does pregnancy do to pregnancy?
Antepartum: Increased risk of •• Large leiomyomas tend to increase in size due to
•• Abortions increase in Estrogen (30%)
•• Preterm labor •• Red degeneration is commonly seen (Explained
•• Placental abruption above)
•• FGR
•• Malpresentations
Intrapartum: Increased risk of
•• Dysfunctional labor
•• Cesarean delivery
•• Retaine placenta
•• PPH
•• Uterine inversion
Postpartum: increased risk of
•• Subinvolution
•• Secondary PPH
•• Lochiometra
•• Puerperal sepsis
4
Obstetrics and Gynecology

Signs
•• Pallor may be present
•• Abdominal examination
–– Felt if it is large and is palpable once it is as
large as a 12 weeks gravid uterus
–– If palpable, the following features are noted
ƒƒ Feel is firm to hard (may be cystic in cystic
degeneration)
ƒƒ Margins are well-defined except the lower 2 Intramural Fibroids on Ultrasound
pole which cannot be reached
ƒƒ Surface is irregular (if multiple fibroids) Other investigations that may be
and regular (is single large fibroid) useful
ƒƒ Mobility is restricted from above •• In submucosal fibroids:
downwards but can be moved from side –– HSG: shows filling defect
to side.
–– Sono-salpingography
ƒƒ Usually non tender unless degeneration/
infection –– Hysteroscopy

ƒƒ Percussion: dull on percussion.

•• Pelvic examination
–– Bimanual examination reveals the uterus
irregularly enlarged by the swelling felt per
abdomen.
–– The cervix moves with the movement of
the tumor felt per abdomen. (Transmitted
mobility) The only exception of these two
findings is a subserous pedunculated fibroid.
*Remember a large single submucous fibroid may
mimic an adenomyotic uterus on examination
HSG showing submucosal fibroid
Investigations
•• Investigation of choice: Ultrasound
–– If pelvic organ: Trans-vaginal scan
–– If abdominal: Trans abdominal scan

HSG showing submucosal fibroid

•• MRI: To map the exact location of fibroids if

planning myomectomy in multiple fibroids or if
suspecting leiomyosarcoma
Submucous Fibroid on Ultrasound
 5
Fibroids (Leiomyoma)

Management of Fibroids a. is very effective to reduce fibroid size and also

menorrhagia.
Asymptomatic b. It reduces the size of the fibroid significantly.
•• Operate if: c. Long-term therapy with mifepristone is avoided
–– Size > 12 weeks as it causes endometrial hyperplasia.

–– Diagnosis uncertain d. Ulipristal acetate is also used for 3 months. IT is

associated with liver toxicity
–– Unexplained infertility with no other
cause esp if submucosal or intramural and 4. Danazol:
distorting the cavity a. Can reduce the volume of a fibroid slightly.
–– RPL with no other cause identified b. Because of androgenic side effects, danazol is
–– Pedunculated (Can undergo torsion) used only for a period of 3–6 months.
c. Not commonly used now
Symptomatic: Treatment could be 5. GnRH agonists:
medical OR surgical depending on
a. Drugs commonly used are goserelin, leprolin,
various factors including
buserelin or nafarelin
•• Age
b. Mechanism of action is sustained pituitary down
•• Symptoms regulation and suppression of ovarian function.
•• Wants fertility c. Optimal duration of therapy is 3 months.
•• Location of fibroid d. Addback therapy may be needed to combat
•• Size of fibroid hypoestrogenic symptoms
e. Reduces size of fibroid by upto 50% at 3 months
Medical Management of Fibroids: 6. GnRH antagonists
Indications
a. Cetrorelix or ganirelix causes immediate
•• To improve menorrhagia and to correct anemia suppression of pituitary and the ovaries.
before surgery
b. They do not have the initial stimulatory effect.
•• To minimize the size and vascularity of the Benefits are same as that of agonists
tumor in order to facilitate surgery
c. Onset of amenorrhea is rapid.
•• As an alternative to surgery in perimenopausal
women or women with high-risk factors for 7. Levonorgestrel-releasing Intrauterine System
surgery. (LNG-IUS):

•• Where postponement of surgery is planned a. Reduces blood loss and uterine size.
temporarily b. However, this is not recommended when the
uterine size is >12 weeks or if the cavity is
Drugs for Medical Management distorted.
1. NSAIDs:
a. Reduce blood loss and reduce dysmenorrhea Surgical Management of
b. Do not reduce size of fibroid
Fibroids
2. Anti-fibrinolytics (Tranexamic acid) Options
c. Reduce blood loss 1. Myomectomy (I.e. removing only the fibroid)
d. Do not reduce size of fibroid a. Laparotomy
3. Antiprogesterones: Mifepristone (RU 486) and b. Laparoscopy
Ulipristal acetate
6
Obstetrics and Gynecology

c. Hysteroscopy (for type 0 and 1 submucosal Instruments that are important to

fibroids) know in a myomectomy
2. Hysterectomy: Removing the entire uterus This
can be done by
a. Laparotomy
b. Laparoscopy (Total laparoscopic hysterectomy
or LAVH)
c. Vaginally Bonney’s Myomectomy Clamp

Important Points in Myomectomy

•• Hysteroscopy or hysterosalpingography—to
exclude any submucous fibroid or a polyp or any
tubal block.
•• Hysteroscopy/endometrial biopsy—in cases of
irregular cycles, not only to remove a polyp but
also to exclude endometrial carcinoma
•• Examination of the husband from fertility point
of view (semen analysis)

Important Points intra-operative in

Bonney’s Myomectomy Screw
myomectomy
When to do a myomectomy in infertility?
•• Try to remove as many fibroids through a single
incision
•• Indications of myomectomy in infertility are:
•• Incisions should preferably be on the anterior
–– Submucous fibroids
uterine wall
–– Large intramural fibroids distorting the
•• Risk of bleeding. This can be reduced
cavity.
–– Preoperatively
–– Intramural fibroids > 5cm
ƒƒ GnRH agonists: They also reduce the size Newer Modalities for treatment of Fibroids
of the fibroid
ƒƒ Correction of anemia/ blood transfusion 1. Uterine Artery Embolization

ƒƒ Uterine Artery Embolization –– It is an is an angiographic interventional

procedure that delivers polyvinyl alcohol
–– Intra-operatively microspheres or other synthetic particulate
ƒƒ Use of Bonney’s uterine clamp/ uterine emboli into both uterine arteries.
tourniquet (tied at the level of the –– Uterine blood flow is thereby obstructed,
uterine arteries) producing ischemia and necrosis.
ƒƒ Use of vasopressin: injected along the –– During UAE, an angiographic catheter is
planned serosal incision placed in one femoral artery and advanced
under fluoroscopic guidance to sequentially
catheterize both uterine arteries (
 7
Fibroids (Leiomyoma)

–– UAE is a management option or women –– During sessions lasting 2 to 3 hours, a patient

(Who are with completed families) with lies prone within the MR imaging unit, and
documented uterine leiomyomas who have the bladder is continuously drained.
significant symptoms despite medical
–– Contraindications are
management and who might otherwise be
considered a candidate or hysterectomy or ƒƒ Pregnancy
myomectomy. ƒƒ Malignancy
–– Based on current evidence and discussed later, ƒƒ Energy-path obstructions such as
women who have not completed childbearing abdominal wall scars, bowel, or foreign
may be better served by myomectomy bodies.
–– Contra-indicated in ƒƒ Future fertility desires
ƒƒ Suspected pregnancy ƒƒ Current pelvic infection
ƒƒ Women who want children ƒƒ Other uterine pathology
ƒƒ Suspected or proven malignancy ƒƒ Menopause
ƒƒ Pedunculated fibroids ƒƒ Myoma size > 10 cm
ƒƒ Submucosal fibroids ƒƒ Uterine size > 24 weeks.
ƒƒ Pedunculated or submucous myomas

2. Magnetic Resonance guided Focused Ultra-

sound MRgFUS

–– It is also called MR-guided high intensity

focused ultrasound (MR-HIFU).
–– Concurrent MR imaging enables precise
targeting and provides real-time tissue
temperature feedback to limit surrounding
thermal injury.
 Adenomyosis

Definition: Adenomyosis is a condition where there is Clinical Features

endometrial implants in the myometrium
Patient profile:
Causes: •• Age > 40
•• The exact cause is not known. •• Usually parous
•• It may be related to •• Symptoms:
–– repeated childbirths –– Menorrhagia (70%)
–– vigorous curettage or –– Dysmenorrhea (30%)
–– excess of estrogen effect •• Signs:
–– Pelvic endometriosis co-exists in about 40 –– Abdominal examination may reveal a mass
percent. arising out of the pelvis and occupying the
•• Pathology: midline.

–– Gross: –– The size usually does not exceed 14 weeks

gravid sized uterus
ƒƒ The uterus is diffusely enlarged in size
–– Pelvic examination—reveals uniform
ƒƒ The size usually does not increase more
enlargement of the uterus.
than a large orange (12–14 weeks pregnant
uterus). –– The findings, however, may be altered due to
associated fibroid or pelvic endometriosis.
ƒƒ The posterior wall is often more thickened
than the anterior one.
Investigations
ƒƒ Sometimes a focal area (Adenomyoma) may
be seen which is not well circumscribed •• Ix of choice: Ultrasound

–– HPE: •• Findings of adenomyosis on USG

ƒƒ Endometrial glandular tissue surrounded

by stromal cells in the myometrium.
2
Obstetrics and Gynecology

•• MRI may help when the diagnosis is in doubt

Treatment:
•• Definitive treatment: HYSTERECTOMY
•• Medical Management can be given to lessen the
symptoms. These include
–– NSAIDs (Mefenamic acid)
–– Antifibrinolytics (Tranexamic Acid)
–– Combined OCPS
Posterior Myometrial Thickening –– Progesterone only pills
–– LNG – IUS (Mirena)

Irregular junctional (Endo-myometrial) zone

 Endometriosis

Definition •• While this theory can explain pelvic

endometriosis, it fails to explain the
•• Endometrial like tissue, i.e., gland & stroma endometriosis at distant sites
outside uterus (ectopic endometrium)
2. Coelomic metaplasia – Transformation of coelomic
epithelium into endometrial tissue
Sites
3. The induction theory – Endogenous biochemical
•• Most common site – ovary (Chocolate cysts factors induce undifferentiated peritoneal cells to
form in the ovary) develop into endometrial tissue
•• Other common sites: fallopian tube, uterosacral
ligaments, Pouch of Douglas) Clinical presentation
•• Most common extra pelvic site – colon
Symptoms:
•• Rarely - pericardium, pleura, lungs & brain
Remember the 5D’s of Endometriosis
Risk factors: 1. Dysmenorrhea: The typical dysmenorrhoea of
•• Infertility endometriosis is described as progressive i.e. it
increases in duration with every cycle
•• Nulliparity
2. Dyspareunia: Deep Dyspareunia due to rectovaginal
•• Early menarche pouch involvement
•• Hyperestrogenism 3. Dull aching abdominal pain
•• Mullerian anomalies (Obstructive) 4. Dyschezia: Painful defecation
•• Exposure to Dioxins 5. Dysfertility (Infertility): Due to altered tubal
•• Genetic motility, poor oocyte quality, adhesions and altered
immune response

Aetiology - 3 theories: **Remember: AUB is not a Primary Symptom of

endometriosis. It is sometimes seen.
1. Retrograde Menstruation (Sampson’s theory):
•• There is retrograde flow of menstrual blood
Signs
through the uterine tubes during menstruation.
•• Abdominal exam: No abnormality detected
•• The endometrial fragments get implanted in
generally on abdominal examination
the peritoneal surface of the pelvic organs
(dependent sites, e.g. ovaries, uterosacral •• Pelvic Exam: Signs which could be seen are:
ligaments). –– Nodularity felt in the pouch of Douglas
•• Subsequently, cyclic growth and shedding of –– Fixed retroverted uterus
the endometrium at the ectopic sites occur
under the influence of the endogenous ovarian –– Forniceal tenderness
hormones
2
Obstetrics and Gynecology

–– Adnexal masses (Chocolate cyst) ƒƒ Non-specific as it is raised in many

conditions, so not useful for diagnosis
–– Blue-black lesions in vagina
ƒƒ Tumor marker of epithelial ovarian
malignancies
ƒƒ Also raised in pregnancy, PID, fibroids
–– Laparoscopy: GOLD STANDARD for
Diagnosis of endometriosis: See and treat
ƒƒ Lesions seen on laparoscopy include
○○ Ovaries: Chocolate cysts
○○ Peritoneum, tubes, utero-sacrals and
Ultrasound image of a chocolate cyst POD: powder burn spots, red flame
shaped areas, red polypoid areas,
yellow brown patches, white peritoneal
Diagnosis areas, circular peritoneal defects or
•• TVS (Transvaginal sonography) – 1st step in sub-ovarian adhesions
suspected endometriosis Staging of Endometriotic Lesions: The most widely
–– Endometrioma (Chocolate cyts): used staging system is the revised AFS Classification
Characteristic stippled appearance as shown below

–– Can sometimes detect deep endometriosis Stage 1: Minimal (Score 1-5)

–– Ultrasonography/ USG (transrectal or renal), Stage 2: Mild (Score 6 – 15)

CT urogram, MRI - In deep endometriosis Stage 3: Moderate (Score 16 – 40)
–– CA-125 Stage 4: Severe (Score > 40)
ƒƒ Mildly raised
 3
Endometriosis

MANAGEMENT SURGICAL MANAGEMENT

Remember: •• Ablation & excision of endometriotic lesions

•• IF pain is the primary symptom: 1st line •• Adhesiolysis

management is MEDICAL •• Ovarian cystectomy- for ≥ 3cm chocolate cyst
•• If infertility is the primary concern: 1 st
line (Remember: Aspiration of cyst is not preferred)
management is SURGICAL •• For pain, some surgical interventions may
MEDICAL MANAGEMENT: The aim is to create benefit. These include interruption of pelvic
a state of amenorrhoea. If the patient doesn’t nerve pathway
bleed, the endometriotic lesions will resolve. This –– Laparoscopic Uterosacral Nerve Ablation
can be done by (LUNA)
•• Hormonal contraceptives (Combined oral –– Presacral Neurectomy (PSN)
contraceptive pills): Continuous use (Not cyclical
i.e. not letting the patient bleed) for 3-6 months •• Hysterectomy with B/l salpingo-oophorectomy-
definitive surgery with removal of the ovaries
•• Progestogens: Oral/ injectable/ LNG-IUS: (to prevent recurrence) and all excision of all
These act by causing endometrial atrophy visible endometriotic lesions; Preferred in
•• GnRH agonist (Gonadotrophin-releasing hormone women with completed families not responding
agonist): Creates a state of pseudo-menopause. to medical management
IF given long term, add back therapy is required. •• For infertility usually surgical management is
Add-back therapy using- combination of followed by fertility treatments like Ovulation
conjugated equine estrogen (0.625 mg) and Induction or IVF
norethindrone acetate (5 mg) daily or Tibolone
2,5mg/ day, to prevent bone loss & menopausal
symptoms along with adequate dietary calcium
and vitamin D intake
 Benign ovarian mass lesions

Benign Ovarian Cysts ƒƒ Seen due to excessive hCG

Types of benign ovarian cysts ƒƒ Seen in multiple pregnancy, OHSS and
molar pregnancy
•• Follicular cysts
ƒƒ Surgical intervention NOT required
•• Lutein cysts
Functional Cysts
•• Multiple functional cysts 2. Benign Neoplastic Masses:
•• Corpus luteal cysts
Neoplastic •• Benign
•• Salpingo-oophoritis (Tubo-
Inflammatory
ovarian mass)
Endometriosis •• Chocolate cyst

1. Functional Ovarian Cysts

a. Follicular Cysts:
–– Form as a result of an unruptured follicle
–– Usually asymptomatic
–– Symptomatic if rupture/ haemorrhage in the
cyst/ torsion
–– Most will disappear spontaneously OR within
4-8 weeks
–– Combined OCPs can be used in persistent
cysts
b. Luteal Cysts
–– Corpus Luteal Cyst
ƒƒ Functional, non- neoplastic enlargements **All the above tumors can be benign or malignant. The
of the ovary malignant ones are discussed under Ovarian Cancer
EPITHELIAL OVARIAN TUMORS
ƒƒ Can cause delay in period
ƒƒ Can cause pain due to haemorrhage in the Serous Cystadenoma:
cyst
•• Most common epithelial ovarian neoplasm
ƒƒ USG: web liked appearance
•• Common in the3rd-5th decade of life
ƒƒ Can be managed conservatively, majority
will disappear •• 50%: bilateral

–– Theca Lutein Cyst •• HPE: cystic spaces; lining is tall columnar

 epithelium resembling the endosalpinx; •• TERATOMA
psammoma bodies may be seen
–– Very commonly asked in the exam
•• Loculi contain straw colored fluid
–– Also called a DERMOID CYST (mature
•• Tumor marker: Ca125 teratoma)

Mucinous Cystadenoma –– Remember:

•• Multiloculated cysts containing mucinous ƒƒ MC ovarian tumor found in pregnancy:

material DERMOID

•• Lining is of epithelium resembling the endocervix ƒƒ MC malignant ovarian tumor in pregnancy:

DYSGERMINOMA
•• Can grow to large sizes
–– Contain all 3 cell lines
•• 5-10% are bilateral
–– Commonly contain sebaceous material, hair,
•• Age group: 30-60 years teeth, cartilage etc
•• If spillage occurs: pseudomyxoma peritonei –– Prone to undergo torsion as it is light and
floats in the peritoneum
Endometrioid Tumor
–– Hilum is called as Rokitansky nodule
•• Lined by epithelium resembling the endometrium
–– USG: Acoustic shadowing
Clear Cell Tumors
•• Usually malignant
•• Hob nail cell appearance on HPE

Brenner Tumor
•• Solid fibroepithelial tumor
•• Can be associated with Pseudo Meigs Syndrome
•• Can present as post-menopausal bleeding
•• Coffee bean nucleus

SEX CORD STROMAL TUMOR

•• YOLK SAC TUMOR
Fibroma
–– Mostly unilateral
•• Meigs Syndrome: Ovarian fibroma + Ascites +
Hydrothorax –– Tumor marker: AFP

Granulosa and Theca Cell Tumors –– HPE: Schiller Duvall body

•• Clinical features are based on the estrogenic •• DYSGERMINOMA

activity but AUB is a common presentation. –– Corresponds to seminoma of the testes
They can also present as precocious puberty
–– Solid tumor
and post-menopausal bleeding.
–– Yellowish grey cut surface
•• HPE: Call Exner bodies
–– Tumor marker: LDH
•• Tumor marker: INHIBIN
3. Inflammatory Cysts (Tubo-ovarian mass):
Sertoli Leydig Tumor
See chapter on PID
•• Virilizing features
4. Endometriosis (Chocolate cyst): See
GERM CELL TUMORS chapter on endometriosis
Approach to a woman with an adnexal mass

How to assess if the cyst is benign or

ƒƒ Ca 125 is measured in IU/ml and can
malignant?
vary between zero to hundreds or even
1. Risk of Malignant Index (RMI) thousands of units.

