ObGyn

Ectopic pregnancy- Management

↳ Ruptured Ectopic:Always R by Surgery

·
Plan of Action:

↑scitation -> ↑ploration ->

↑ingectory
Fluid Replacement)
1 removal of FT)

1
-

Unstable atstrable pt. (rare)

# ↓

Laparotomy Laparoscopy
↳ Unraptured Ectopic:Options:
as Surgical Mx
3) Medical Mx (mostcommon)
Mx (Wait & Watch)
1) Expectant -
rarely done
Medical Mx:
Doc-recate
L
- >
Single dose variable dose
Therapy preferred) Therapy
H ↓

Day-2] Jnj. Mtx (somg/m2 23 D., D3, D5, 7

-Jnj. Mtx (2 mg/kg)
Day-4] Check B.HCG leg: 2000 T/2)
2382 8400 88
Day-7] Recheck B-HCG Inj. Falinic Acid & Do B-HCG
=

I should & by 15%) (eg. 1700 TV/2) ↓

- 4 B-HCG falls by 15%, no

A Yes If No further closes are

given
H ↓

&is over Repeat

204 07 If
* failed
4 inj. have
/Max. I repeats) Treatment
-
Failure

Requirements for Medical Mx:

1) Stable pt.
2) B-MCG upto 5000 [W/L
Acc to DVT
2023
-3) Gest saw size upto
3.5 cm
activity + nt)
(If cardiac
Worktookpg665 4)Gest. sac size upto 4cm (If cardiac activity -nt)
↓ 3) No 2/1 to Medical My (eg. Anemial
If condiac
Activity
Surgical Mx:Laparoscopy
N
Surgery is preferred

If family
is COMPLETE If family, NOT COMPLETE
11

SALPINGECTOMY SALPINGOSTOMY
removal) (Open tube, remove ectopic.
Do NOT close the tube)

Rubin's
*
Paalmann's
*
Criteria
Criteria
I For Dx of Cervical Ectopic

Spiegelberg
*
criteria:Dx of Ovarian Ectopic

Studiford
* Criteria =
Dx of 1 Abdominal Ectopic
Terminologies:
*

2YGOTE fertilization to
=
2 weeks

EMBRYO=3rd week 8th week

to

FETUS gt
-
week till birth

Zygote = Collection
of cells %
Embryo
Fetus
-

=
Poles are present
Resembles human being.
0
⑤

(171) all the following drugs are contraindicated in pregnancy except

a. ACE inhibitors
b. Tetracyclines
c. Warfarin
d. Valproate

Solution. ACE Inhibitors, tetracyclines and valproate should not be used throughout
pregnancy
Warfarin if needed can be given specially in second and third trimester and can also
be continued in third trimester if the dose is less than 5mg/day. Teratogenicity is
maximum when dose is more than 5mg/day and between 6-12 weeks
Answer. c
The following changes occur in puberty:

Thelarche refers to breast development, which signifies

the start of puberty in girls. It is due to the action of
estrogen and progesterone.
Pubarche occurs after thelarche, and refers to the
appearance of pubic hair. Adrenarche refers to the
increased secretion of adrenal androgens which leads to
pubarche.
• Growth spurt occurs due to a rise in sex steroids, which
leads to an increase in growth hormone levels and IGF-1.
• Menarche refers to the beginning of menstruation due
to an increase in follicle-stimulating hormone (FSH) and
luteinizing hormone (LH).

-Thickness of Endometrium...
↳
After menses =0.5 min
↳ Around ovulation= 3 mm

↳ Luteal phase 6mm

=

(5-6mm)
↳ Implantation 10-12 mm
=
Primary > Absence of menses by 15 yrs of age,
Amenorrhea In presence of 2" sexual characters

Rule
* outPregnancy ·If 2 sexual characters ABSENT
yes is cutoff.
↓
↳ 13
then

USG

steries
Uterus #

↓ ↓
FsU levels
Karyotype ↓
- >
↓ d
↓ High ① Low
46XX 46 XY ↓
↓
↓ ↓
S
MRI
*
⑤MULLERIAN
AGENESIS *
GONADAL
DYSGENESIS
RF0RATZ
HYMEN
↓
⑤
# ↓ ·
KALLMANN
R:Sacral Contact HRT Δ/d SYNDROM
~ Vaginoplasty =Transverse
TVF+ surrogate Adoption Vaginal
⑤
TUMOUR
·