–– RMI = U X M X CA 125 –– An RMI > 200 is suspicious of ovarian

malignancy
ƒƒ The ultrasound result is scored 1 point for
each of the following characteristics:
multilocular cysts, ascites, and bilateral
lesions. U= 0 (for an ultrasound score of 2. IOTA Scoring
0), U= 1 (for an ultrasound score of 1), •• Ultrasound Findings:
U=3 (for an ultrasound score of 2-5).
–– B means benign features
ƒƒ The menopausal status is scored as 1=
premenopausal and 3= post-menopausal –– M means malignancy
 B rules M rules
Unilocular cysts Irregular solid tumor
Presence of solid components where the largest solid Ascites
component < 7 mm
Presence of acoustic shadowing At least four papillary structures
Smooth multilocular tumor with a largest diameter < Irregular multilocular tumor with largest diameter ≥100 mm
100mm
No blood flow Very strong blood flow
 Benign Diseases of the Vulva

1. Bartholin Cyst and Abscess incision and drainage with Word catheter
placement due to ease and effectiveness of
•• Bartholin glands, also known as the greater
treatment.
vestibular glands
–– Marsupialization is the procedure of choice.
•• They are a pair of 0.5 cm glands located in the
lower right and left portions at the 4 o’clock –– It is performed by creating a 2-cm incision
and 8 o’clock positions of the vaginal introitus. lateral to the hymenal ring, everting the
edges with forceps, and suturing the edges
•• The Bartholin gland is a mucus-secreting gland,
onto the epithelial surface with interrupted
which plays a role in vaginal lubrication.
absorbable sutures
•• Bartholin glands are generally nonpalpable when
–– Women with recurrent cysts or those who
not obstructed.
are post-menopausal (risk of malignancy)
•• Cysts and abscesses are often found after the should have the cyst completely excised
onset of puberty and a decrease in incidence
after menopause
•• Pathophysiology:
–– Bartholin glands can form a cyst and an
abscess in women of reproductive age.
–– The cyst is usually 2-4 cm in diameter and
may cause dyspareunia, urinary irritation,
and vague pelvic pain. The cyst is usually
filled with non-purulent fluid that contains
staphylococcus, streptococcus, and E.coli.
•• C/F:
–– The physical exam will often reveal asymmetry
with a protrusion of one side (left or right)
of the inferior aspect of the vulva.
–– Bartholin gland abscesses, unlike Bartholin
cysts, are very painful. 2. Gartner Duct Cyst
–– While both are primarily unilateral, Bartholin •• Gartner duct cysts (GDCs) are vaginal cysts
abscesses are often tender to palpation, that can develop along parts of the mesonephric
erythematous, indurated, and may have an duct, (Wolffian duct), when the duct has failed
area of fluctuance and/or purulent drainage. to regress.
•• Treatment •• The remnant of the mesonephric duct is known
–– Asymptomatic Bartholin cysts do not require as the Gartner duct.
further treatment. •• GDCs are usually located along the anterior and
–– Bartholin abscesses may be treated with lateral parts of the vaginal wall and, rarely, on
2
Obstetrics and Gynecology

the posterolateral wall. –– It involves clitoris, labia minora, inner aspects

of labia major and the skin around the anus.
•• These vaginal cysts are mostly benign with only
mild symptoms. –– It is usually bilateral and symmetrical in a
figure of eight distribution.
•• GDCs are frequently associated with
malformations of the urinary tract –– It may also affect other parts of the body
(trunk and limbs—18%).
•• Physical examination is essential for diagnosis
and can be enhanced by further imaging. •• Histology: The epithelium is thin with epidermal
atrophy. At times, there is hyperkeratosis,
•• Surgical excision of the vaginal cyst is preferred
parakeratosis, acanthosis, and elongation of rete
among the treatment options and is necessary
ridges with evidence of collagen hyalinization.
only if the individual is severely symptomatic.
Fibroblasts are absent. There is presence of
Vulval dermatoses: (These do not include inflammatory cells including lymphocytes and
premalignant lesions of the vulva which are termed plasma cells.
VIN)
•• Clinical features:
Classification of vulval dermatoses (ISSVD-2006)
–– Pruritus is more than soreness.
–– There is dyspareunia, sleeplessness and
dysuria.
–– Dyspareunia is due to stenosis of the vulval
outlet
–– The skin is thin and looks white.
–– Inflammatory adhesions of the labia minora
and fusion may cause difficulty with
micturition and even retention of urine.
–– There may be narrowing of vaginal introitus.
–– Pruritus is related to active inflammation
with erythema.
–– Scratching results in subepithelial
hemorrhages (ecchymosis)
•• Diagnosis:
–– The diagnosis should be confirmed by biopsy
having characteristic changes.
–– The risk of malignancy is about 1-4 percent.
Lichen Sclerosus
•• Treatment
•• The epithelium is metabolically active.
•• Main stay of treatment is to avoid any irritants,
•• It usually occurs following menopause anti-histaminic
•• Distribution of lesion: •• Ultrapotent topical steroids (clobetasol) is
–– The entire vulva is involved. helpful to break the itch-scratch cycle.

–– Lesion encircles the vestibule.

 3
Benign Diseases of the Vulva
Ulcers of the vuvla
 ABNORMAL UTERINE BLEEDING (AUB)

NORMAL MENSTRUAL CYCLE Dilation and Curettage – present as

hypomenorrhea/secondary amenorrhea/
•• Earlier: secondary infertility – treated by
Normal length of cycle 21-35 days hysteroscopic adhesiolysis
Average length 28 days (seen in 15%) 2. Genital Tuberculosis: initially presents
Duration 2-7 days
with menorrhagia then hypomenorrhea
then amenorrhea
Flow volume 5-80ml (average is 30ml)
3. Thyroid disorders: presents with both
•• New:
menorrhagia and hypermenorrhea.
Frequency ≥24 days to ≤38 days
–– Polymenorrhea:
Duration ≤8 days
Regularity Shortest to longest cycle variations ≤7-9 ƒƒ Frequent cycles occurring at short
days
intervals (<21 days)

Flow volume Normal ƒƒ Causes:

•• Older definitions: 1. Pelvic inflammatory disease
–– Menorrhagia: 2. Short luteal phase (ovulatory causes):
if corpus luteum breaks down early, it
ƒƒ Heavy bleeding either in amount or duration
will cause early cycle/abnormal uterine
in a regular Cycle
bleeding
ƒƒBlood loss > 80ml and/or >7 days
–– Oligo-menorrhoea:
ƒƒ Bleeding is increasing in amount or in
ƒƒ Infrequent cycles occurring at long
duration but in regular cycle
intervals (>35 days)
ƒƒ Causes:
ƒƒ Causes (Anovulation)
1. Structural (fibroid/ polyp/adenomyosis)
1. PCOS
2. Systemic (Coagulopathy/hypothyroidism)
2. Adolescence/Peri-menopausal
3. Iatrogenic (Anticoagulants/Intrauterine
3. Thyroid disorders
Device)
4. Androgen secreting tumor.
–– Hypomenorrhoea:
–– Metrorrhagia:
ƒƒ Less bleeding in a regular cycle
ƒƒ Irregularly timed episodes of bleeding
ƒƒ <5ml and/or <2 days
superimposed on normal cyclical bleeding
ƒƒ Opposite of menorrhagia
ƒƒ Causes:
ƒƒ Causes:
1. Endometritis
1. Asherman Syndrome: occur due to
2. Submucosal fibroid, polyps
intrauterine adhesions and repeated
2
Obstetrics and Gynecology

3. Malignancy(cervical/endometrial) 2. Submucosal fibroid, polyps

–– Menometrorrhagia: 3. Malignancy(cervical/endometrial)
ƒƒ Excessive prolonged bleeding occurring at
irregular intervals. (IMPORTANT)
ƒƒ Causes:
1. Endometritis

Definition Interval Frequency Amount Others

Menorrhagia Regular Normal Excessive >7 days/> 80ml

Hypomenorrhea Regular Normal Reduced <2 days/< 5ml

Polymenorrhea Regular Increase Normal <21 days

Oligomenorrhea Regular Decrease Normal >35 days, anovulatory

Metrorrhagia Irregular Normal Normal Irregular menstrual bleeding

Menometrorrhagia Irregular Normal Excessive Menorrhagia + Metrorrhagia

ABNORMAL UTERINE BLEEDING (NEW FIGO CLASSIFICATION)

CLASSIFICATION OF ABNORMAL UTERINE BLEEDING

•• PALM COEIN classification

–– Palm described the structural causes.
 3
Abnormal Uterine Bleeding (AUB)
–– Coein described the non-structural causes.

CAUSES OF AUB (BY AGE): Think of common things first depending on age! The causes have been put as
the more common ones on top.

Adolescence Reproductive (19-39) Perimenopausal (40+)

Anovulation. Pregnancy Anovulatory Bleeding.
OCP/contraception Structural lesions (fibroid/polyp/adenomyosis) Endometrial Hyperplasia.
Coagulopathy. Anovulatory. Endometrial cancer.
Malignancies (Rare) Endometrial atrophy.
Contraception(hormonal).
Structural causes
Endometrial hyperplasia.
Endometrial cancer.

ENDOMETRIAL HYPERPLASIA •• Risk factors:

•• Endometrial thickening with proliferation of –– Unopposed estrogen stimulation: Single most

irregularly sized and shaped endometrial glands important cause
and an increased endometrial gland:stroma ƒƒ PCOS.
ratio
4
Obstetrics and Gynecology

ƒƒ Early menarche.
ƒƒ Late menopause.
ƒƒ Tamoxifen.
•• Classification:

TYPES HISTOLOGY PROGRESSION HPE

TO CANCER (%)
Simple hyperplasia, Glands are increased in 1%.
also called cystic number and are cystically
glandular hyperplasia dilated.

and Metropathia No glandular

Hemorrhagica. architectural
normality.

Complex hyperplasia. Architectural 3%.

abnormalities of
endometrial glands like
crowning seen.

Simple hyperplasia with Cystically dilated glands 8%.

atypia. with abundant stroma with
nuclear atypia.

Complex hyperplasia Architectural 29%.

with atypia. abnormalities of
endometrial glands with
nuclear atypia.

Clinical features: Diagnosis:

•• History: 1. Trans vaginal scan: Thickened endometrium.
–– Most common symptom: amenorrhea with
heavy bleeding.
–– Always think of endometrial hyperplasia in a
woman who is on tamoxifen with menstrual
complaints
•• Examination:
–– Normal pelvic examination (This is an
important CLUE to solving clinical problems) Thickened endometrium
 5
Abnormal Uterine Bleeding (AUB)
dilation of cervical so not painful; but bling
procedure so tissue can be missed

Thickened endometrium with cystic look: typically

seen in a female on tamoxifen which is known to
cause endometrial hyperplasia

1. Endometrial biopsy: This can be obtained by any

one of the methods described below
•• Dilatation and Curettage •• Hysteroscopic biopsy – gold standard for
endometrial biopsy – can see inside uterine
cavity and biopsy the abnormal areas.

TREATMENT OF ENDOMETRIAL
HYPERPLASIA.

POST MENOPAUSAL BLEEDING.

•• Vaginal bleeding from genital tract after
established menopause
•• Bleeding after 6 months of amenorrhea in the
menopausal age groups.
•• Main worry: Premalignant and malignant
conditions.
•• Causes:
•• Endometrial aspiration: Aspiration syringe,called
pipelle – office procedure – does not require
6
Obstetrics and Gynecology

•• Endometrial causes:

–– Aim is to exclude Malignancy

Causes of bleeding Percentage
–– Cervical biopsy from a suspicious mass on the
Atrophic endometrium (thin): Most 60-80
cervix
common endometrial cause
–– Trans vaginal ultrasound for:
Exogenous estrogens 15-25
ƒƒ Endometrial thickness (ET)
Endometrial cancer 10
ƒƒ Uterine pathologies
Endometrial polyps 2-12
ƒƒ Adnexal masses (ovary)
Endometrial hyperplasia 5-10
–– Endometrial biopsy: IF Endometrial thickness
•• Evaluation: > 5 mm in a patient with postmenopausal
bleeding
 PELVIC ORGAN PROLAPSE

RISK FACTORS
•• Pregnancy and Childbirth
•• Menopause: Hypoestrogenism
•• Chronically increased intra-abdominal pressure
–– COPD
–– Constipation
–– Obesity
•• Pelvic floor trauma
•• Genetic Factors

LEVELS OF VAGINAL SUPPORT

•• De-Lancey: Q
–– Level 1: suspends the upper or proximal vagina
DEFINITION –Uterosacral and cardinal ligaments/failure
•• Descent of the anterior vaginal wall, posterior of level one – cystocele and rectocele
vaginal wall, uterus (cervix), the vaginal apex
–– Level 2: mid-vaginal support –pubocervical
(after hysterectomy), rectum or the perineum
and puborectalis fascia – Apical defect
alone or in combination is termed as Pelvic organ
prolapse (POP). –– Level 3: fusion of the distal vagina to adjacent
structures- perineal body - urethrocele.
2
Obstetrics and Gynecology

Grade 1 Grade 2 Grade 3/4

•• Grade 3 and 4 look the same but can be down but it is short of TVL -2
differentiated by doing a thumb finger test.
–– Stage 4: when the prolapse is beyond TVL -2
•• If the thumb and finger approximate over the
prolapse, it is a procidentia (grade 4)
POP-Q CLASSIFICATION
POP-Q Classification (Pelvic Organ Prolapse
Quantification)
•• Advantage: POP-Q is more standardized and
objective; good for research purpose and for
conveying information
•• Disadvantages of POP-Q: it takes time and is
cumbersome.
•• It came into use in 2002.

•• The POP-Q classification is done in a 3 x 3 grid

format.
•• The reference point is taken as the hymen
•• There are 6 points and 3 measurements.
•• 6 points are on the top and bottom and the 3
measurements are in the middle of the grid.

Measurements:
•• Staging is done based on the maximal descent 1. Genital hiatus (GH): the length of the genital from
point. the midpoint of the urethra till the posterior
–– Stage 0: no prolapse vestibule of the vagina.

–– Stage 1: the maximum point of descent is 2. Perineal body (PB): the distance between the
within the vagina and 1 cm above the hymen posterior vaginal fourchette to the centre of the
anal orifice.
–– Stage 2: the maximal decent has come down
near the hymen to +1cm/-1cm near the hymen 3. Total Vaginal Length (TVL): it is usually measured
with the marked spatula inserted to its maximum
–– Stage 3: prolapse has come even further into the vagina.
 3
Pelvic Organ Prolapse
The GH and PB measurements are done in the to the hymen. When there is no prolapse, we take
bearing down position while the TVL is done in non- point Aa to be the same as point Ba.
bearing down position.
3. Cervix or cuff (C): on maximum straining, we see
Points: where the cervix is with respect to the hymen
1. Aa: marking is taken from 3 cm above the anterior 4. Posterior wall (Ap): mark a point 3 cm from the
vaginal wall above the hymen; on asking the patient hymen on the posterior vaginal wall without bearing
to bear down, note the position of this point down, then ask to bear down and see where the
with reference to the hymen. Point Aa marks the point is coming.
urethra-vesical junction
5. Posterior wall (Bp): it is the point on maximum
Remember: Anything above the hymen is given a straining where the maximum posterior vaginal wall
negative sign and anything below the hymen is given is coming.
a positive sign and at the hymen is given zero. This
6. Posterior wall (D): posterior fornix – this tells
3cm marks the urethra vesical junction.
whether there is enterocele. It is omitted in a
2. Ba: on maximum bearing down, it is the maximum patient who has undergone hysterectomy as in such
point seen on the anterior walls with reference a patient point C will coincide with point D
•• Stages:

SYMPTOMS ASSOCIATED WITH Prolapse

•• Bulge Symptoms:
–– Mass per vagina
•• Bowel symptoms:
–– Constipation
–– Incomplete defecation
4
Obstetrics and Gynecology

•• Urinary symptoms:
–– Stasis
–– Incomplete, frequent urination
–– UTI
•• Pain:
–– Back ache (stretching of Uterosacral
ligaments)

TREATMENT :
Non-Surgical:
•• Pessary
•• Pelvic Floor Muscle Exercises

Surgical:
•• Obliterative procedures •• The curved part should be facing the ceiling,
•• Reconstructive Procedures like a taco.
•• Put a small amount of water-soluble lubricant,
PESSARY such as KY Jelly, on the insertion edge.
•• Hold the folded pessary in one hand and spread
the lips of vagina with the other hand.
•• Gently push the pessary as far back into the
vagina as it will go.
•• The anterior part rests below the pubic
symphysis, the posterior part in the post fornix
•• The patient can be taught to remove and re-
insert it; she should remove it, wash it and re-
insert it weekly. If she int able to do this, it
should be changed at least once in 3 months.

PELVIC FLOOR EXERCISE

Ring pessary – Gellhorn -space oc-

support pessary cupying pessary

Indications for Pessary:

•• Not fit for surgery
•• Early onset or early prolapse; it prevents
•• Treat decubitus ulcer
further worsening

Fitting a Pessary: •• Kegel’s exercise

OBLITERATIVE PROCEDURES
 5
Pelvic Organ Prolapse
(COLPOCLEISIS) vagina may cause bladder to droop onto
vagina’s front wall.
•• This is a specific type of POP called an anterior
wall prolapse.
•• Anterior colporrhaphy tightens the muscles in
the front wall that hold the bladder in place.

•• Lefort Colpocleisis:
UTEROSACRAL SUSPENSION
–– Preferred in old age
–– With multiple comorbidities
–– Ensure
ƒƒ Pap smear taken – normal
ƒƒ Endometrial biopsy taken

RECONSTRUCTIVE PROCEDURES
•• Combination of procedures
•• Anterior compartment:
–– Anterior colporrhaphy/cystocele repair
–– Vaginal apex: •• A uterosacral ligament suspension is a surgical
procedure to restore the support of the top
–– Usually involves a vaginal hysterectomy
of the vagina after hysterectomy.
–– Uterosacral ligament fixation
•• Ways to prevent prolapse following a
–– Sacrospinous ligament fixation of the vault hysterectomy are
–– In women who have had a hysterectomy –– Enterocele repair by McCall’s Culdoplasty
(Vault prolapse): Abdominal or Laparoscopic
–– Sacrospinous fixation of the vault
Sacrocolpopexy is done
–– Uterosacral suspension to the vault
•• Posterior compartment:
–– Colpoperineorrhaphy
SACRO-COLPOPEXY
ANTERIOR COLPORRHAPHY

•• Cystocele repair
•• Weakened muscles in between bladder and
6
Obstetrics and Gynecology

•• A surgical procedure that treats VAULT 3. Khanna’s Sling: ASIS to cervix

prolapse (I.e. in a hysterectomized woman)
•• Fothergill or Manchester Repair: Infra-vaginal
cervical elongation
POSTERIOR COLPORRHAPHY –– Amputation of the cervix
–– Plication of the Mackenrodt ligament in front
of the cervix
–– Anterior colporrhaphy and posterior
colpoperineorrhaphy
•• Shirodkar’s Modification:
–– No cervical amputation

COMPLICATIONS OF PROLAPSE

•• Rectocele repair
•• This procedure can help ease chronic discomfort
and difficulty having bowel movements.
•• Advantages of vaginal reconstructive
procedures include: Small vaginal incision, no
abdominal incision.

WARD MAYO REPAIR •• Decubitus ulcer:

•• Ward Mayo’s Hysterectomy is Vaginal –– It is not because of some infection but

Hysterectomy + Anterior Colporrhaphy + because of prolonged stasis and oedema of
Posterior Colpo-perineorrhaphy that area.
–– Postpone surgery till the ulcer heals as this
SURGERIES INVOLVING area is very vascular and will bleed
PRESERVATION OF UTERUS –– It is treated by keeping the prolapse reduced
by a tampon/ ring pessary and applying
•• Sling Surgeries:
glycerine acriflavine solution
1. Shirodkar’s Abdominal Sling: Using fascia lata:
Cervix to Sacrum
2. Purandare Sling: Rectus sheath/Mersilene tape
 Uro-Gynecology

URINARY INCONTINENCE Mechanism of Continence

•• Urinary incontinence is defined as involuntary
leakage of urine.
•• Types:
1. Stress urinary incontinence (SUI): Involuntary
leakage of urine with increases in intraabdominal
pressure.
2. Urgency (or urge) urinary incontinence is the
involuntary leakage accompanied or immediately
preceded by a perceived strong imminent need to
void.
3. Overactive bladder: describes urinary urgency Mechanisms of Continence
with or without incontinence and usually with
•• In an ideally supported urogenital tract,
increased daytime urinary frequency and nocturia.
increases in intraabdominal pressure are
4. Mixed Incontinence: When both stress and equally transmitted to the bladder, bladder
urgency symptoms are present, it is called mixed base, and urethra. In women who are continent,
urinary incontinence. increases in downward-directed pressure from
1. Overflow incontinence: When cough, laugh, sneeze, and Valsalva maneuver are
there is loss of sensation of a full countered by supportive tissue tone provided by
the levator ani muscles and vaginal connective
bladder (in neurogenic bladder)
•• With loss of support, the ability of the urethra
• According to International Continence and bladder neck to close against a firm
Society guidelines, urinary inconti- supportive “backboard” is diminished. This
nence is a symptom, a sign, and a con- results in reduced urethral closing pressures, an
dition inability to resist increases in bladder pressure,
and in turn, incontinence.
•• Urethral Integrity: This includes urethral
mucosal coaptation, the underlying urethral
vascular plexus, the combined viscous and
elastic properties of the urethral epithelium,
and contraction of appropriate surrounding
musculature. Taken together, these components
contribute to urethral integrity. Problems in
the urethra are called as Intrinsic Sphincteric
Defect.
 Risk factors for urinary incontinence this means the incontinence is due to urethral
descent and can be corrected by surgical
procedures.

•• Examination findings in SUI (Local

Examination): Done with a full bladder
–– Some degree of pelvic relaxation with Bonney’s Test
cystocele or cysto-urethrocele is usually
evident. Investigations to determine the cause and type of
Incontinence
–– Stress test—When the patient is asked to
cough, a few drops of urine are seen escaping 1. Urine Culture and sensitivity: UTI can present
from the external urethral meatus. If the with symptoms of urge incontinence
escape is not detected in supine position, the 2. Postvoid Residual Volume:
examination is to be conducted in a standing
position. •• It is volume is routinely measured during
incontinence evaluation. After a woman voids,
–– Q-tip test—The Q-tip test has been tried the postvoid residual (PVR) volume may be
to predict SUI. A sterile (lubricated with measured. A large PVR volume reflects
2% xylocaine jelly) cotton tipped swab is
introduced to the level of bladder neck –– Recurrent infection
through the urethra. Then the patient is –– Urethral obstruction from a pelvic mass
asked to sit and cough (valsalva). If there
is marked upward elevation (>30°) of the –– Neurologic deficits. In contrast
cotton tipped swab, urethra is considered –– Abnormally small PVR volume is often found
hypermobile. in those with SUI.
3. Urodynamic Studies
•• Testing can be performed with a woman
standing or seated upright in a specialized
testing chair.
•• During evaluation, two catheters are used. One
is placed into the bladder and the other into
either the vagina or rectum (for intra-abdominal
pressure recording)
•• Distinct pressure readings are obtained or
calculated. These include:
•• Bonney’s Test: This test tells us if the
incontinence is due to descent of the urethra or –– intraabdominal pressure
intrinsic sphincteric deficiency. By supporting –– vesicular pressure
and lifting the urethra upward and asking the
patient to cough, if SUI is NOT demonstrated, –– calculated detrusor pressure
 3
Uro-Gynecology
–– bladder volume •• Able to interrupt flow on command
–– saline-infusion flow rate. •• Maximum detrusor pressure during void: < 50
cm H2O
•• Peak urine flow rate: > 15 ml/ sec

Treatment
•• Remember the mainstay of urge incontinence is
medical and of stress incontinence is surgical
•• Initial conservative management is tried
for both: This includes dietary, scheduled
voiding training and estrogen replacement in
postmenopausal women
•• For stress urinary incontinence, the surgical
options are as shown in the table
•• Remember
–– Gold standard surgical treatment is: Burch
Normal Findings on Cystometry (Filling phase of Colposuspension
urodynamic testing)
–– Other common treatment options are mid
•• Residual volume: 0-50 ml urethral slings:
•• 1st sensation of urination: 150-200 ml ƒƒ Trans Obturator Tape (TVT-O)
•• Capacity: 400-600 ml ƒƒ Trans vaginal Tape (TVT)
•• Intra vesical pressure on filling and standing:
0-15 cm H2O
•• No leakage on cough

Summary of incontinence procedures

4
Obstetrics and Gynecology

•• Management of Detrusor Overactivity and Urge Obstetrical (MC cause in developing and under
incontinence mainly involves bladder retraining developed areas); due to ischemia or trauma
and medical management. These include:
•• Obstructed or prolonged labor due to ischemia
–– Oxybutinin (Anticholinergic, antimuscarinic) on the bladder due to prolonged compression
effect on the bladder base between the fetal
–– Tolteridine (Antimuscarinic)
head and symphysis pubis. This results in
–– Solifenacin (Antimuscarinic) ischemic necrosis, infection and a sloughing
–– Darifenacin (Antimuscarinic) fistula (VVF). It takes few days (3–5) following
delivery to produce such type of fistula. Hence
–– Mirabegron (beta 3 agonist) prolonged catheterization is advised following
–– Botox injection (Botulinum Toxin A Injection an obstructed labor.
or botulinum toxin A (onabotulinumtoxin •• Traumatic:
A) into the bladder wall is approved or the
treatment of idiopathic detrusor overactivity –– Instrumental vaginal
–– Abdominal operations such as hysterectomy
Genito-Urinary Fistulas for rupture uterus or Cesarean section
specially a repeat cesarean
Classification of Fistulas Gynecological: More common in developed countries.

Following are the type of fistula 1. Operative injury likely to produce fistula includes
operations like
•• Anterior colporrhaphy
•• Abdominal hysterectomy for benign or malignant
lesions
•• Laparoscopic hysterectomy
•• Vaginal procedures like removal of Gartner’s
cyst
1. Traumatic—The anterior vaginal wall and the
bladder may be injured following fall on a pointed
object, by a stick used for criminal abortion,
following fracture of pelvic bones or due to
retained and forgotten pessary.
2. Malignancy—Advanced carcinoma of the cervix,
vagina or bladder may produce fistula by direct
spread
3. Radiation—There may be ischemic necrosis by
endarteritis obliterans due to radiation effect,
when the carcinoma cervix is treated by radiation.
Types of genitourinary fistula- 1. vesicovaginal, 4. Infective—Chronic granulomatous lesions such as
2. vesicourethrovaginal, 3. urethrovaginal, 4. vaginal tuberculosis, lymphogranuloma venereum,
Vesicocervical, 5. Ureterovaginal, 6. Vesicouterine schistosomiasis or actinomycosis may produce
•• The most common type of genito-urinary fistula fistula.
is a Vesico-vaginal fistula (VVF)
Types of Fistulas:
Causes of Fistula: •• Simple (Healthy tissues with good access)
•• • Obstetrical •• Complicated (tissue loss, scarring, difficult
•• • Gynecological access, associated with RVF)
 5
Uro-Gynecology
Clinical Features Three swab test

Symptoms
•• Continuous escape of urine per vaginum (true
incontinence) is the classic symptom.
•• The patient has got no urge to pass urine.
•• However, if the fistula is small, the escape of
urine occurs in certain positions and the patient
can also pass urine normally.
•• Such history has got a positive correlation with
the related events mentioned in etiology.
•• Leakage of urine following surgical injury may be
present from 1st day, but ureterovaginal fistulas Other Confirmatory
typically present after about 1 week. Investigations
•• In obstetric fistulae symptoms may take 7–14 •• Intravenous urography
days to appear •• Retrograde pyelography
•• CT urography (preferred Ix)
Signs
•• Cystourethroscopy
•• On speculum exam, pooling of urine is seen ion
the speculum
Immediate management (VVF)
•• A large fistula me be visible
•• Once the diagnosis is made, continuous
Confirmation of Diagnosis: To confirm the diagnosis, catheterization for 6–8 weeks is maintained.
following are helpful
•• This may help spontaneous closure of a small
1. Dye test—A speculum is introduced and the fistula
anterior vaginal wall is swabbed dry. When the
methylene blue solution is introduced into the •• Unobstructed outflow tract helps
bladder by a catheter, the dye will be seen coming epithelialization, provided the tissue damage is
2. Three-swab test—The three-swab test not only minimum.
confirms the VVF but also differentiates it from •• The management of genitourinary fistula needs
ureterovaginal and urethrovaginal fistula. a team approach both by the gynecologists,
nursing staff and the urologists
Operative: local repair of the fistula is the surgery
of choice

Three swab test using methylene blue

6
Obstetrics and Gynecology

to know are:
•• Most commons in ureteric injury are:
–– Most common site: Cardinal ligament and
uterine vessels
–– Most common procedure: Simple TAH (but if
asked which gyn surgery has highest risk of
ureteric injury: then the answer is Radical
hysterectomy)
–– Most common type: Obstruction
–– Most common activity: Attempts to attain
hemostasis
–– Most common time: 50-50

Principal steps of repair of old VVF by flap method

(see the image above)
1. line of incision
2. sepration of the vaginal wall from the bladder. to
excise the fibrous tissue around the margin of fistula.
3. closure of the bladder opening by interrupted
sutures taking bites through the muscle wall excluding
the bladder mucosa. Common sites of ureteric injury during hysterectomy
4. reinforcing interrupted sutures taking superficial
•• Management of ureteral injury
muscle and bladder fascia.
–– Recognized intra – operative
5. look of the suture line after final repair
ƒƒ Ureteral ligation: Delegation, stenting
Also remember: ƒƒ Partial transection: Repair over a stent
Advice on discharge following repair of a VVF: ƒƒ Complete transected:
•• To pass urine more frequently ƒƒ Ureteric re-implantation
•• To avoid intercourse for at least 3 months ƒƒ Ureteroureterostomy
•• To defer pregnancy for at least 1 year. –– Recognized later (post operative)
•• If conception occurs, to report to the hospital ƒƒ Ureteric stenting
and must have mandatory antenatal check up ƒƒ IF not possible: per cutaneous nephrostomy
and hospital delivery. A successful repair should
have an abdominal delivery. (Cesarean section) ƒƒ Plan repair depending on site and type of
fistula
Fistula following Gyn surgeries (Hysterectomy) are
usually uretero-vaginal fistulas. Important things
 PRECANCEROUS LESIONS OF CERVIX

•• Highly preventable cancer.

•• After Breast cancer, Cervical cancer is the
second Most Common in Indian women.

•• The endocervix is lined by Columnar Epithelium;

Ectocervix is lined by squamous epithelium Outer ring is original SCJ; Inner ring is new SCJ;
Yellow marked area is original SCG; Blue line is new
•• The junction of both is called squamo-columnar
SCG; Between these is the transformation zone
junction (SCJ).
•• During childhood, SCJ is inside the cervix. With
changes of increased estrogen during puberty,
this junction comes out and this reddened
columnar epithelium visible outside on the
ectocervix is called a cervical erosion.
•• The columnar epithelium, now exposed,
undergoes squamous metaplasia, and a new
squamo-columnar junction is formed
•• This area between the old and new SCJ is called
the Transformation Zone (TZ) and is prone to
converting into malignancy especially with HPV
virus.
•• 90% of cervical malignancies occur at the TZ
•• The TZ is the area screened in cervical cancer
screening programmes
 GUIDELINE FOR SCREENING FOR CANCER
CERVIX

•• For pap smear, Cusco’s self-retaining speculum,

ayre’s spatula and a cytobrush are used.
•• Put the slide in the fixator or spray the slide
with cytofix spray (containing 95% ethanol and
ether).
•• When not to take Pap Smear:
–– If any sexual history in last 48 hours
–– Use of vaginal pessary in the last 48h
–– Vaginal douching in the last 48h
–– Any bleeding present
•• Now primary screening of HPV is preferred
•• Pap smear can also be taken by using Liquid
over pap smear.
based cytology.
•• Should start screening at the age of 25 years.
•• Broom brush will put in media
•• At 25 to 65 years, HPV screening should be
•• The same sample can be used for cytology and
done every 5 year.
HPV

OTHER WAYS OF CERVICAL CANCER

SCREENING
HOW DO WE TEST?
•• In villages/primary health centers, visual inspection
with acetic acid can be done.
•• If Abnormal area is seen (white) called acetowhite
appearance, then punch biopsies are taken from
abnormal areas and the sample is sent.
2
Obstetrics and Gynecology

MANAGEMENT OF ABNORMAL HPV

•• If HPV is Negative: Return to routine 5 yearly
Screening
•• If HPV is positive, Do Cytology (pap smear) –
IMPORTANT.
–– Cytology ≥ ASCUS means abnormal
–– So do colposcopy and biopsy – do HPV
Genotype: for High Risk (16 > 18)
VILI positivity in a case of HSIL

VISUAL INSPECTION WITH LUGOL’S MANAGEMENT OF ABNORMAL

IODINE: CO-TEST
•• Cells which are malignant will not take the stain •• HPV negative; Cytology normal: return to routine
because they are glycogen depleted so appear testing
as mustard yellow.
•• HPV negative; cytology positive:
•• Stained normal areas will look like brown
(mahogany). –– ASC-H/HSIL: colposcopy and biopsy
–– LSIL/ASCUS: Repeat cytology at 1 year
•• HPV positive; cytology negative: Repeat
contesting at 1y/, Do genotype
•• HPV positive; cytology positive: Colposcopy and
biopsy

MANAGEMENT OF ABNORMAL
CYTOLOGY
VILI positivity in a case of HSIL ASCUS:
•• HPV positive: Colposcopy and biopsy
COMBINED TESTS
•• HPV negative: Return to normal testing
•• Co testing (HPV + pap smear)
•• Reflex testing: take HPV and pap smear, and LSIL:
both are sent to lab (HPV is preferred)
•• HPV positive: Colposcopy and Biopsy

CERVICAL CYTOLOGY: BETHESDA •• HPV negative: Repeat cytology at 1 year

SYSTEM (CYTOLOGICAL TEST) HSIL/ASC-H: Colposcopy and Biopsy

EPITHELIAL CELL ABNORMALITIES

COLPOSCOPY: Visualizing the cervix under

magnification
 3
Guideline for screening for cancer cervix

HOW VESSELS ARE SEEN IN MANAGEMENT OF ABNORMAL

MAGNIFICATION BIOPSY (IMPORTANT)
•• CIN 1: Co-test after 1 year OR do an ablative
procedure (by cryo/thermal ablation) .
•• CIN 2/3:
–– Excisional procedures preferred: LEEP/
LLETZ P
ƒƒ LLETZ large loop excision of the
transformation zone
ƒƒ LEEP: Loop Electro-surgical Excisional
Procedure
ƒƒ Both basically mean the same thing

Ablative Procedure
•• Cryoprobe:

REID’S COLPOSCOPIC INDEX/SCORE

(RCI)
Score Colposcopic findings
0.2 Likely to be CIN I
3-5 Likely to be CIN I-II
6-8 Likely to be CIN II-III
If any abnormal area is visualized, a colposcopy guided

NIELM Epithelial cell abnormalities Glandular cell abnormalities

•• Negative for intraepithelial •• ASCUS (abnormal squamous cells of •• AGCUS (Abnormal glandular cells
lesions or malignancy undetermined significance) of undetermined significance)
•• Normal •• LSIL (low grade squamous intra- •• Adenocarcinoma in situ
epithelial lesion)
•• HSIL (high grade squamous intra-
epithelial lesion)
•• Carcinoma in situ
•• Squamous cell carcinoma

biopsy is done. This can be reported as normal, CIN 1 –– Cryoprobe is attached to a cylinder containing
or CIN 2 or CIN 3 N2O at 89⁰C
–– Apply the pressure for 3 minutes and then,
release and then again release for 3 minutes
(Freeze-thaw-freeze-thaw cycle)
•• Other ablative procedures
–– Thermal ablation
–– Laser ablation
–– Ablation procedures are done at CIN 1
4
Obstetrics and Gynecology

EXCISIONAL PROCEDURE CONE BIOPSY

•• Done by scalpel
•• No electricity is used
•• Preferred in
–– Recurrent high grade lesion, if suspected
endocervical involvement
–– Cytology – histologically disorders
–– Suspecting micro-invasive cancers
–– Doubtful cytological and histopathological
LEEP / LLETZ reports

INDICATIONS FOR HYSTERECTOMY

IN CIN
•• AIS (Adenocarcinoma in situ)
•• CIN 3 with margins involved
•• Recurrent high-grade lesion
•• Follow up – if the patient is not regular, do
hysterectomy.