Septum IN BRAIN
~

Pulsatile
GnRH Ago

* 1 Ix to be done after rulingoutpregnancy = USG

* 1.0.1. for 1Amenorrhea Karyotype

=

↑ AIS (Refeinstein syndrome)

Partial
↓
Some receptors are sensitive

differentiate?
How to
↓

Clitoris
I ↓
Hypoplastic Clitoromegaly
1 11
AIS Partial
AIS
Lab Abnormalities in PCOS:

1) Serum Testosterone levels:mildly raised

· value in females 70ng/dL

=

· In PCOS =
Unto 150 ng/d2, definitely < 200ng/dL
1,280 Tumour secreting Androgens)
=

Sometimes
* => ΔHEAS may also be mildly raised (Adrenal

levels: 3
2) LH levels:
Hratio
pr
FSH

↓ (x2 -

3:2)
Is itmandatory for PCOS?
=> is
No, it a
finding.

3) Total Estrogen : . ↑ (in obese

↓
-
⑧
④ (in thin)
zza Ez
π

RahiEs/2 reversed
is

4)
SHBG
Why? - i) Hyponinsulinemia
2) ↑ Testosterone
3 ve influence on
SHBG synthesis

5) Lipid profile:Dyslipidemia

6) OGTT:Insulin Resistance

7) TSH :
-
Why done?I: they present
with
8) Probachn: ④
->

Amenorrhea

9) USG =>
Polycystic
Ovaries.
Managementof PCOS:
① Wt lors

② For himatism/Menstrual
irregularities:
· DOC 0C Pills
=

2nd=
·
Spironolactone
· 3rd Cyproterone acetate
=

Others: GnRH Ago &

·
-
Antag
-
Flutamide
-
Finasteride
-

Eftornithine (topical)
-

(it Insulin
Metformin Perist

Infertility
③ For
Wt.
① reduction
② Ovulation
Induction - DOC Letrozole
= (Aromatase a
↓ (others:SERMs+Cmi.Cit., Tamoai)
2nd line:

Injectable Gonadotropics > Ovarian

Drilling
-

Enj. 4MG (Laparoscopic

-
Recomb. FSH
* ASRM clarification
[American Society of Reproductive Medicine]

I
Type -I Mullerian
=
Agenesis

Type-2 Uniconnuate Uterus

=

↓
·
May be alw Ectopic
Ovary
· Can cause U/L Dysmenorrhea
(If rudimentary horn opening is blocked)
·
Pregnancy may occur in rudimentary horn

Type -
3 = Uterine Didelphius
Type-4 Bicornuate
=
(Unicollis)
Type-5 Septate
=

Aeratogen)
Type-C Due to exposure to DIS (in utero)
=

edterine
Cavity. Bo
ngitis
* anomalies
Any female with Mullerian
Has high risk of S.Urinary TractAnomalies
Parameson
Mesonephros & are close)

**DES -0T-shaped uterine cavity (infemale baby)

② Clear Cell Ca of vagina
③ Male fetus - Hypospadias
④ female fetus - no renal anomalies
seen

⑤ Male fetus - also causes Renal

anomalies.
Septic pelvic thrombophlebitis- Management
=IV Antibiotics + Heparin

* If an elective
Surgery is planned
H
Ok pills are to stopped 4 weeks before Surgery.
ABNORMALITIES PLACENTA:
OF

1) URVALLATE
PLACENTA

= Plate Unutilized
Smaller Chorionic +

ring of
Decidua Basalis

·o
raised margins

*
marginateplacenta
Circus "raised margin"is a sent

&>
↳ Small placenta
functional
↓
May cause:

· IWGR
·
Oligohyd
· Preterm
· APH mother's blood
=

↳ Mx Fetal =

Monitoring (Biweekly)
Terminatepregnancy @36 weeks (Oligohydr)
⑨ 38 weeks (If IWGR)
· 34 weeks (Oligo IUGR)
+
2) NTURA TZ
PLACENTA

O
~

extra late
=
↳
May cause PPH due to retained
lobe of placenta

↳ R.Manual removal of extra late of placenta

#R
Post-Partum
curettage (Highestrate of Asherman synchrome)
Placenta
* Spuria Extra lobe notconnected by vessels
=

=
of succenturiate placenta:
Complications
· PPH
·
Subinvolution
Uterine
·

sepsis
~
Uterine Polyp

Mx:Utenus exploration removal of missing lobe under GA.

3) LEDORE
PLACENTA

&
~
-

=
Marginal
insertion of L. cord

↳ Rare
↳
May cause cord avulsion and bleeding
↳ May cause fetal Distress
4) VELAMENTOUSPLAC.CN#
= Card inserted into membranes
(vessels in membranes)

0 =
bit

①
. 0s

Cervix * Vasa Previn A-

= Vessels above
internal 0s

* Vrasa Previn -
B = Vessels above
tent 0s in
.

succent.usate Plac .

↳ ARM ( Artif .
Rupture of Merrill
is CONTRAINDICATED

↳ On WSG Doppler (I0C in AN C)

d
•
If Alive Baby + Vasa Previn =
C. section

•
If Dead Baby + Vasa Previn =
10L / Va g. delivery

* Ix used to detect fetal blood in APH

= Art .
test ( Qualitative Test)

Principle : Fetal blood is ALKALI RESISTANT

t
No Hemolysis adding alkali IK0H)
'

. .
on

in fetal blood
= APT + ve
t
Emery C- Section ?
.
PROLAPSE
Herniation
=

of Pelvic
Organs into
or
beyond the vaginal walls.

#Lanery's
levels of Supports:

① Level-2=Uterosacral & Cardinal Ligaments

-
If weak
↓
· Uterus & Servix +
pholapsa
·
Vault
Prolapse
Nault=Apexof vagina a
in
post-hysterectory pt.
·
Enterocele
* Some terms:
1stdegree prolapse =
Descent butorgan lies above
the vaginal opening
2nd Descent upto
the level of
=
vaginal
opening
3rd Lies outside the vagina
=

Procidentia = Entire uterus lies outside

② Level- 2 =
Paravaginal attachment
tissue and its
to
fascia covering Levator Ani
↓
If Weak Cystocele
=

↓
m.c.
organ prolapse
type of Pelvic
↓
c/c =

Difficulty in
passing wine

Prolapse of
-

bladder from Ant. Vag. wall (2/3)

③ Level-3 Perineal
=

body and muscles attached

to it.
↓
Posterior:D istal Rectoccle
Anteriors Wrethral
=

Hypermability
[c Stress
=

Urinary Incontinence (SVI]]

↓
when Intra-abdo pressure res

-> from lower 3 of Post.Vag. wall

Uppents of post. wag. wall

(level. I defectred risk post-Hysterectomy.

Prolapse
* - More common in Elderly females
(less common in reproductive age)
Toxic Shock Syndrome in Septic abortion

Organisms causing toxic shock syndrome in septic abortion:

Streptococcus pyogenes
Clostridium perfringens
Clostridium sordellii

Clinical features of septic abortion:

Fever with chills and rigors
Abdominal or chest pain
Diarrhoea and vomiting
Renal angle tenderness
Offensive purulent vaginal discharge.

Clinical grading of septic abortion:

Grade I - infection localized in the uterus
Grade II - infection spreads to parametrium, tubes, ovaries,
or pelvic peritoneum
Grade III - generalized peritonitis, endotoxic shock,
jaundice, or acute renal failure

Empirical antibiotic therapy in septic abortion is

started for the broadest microbial coverage. Piperacillin-
tazobactam or carbapenem and clindamycin are
given intravenously. Antibiotics can be changed once
culture sensitivity reports are available.
HOV vaccines

Nov and associated lerions:

-3id-4th week postpartum
Mastitis ->
Red, swollen breast. Fever, tachycardia
↳ M.C. =
Staphylococcus aureus It is infant's more & throat)
4 Mx:

· should be continued. Expression of breat

Breastfeeding
milk & Pumping of breasts relieves engorgement Crdema.