Conization
•• For CIN 2, 3
–– LEEP/LLETZ (procedures of choice)
–– Excise the transformation zone by cautery.
 5
Guideline for screening for cancer cervix

HPV VACCINE
•• Prevention of primarily CIN & Ca cervix
•• Also, against: CA Vulva, Vagina, Anal canal, Penis
and Oropharynx & Genital warts
•• Contains recombinant VLP (L1 synthetic capsid
protein)
•• Types:
–– Cervarix: Bivalent (16,18)
–– Gardasil: Quadrivalent (6,11,16,18) Catch up of missed and older cohorts of girls. These
–– Gardasil 9: Nonavalent (6, 11, 16, 18, 31, 33, recommendations will enable more girls and women
45, 52, 58) to be vaccinated and thus prevent them from having
cervical cancer and all its consequences over the
–– Dosing: course of their lifetime.
ƒƒ As per IAP: WHO’s Safe Advisory Group (SAGE) in 2021 advised
○○ Girls 9 to 14 years: 2 doses regarding updating dose schedules for HPV as follows:
○○ > 15 years: 3 doses •• One or two-dose schedule for the primary
target of girls aged 9-14
–– New:
•• One or two-dose schedule for young women
ƒƒ On june 1, 2023 there will be the launch of aged 15-20
Indian indigenous vaccine called Cervavac
, quadrivalent vaccine produce by Serum •• Two doses with a 6-month interval for women
Institute of India (6, 11, 16, 18) older than 21.
Immunocompromised individuals, including those with
DGCI has granted market authorization to Serum
HIV, should receive three doses if feasible, and if not
Institute of India (SII) to manufacture CERVAVAC, at least two doses. There is limited evidence regarding
an indigenously-developed vaccine against cervical the efficacy of a single dose in this group.
cancer.
 ENDOMETRIAL CANCER

•• Most common gynecological cancer in the •• Risk of endometrial cancer in Lynch syndrome
Developed world = 60%

TYPES •• Risk of ovarian cancer in Lynch syndrome = 40%

•• Type 1: Endometrioid type – Estrogen excess – •• Cowden syndrome: Hamartoma +increased

has better prognosis – low grade tumor incidence of breast, endometrial, and thyroid
cancer
•• Type 2: poorly differentiated – worst prognosis
TYPE 2 ENDOMETRIAL CANCER
TYPE 1 ENDOMETRIAL CANCER
•• Rare
(ENDOMETRIOID)
•• Estrogen Independent
Causes
•• Clear Cell/Papillary Serous
1. Hyperestrogenism: seen in
•• High Grade
i. Endometrial hyperplasia
•• Poorly Differentiated
ii. PCOS
•• Poor Prognosis
iii. Obesity
iv. Early age at menarche PRESENTATION
v. Late menopause, •• Age group: 50-60 years

vi. Nulliparity •• Post-menopausal bleeding due to endometrial

atrophy (most commonly)
2. Genetic syndrome:
•• Pre-menopausal: patient present with heavy
a. Lynch syndrome menstrual bleeding
b. Cowden syndrome •• Abnormal uterine bleeding pattern, uterus is
3. Tamoxifen: causes endometrial hyperplasia – normal or slightly increased in size
Increases risk of endometrial cancer
DIAGNOSIS
4. Diabetes & hypertension + endometrial cancer –
Corpus cancer syndrome
2
Obstetrics and Gynecology

•• Transvaginal scan (TVS) is done in women with TREATMENT

Post-menopausal bleeding
•• Mainly Surgical: TAH+BSO
•• Normal Endometrial thickness in postmenopausal
women is ≤ 4mm •• Higher stages require Post Op Radiotherapy
•• Endometrial biopsy is indicated in women with •• Hormonal Therapy:
post menstrual bleeding with endometrial
thickness > 5mm –– Young Women with Early Stage (1A grade 1)
and wanting Fertility
ENDOMETRIAL BIOPSY –– Adjuvant Therapy Post Surgery
1. Office biopsy: –– Not Fit for Surgery
•• Thin cannula is used called vabra aspirator or –– Recurrent Disease
pipelle or endometrial sampler
–– High dose of estrogen is given
•• OPD procedure
•• Advantage: Simple office procedure not
requiring cervical dilatation
UTERINE SARCOMA
•• Disadvantage: blind procedure, insufficient
tissue

2. Dilatation and curettage

3. Hysteroscopy and Biopsy: •• Leiomyosarcoma: sarcomatous change in fibroid
uterus
•• Gold standard to take biopsy: hysteroscopy
•• Rare event < 0.1%
STAGING OF ENDOMETRIAL CANCER •• Preoperative Sarcoma Scoring System (PRESS):
(IMPORTANT) To determine risk of malignancy in a fibroid
Score > 7: suggestive of malignancy
1 Tumor Confined to The Corpus Uteri
1A < 50% Myometrial Invasion Predictors 0 Point 1 Point 2 Points
1B ≥ 50% Myometrial Invasion Age < 49 ≥ 49
2 Tumor Invades The Cervical Stroma But Does Serum LDH value < 279 ≥ 279
Not Extend Beyond The Uterus Cytologic Findings Negative Positive
3 Local and/or Regional Spread MRI Findings Negative Positive
3A Serosa and/or Adnexa
3B Vagina and/or Parametrium
3C Pelvic and/or Para-Aortic LN
3C1 Positive Pelvic Nodes
3C2 Positive Para-Aortic Nodes
4 Tumor Invades Bladder/ Bowel Mucosa and/or
Distant Mets
4A Bladder and/or Bowel Mucosa
4B Distant Including Inguinal LN
 OVARIAN CANCER

CLASSIFICATION

Surface Epithelial Tumors Germ Cell Tumors Sex Cord Stromal Tumors
Serous Dysgerminoma Fibroma
Mucinous Endodermal sinus tumor / Yolk Sac Tumor Sertoli Leydig
Brenner Teratoma Granulosa Theca Cell Tumor
Endometrioid Choriocarcinoma
Clear cell
•• Surface Epithelial Tumors can be malignant •• White race
or benign; Serous and mucinous are the more
•• Diet
common varieties
•• Talcum powder
•• Mature teratomas are benign (dermoid)
•• Race
•• Immature teratomas are malignant
•• HRT
•• Choriocarcinoma are non-gestational choriocarcinoma
of ovary
PROTECTIVE FACTORS
RISK FACTOR •• Combined OCP

1. Age: Epithelial ovarian tumors are more common –– Estrogen + Progesterone give protection
in postmenopausal women against 3 cancers – colorectal, endometrial,
and ovarian but increases the risk of breast
2. Genetic:
cancer and possibly cervical cancer
•• BRCA 1 – 40-45% women can develop malignancy
•• Multiparity
•• BRCA 2 – 10-20% chance of ovarian carcinoma
•• Tubal ligation
•• HNPCC (Hereditary Non-Polyposis Colorectal
•• Prophylactic salpingectomy
Cancer)
•• Prophylactic salpingo-oophorectomy in BRCA1,
3. Incessant ovulation – repeated breaches on surface
BRCA2
of ovary cause triggering effect for malignancy – in
women taking ovulation induction drugs, there is a
theoretical risk of ovarian carcinoma and hence it is
TUMOR MARKERS (Very Imp.)
not recommended to take Ovulation induction agents > •• CA125 for epithelial ovarian cancer
6 months at a stretch. •• LDH for dysgerminoma
4. Early menarche and late menopause •• Alpha Feto Protein for yolk sac tumor
5. Nulliparous women – multiparity is a protective •• Inhibin for granulosa cell tumor
factor
•• HCG for non-gestational choriocarcinoma
6. Others:
2
Obstetrics and Gynecology

PATHOLOGY
1. Serous Adenocarcinoma:

•• Stage 2:

•• In 40% cases, it is bilateral

•• Solid + cystic areas
•• Papillary projections •• Stage 3:

•• HPE (Psammoma bodies)

2. Mucinous cystadenocarcinoma:

•• Stage 4:
–– Distant metastasis
•• Unilateral
•• 2nd most common
•• Contain mucin
•• These resembles endocervical linings
•• Very large sizes; if rupture pseudomyxoma
peritonei.
3. Endometroid, clear cell, Brenner (in clear cell hob- •• Stage 1 – Till ovary
nail appearance) •• Stage 2 – pelvic
•• Stage 3 – extra pelvic +/- lymph nodes
SPREAD OF OVARIAN CANCER •• Stage 4 – distant metastasis
•• Transcoelomic – most common type of spread
TREATMENT
•• Lymphatic (para-aortic)
•• Direct spread Surgical staging:

•• Hematogenous spread •• Staging laparotomy:

–– Vertical incision is made in midline
STAGING ON SURGICAL BASIS –– If there is ascites, send ascitic fluid for
•• Stage 1: cytology
–– If no ascites is there, do peritoneal washing
 3
Ovarian Cancer

–– Then, examine the whole abdomen in a clock- DYSGERMINOMA

wise and anti-clock wise direction
–– Do TAH+BSO
–– Do peritoneal examination and take biopsy
–– Remove all malignant deposits
–– Infracolic omentectomy:
Aim is to achieve optimal debulking
Should leave less than 1 cm margin
•• MC malignant ovarian tumor in Pregnancy
•• Post-surgical chemotherapy:
(Remember most common ovarian tumor
–– Paclitaxel + Carboplatin (DOC) in pregnancy is Dermoid and most common
–– 6 cycles; every 3 weeks malignant tumor is dysgerminoma)

–– Follow up: •• Occurs in young age

ƒƒ 3 monthly for 2 years •• Common in dysgenetic gonads (androgen

insensitivity syndrome/ Swyer syndrome)
ƒƒ 6 monthly for 3 years
•• Tumor marker: LDH
ƒƒ Yearly lifelong
ƒƒ Give Carboplatin and Cisplatin
ƒƒ If during chemotherapy, patient have a recurring
tumor i.e., she’s platinum refractory, then
change the therapy
ƒƒ If tumor is recurring within 6 months, the patient
is Carboplatin and Cisplatin resistant
ƒƒ If tumor is recurring within 6 months to 1 year,
patient is partially sensitive to Carboplatin and
HPE – fried egg appearance
may respond to the next dose
ƒƒ If tumor is recurrent after 1 year, the patient is Treatment:
Carboplatin sensitive and it can be given again •• Staging laparotomy, oophorectomy then
with a good response chemotherapy
•• Give bleomycin, etoposide, Paclitaxel
•• If young patient, do ovariectomy (fertility
preserving surgery)
•• If patient is not young. then do staging
laparotomy, followed by bleomycin, etoposide,
and paclitaxel
4
Obstetrics and Gynecology

YOLK SAC TUMOR

Coffee bean nucleus

•• Granulosa cell tumors
•• Schiller-Duval body
•• Has feature of excess estrogen, heavy
•• Tumor marker:AFP(alpha feto protein) menstrual bleed or precocious puberty

MALIGNANT SEX CORD STROMAL SERTOLI LEYDIG CELL TUMOR

TUMORS
•• Present with hyperandrogenism, virilisation,
clitoromegaly, hoarseness of voice.

Call Exner bodies

GESTATIONAL TROPHOBLASTIC NEOPLASIA

Modified WHO Classification of GTD PRESENTATION

Molar Pregnancies •• AUB.
Hydatidiform mole
•• Usually following a pregnancy event (commonly
Complete after a molar pregnancy).
Partial
•• Metastatic symptoms: cough commonly (lung
Trophoblastic Tumors
metastases).
Invasive mole
•• If there is a headache, it can be a sign of brain
Choriocarcinoma
metastasis.
Placental site trophoblastic tumor
Epithelioid trophoblastic tumor SIGNS
•• Enlarged uterus, sub-urethral nodules, chest
POST MOLAR EVACUATION symptoms (cannonball metastasis)
SURVEILLANCE
•• Invasive moles are locally invasive tumors. INVESTIGATION
•• If it is metastatic, then it is called •• Serum beta-hCG levels
Choriocarcinoma. •• Chest X-Ray: Cannonball metastases
•• Commonly after evacuation of molar pregnancy
(Though it can happen after any pregnancy
event)
–– 5% of partial mole and 15% of complete moles
ends up with GTN
–– If β-Hcg level rising or not falling, think
about choriocarcinoma/GTN
–– If β-Hcg in blood is high even after 6 months
of evacuation of a mole, then think of
choriocarcinoma.
•• MRI brain if suspecting brain mets
DIAGNOSIS (IMPORTANT).

FIGO Criteria for Diagnosis of Post-molar GTN

Plateau of β-hCG level lasts for four measurements over a period of 3 weeks or longer (days 1, 7, 14, and 21)
Rise in β-hCG level for three consecutive weekly measurements over a period of 2 weeks or longer (days 1, 7, and 14)
β-hCG level remains elevated for ≥ 6 months.
histologic diagnosis of choriocarcinoma.
2
Obstetrics and Gynecology

•• LFT/KFT/CBC should be normal to start methotrexate – treatment of choice

treatment
•• If low risk metastatic GTN, give single agent
methotrexate
MANAGEMENT
•• If high risk, give EMA-CO
•• Methotrexate is the chemotherapy of choice
•• Based on 2 things: stages and prognostic scores CHEMOTHERAPY
(WHO, FIGO)
•• Methotrexate will be given every 3 weeks till
β-Hcg falls to zero.
FIGO Anatomic Staging of GTN
•• Schedule:
Stage I Disease confined to the uterus.
–– D1, D3, D5, D7 Methotrexate 1 mg/kg
Stage II GTN extends outside of the uterus
but is limited to the genital structures –– D4, D6, D8 folinic acid 0.1 mg/ kg are given
(adnexa, vagina, broad ligament).
•• After beta hCG reaches zero, 2 additional
Stage III GTN extends to the lungs, with cycles are given.
or without known genital tract
involvement EMA-CO
Stage IV All other metastatic sites (brain,
•• It is etoposide,methotrexate, actinomycin,cyclophosphamide,
liver)
oncovin

FIGO Prognostic Scoring for GTN ROLE OF HYSTERECTOMY

(2000) Done if,
FIGO Scoring 0 1 2 4
Age (years) <40 >40
Antecedent pregnancy Mole Abortion Term --
Pregnancy to treatment interval (months) <4 4 to <7 7 to <13 ≥13
Pretreatment serum hCG (Iu/l) <1000 1000-10,000 10,000-100,000 >100,000
Largest tumor size, including uterus (cm) <3 3 to <5 ≥5 --
Site of metastases Lung Spleen & Kidney Gastrointestinal Liver & brain
Number of metastases -- 1-4 5-8 >8
Previous failed chemotherapy -- -- Single drug ≥2 drugs
Total Score Survival: ≤ 6 = Low risk (100%) ≥7 = High risk. (95%)

•• Invasive mole with perforation.

•• If score is low (good prognosis), give Multi-dose
Methotrexate (i,e, single agent chemotherapy) •• Uncontrolled vaginal bleeding.

•• In high risk, use multi-agent called EMA-CO •• Resistance to CT.

•• In Placental site trophoblastic tumors,
hysterectomy can also be done.

•• If non-metastatic, it means it is in the uterus

and there are invasive moles – give single agent
 VULVAR CARCINOMA

Incidence: Rare; 1.7 per 100,000 women •• Pelvic nodes are secondarily involved in about
20 percent with affected inguinal nodes.
Etiology
•• Lymphatics of the clitoris, anus and rectovaginal
•• Usually occurring in postmenopausal women with septum may drain directly into the pelvic lymph
a median age of 60. nodes.
•• More common amongst whites •• Incidence of lymph gland involvement is directly
•• Increased association with obesity, related to the site, size of the lesion and the
hypertension, diabetes and nulliparity depth of stromal invasion

•• Associated vulval epithelial disorders (lichen •• Chance of bilateral lymph node involvement also
sclerosus) specially of atypical type are the risk increases when the midline structures (clitoris,
factors perineum) are involved.

•• Human papilloma virus (HPV) DNA (type 16, 18) •• Regional lymph nodes are assessed clinically
and also by using MRI, sentinel node
•• Condyloma accuminata (HPV 6, 11), syphilis and lymphoscintigraphy, ultrasound and PET scan
lymphogranuloma venereum.
•• Chronic pruritus
•• Chronic irritation of the vulva by chemical or
physical trauma associated with poor hygiene
may be a predisposing factor.
•• Other primary malignancies have been observed
in about 20 percent of cases with vulval cancer
of which ca cervix is most commonly affected

Sites:
•• The MC is labia majora
Clinical Features

•• Followed by clitoris and labium minus. Symptoms

•• Anterior two-third are commonly affected •• Postmenopausal (60y)

•• Often with obesity, hypertension and diabetes.
Spread
•• Pruritus vulvae
1. Direct: to the urethra, vagina, rectum and even to
pelvic bones •• Swelling with or without offensive discharge

2. Lymphatics: •• Vulval ulceration

•• It is the commonest method of spread of lesion. •• Inguinal mass

•• The lymph node involvement follows a sequential •• Vulvar pain

pattern. The lymphatics of labia → superficial
inguinal lymph nodes → deep inguinal lymph
nodes → pelvic nodes.
Signs
•• Vulval inspection reveals an ulcer or a fungating
mass on the vulva.
•• It may bleed on touch
•• Surrounding tissue may be edematous and
indurated
Treatment
•• The inguinal lymph nodes of one or both the
sides may be enlarged and palpable. •• Primarily surgical
•• If microinvasive (< 1mm): wide local excision
•• Clinical examination of the pelvic organs, with 1 cm margin
including the cervix, vagina, urethra and rectum
must be done. This is due to the co-existence of •• If the lesion is > 1mm then
other primary cancers in the genital tract. –– If it a lateral lesion (> 2cm from the midline):
Radical local resection OR modified radical
Diagnosis vulvectomy with ipsilateral groin LN evaluation
with sentinel LN mapping OR LN dissection
•• Biopsy (When a definite growth is present, the
biopsy is to be taken from the margin) –– If it is a midline lesion (< 2 cm from the
midline): Radical local resection OR modified
•• Cystourethroscopy radical vulvectomy with Bilateral groin LN
evaluation with sentinel LN mapping OR LN
•• Proctoscopy dissection
•• CT/MRI or PET-scan (for nodes) may be needed Role of Sentinel LN Biopsy
Histological Types of Vulvar cancer •• Reduces the requirement of LN dissection
•• Squamous cell carcinoma: MC (90%) •• Done by lymphoscintigraphy with Tc99 labelled
isosulfan blue dye/ indocyanine fluorescent
•• Melanoma (5%) green
•• Adenocarcinoma of the Bartholin gland •• Groin incision made 10 mins later
•• Basal cell carcinoma •• Colored node is excised and examined

•• Sarcoma •• If negative: No lymphadenectomy

STAGING •• IF positive: B/l inguinofemoral Lymphadenectomy

 CERVICAL CANCER

•• 2nd most common cancer in Indian women (MC is TYPES

breast cancer)
1. Squamous cell carcinoma (80 % of all carcinoma)
•• Most common genital malignancy in women
2. Adenocarcinoma (20%)
•• India accounts for 1/5th of the world’s cervical
•• Most common site is transformation zone
cancer .
(squamo-columnar junction)
•• Screening program is very important for
•• With estrogen exposure, squamo-columnar
diagnosis and awareness.
junction starts coming out – undergoes squamous
metaplasia
RISK FACTORS
•• Most endocervical cancers are Adenocarcinoma
•• Exposures to HPV (cause of cancer cervix)
•• Rare cancers are clear cell adenocarcinoma of
•• Multiple sexual partner
cervix and vagina
•• 1st intercourse in early age
•• Multiparous TUMOR SPREAD
•• HIV
•• STDs
•• Immunodeficiency
•• Poor nutritional and socioeconomic status
•• Smoking
•• OCP pills

ETIOLOGY
•• Direct
•• HPV virus
•• Lymphatic spread (bad prognosis)
•• Cells in HPV infections are called koilocytes
•• First spread to pelvic lymph nodes

PRESENTATION

•• HPV has now replaced pap smear as the primary

mode of cervix cancer screening
2
Obstetrics and Gynecology

•• Foul smelling bloody discharge Stage 1: Cancer confined to cervix

•• Contact bleeding
•• Post-menopausal bleeding
•• Cachexia
•• Intermenstrual bleeding

SIGNS
•• Friable cervix
•• Bleeding on touch •• Stage 1A: microscopic lesion of less than 5mm

•• Ulcerative or cauliflower growth –– Stage 1A1: microscopic lesion of <3mm

–– Stage 1A2: microscopic lesion between 3-5
PER SPECULUM EXAMINATIONS: mm
Cervical growth •• Stage 1B: cancer confined to cervix
–– Microscopic lesion of more than 5mm, visible
to naked eyes
–– Stage 1B1: microscopic lesion between 5mm
to 2cm
–– Stage 1B2: microscopic lesion between 2-4
cm
–– Stage 1B3: microscopic lesion>4cm

Stage 2: cancer spread beyond the

cervix but not gone to lower 1/3rd
vagina or pelvic wall

Punch biopsy forceps

Important things in a punch biopsy:
•• If growth on cervix, do punch biopsy
•• Take biopsy from peripheral area preferably
•• If bleeding occurs during punch biopsy, then
apply Monsel solution (contain ferric subsulfate,
which is a hemostatic agent.

STAGING
•• It is a clinical staging (ovarian and endometrial
cancer are surgically staged)
•• FIGO 2018 includes radiological and pathological o Stage 2A: cancer startsinvading vagina
staging
ƒƒ Stage 2A1: lesion less than 4cm
•• Lymph nodes metastasis occurs in 3rd C stage
 3
Cervical Cancer

ƒƒ Stage 2A2: lesion more than 4 cm (up to proven

parametrium, not reached till pelvic side
•• Stage 4B: distant metastasis
wall)
–– Stage 2B PROGNOSTIC FACTORS
•• FIGO Stage
Stage 3:
•• LN metastases
•• Tumor goes beyond lower 1/3rd of vagina and
touches the pelvic side wall •• Grade
•• Size
•• LV space invasion (lympho-vascular invasion)
•• Old age
•• HIV
•• Endometrial extension
•• Comorbidity

PREVENTION
•• Primary: HPV vaccination
•• Secondary: pap smear/HPV (cancer cervix
screening)
•• Tertiary: Early diagnosis and treatment

TREATMENT
•• Surgery: for early stages like stage 1, stage 2A1
•• Radiotherapy: for all patients from Stage 1 to 4
•• Stage 3A: involves lower 1/3rd of vagina 1A1 (With LVSI) Simple Extra-Fascial Hysterectomy
OR Conization
•• Stage 3B: cancer reaches till pelvic side wall +/-
1A1 (With LVSI) Radial Trachelectomy and Pelvic
hydronephrosis
Lymphadenectomy

Stage 4: or
Radial Trachelectomy and Pelvic
Lymphadenectomy
1A2 Radical Hysterectomy (Type 3) and
Pelvic Lymphadenectomy
or
Radical Trachelectomy with Pelvic
Lymphadenectomy
1B1 Small 1B2 and Radical Hysterectomy with pelvic
2A1 Lymphadenectomy
Radical Hysterectomy with pelvic
Lymphadenectomy
•• Stage 4A: bladder or rectum invasion – biopsy
B2 Onwards Chemoradiation
4
Obstetrics and Gynecology

•• Partial hysterectomy – subtotal hysterectomy –

done in in severe PPH
•• Complete hysterectomy – called extra facial
Specimen of a Type 2 hysterectomy (earlier called
surgery – done for benign diseases.
as Wertheim Hysterectomy) with pelvic lymph node
lymphadenectomy
TYPES OF HYSTERECTOMY

Class Piver-Rutlidge Smith Indications Querleu and Morrow

I Simple (Extra-Fascial): CIN Stage 1 Without Type A: Extrafascial Hysterectomy
Uterine arteries ligated at LVSI ● Identification and Palpation of Ureters Without
the isthmus Dissection
No parametrium removed ● Uterine Arteries, Uterosacral and Cardinal
Ligaments Resected as Close to the Uterus
● Removal of Vaginal Portion is Small
II Modified radical State 1A1 with LVSI Type B
Hysterectomy: Medial Half ● Ureters are deperitonized and Rolled to the lateral
of parametrium removal side
upper 1/3rd of vagina ● Partial resection of uterosacral and vesico-uterine
removal uterine vessels ligaments
ligated at level of ureter. ● At least 10 mm of vagina removed
● Section of paracervical tissue removed
III Radical Hysterectomy Stage 1A2 Type C:
● Removal of entire Stage 1B1 ● Ureters fully mobilized
uterosacral and cardinal 1B2 and 2A1 ● Sectioning of Vesico-Uterine Ligaments at Level of
ligaments Bladder
● Uterine vessels ligated ● Complete resection of Para cervical tissue
at origin ● 15-20 mm vagina resected with paracolpos.
● Upper ½ vagina removed
IV Type 3 + Anteriorly Type D:
Periuretral tissue + ¾ vaginal Occurring ● Full resection of the para cervical tissue up to the
+ Ligation of Sup Vesical Recurrence wall of the pelvic bone + Hypogastric vessels exposing
Artery the sciatic nerve root
● Ureter fully ambulant.
V Type 4 + distal ureter and Central recurrence
bladder removed involving the bladder
or distal ureters
 5
Cervical Cancer

RADIOTHERAPY

Cisplatin used with external beam radiotherapy to

increase sensitivity of cells of radiotherapy

FOLLOW UP
● Most recurrences occur in 2 years
● Follow up:

● Both EBRT external and intra-cavitary ● 3 monthly for 2 years

brachytherapy
● 6 monthly for 3 years
● 2 points are used:
● Yearly after 5 years
● Point A:
● Each visit:
–– 2 cm above and 2 cm lateral to left external
os ● Clinical evaluation with pap/vault smear
–– Here, the uterine artery crosses over the ● CT/ PET-CT if suspicion of recurrence
ureter.
● MC cause of death in CA cervix is renal failure
–– Radiation given to Point A is 80 to 85 G
● Point B:
–– 5 cm lateral to cervical canal and 3 cm lateral
to point A.
–– Corresponds to obturator nodes
–– Radiation should be given between 50 to 60 G
● Corresponding to obturator lymph nodes EBRT: 25
Fractions over 5 weeks (5 days a week) to shrink the
tumor
● Brachytherapy or intra-cavitary radiation: 2
Fractions of 15-20 Gy/ fraction

Tandems and ovoids used for radiotherapy

 INSTRUMENT IN GYNECOLOGY

Sim’s Speculum Cusco Speculum

•• Duck Billed speculum

•• Double blade
•• Self-retaining (has a lock)
•• Used along with an anterior vaginal wall
retractor to •• Uses

–– Visualize the cervix and vagina –– To visualize the cervix

–– Aid in diagnostic and operative procedures –– In a few procedures (As it has limited space)
like like

ƒƒ Cervical biopsy ƒƒ Colposcopy

ƒƒ IUD insertion and removal ƒƒ Removal of an intra-uterine device

ƒƒ D & C ƒƒ Cervical biopsy

ƒƒ Dilatation and evacuation •• Advantages:

ƒƒ Cervical cerclage –– Self-retaining so doesn’t require assistance

ƒƒ Cervical tear repair •• Disadvantages:

ƒƒ Gyn surgeries like vaginal hysterectomy –– Less space; cannot introduce more than 1
instrument inside so only a few procedures
•• Central groove: drainage of secretions
can be done
•• Advantage
Anterior Vaginal Wall Retractor
–– Lot of space
–– Does not obscure vaginal walls
•• Disadvantages:
–– Requires assistance
2
Obstetrics and Gynecology

•• Used along with a Sim speculum to retract the Uterine Sound

anterior vaginal wall

Vulsullum

•• To gauge the direction and length of the uterus.

•• It has gradations
•• Where resistance is felt is the utero-cervical
length
•• Should not be used in a pregnant uterus for the
•• This is a long, curved instrument used to hold risk of perforation
the cervix
ANGLE of ANTEVERSION:
•• It has a toothed end
•• It is a forward angle formed by the long axis
•• Usually, the anterior lip of cervix is held of the vagina and cervix at the level of the
•• A pregnant cervix is preferably held by a sponge external os
holding forceps •• Measures about 90°
•• Sometimes the posterior lip of cervix is held if
ANGLE OF ANTEFLEXION
access to the POD is needed
•• It is a forward angle formed by the long axis
–– Culdocentesis
of uterus and that of the cervix at the level of
–– Drainage of pelvic abscess the internal os
•• Instead of a vulsellum, a tenaculum can be used •• Measures 125 - 170°
(single toothed)

Tenaculum

Hegar Dilators

•• Similar to Vulsullum; the only difference is that

this is straight and has single tooth
•• Not used on a pregnant cervix
 3
Instrument in Gynaecology

•• These are graduated metal dilators increasing •• Using rotatory and back and forth movements,
in size from smallest to largest the products
•• The smallest is 1 mm in diameter and the largest Ovum Forceps
14 mm
•• They are used to dilate the cervix prior to any
procedure requiring a dilated cervix
•• Cervical dilatation is done
–– Pharmacologically by PGE1 (misoprostol)
–– Mechanically (Hegar dilators)
•• It is a long instrument used to evacuate products
•• In a dilatation and evacuation done for a of conception in
surgical MTP, the cervix is dilated to the period
–– Missed abortion
of gestation; so if the patient is 8 weeks, the
cervix is dilated to Hegars no 8. –– Incomplete abortion

Manual Vacuum Aspirator and Karman Cannula –– Inevitable abortion

–– Surgical MTP till 12 weeks
–– Evacuation of molar pregnancy
•• Imp features of this instrument
–– End is oval or egg shaped
–– There is no lock; this is to prevent inadvertent
injury to the uterus in case uterine tissue
gets caught in the jaws

Uterine Curette

•• A Manual Vacuum Aspirator (MVA) is a large

syringe which has a 60 ml cannula with a double
valve system and a plunger
•• It is used in dilatation and evacuation procedures
or suction and evacuation procedures in
–– Missed abortion •• This is an instrument which is used to curette
the endometrium
–– Incomplete abortion
•• It is used following a suction evacuation after
–– Inevitable abortion
suctioning out the products or after removing
–– Surgical MTP till 12 weeks them with an ovum forceps to ensure everything
–– Evacuation of molar pregnancy has been removed

•• After creating a vacuum manually, it is attached •• It is also used in gyn procedures like a dilatation
to the Karman cannula and the loaded apparatus and curettage to get an endometrial biopsy
is introduced into the uterus •• It has 2 ends
•• The size of the Karman cannula is the POG in –– Blunt: used in obstetric procedures
weeks
–– Sharp: Used in gyn procedures
4
Obstetrics and Gynecology

•• Procedure is complete if
–– Grating on all 4 walls
–– Presence of air bubbles
–– No bleeding

Endometrial Aspirator

Colposcopy

•• This is a thin cannula attached to a syringe used

to aspirate endometrium for an endometrial
biopsy
•• Colposcopy is in-situ examination of the cervix
•• It can be done as an OPD procedure as the with a low magnification (6–16 times) microscope
cervix need not be dilated (unlike when doing a
Dilatation and Curettage) •• Colposcopy evaluates mainly the changes in the
terminal vascular network of the cervix which
Instruments used in a Dilatation and Curettage
•• Speculum (Preferably Sim)
•• Anterior vaginal wall retractor
•• Vulsullum/tenaculum to hold the cervix
•• Hegar dilators to dilate the cervix
•• Uterine curette

Instruments uses to take a pap smear reflect the biochemical and metabolic changes
•• Speculum (Cuscos or Sims) of the tissue

•• Ayre’s spatula and cytobrush or cervical broom •• Colposcopy identifies the site where from
(for liquid based cytology) biopsies are to be taken

•• Glass slides Cryotherapy Equipment

•• Fixative (95% ethanol): either a spray or in a
jar

Ayres Spatula
Cytobrush

Cytobroom

Punch Biopsy Forceps •• Cryotherapy is an ablative procedure used in low

 5
Instrument in Gynaecology

grade cervical intra-epithelial lesions (mainly sheath, edges of the vaginal vault after a
CIN-1) hysterectomy, edges of the incision in a
myomectomy etc
•• It acts on the principle of crystallizing the
intracellular water at temperature of –90°C Myoma Screw
•• It uses either nitrous oxide (MC) or carbon
dioxide.
•• Depth of tissue destruction is 5 mm.
•• This method is ideal for minor degree
and localized CIN lesions. Double freeze
technique (freeze-thaw-freeze) increases the
effectiveness of cryotherapy
•• The image is of a myoma screw.
Sponge Holding Forceps/ Ring Forceps
•• It is an instrument used in myomectomy.
•• Myomectomy is a conservative surgery for
fibroid uterus
•• It can be done laparoscopically or via laparotomy

Bonney’s Myomectomy Clamp

Babcock’s Forceps

•• Used to hold delicate structures like the

fallopian tubes
•• Used in tubal sterilization procedures
like Pomeroy technique and also in tubal •• This is a Bonney’s myomectomy clamp
recanalization procedures
•• It is applied at the level of the uterine arteries
Allis Forceps during abdominal myomectomy to reduce the
intra-operative blood loss
•• In its absence, a red rubber tourniquet can be
tied at the level of the uterine arteries around
the uterus
•• The clamp is released every 20 mins to ensure
blood supply to the uterus is maintained

Leech Wilkinson Cannula

•• Used to hold tough structures like the rectus

6
Obstetrics and Gynecology

cavity.
–– Liver dullness is obliterated if CO2 is flowing
intra-peritoneally.
2. Trocar and cannula

•• This is a Leech Wilkinson cannula.

•• It is used to inject dye into the uterus
during testing for tubal patency during
hysterosalpingography (HSG) OR during a
Laparoscopic Chromotubation.

Laparoscopy Instruments •• These are the sheaths through which the

1. Verres Needle laparoscope and other instruments pass through
•• The most common sizes are 10 mm (primary
laparoscopic port) and 5mm (Secondary port)
3. Laparoscope

•• An important part of laparoscopic surgeries is

4. Laparoscopic Instruments (graspers, scissors etc.)
creation of pneumoperitoneum
•• The image below is of a Verres needle which is
used to create a pneumoperitoneum.
•• It is typically inserted at the level of the
umbilicus as there is no fat of muscle at this
site.
•• Palmer’s point is preferred if adhesions are
anticipated. This point is 3 cm below the left
costal margin in the mid-clavicular line.
•• Intraperitoneal placement of the needle is 5. Electrical energy source (Bipolar and Monopolar):
confirmed by These coagulate the vessel
–– Drop test: place a drop of saline on the hub
of the needle and life the abdominal wall; the
drop is sucked in
–– The insufflator will show a reading of
intraperitoneal pressure < 10 mmHg (single
digit reading)
–– Push 5 ml of saline in the peritoneal cavity
and then attempt to aspirate it. No fluid can
be aspirated if the needle is in the peritoneal 6. Ultrasonic (vibration) energy source (Harmonic
 7
Instrument in Gynaecology

scalpel) •• There is a gas cable which connects the

insufflator to the Verres needle/ port for
inflow of gas.
10. Light Source and light cable

7. Laparoscopic Ring Applicator with Falope Rings:

This is the instrument used for laparoscopic tubal
ligation
11. Laparoscopic Tower

8. Camera head with Camera system: The camera

head is attached to the laparoscope and this displays
the image on the monitor

Hysteroscope

9. Electronic Insufflator: This connects the CO2

insufflator to the gas tubing that allows CO2 gas to
enter in a controlled manner

This is of 2 types
•• Diagnostic
•• Operative
They assembled hysteroscope consists of
1. Scope
•• This is an image of an electronic gas insufflator
2. Inner sheath
•• The insufflator regulates the rate of inflow
of gas to create/ maintain the intra-abdominal 3. Outer sheath
pressure. 4. Instrument channel (Absent in diagnostic
•• It shows 3 readings hysteroscope)

1. Intra-abdominal pressure 5. Inflow channel

2. Rate of gas flow 6. Outflow channel

3. Volume of gas used

 DRUGS IN GYNECOLOGY

1. PGE1 (MISOPROSTOL) –– For cervical dilatation: 400 mcg (oral/

vaginal/ sublingual)
–– For Medical MTP: used with mifepristone
–– For induction of labor: much lesser dose: 25-
50 mcg vaginal/ oral/ sublingual)

2. TRANEXAMIC ACID

•• Available as a tablet
•• Routes: oral, sub rectal, sublingual, buccal and
vaginally
•• Useful in Obstetrics and in Gynecology •• Used in treatment of Postpartum hemorrhage
(any cause), recommended by WHO: 1g IV given
•• In Obstetrics:
within 3 hours of PPH, dose can be repeated
–– Used in MTP in the first and second after 30 mins
trimesters
•• It acts as anti-fibrinolytic (non-hormonal).
–– In the third trimester: for induction of labor
•• Used in patients with heavy menstrual bleeding
–– Postpartum for AMTSL and treatment of with huge blood loss.
atonic PPH.
•• First line medication for women with:
•• MOA: Uterotonic (increases uterine
1. Fibroids with heavy bleeding
contractions)
2. Adenomyosis with heavy bleed
•• In Gynecology: uterotonic action leads to
cervical dilatation. 3. IUCD in situ with bleeding

•• In Operative Gynecology, given prior to any 4. Endometrial hyperplasia or endometrial polyp

operative procedure where cervical dilation with heavy bleeding
is needed, e.g. in dilatation and curettage;
Hysteroscopic myomectomy, polypectomy 3. MEFENAMIC ACID
•• Office Hysteroscopy does not need cervical
dilatation but operative Hysteroscopy needs
larger diameter and cervix need to be dilated.
•• Cervical dilatation can be done pharmacologically
using Misoprostol or mechanically with Hegar’s
dilator or a combined method
•• Dose:
2
Obstetrics and Gynecology

•• It is an NSAID –– Perimenopausal bleeding

•• Used to reduce pain in dysmenorrhea –– In endometrial hyperplasia of simple or
complex variety without atypical and
•• Used to reduce heavy menstrual bleeding
abnormal uterine bleeding, start → high
•• Combination of tranexamic acid + mefenamic dose of Progesterone in the form of
acid medroxyprogesterone acetate
•• Commonly available and useful for women with –– Contraceptives:
fibroid, endometriosis, adenomyosis
ƒƒ Levonorgestrel in Mala N and Mala D
ƒƒ Desogestrel
4. PROGESTOGENS
ƒƒ Norgestimate
1. Natural micronized – orally, vaginally
ƒƒ Norelgestromin
ƒƒ Norethisterone
ƒƒ Etonogestrel (in vaginal ring, NuvaRing)
ƒƒ Gestodene
–– 4th Generation Progesterone (newer/better
side effect profile):
ƒƒ Dienogest: used in endometriosis – given for
3 to 6 months – dries up the endometrial
2. Hydroxyprogesterone caproate – IM, oil-based spots – dose: 2-4 mg per day
progesterone ƒƒ Drospirenone: anti mineralocorticoid action
– derivative of spironolactone

3. Norethisterone acetate
4. Medroxyprogesterone acetate
○○ Anti-androgenic effect
•• Uses in obstetrics (same for both natural and
○○ Lessens the water retention causing
hydroxyprogesterone caproate)
weight loss
–– Threatened abortion.
○○ Useful in women with PCOS for
–– At risk of preterm labor or recurrent regularizing the cycles or as
pregnancy loss. contraceptive
•• Gynecological uses of progesterones ○○ Present alone as Progesterone only
pills
–– Used as a hemostatic agent to stop bleeding.
This is known as MEDICAL CURETTAGE. ○○ Available with ethinyl estradiol +
Norethisterone is commonly used for this. Drosperinone as Combined OCP
–– Abnormal uterine bleeding for many days •• Adverse effects of progesterones:
–– Puberty menorrhagia –– Nausea, Vomiting
 3
Drugs In Gynecology

–– Mastalgia –– Known as Premarin 0.625 mg tablet

–– Weight Gain, bloating –– Given continuous or with Progesterone in case
of an intact uterus
–– Acne
–– In case of no uterus, it is given alone
–– Irregular Periods / Amenorrhea
•• Synthetic:
–– Androgenic Side Effects
1. Ethinyl Estradiol: most commonly available
–– Depression/Mood Swings
forms – all combined OCP, patch, ring have
this
5. SPRMs (SELECTIVE
2. Estradiol Valerate: vaginal gel – used in
PROGESTERONE RECEPTOR females undergoing IVF.
MODULATORS)- important. ƒƒ Given in postmenopausal women for senile
1. Ulipristal acetate: vaginitis.
•• Adverse effects of estrogens:
–– Nausea, Vomiting
–– Breakthrough Bleeding
–– Breast Tenderness
–– Weight Gain
–– Endometrial Cancer
–– Breast Cancer
–– Thromboembolism

•• Uses: 7. SERM (SELECTIVE ESTROGEN

1. Emergency contraceptive: RECEPTOR MODULATORS)
–– Single dose of 30 mg tablet given up to 120 1. Clomiphene:
hrs or 5 days after an episode of unprotected
intercourse.
–– It is not available in our country.
–– DOC for emergency contraception in India
is levonorgestrel.
–– DOC for emergency contraception all over
the world is ulipristal acetate.
2. For fibroids:
–– 5 mg per day × 13 weeks
–– Shrinks the fibroid by 50% in size
–– Side Effect: liver toxicity – LFT has to be
done before giving it
•• Induce ovulation to treat infertility
6. ESTROGENS •• Strong anti-estrogenic effect that leads to
•• Natural: Conjugated Equine Estrogen: increase of FSH and multiple follicles