Baby fed from uninvolved breast first. (allows milk

is

let-down reflex to begin before

moving to involved breast)

·
Dicloxacillin. Erythromycin for penicillin-sensitive
women.

* If resistant organisms suspected:

vancomycin/Clindamycie / Cotrinoxazole

* If Abscess formed -
surgical drainage under GA

Vasectomy
↳ Patient should use additional contraceptive measures

for 3 months after undergoing racectomy.

the
(At least 20 ejaculations are required to empty
-

stored semen (
E
·
WHO Semen Analysis parameters :

(min values required for conception)

·
Volume =
1.5mL

·
pH = 7.2

·
Total Spam Count 39
= million / ejaculate

sperm concentration
· 15 million Imh
· Total Motility 40%
=

·
Progressive Motility =
32%

·orphology
or
on
= 4% (StrictTygenberg Criteria

·
Vitality 580/0
=

Some
* conditions;

①
Oligospermia : <15 million / mL
② Aspermia : Absent semen

③ Azoo spermia No sperms in semen

/
④Teratospormia:A morphology
⑤ Asthenospermia:Ab motility
-
Kartagener Syndrome
Cabsent was)
Non-obstructive Klinefelter's (Cystic
Fibrosis / Young Syndrome
Azrospermia
(testes - Hypoplastic obstructive acoosperials
#AMENT of Male factor Infertility:
1) Obstructive
Azoospermia
#

Surgical Resection
and Reanastomosis

2) Non-Obstructive (defectin spermatogenesis)

Azoospermia
Microsurgical TESE (Esticular Sperm Extraction)

TESE ICSI
+
is treatment

* If sperm counts 10-15 million (mL - IVZ

5-18 million/mL -> IVF

<5 million/mL ->

ICSI
Endometriosis Management
Pain (CDysmenorrhea) (m.c.c. Endometriosis) =

(Relevanthistory /examination)
↓
WSG
#
·the
patient
Minimal to Severe
Moderate pain Pain

↓ Long Eth. Estradiol)

#
↑Ds
+ OCPs

-
Laparoscopy

surness overies
+

GnRH Ago/ Antag

If not
responding
↓ AGICAL
MANAGEMENT
↓

Therapy redualisee
ty
#

↑sterone ·
Adhesiolysis
Continuous ·
Laser / Electrocautery
·
(Mirena)
JUD -

Burn the implants

·
Injectable ·
LUNA
(ΔMPA) (Laparoscopic terosacral

↓ Ablation)
Not Nerve
Responding After confirming 0x
by Laparoscopy ·
For patients
who have
completed family
↳
Agonists/Antag, ↓
For long duration Last
Resort

↓
=
HYSTERECTOMY
Not
responding

xmatase
Inhibitors (LastResort)
Cyst
Ovarian -

Chocolate Cyst
Does notrespond to Medical Mx

↳ If <5cm and asymptomatic

A
·
No treatment 1: Some ovarian
tissue may also be destroyed)
Follow-up
· with USG

↳
If > 5a and /or symptomatic
(Pain, Pressure)
H
Treat

C
No Aspiration
R.O.C:SURGERY=> CYSTECTORY
(Laparoscopic)
No Drainage C
Infertility
No ar 3 ovulation
Inhibit

↳ If Minimal-Mild Indometriosis -
Infertility
-
Clomiphene Citrate IWI X3 cycles
+

↓
SuperOvulation
↓]
If does not conceive
H
IVF
↑
↳ If Moderate -
Severe Endometriosis + Infertility
Functional Ovarian Cyst
↳ Asymp,
unilocular, clear third
↳
Usuallyregress sent. Within few months

My:<7cm = Observe. Can

give OC pills too

77cm =

Cystectomy)
Laparotomy (Inudeation
↓
if
notpossible
Ovariotomy
In
* peri-menopausal:Hysterectory with BSO
leven in benign & unilocular)