–– Used as HRT in menopausal and postmenopausal •• Increases chances of multiple pregnancy

age groups.
4
Obstetrics and Gynecology

•• High anti estrogenic effect can cause: conceive within 2-3 months
–– endometrial thinning and decrease chance of 4. Raloxifene
implantation
•• Given as HRT, specially as bone protecting
–– hot flushes agent in females with osteopenia, osteoporosis
in postmenopausal age group.
–– palinopsia, visual disturbance – rare but
characteristic side effect of Clomiphene
•• Used in anovulatory cycles (PCOS)
8. LETROZOLE
•• DOC for ovulation in PCOS is letrozole Q
2. Ormeloxifene:

•• DOC for ovulation induction in PCOS to treat

infertility.
•• MOA: aromatase inhibitor
•• It reduces synthesis of Estrogen by inhibition
of aromatase enzyme.
•• Antiestrogenic effect: positive feedback on FSH
– more follicles (mono follicular development)
•• Increases risk of multiple pregnancy
•• Non-steroidal contraceptive
•• Dose: 2.5 mg from Day 2 to Day 6 of cycle
•• Earlier known as SAHELI, now known as and from day 9 we do ovulation study by
CHHAYA, under National Family Planning follicular imaging.
Program
•• CDRI Lucknow introduced it as centchroman. 9. GnRH AGONIST
•• Good safety profile
•• Given for first 3 months twice a week for
contraception, then given once a week
•• Can be given to women with Thromboembolism.
•• Safe in postpartum period
•• Very effective and used in abnormal uterine
bleeding also
•• Does not interfere with breast-feeding •• Used for:

3. Tamoxifen: –– precocious puberty

•• Estrogenic agonist and antagonist effect –– IVF (long protocol) controlled ovarian
hyperstimulation
•• Given in breast cancer post-surgery, post
radiotherapy –– endometriosis (cause amenorrhea which will
dry up endometrial implants)
•• Causes endometrial hyperplasia and endometrial
cancer –– fibroids

•• Women on tamoxifen need routine/yearly –– adenomyosis

endometrial screening by TVS to see the •• Adverse effects:
endometrial thickness.
•• Hypoestrogenic Effects
•• After stopping Tamoxifen, a woman can
 5
Drugs In Gynecology

•• Decrease in bone mineral density > 6 Months

(add back therapy given when used for >6
months to prevent bone mineral loss)

10. GnRH ANTAGONIST

•• Available as FSH, HMG

•• HMG (human menopausal gonadotropin) is
extracted from urine of a Post-menopausal
female when levels of FSH and LH are very high.
•• Buserelin, goserelin
•• Uses:
•• Used in IVF cycle as a short protocol.
–– Ovulation induction in females not responding
•• Can be used in AUB to Letrozole, Clomiphene.
–– For controlled ovarian hyperstimulation in
11. GONADOTROPINS IVF cycle.
 CONTRACEPTION: TEMPORARY METHODS -
PART -1

THE IDEAL CONTRACEPTIVE

1. Safe to use
2. Cheap
3. Effective
4. Easily available
5. Motivated easily
6. Easy to use
7. Easy to maintain
8. Easy return to fertility
The ideal contraceptive does not exist

MEASUREMENT OF EFFICACY •• The WHO Medical Eligibility Criteria (MEC)

Wheel for Contraceptive Use is a tool to guide
Pearl Index: (IMPORTANT) healthcare providers in determining the safety
•• Defined as the number of pregnancies that and suitability of different contraceptive
occur in 100 women using a particular method of methods for individual women based on their
birth control for one year. medical history and other individual factors.
•• Example: If a method has a pearl index of 2, •• The MEC Wheel simplifies the complex medical
it means that 2 out of 100 women using that eligibility criteria for contraceptive use into a
method for one year will become pregnant. visual and practical format.
•• The lower the pearl index, the more effective •• It consists of four coloured sections
the method is at preventing pregnancy. representing different categories of medical
eligibility, with a central axis that indicates the
Pearl index = no. of accidental pregnancy X different contraceptive methods.
1200/total months of exposure X no. of patients
exposed
The four categories of medical
Example
eligibility are:
If 200 couples used a new method of male
•• Category 1: No restrictions on use of the
contraception for 3 years with 20 pregnancies
contraceptive method
occurring then,
•• Category 2: Advantages of using the
PI – 20 X 1200/ 200 X 36 = 3.3
contraceptive method generally outweigh the
<1 Pearl Index is said to be very effective theoretical or proven risks
•• Category 3: Theoretical or proven risks
usually outweigh the advantages of using the
2
Obstetrics and Gynecology

contraceptive method (Relatively contra- Rhythm Method (Calendar

indicated)
method):
•• Category 4: The contraceptive method should
•• Calculating the fertile period
not be used (Absolutely contra-indicated)
•• 1st unsafe day: subtract 18 days from the
shortest cycle.
•• Last unsafe day: subtract 11 days from the
longest cycle.

Cycle Beads method:

•• The different contraceptive methods are

indicated on the central axis of the wheel
•• These include
1. Intrauterine copper devices
2. LNG-IUS
3. Combined OCPs Cycle Beads is a natural family planning method that
4. Progesterone only pills uses a visual aid to help women track their menstrual
cycle and identify their fertile days.
5. Progesterone implants
6. DMPA
How it works?
•• Cycle Beads consist of a string of 32 color-
NATURAL METHODS coded beads, with each bead representing a day
of the menstrual cycle.
Fertility Awareness-Based Methods:
•• The first bead is dark brown and represents
1. Rhythm method (Calendar method) the first day of the menstrual period.
2. Basal body temperature method •• The next seven beads are white and represent
3. Sympto-thermal method the days when pregnancy is unlikely.
4. Standard days method using cycle beads •• The 8th through 19th beads are brown, and
represent the days when pregnancy is most
5. Coitus interruptus
likely to occur.
6. Lactation Amenorrhea Method (LAM)
•• The 20th through 32nd beads are white again,
7. Abstinence indicating that pregnancy is unlikely.
 3
Contraception: Temporary Methods - Part -1

Basal Body Temperature method:

•• Women typically experience a slight increase •• At the beginning of cycle, the mucus is usually
in basal body temperature (about 0.50C) after thick and sticky, making it difficult for sperm
ovulation, which lasts until the next menstrual to penetrate.
period.
•• As ovulation approaches, the mucus becomes
•• To use the BBT method, a woman takes her thinner and more slippery, allowing sperm to
temperature with a special thermometer travel more easily through the cervix, into the
immediately upon waking up each morning, uterus.
before getting out of bed or engaging in any
activity.
Symptothermal method:
•• The temperature is recorded on a chart, which
Rhythm method + Basal body temperature + Cervical
can be used to track changes in temperature
music method
over time.

Advantages:
Cervical mucus method
•• Free
(Billing method):
•• Easily available
•• Minimum motivation
•• No side effects

Disadvantages:
•• Efficacy: 8-10 percent
•• Inhibits spontaneous
•• Prevent against STDs
Lactational Amenorrhea Method (LAM): A woman
who is lactating will be anovulatory as long as the
•• The cervical mucus changes in response to
Bellagio criteria is met.
fluctuations in oestrogen levels.
4
Obstetrics and Gynecology

Bellagio Criteria transmitted infections (STIs) by preventing

contact between body fluids
•• Safe and non-hormonal: do not contain hormones
or require any invasive procedures
•• Pleasure enhancement and prolong sexual
activity, as they can help reduce sensitivity and
delay ejaculation.
•• No adverse health effects

•• Infant < 6 months Disadvantages:

•• Exclusively breastfeeding 1. Reduced sensation: Some people may find reduced
sensitivity during sexual activity, affecting sexual
•• Amenorrhea pleasure
2. Risk of breakage: Condoms can break or tear
Barrier Method: during sexual activity, if not used correctly or are
expired or damaged, reducing their effectiveness
at preventing pregnancy and STIs
3. Allergies or irritation: Some people may be allergic
to latex or other materials used in condoms, which
can cause irritation or discomfort.
4. Availability and cost: difficult to obtain in low-
income or rural communities. Additionally, the cost
of condoms can be a barrier for some people who
Male Condoms:
may not have access to affordable contraception.
•• Made up of latex
•• 15-20 cm long Female Condom (Femshield):
•• Diameter: 3-3.5 cm
•• Thickness: 0.3 to 0.8 cm
•• Involves the male partner
•• Prevents against sexually transmitted diseases
•• Efficacy:
–– Perfect use: 2 hwy
–– Typical use: 15 hwy

Advantages:
•• Highly effective when used consistently and •• A female condom is a thin, soft pouch made of
correctly – up to 98% effective at preventing polyurethane or nitrile that is inserted into the
pregnancy vagina before sexual intercourse.

•• Easy to obtain, widely available and can be •• It works by creating a physical barrier that
purchased over-the-counter at drugstores, prevents sperm from entering the vagina and
supermarkets, or online retailers, without the reaching the egg, thus preventing pregnancy.
need for a prescription •• Additionally, it can help reduce the risk of STIs
•• Protection against STIs: provide a physical by preventing contact between body fluids.
barrier that can reduce the risk of sexually
 5
Contraception: Temporary Methods - Part -1

•• Female condoms are available in a variety of Cervical Cap:

sizes and shapes to suit different preferences.
•• To use a female condom, the user should
carefully remove the condom from its packaging
and insert it into the vagina, making sure that
the outer ring sits outside the vagina and covers
the labia.
•• After intercourse, the user should carefully
remove the condom to avoid any spillage of
semen.
•• Lines the vagina, occludes the cervix, and
partially covers the perineum
•• Pre-lubricated
•• 2 rings – inner ring is a closed end which occludes •• The cervical cap is designed to fit over the
the cervix cervix and prevent sperm from entering the
uterus.
•• Available as Femshield and Femidom
•• Disadvantages:

Advantages: 1. Fitting and insertion requires to be learnt

•• Protection from STDs 2. Displacement: it can become dislodged or move out

of place during sexual activity, which can reduce
•• Easy to use its effectiveness at preventing pregnancy.
3. Increased risk of cervical infections: it can
Disadvantages: increase the risk of developing cervical infections,
•• Interference with sexual pleasure particularly if the cap is not cleaned or sterilized
properly between uses.
•• Latex allergy
4. Not suitable for women with prolapse/ retroverted
•• Not easily used
uterus
•• Only for single use
•• High failure rate Cervical Diaphragm and Cap:
•• Advantages:
Cervical Diaphragm: –– It can be used before and after act
–– Reusable
–– No method-related health risks
–– Some protection against STDs
–– Some protection against cancer cervix
•• Disadvantages:
–– High failure rate
–– Training – insertion requires practice

Female Diaphragm –– Toxic shock syndrome

–– Cannot be used in prolapse
–– High failure rate (8-20/ HWY)
6
Obstetrics and Gynecology

Spermicides:
•• Spermicides are a type of contraceptive agent
that contain chemicals that are designed to kill
or immobilize sperm, thus preventing them from
fertilizing an egg.
•• Disadvantages:
1. Limited effectiveness
2. Allergic reactions 2nd Generation
3. Increased risk of STIs
4. Messy or inconvenient

Phexxi:

3rd Generation

Mechanism of action:
1. Chemical and cellular changes in the endometrium:
MAIN MECHANISM
2. Increased tubal motility
3. Impaired sperm ascent
•• Phexxi is a non-hormonal contraceptive gel that
is designed to be used before sexual activity to 4. LNG IUD: Endometrial atrophy and cervical
prevent pregnancy. mucus thickening

•• The gel contains three active ingredients: lactic

acid, citric acid, and potassium bitartrate.
Timing of Insertion:
•• Post menstrual (usually preferred time)
•• These ingredients work together to create
an acidic environment in the vagina that is •• Postpartum
inhospitable to sperm, preventing them from –– PPIUCD – post placental (within 10 min of
fertilizing an egg. placental delivery)
–– Early Post Partum (within 48 hours of
Intra-Uterine Devices: delivery)
–– Intra caesarean (at the time of cesarean)
–– Late Postpartum: After 6 weeks of delivery
(As per WHO, can insert > 4 weeks) (cannot
insert between 48 hours to 6 weeks)
ƒƒ Post abortal
ƒƒ Post coital (as emergency contraception -
within 5 days)

Copper-containing IUDs:
1st Generation 1. Cu T 380 A:
 7
Contraception: Temporary Methods - Part -1

•• High rate of device expulsion and perforation.

•• The device consisted of a small, 7-shaped
frame made of plastic with copper wire coiled
•• The device consists of a small, T-shaped frame
around the arms and stem.
made of plastic with copper wire coiled around
the arms and stem. 4. Multiload:
•• 314mm2 + 33mm2 copper on each arm = 380mm2
•• Insertion is by Withdrawal technique
•• Plastic ball at base to prevent cervical
penetration
•• Frame: Radio-opaque
•• 50 mcg/day copper released
•• Can be kept for 10 years
•• Free of cost •• Flexible serrated arms

2. Copper T 200: •• Vertical stem is radio-opaque

•• 250mm2; 75 mcg/ day
•• Remember: no copper on the arms
•• 5 years life (Cu 375) and 3 years (Cu 250)
•• Free of cost

Hormonal IUDs:

•• Also Called Gyne T

•• It was supplied free of cost by GOI but is now
replaced by CuT380A
•• 200mm2of copper
•• Life: 3 years
•• Cu 200B: More copper
3. Copper 7:

•• LNG-IUS (Mirena)
•• Duration of use is now 8 years (Earlier 5 years,
8
Obstetrics and Gynecology

but this was recently updated by manufacturers •• Pain

of Mirena in 2022)
B. Late:
•• Radio opaque frame
•• HMB
•• T-shaped
•• Dysmenorrhea
•• 52mg LNG/ releases 20 mcg/ day
•• Perforation

Other uses (Non-contraceptive): •• Ectopic pregnancy: 30% of pregnancies

occurring in women with IUD are ectopic
•• Menorrhagia
•• Misplaced IUD/ Missing thread
•• Dysmenorrhea
•• Expulsion higher post placental, post 2nd
•• Endometriosis
trimester abortion, older devices, young
•• Symptomatic fibroid (not distorting the cavity) women, nulliparous, large uterus
•• Endometrial hyperplasia
Missing thread of intrauterine devices:
•• Adenomyosis
Causes:
Absolute C/I to Intrauterine Devices •• Thread coiled inside
(IMPORTANT). •• Thread broken
1. Pregnancy
•• IUCD expelled
2. Infection (PID/ sepsis/ genital TB)
•• Perforated uterus
3. Cancers (Breast/ endometrial/ ovarian/ cervical/
•• Pregnancy (enlarged uterus pulls the IUCD
GTN)
inside)
4. Distorted uterine cavity/ Mullerian Anomaly
What should be done?
5. Undiagnosed vaginal bleeding
•• Locate the device by

Advantages of IUD: –– First: USG (TVS): This will tell us if it is

in the uterus (Excludes causes of broken
•• Long-acting
thread/ coiled thread/ pregnancy)
•• Reversible
–– If not visible on TVS, get an X-ray with a
•• Available free of cost by Government of India uterine sound. This will tell us if the IUD is
(Cu 380A and Cu 375) in the abdominal cavity or has been expelled
•• Do not interfere with sexual act outside

•• Non contraceptive benefits with LNG-IUS •• If intrauterine (and displaced/ patient wants
it removed/ lifespan complete): IUD hook /
•• Highly effective (0.1) long artery / Hysteroscopic (This is preferred
•• Does not require repeated usage method)

•• Early return to fertility •• If intrauterine and correctly placed and patient

wants continued contraception: Nothing to be
•• Safe in the postpartum period done (leave it in place)
•• No interaction with drugs •• In extra uterine:Laparoscopy (preferred)/
Laparotomy
Complications of IUD:
A. Immediate/ Early: Pregnancy with IUD:
•• Vasovagal attack •• Rule out ectopic pregnancy (increased incidence
of ectopic pregnancy)
•• Perforate the uterus
 9
Contraception: Temporary Methods - Part -1

•• If thread is visible: Remove the device removal)

•• Thread not visible: Continue pregnancy (not •• Recurrent PID
teratogenic) but increased chance of infection/
•• Uterine perforation
abortion/ PPROM/ IUGR/ Preterm labor
•• Partial expulsion
Indication of removal of IUD: •• Pregnancy with device in situ
•• Lifespan completed •• Return of fertility (patient wants to conceive)
•• 1 Year post menopause
•• Heavy bleeding (most common reason for

•• CuT380A •• Multiload •• CuT200 •• Copper 7

•• T-shaped frame (Ba sulfate •• Copper on the vertical shaft •• Gyne-T •• Gravigard
for X-ray opacity) only •• No longer supplied by GOI •• Shape of number 7
•• 314 mm + 33 mm on each
2 2
•• The 2 arm are flexible and •• 200 mm copper
2
•• 200 mm2
arm = 380 mm2 serrated •• Life span: 3 years •• 3 years
•• Insertion withdrawal •• No plunger
technique •• Pre-loaded withdrawal inserters
•• Supplied free of cost by GOI •• 250 mm2 / 375 mm2
•• 10 years •• Cu 375: GOI, 5 years
 CONTRACEPTION: TEMPORARY METHODS -
PART -2

HORMONAL CONTRACEPTIVES 1. Age > 35y

2. Taking > 15 cigarettes/ day
3. Postpartum breastfeeding < 6 weeks
4. DVT/ pulmonary embolism
5. Ischemic heart disease
6. BP > 160/100 and with vascular ds
Combined oral contraceptive 7. SLE
pills 8. Migraine
•• Ethinyl estradiol + Progesterone
9. Current breast cancer, ca end, breast, HCC
•• Failure rate: 0.1 HWY (with ideal use)
10. Severe cirrhosis
•• Typical – 1.8 to 2 HWY
11. Major surgery with prolonged immobilization

Types:
OCPs in Breast-Feeding
•• 1st generation pills: 50 μg EE
Women: (IMPORTANT)
•• 2nd generation: 30-35 μg EE + LNG/ d-LNG
•• If she is < 6 weeks and breastfeeding: DO NOT
•• 3rd generation: 20-30 μg EE + Norgestimate/ GIVE Combined OCP (MEC 4)
desogestrel/ gestodene
•• If she is between 6 weeks and 6 months and
•• 4th generation: Progesterone: Drosperinone: breastfeeding: DO NOT GIVE Combined OCP
Weak anti-mineralocorticoid activity (MEC 3)
•• If she is breastfeeding and > 6 months: Can
Combined Pills: Give Combined OCPs (MEC 2)

Mechanism of Action: Advantages:

•• Ovulation suppression (main mechanism of •• Effective 0.1 HWY
action)
•• Easy return to fertility
•• Endometrial atrophy
•• No effect on future fertility
•• Cervical mucus changes
•• Effective at all ages
•• Alteration of ovum transport
•• Coitus independent

Contra-indications: •• Simple

(IMPORTANT) •• Non contraceptive benefits

•• MEC 4 (Absolute contra-indications):

2
Obstetrics and Gynecology

Non contraceptive benefits: Missing a Pill: (important)

•• Regular periods One Missed Pill
•• Reduced PID
•• Decreased risk of ectopic pregnancy The missed pill should be taken as soon as
possible The remaining pills taken as usual No
•• useful in Endometriosis
additional contraception required
•• Useful in fibroid
•• Prevents loss of bone density
2 or more missed pills (> 48 h late)
•• Reduces benign breast disorders
•• Prevents cancers: Endometrial, ovarian and
The last missed pill should be taken as soon
colorectal
as possible Leave the earlier missed pills Use
•• Reduced menstrual blood loss / Regularization additional contraception for 7 days Further to
of menstrual cycle / Improved dysmenorrhea / reduce risk of pregnancy
Fewer pre-menstrual complaints
If pills missed in 1st week: Consider
Emergency Contraception Pills missed
Side effects: in 2nd week: No need for Emergency
•• Gastro-intestinal: nausea, retching, vomiting, Contraception Pills missed in the 3rd week:
anorexia Omit the pill free interval and start the
next pack after finishing the active pills in
•• Headache and migraine
the current pack
•• Effect on weight
•• Skin changes
Important drug interactions:
•• Breast changes
Efficacy reduced by enzyme inducers:
•• Breakthrough bleeding
•• Rifampicin
•• Increased risk of cholestasis and jaundice
•• Anti-epileptic drugs
•• Cardiovascular and Vascular complications
•• Anti-fungal (griseofulvin, ketoconazole)
•• OCPs and cancers: Increased risk of breast
•• Sulfonamides
cancer, cervical cancer (controversial) and
liver adenomas •• Barbiturates
and Antibiotics:
Starting the pill:
•• Chloramphenicol
Instructions: •• Ampicillin
•• Can be started •• Tetracycline
–– immediately after 1 st
trimester / 2 nd
•• Amoxicillin
trimester abortion
•• Doxycycline
–– 3 weeks after delivery if not breastfeeding;
•• Reduce absorption of Estrogen from the
–– Within the 1st 5 days of menses intestine
•• 1 pill every day for 21 days – take every day at
the same time Other formulations of OCPs:
•• 1-week gap •• Biphasic
•• After 1 week, start again; new packet on 8thday •• Triphasic (Triquilar)
•• Review after 3 months and then, annually. •• Continuous use OCPs: Seasonale/ Seasonique
 3
Contraception: Temporary Methods - Part -2

Injectable Combination of E fewer side effects such as weight gain, acne,

and mood changes.
+ P:
1. Cyclo-provera/ Cyclofem:
Disadvantages:
–– 25mg depot MPA + 5 mg ethinyl cypionate
1. Costly
–– Monthly injection
2. Insertion and removal: Some people may find it
–– Rapid reverse to fertility uncomfortable or difficult to insert or remove the
vaginal ring.
2. Mesigyna:
3. Side effects: Although vaginal rings have fewer
–– 50 mg norethindrone enanthate + 5mg
side effects than other hormonal contraceptives,
estradiol valerate
some people may experience side effects such as
–– Monthly injection headaches, nausea, or breast tenderness.
–– Both are highly effective: Failure rate is 0.2- 4. No protection against STIs
0.4/ HWY
5. Increased risk of thrombo-embolism as it is an
estrogen containing contraceptive
Vaginal Rings
6. Local discomfort/ irritation
7. Expulsion can occur
•• Forgetting to remove the ring:
–– If in week 4: continue the ring for that week
–– Remove the ring after week 4
–– Insert a new ring after 1 week
–– Use a backup method for the 1st 7 days with
the insertion of a new ring
–– If forgotten beyond 4 weeks: Chance of
pregnancy is high
•• The ring is a small, flexible device that is placed
deep in the vagina and left in place for three
weeks at a time – remove for 1 week – withdrawal
Transdermal Contraceptive
bleeding – then, wear a new ring after 1 week Patch
•• Releases 15 μg ethinyl estradiol and 120 μg
etonorgestrel

Advantages:
•• Convenient
•• Efficacy: Vaginal rings are highly effective at
preventing pregnancy, with a failure rate of less
than 1% (Failure rate: 0.3% with ideal use/8%
with typical use)
•• Regular periods: The hormones in the vaginal •• Applied to the skin once a week for three weeks,
ring can help regulate menstrual cycles, making followed by a patch-free week
periods more regular and reducing the symptoms
of premenstrual syndrome (PMS). •• Release 20 μ EE + 150 μg Norelgestromin

•• Fewer side effects: Compared to some other •• Can be applied over Buttocks or abdomen – not
hormonal contraceptives, vaginal rings have to be applied over the breast
4
Obstetrics and Gynecology

•• If the patch was detached for less than 24 h, Advantages:

the same patch can be reattached or replaced
with a new one. •• Convenient

•• If a patch is partially or completely detached •• Highly effective: When used correctly, POPs
for >24h: Stop the current contraceptive cycle are a highly effective form of contraception,
and start a new cycle immediately by applying a with a failure rate of less than 1%.
new patch; use back-up contraception for the •• Can be used while breastfeeding: POPs are a
first week of the new cycle. good option for people who are breastfeeding
because they do not affect milk production.
Progesterone Only Pills •• Fewer side effects: Compared to combination
(IMPORTANT) hormonal contraceptives, POPs have fewer side
effects such as blood clots, stroke, and heart
•• Contains only progesterone (LNG/ norgestrel/
attack. They may also be a good option for
desogestrel/ norethindrone)
people who cannot take estrogen due to health
•• Also called as mini pill reasons.
•• Efficacy: Consistent use: 0.5 per HWY/3-10% •• Useful in women > 40 years of age
with typical use
•• Can be taken by women with a H/o Diabetes,
•• Mechanism of action: epilepsy, smoking, thromboembolism
–– Cervical mucus thickening •• Decrease incidence of PID, endometrial cancer
–– Endometrial atrophy
–– 60%: delayed ovulation
Disadvantages:
•• Must be taken at the same time every day with
•• Absolute contra-indication: Breast cancer
no more than a three-hour window. This can be
•• Has to be taken at the same time every day difficult for some people to remember.
(3h) error margin
•• Irregular bleeding or spotting between periods,
•• Can be given in which can be bothersome for some people.
–– Lactating mothers (immediate postpartum: •• Less effective if not taken on time: POPs
MEC 2/ after 6 weeks: MEC 1) must be taken consistently and on time to be
–– Day 1 of period effective. If a pill is missed or taken late, the
effectiveness may be reduced.
–– Daily at the same time
•• No protection against STIs
•• May not be suitable for people with certain
health conditions like liver disease or breast
cancer.
•• Minor side effect: acne, mastalgia, headache
•• Amenorrhoea in some women

Progestogen Only Injectable

•• Depot Medroxyprogesterone Acetate (Available
by the govt of India by the name Antara)
•• 150mg deep IM (Z track) every 3 months
•• Start within 7 days of period
•• Depot sub Provera: 104 mg/ given subcutaneously
 5
Contraception: Temporary Methods - Part -2

•• Failure rate: 0.3 per HWY cycles, amenorrhoea

•• Not protective against STDs
Progesterone Implants •• Costly

Long-Acting Reversible
Contraception (LARC)

•• Subdermal implants
•• Norplant, Norplant-2 (Jadelle), Implanon,
Nexplanon
•• Highly effective (0.005-0.1 per HWY) •• Methods requiring administration less than 1
•• Advantages: cycle/month
–– Highly effective •• LARC Methods include:
–– Long acting –– Intrauterine Devices
–– Quick return to fertility –– Implants
–– Independent of sex –– Injectables
–– No estrogenic side effects
–– Low risk of ectopic pregnancy
Emergency Contraception
(IMPORTANT)
Disadvantages: •• Emergency contraception (EC) is a type of birth
control that can be used to prevent pregnancy
•• Removal is not easy – requires a minor procedure after unprotected sex, contraceptive failure,
for insertion and removal or in cases of sexual assault.
•• Side effects: mastalgia, weight gain, irregular

Methods of Emergency Contraception:

Drug Dosage Time of use

Combined OCPs (Yuzpe regime) Approx 100 mcg of ethinyl estradiol + 0.5 mg of Upto 72 h
Levonorgestrel (LNG) – each dose; 2 doses 12h apart
Progesterone only (LNG) 1 single tablet containing 1.5 mg of LNG (preferred Upto 72 h
regime; also available by GOI)
Selective progesterone receptor 1 tablet – 30mg of ulipristal acetate (Most effective Upto 5 days
modulator (Ulipristal acetate) but not available in India)
Intra-uterine copper device Single IUCD Upto 5 days
 PERMANENT METHODS OF
CONTRACEPTION

FEMALE STERILIZATION –– With MTP/ abortion

•• Permanent –– With other surgeries (like ectopic pregnancy)

•• Failure rate: 0.1-0.8% •• Routes

•• Eligibility for the procedure as per the Govt of –– Abdominal

India: ƒƒ Laparotomy
–– Clients should be married ƒƒ Mini-laparotomy
–– Female clients should be between 22-49 ƒƒ Laparoscopy
years
–– Vaginal
–– The couple should have at least one child
whose age is above one year unless the •• IF done by Laparotomy/ mini-laparotomy, the
sterilization is medically indicated following techniques can be done

–– Clients or their spouses/partners must not 1. Pomeroy’s Technique: Recommended by the Govt
have undergone sterilization in the past (not of India
applicable in cases of failure of previous
sterilization)
–– Basic Qualification Requirement of Provider
ƒƒ Minilap services: Trained MBBS doctor
ƒƒ Laparoscopic sterilization: DGO, MD
(Obst. & Gynae.), MS (Surgery) (trained
in laparoscopic sterilization)
–– Clients must be in a sound state of mind
to understand the full implications of
sterilization.
–– Mentally ill clients must be certified by a •• The isthmic portion of the fallopian tube is held
psychiatrist, and a statement should be with the Babcock forceps
given by the legal guardian/spouse regarding
the soundness of the client’s state of mind. •• A 2 cm loop is made which is ligated at the base

•• Timing of surgery •• A security knot may be taken at the base

–– Interval ligation (unrelated to delivery); •• The loop is cut off and sent for HPE
done post-menstrually; within 7 days of the 2. Parkland Technique
menstrual period
•• A segment of the tube is removed without
–– Postpartum ligation creating a loop
–– With cesarean •• Usually performed in patients who present with
a failed tubal ligation
2
Obstetrics and Gynecology

6. Kroner Technique: Fimbriectomy, low failure

rate

3. Madlener:
•• Associated with a high failure rate as the tube
is not cut, just a loop is created and tied

7. Aldridge Technique: Burying the fimbria into the

mesosalpinx

4. Irving Method

•• Proximal end buried into the myometrium

•• Distal end brought up •• Laparoscopic Sterilization: The below shown
instrument is used. It is called a laparoscopic
•• Low failure rate
ring applicator or a laparocator
5. Uchida Method: Low failure rate
 3
Permanent Methods of Contraception

–– No scalpel vasectomy (Recommended by the

GOI)
•• Advantages
–– Simple procedure
–– Does not require hospitalization
–– No long term side effects
–– Low failure rate
–– Does not alter sexual function
–– Low cost
–– Surgical reversal possible
•• Disadvantages:
–– Permanent
•• Laparoscopic Tubal ligation can be done by –– No protection against STDs
–– Falope rings: using the laparocator shown –– Not effective immediately (effective after
–– Hulka clips about 3 months or 20 ejaculates): A semen
analysis report confirming azoospermia is
–– Filshie clips essential to confirm this.

MALE STERILIZATION –– Surgical risks

•• Efficacy: 0.15/ 100 person years

•• Methods
–– Vasectomy
 MEDICAL TERMINATION OF PREGNANCY

•• MTP Act: 1971; revised in 1975, 2003 and in 1ST TRIMESTER MTP: MEDICAL
2021
METHODS (IMPORTANT).
•• Most of the major changes were made in the
Day Drug used
MTP Act in 2021
Day 1 200 mg Mifepristone oral tablet
Day 3 •• Up to 7 weeks: 400 mcg misoprostol
METHODS OF MTP (sublingual/buccal/vaginal/ oral)
1. Medical •• 7-9 weeks: 800 mcg
2. Surgical •• In addition:
–– Analgesics (Ibuprofen)
1 ST
TRIMESTER MTP –– Antiemetic
•• Less than 12 week Day 14 Confirm completion of procedure
Offer contraception
Medical Methods:
•• Do an ultrasound to check the complete removal
•• Misoprostol PGE1 of the conceptus.
•• Mifepristone (Selective Progesterone Receptor •• Mechanism of Action:
Modulator) + Misoprostol: Most common and
currently recommended regime 1. Mifepristone (RU 486):

•• Methotrexate Selective Progesterone receptors modulator

*Recent Update: WHO 2021 has approved Letrozole Act by Antiprogesterone action because
for MTP (10 mg/ day for 3 days f/b misoprostol) Progesterone is pregnancy supporting hormone

•• As per Government of India MTP can be done Acts by blocking Progesterone receptors
till, 9 weeks, but after 7 weeks, efficacy 2. Misoprostol (PGE1):
decreases
Available as 200 mcg tablets
Binds to myometrial cells and causes strong uterine
Surgical Methods:
contractions leading to cervical ripening and
Dilatation and Evacuation (5 weeks till 12 weeks) – dilation so that conceptus gets expelled out
Dilatation of cervix and Evacuating conceptus via
Uses:
1. Evacuation with ovum forceps
•• MTP medical management
2. Manual vacuum aspiration
•• Induction of labor
3. Electrical vacuum aspiration
•• Prevention and treatment of atonic uterus of
PPH
•• Used prior to dilatation and curettage, or
hysteroscopy to dilate cervix
2
Obstetrics and Gynecology

CONTRAINDICATIONS TO Ovum forceps

MEDICAL METHODS
Absolute:
1. Suspected ectopic pregnancy
2. Undiagnosed adnexal mass
3. Allergy to drugs

Relative:
1. Heart disease
2. Liver Disease
3. Hemorrhagic disorder
MVA manual vacuum
4. Asthma
aspiration
COMPLICATIONS OF MEDICAL
METHOD
Complication Incidence
Heavy bleeding requiring 1-2%
vacuum aspiration
Incomplete abortion 1-2%
requiring vacuum aspiration
Continuation of Pregnancy 1-2%
Heavy bleeding requiring 0.1-0.2%
blood transfusion

•• Success of Medical management till 7 weeks is

98% Suction apparatus Attached
•• Till 9 weeks is 95% to Karman’s cannula
•• Dilatation via Ovum forceps
1ST TRIMESTER MTP: SURGICAL •• Ovum forceps doesn’t have lock and it has oval
METHODS ends like ovum (egg-shaped)
1. Dilatation and evacuation: •• Lock is absent to prevent trauma if you
accidentally catch part of uterine tissue or
endometrium and lock the forceps
•• Dilate and evacuate using MVA manual vacuum
aspiration
•• Attached to MVA is Karman’s cannula which is a
plastic,disposable cannula that suction out the
conceptus
•• Suction apparatus is attached to Karman’s
cannula
•• Difference is that, in MVA, manual suction is
applied and in suction apparatus, electrical
 3
Medical Termination of Pregnancy – Part-1

suction is applied 7. Evacuation is done by using ovum forceps/ MVA or

Electrical aspiration
•• Dilatation prior to the procedure is done by
8. Gently curate out all the 4 walls of endometrium
–– Pharmacological techniques (PGE1
(misoprostol) before procedure given at a 9. Procedure is complete when
dose of 400 mcg (oral, vaginal, sublingual))
a. No products are aspirated
–– Mechanical Methods (Hegar’s dilator) or
b. Grating sensation on all 4 walls
combined methods (PGE1 + mechanical
method) c. Air bubbles are seen at the os

–– USing both pharmacological and mechanical d. Gripping sensation of the instrument at the
methods internal os

Procedure SIGNS OF COMPLETION

1. Process is done under local or general anesthesia End of procedure:
2. Position of Lithotomy •• No more material sucked out
3. SIMS speculum is introduced in posterior vaginally •• Gripping of cannula by the contracting uterus
wall
•• Grating sensation on all uterine walls with the
4. Cervix is held with a non-traumatic sponge holding curette
forceps (not a vulsullum)
•• Air bubbles seen
5. Don’t sound the pregnant uterus – it will end up
with perforation
6. Hegar’s dilators used to dilate cervix

COMPLICATIONS OF DILATATION AND CURETTAGE

Early Delayed Long term

•• Perforation •• Persistent bleeding •• Asherman syndrome
•• Hemorrhage •• Retained products •• Subfertility
•• Cervical Laceration •• Pelvic infection •• Cervical insufficiency
•• Vasovagal syncope •• Continued pregnancy

Asherman Syndrome (Intrauterine adhe-

sions)

1. patient comes with secondary infertility and has a

history of D and C
2. Scanty bleeding during menstruation/secondary
amenorrhea/hypomenorrhea
3. Adhesions formed within walls of uterus

PERFORATION
4
Obstetrics and Gynecology

•• Anteverted uterus =Angle between vagina and

cervix is 120 degree
•• Anteflexion = Angle between uterus and cervix
•• Normally, uterus is anteverted and anteflexed,
so curette goes straight into it and causes
perforations

2ND TRIMESTER MTP

Retroverted uterus – more No fixed guideline
chance of perforation
Medical Method is the method of choice because
•• Acutely anteverted and anteflexed uterus also of large uterus
have more chance of perforation
D and E have more risk of perforation
•• Common sites: Anterior wall, funds and cervix
Surgical Methods are used only if medical method
•• Instruments: most commonly due to Karman’s fails.
cannula, Hegar’s Dilator, curette
Medical methods:
•• Risk Factor:
1. Mifepristone + Misoprostol
1. Abnormal position of uterus
2. Misoprostol alone
2. Retroverted, acutely anteverted and anteflexed
3. Dinoprostone gel (PGE2) (mainly used for induction
uterus
of labor in term pregnancy)
3. Larger uterus
4. Oxytocin
4. More period of gestation
•• Surgical Methods:
5. Second trimester MTP
1. Dilatation and Evacuation
6. Previous scars on uterus due to D and C
2. Intrauterine instillation of hypertonic solutions
7. Cesarean section
a. Extra-amniotic ethacridine lactate
Prevention by using ultrasound-guided procedure and
correct assessment of size and position of uterus b. Intra-amniotic hypertonic saline
 5
Medical Termination of Pregnancy – Part-1

c. Hysterotomy: Taking the baby out by a uterine THE OLD ACT vs THE 2021 AMEND-
incision (abdominally) – done only if other MENT (IMPORTANT).
methods fail.

MTP ACT
•• Introduced in 1971
•• Implemented in April 1972
•• Amended in 1975, 2003 and 2021
•• The Act defines:
–– Indications of MTP
–– Who can perform an MTP?
–– Where can it be done?
–– Till what gestational age it can be done?

INDICATIONS OF MTP OTHER FEATURES OF 2021 MTP

AMENDMENT
•• Most commonly done in case of failure of
contraception. •• For MTPs > 24 weeks and for substantial fetal
1. Maternal: therapeutic or medical indication anomalies, the state is to constitute a medical
board consisting of
2. Eugenic/Fetal
–– Gynecologist
3. Social: rape
–– Pediatrician
4. Failure of contraception
–– Radiologist or sonologist

WHERE CAN MTP BE DONE? –– Any other member as deemed appropriate

•• Government hospitals or hospitals recognized

by the Government
•• Establishments which have been approved for
MTP

WHO CAN DO MTP?

A Registered Medical Practitioner who
•• Has a diploma/degree in Obs & Gyn
•• Has done 6 months house surgeon training in
Obs & Gyn
•• Has assisted at least 25 MTP in an authorized
center
 Imaging in Gynecology

•• Modalities: •• In the secretory phase, the endometrium

becomes more homogenous and thicker and
–– Ultrasound
appears like this
ƒƒ Transvaginal scan: If the uterus is not
palpable abdominally
ƒƒ Transabdominal scan: If the uterus is
palpable abdominally
–– MRI
–– HSG
–– Sonosalpingography
•• Normal Pelvic Anatomy on TVS looks like this:

•• The ovaries look like this on the scan. The black

rounded things you see are developing follicles.
The ovaries are located in proximity to the iliac
vessels

•• In the proliferative phase, the midline

endometrium, the appears trilaminar (3 lines
are seen)

Lets Discuss different Ultrasound images:

1. Endometrial polyp:
•• On ultrasound appears like a thickening at one
point of the uterus
•• On Doppler (seeing the flow in the vessels), a
single feeding vessel will be supplying the polyp
•• Polyps usually present as abnormal uterine
bleeding patterns or as infertility
•• Treatment: Hysteroscopic polypectomy
2
Obstetrics and Gynecology

2. Asherman Syndrome
•• Intrauterine adhesions HSG - Asherman

•• Presents as hypomenorrhea or secondary 3. Fibroids (Leiomyoma)

amenorrhoea or secondary infertility following
•• These appear as well circumscribed masses in
a h/o curettage.
the uterus
•• On TVS: broken/ irregular endometrium
•• The 3 main types of fibroids are
•• HSG: Filling defect/ moth eaten appearance
–– Submucous
•• Ix of choice: Hysteroscopy
–– Intramural
•• Treatment: Hysteroscopic adhesiolysis
–– Subserous
•• An MRI helps in detailed mapping of the fibroids
if a myomectomy is planned
4. Adenomyosis
•• Ultrasound is the investigation of choice for
adenomyosis
•• Several features are seen on the ultrasound.
•• These include the following

USG - Asherman
 3
Imaging in Gynecology

5. Polycystic Ovaries
•• Polycystic ovarian syndrome is diagnosed by
Rotterdam criteria which says 2 of 3 of the
following should be present
1. Oligomenorrhoea
2. Hyperandrogenism (biochemical or clinical)
3. Polycystic ovarian morphology in 1 or both ovaries
(≥ 12 follicles of 2-9mm diameter in either or
both ovaries and/or ovarian volume ≥ 10ml)

Simple Ovarian Cyst: Clear cyst > 3 cm

7. Endometriotic Cysts
•• These are ovarian cysts which have a typical
ground glass appearance on the ultrasound (fine
stippling)

Necklace pattern of follicles in the ovary

6. Simple Ovarian Cyst

4
Obstetrics and Gynecology

8. Ovarian Hyperstimulation Syndrome

Hydrosalpinx on USG

9. Intrauterine Device in the Uterine Cavity appears

like this

Hydrosalpinx on HSG

10. Pyometra Let’s Discuss some HSG Images. An HSG basically

•• Typically seen in cervical stenosis tells us 2 things
•• If seen in a postmenopausal woman, think of 1. Uterine contour
cervical cancer 2. Tubal patency
Also an HSG is usually done on Day 8 – 9 of a menstrual
cycle.
It is an Xray with a water or oil based radio-opaque
dye that helps see the uterus and fallopian tubes
better

11. Hydrosalpinx
•• Retort shaped hypoechoic adnexal mass is seen
 5
Imaging in Gynecology

Normal HSG: Shows a normal uterine

outline with b/l tubes and spill in the
peritoneal cavity

1. This HSG shows a proximal tubal block on both

sides (b/l cornual block)

b. Bicornuate uterus

2. B/l Distal tubal block with hydrosalpinx

The inter cornual angle is >1050

c. Septate uterus
Septate Uterus: Inter cornual angle < 750

3. Asherman’s Syndrome

** But remember, an HSG is not a good modality to

4. Mullerian anomalies can also be diagnosed on an differentiate or delineate Mullerian anomalies. The
HSG. best Ix for Mullerian Anomalies is an MRI

a. Unicornuate uterus d. Uterine Didelphys

6
Obstetrics and Gynecology

–– If the line cuts across the fundus or the

distance between this line and the fundal
indentation is < 5mm: BICORNUATE UTERUS
–– If the line joining the 2 horns is > 5mm from
the fundal indentation: SEPTATE UTERUS
5. Submucosal Fibroid

A better way to differentiate between a septate and

a bicornuate uterus is a 3D USG

Well defined space occupying lesion in the uterine cavity

•• In the above image, draw a line connecting the 2

uterine horns (dran in red)
 Operative Gynecology

Common Gynecological underlying cyst wall, and pus or mucus under

pressure spills out.
Procedures include:
•• Pus is drained ans the cavity explored to break
Minor Procedures up fluid loculations and completely clean the
cavity
1. Marsupialization of Bartholin Cyst
•• Allis clamps are then placed on the edges of the
2. Imperforate Hymen
cyst wall, edges of the cyst wall are sutured to
3. Dilatation and Curettage adjacent skin edges with interrupted sutures
4. Fractional Curettage •• In cases of recurrent Bartholin or Bartholin in
the post – menopausal age group, a cyst excision
Major Procedures is preferred to be done.
1. Hysterectomy:
Imperforate Hymen:
•• Abdominal
•• Vaginal
•• Laparoscopic (TLH/ LAVH)
2. Myomectomy
3. Prolapse Surgeries
4. Ovarian Cystectomy
5. Ovariectomy
6. Salpingectomy

Endoscopic Procedures
1. Laparoscopic
2. Hysteroscopic •• A cruciate incision is placed on the most bulging
point
Marsupialization of Bartholin Cyst •• The hematocolpos is drained
•• A vertical or elliptical incision measuring 2 cm is
•• The edges of the cut hymen are sutured to the
made across the skin overlying the cystic bulge
vaginal mucosa
using a scalpel
•• The incision is made atop the cyst, is placed Dilatation and Curettage
just outside and parallel to the hymen at 5 or 7
•• This is a procedure done in gynecology for the
o’clock (depending on the side involved)
following indications
•• Cyst Incision: A second incision then opens the
–– Diagnostic (Endometrial biopsy)
2
Obstetrics and Gynecology

ƒƒ Abnormal uterine bleeding (Esp. in the

perimenopausal age group)
ƒƒ Post menopausal bleeding
–– Therapeutic
ƒƒ Excessive bleeding not responding to
medical management (Therapeutic
curettage)
ƒƒ Incomplete abortion/ retained products of
conception
ƒƒ Retained bits of placenta
•• This has also been discussed under Operative
Obstetric procedures
•• It primarily consists of 2 steps Instruments used in a D & C (in this order)
1. Dilatation 1. Sims Speculum
2. Curettage 2. Anterior Vaginal Wall retractor
1. Dilatation: Can be achieved my medicine or by 3. Vulsullum
surgery
4. Uterine sound
a. Pharmacological dilatation: Misoprostol (PGE!)
4oo mcg 2 hour prior to procedure (oral/ 5. Hegar Dilators
vaginal/ sublingual) 6. Uterine curette
b. Mechanical dilatation: Hegar’s dilator •• In Fractional Curettage, the endocervix is
also curetted prior to sounding the uterus and
dilating the internal os. This is useful in post-
menopausal bleeding when there is a suspected
endocervical cause of bleeding also

HYSTERECTOMY
Types and Routes
1. Abdominal
2. Curettage: Curetting the endometrium; when used 2. Vaginal
in a non-pregnant uterus, the sharp end of the
3. Laparoscopic
curette is used
a. Laparoscopic Assisted Vaginal Hysterectomy
(LAVH)
b. Total Laparoscopic Hysterectomy (TLH)
Steps in an Abdominal Hysterectomy: Basic steps
(After entering the peritoneal cavity)
•• Clamp, cut and ligate the Round ligament
•• Clamp, cut and ligate
–– The ovarian ligament (if ovary is to be
preserved)
–– The infundibulopelvic ligament (if ovary is to
be removed)
 3
Operative Gynecology

•• Open the leaves of broad ligament ligaments but in the opposite direction
•• Open the utero-vesical fold of peritoneum and –– B/l Uterosacral ligaments are clamped, cut
dissect the bladder away anteriorly and ligated
•• Skeletonize (make bare) the uterine arteries –– B/l Mackenrodt ligaments are clamped, cut
and ligated
•• Clamp, cut and ligate the uterine arteries
–– B/l Uterine arteries are clamped, cut and
•• Clamp cut and ligate the Mackenrodt (Cardinal)
ligated
ligaments
–– B/l cornual structures (round ligament and
•• Clamp, cut and ligate the uterosacral ligaments
fallopian tube) are clamped, cut and ligated
•• Clamp and cut the angles of the vault
•• Usually in a vaginal hysterectomy, the ovaries
•• Remove the uterus are not removed as the infundibulopelvic
•• Suture the vault ligaments are difficult to approach vaginally.

Steps in a Vaginal Hysterectomy: Vaginal Steps in a Total Laparoscopic Hysterectomy:

hysterectomy is preferred when there is uterine
•• These are similar to an abdominal hysterectomy
prolapse and when there
•• The main difference here is the ligaments are
•• Here, first the peritoneal cavity needs to be
not clamped
entered
•• They are coagulated (using energy sources) and
•• A circumferential incision is given on the cervix
then cut
•• Anteriorly the bladder is separated from the
Other important points to keep in mind during a
cervix and peritoneum is entered by opening the
hysterectomy
utero vesical fold
•• Posteriorly, the Pouch of Douglas is entered
•• Now begins the clamping, cutting and ligating of

1. Ureteric injury: is seen during hysterectomy

MC site At the ligation of cardinal ligaments and uterine vessels

Simple abdominal hysterectomy (As they are commonly performed but if asked most
MC surgery
likely with; then the answer is during a radical hysterectomy)

MC type of
Obstruction
injury
MC activity
Attempts to obtain hemostasis
leading to injury
MC time of
None; 50-50 split between intra-op and post-operative diagnosis
diagnosis
•• Anatomy of the ureter c. Courses below the uterine artery
a. The ureter enters the pelvis by crossing over anteromedially towards the bladder base
the bifurcation of the common iliac artery
MYOMECTOMY
b. Passes medial to the ovarian vessels
•• This is a surgery which involves removing
c. As it descends, it lies medial to the internal leiomyomas; usually done to preserve fertility
iliac branches and anterolateral to the
uterosacral ligaments •• This can be done by

d. Traverses through the cardinal ligament 1 – a. Laparotomy

2cm lateral to the cervix
4
Obstetrics and Gynecology

b. Laparoscopy
c. Hysteroscopy (type 0 and 1 fibroids)

IMPORTANT CONSIDERATIONS PRIOR TO MYOMECTOMY

• It should be done mainly to preserve the reproductive function.
• The wish to preserve the menstrual function in parous women should be judiciously
complied with.
• Myomectomy is a more risky operation when the fibroid(s) is too big and too many.
• Risk of recurrence and persistence of fibroid is about 30-50 percent.
• Risk of persistence of menorrhagia is about 1-5 percent.
• Risk of relaparotomy is about 20-25 percent.
• Pregnancy rate following myomectomy is about 40-60 percent.
• Pregnancy following myomectomy should have a mandatory hospital delivery,
although the chance of scar rupture is rare (little more when the cavity is open).

•• Myomectomy can be associated with

significant blood loss. Steps to reduce
blood loss at myomectomy are:
–– Preoperatively
ƒƒ GnRH agonists: They also reduce the size
of the fibroid Bonney myomectomy clamp
ƒƒ Correction of anemia/ blood transfusion
ƒƒ Uterine Artery Embolization SURGERIES FOR UTERINE PROLAPSE

–– Intra-operatively Depends on the type of prolapse and usually involves

a combination of procedures
ƒƒ Use of Bonney’s uterine clamp/ uterine
tourniquet (tied at the level of the •• For Anterior compartment defects
uterine arteries) –– -Anterior colporrhaphy
ƒƒ Use of vasopressin: injected along the • For vaginal apex defects
planned serosal incision
–– In a patient with a uterus: Usually involves a
•• Important Instruments to be able to identify vaginal hysterectomy along with suspension
used in a myomectomy are of the vault by uterosacral ligament fixation
a. Myoma screw OR Sacrospinous ligament fixation of the
vault
b. Bonney’s myomectomy clamp
–– In a patient without a uterus: Abdominal
sacrocolpopexy (anchoring of the vault with
the sacrum)
•• Posterior compartment
–– Colpoperineorrhaphy

Myoma screw
 5
Operative Gynecology

Anterior Colporrhaphy

Abdominal/ Laparoscopic sacro-colpopexy

•• Ward Mayo repair means Vaginal Hysterectomy

+ Anterior colporrhaphy + Posterior
colpoperineorrhaphy
•• In women who are very old and have several co-
morbidities and are unfit for major surgery,
an obliterative procedure can be done where
the anterior and posterior vaginal walls are
approximated. This is a short procedure which
can even be done under local anesthesia. It is
Posterior Colporrhaphy
called Le Fort’s Colpocleisis

Le Fort Colpocleisis

•• Surgeries involving preservation of the uterus

1. Sling surgeries
Uterosacral suspension
ƒƒ Shirodkar’s Abdominal Sling: Using fascia
lata: Cervix to Sacrum
ƒƒ Purandare Sling: Rectus sheath/ Mersilene
tape
•• Khanna’s Sling: ASIS to cervix
2. Fothergill or Manchester Repair: Done in
Infra-vaginal cervical elongation in patients who
do not want conception. It involves:
ƒƒ Amputation of the cervix
ƒƒ Plication of the Mackenrodt ligaments
(And uterosacral) in front of the cervix
Sacrospinous fixation
ƒƒ Anterior colporrhaphy and posterior
colpoperinorrhaphy
6
Obstetrics and Gynecology

3. Shirodkar’s Modification: No cervical amputation

•• Steps of Manchester Repair

Amputation of the cervix

Striping the cervix of the overlying vagina

Bringing the uterosacral and cardinal ligaments over the

amputated cervix

Separating the bladder

Separating the posterior vaginal wall

Covering the cervix with the vaginal mucosa

Clamping and cutting the uterosacral and cardinal liga-
ments
ENDOSCOPIC PROCEDURES
LAPAROSCOPY
Indications of Laparoscopy in Gynecology
Diagnostic:
•• Acute pain
•• Chronic pelvic pain
•• Pelvic mass
•• Infertility
•• Amenorrhoea
 7
Operative Gynecology

•• Mullerian anomalies

Operative Indications
•• Tubal sterilization
•• Adhesiolysis
•• Biopsies
•• Salpingectomy
Verres needle
•• Ovariectomy
•• Ovarian cystectomy
•• Hysterectomy
•• Myomectomy

C/I to Laparoscopy
•• Comorbidities (severe cardiac/ respiratory)
•• Acute glaucoma
•• VP shunt
•• Generalized peritonitis
•• Shock Different point of entry of the verres needle
•• Advanced pregnancy
2. Primary port and Accessory port creation
Principles of Laparoscopy •• The primary port is through which the
1. Creating a pneumoperitoneum. laparoscope will enter

•• This can be done by a Verres needle •• The accessory or secondary ports are through
which the laparoscopic instruments will enter
•• It is typically inserted at the level of the
umbilicus as there is no fat or muscle at this 3. Instruments and equipment in a laparoscopic
site. surgery

•• Palmer’s point is preferred if adhesions are •• Laparoscope

anticipated. This point is 3 cm below the left •• Camera head and camera system
costal margin in the mid-clavicular line.
•• Light source
•• Intraperitoneal placement of the needle is
•• CO2 (is the gas used) with insufflator
confirmed by
•• Laparoscopic Instruments
–– Drop test: place a drop of saline on the hub
of the needle and life the abdominal wall; the •• Energy sources
drop is sucked in
–– Monopolar
–– The insufflator will show a reading of
–– Bipolar
intraperitoneal pressure < 10 mmHg (single
digit reading) –– Harmonic (ultrasonic)

–– Push 5 ml of saline in the peritoneal cavity

and then attempt to aspirate it. No fluid can
be aspirated if the needle is in the peritoneal
cavity.
–– Liver dullness is obliterated if CO2 is flowing
intra-peritoneally.
8
Obstetrics and Gynecology

HYSTEROSCOPY ƒƒ Good for minor procedures using bipolar

instruments/ office procedures as there
is very less risk of electrolyte imbalance
•• Dextran 70
–– Useful in patients with bleeding as it does
not mix with blood
Hysteroscope –– Can cause anaphylaxis, electrolyte imbalance
•• Hysteroscopy is a procedure to visualize and and fluid overload
operate inside the uterine cavity •• Low viscosity, nonconductive fluids like 1.5%
•• Indications of Diagnostic hysteroscopy include: Glycine, 3% sorbitol and 5% mannitol

–– Abnormal uterine bleeding including –– Used in operative hysteroscopy using

postmenopausal bleeding monopolar resectoscopes

–– Infertility –– Safe as there is no electrolytes to disperse

the current and impede the electrosurgical
–– Mullerian anomalies (usually combined with effect
laparoscopy for diagnosis)
–– Associated with electrolyte disturbances and
–– Recurrent pregnancy loss fluid overload
–– Misplaced IUD •• Fluid Management during hysteroscopy
–– Chronic pelvic pain –– During hysteroscopy, systemic absorption of
–– Suspected AV malformation uterine distension fluid occurs through open
sinuses or vessels.
•• Indications for operative hysteroscopy include
–– Increased fluid absorption is seen in
–– Endometrial polyp
ƒƒ Higher intrauterine pressure
–– Submucosal fibroids
ƒƒ Longer procedure duration
–– Lysis of intrauterine adhesions (Asherman
syndrome) ƒƒ Deep myometrial penetration

–– Endometrial ablation in AUB ƒƒ Large uterus

–– Septoplasty (Resection of septum in a septate –– Excessive absorption of hypotonic

uterus) electrolyte free fluids, such as 1.5% glycine
and 3% sorbitol, can cause hypo-osmolality,
–– Removal of missing IUD/ Foreign body in the hyponatremia, cerebral edema, hypotonic
uterine cavity encephalopathy, permanent neurologic
–– Endometrial bipsy injury, heart failure, pulmonary edema, and
death.
–– Tubal cannulation under hysteroscopic and
laparoscopic guidance –– Excessive absorption of normal saline is not
associated with hyponatremia; however, it
–– Insertion of Essure device for female
can cause volume overload, right-sided heart
sterilization
failure, pulmonary edema, and death.
•• Fluid media: The following distension media
–– Fluid deficit can be estimated by manual
can be used in hysteroscopy
calculation or by use of an automated fluid
–– CO2: Good for diagnostic procedures but management system.
not for operative hysteroscopy and not
ƒƒ When using hypotonic solutions, the
commonly used
maximum allowed fluid deficit is 1000mL
–– Normal Saline for healthy patients and 750mL for
elderly patients or those with medical
ƒƒ Not to be used with monopolar electrocoagulation
comorbidities.
 ƒƒ For normal saline, the maximum allowed
fluid deficit is 2,500mL for healthy
patients and 750mL for those with
cardiovascular disease.
•• Fluid absorption can be reduced by
–– Pre-operative treatment with GnRH agonists
–– Intraoperative injection of dilute vasopressin
(0.05 U/mL)
–– Using the lowest intrauterine pressure that
provides adequate visualization
–– Intra-uterine pressure should be below the
mean arterial pressure.
•• If excessive absorption of fluid occurs with
a hypotonic fluid; obtain serum electrolytes
and the patient should be evaluated for volume
overload.
–– Asymptomatic hyponatremia can be treated
with fluid restriction and careful monitoring
of urine output
–– Treatment of symptomatic hyponatremia
requires infusion of 3% sodium chloride and
managed in intensive care.
–– Fluid overload from normal saline can be
managed by fluid restriction; IV furosemide
(20-40mg) is indicated if there is clinical or
radiological evidence of pulmonary edema.