Findings
* risk
with
of malig:
·
cystpersists for 3 months
·
lize Iam
Vacuum delivery

·
suction cup placed at a point near occipat
= Flexion point
-
or saggital nature
-
6cm form centre of anterior fontanel and
3 cm from posterior fontanel

·
Vacuum presume: 0.2kg/cm I
gradually fed to
kg/cm @O.1kg)cmair
-
0.8

Traction
Synthesightangle to
·

a
ring contraction
EPISIOTOMY SCISSORS:

*structures
cut episiotomy
in

1) Posterior vaginal wall

2) Bulbo cavernosus

3) Transverse periscal muscles

4) Parts of Levator Ani (Pubococcygens inually)

5) Subcutaneous a skin
tissue

6) Transwers perineal branch of pudendal venels

& nerves.

↳ Done under LOCAL ANAESTHESIA

↳ Notdone routinely.
a. given bilaterally
b. 18-20 gauge needle used
c. given superior to the ischial spine
d. does not abolish sensation from anterior perineum

Solution. C

Lower vagina, perineum and vulva obtain their sensory and motor
innervation from sacral nerve roots 2,3,4 via pudendal nerve.
Pudendal nerve block does not abolish sensation to the anterior
part of perineum because the region is supplied by branches of
ilioinguinal and genitofemoral nerve 10 ml syringe with 18-20
gauge needle is used. The block is bilateral the needle is placed on
sacrospinous ligament approximately 1 cm medial and inferior to
ischial spine.
Answer: c
NORMAL
② LABOR PARAMETERS

Nullipara Multipara
Eupper limitsof ] Supper limits of]
Latent
phase < 18.2s his 114 his
[Arg:-12 his] [Arg! 8 his]
Active phase ->-x
Continued progress -

I see above)

second stage = 3 his =2 hrs

# 4 has if epidural) 13 has if epidemal)

Carg:1h) Carg:30 min)
Third stage = 30 min =30 min.

Aug:15 mins) (Arg:15 min)

Parameters
*
of Uterine Contractions

·tone:
<20mm4g
(Pressure When contraction

goes away)
·
pressure:
80 Hg mm

Adequate contractions:
contractionson
has
a
· in the
*

&
contractions
which generate a pressure
of Montevideo
25 0 units

* Montevideo units No. of uterine contractions

=
in 10 mins

Pressure generated
Eg.-3 x 40:120 Montevideo units

Why is itimp, for uterus to relax

* adequately?
=> Because only duringrelaxation
there is
UTEROPLACENTAL CIRCULATION

Min. of contractions
10 minone
=see
* no.

Max. no
of contractions =

↓
Because there will be LESS RELAX Why?
Impaired -p blood flow. FETAL DISTRESS
=
#NORMAL
UTERINE ACTIVITY

(I<m/hr)
·
Hypoactive uterus Interine inertia slow progress.

·
Hyperactive, over-efficient -> Precipitate Labor

·
Hyperactive, inefficient-incoordinate contractions -

Slow Labor (Contraction Ring / Schroedders ring)

· Tonic
contraction (Retraction
retraction ring Bandls ring) /
-
slow labor.

EXCESSIVE UTERING
CONTR

① · Tachysystole =>5 contractions / 10 min

= ·
Hyperstimulation:Tachysystole al FETAL DISTRESS
(ted FHR)

· contractions
Tetanic
single contraction
lasting >3 mins

·
Hypertonic
riterine contraction
Red Baseline pressure
=
>20 mmHg.
When atcomes I LABOR PAINS

#
False True
no chance in cervical Change in cervical
dilatation) dilatation)
↓ * n

My ATION =
LATENT ACTIE
[Pethidine Phenorgan) +

[cerv.dil.:0-5(m] [I6ch]
( Antihistamine
(Promethazine) ↓ ↓
[Diazepam used
not ->
why? · Painrelief & Slow?
May
=> cause
Flappy Baby Syndrome,
also causes muscle relax
adequate rest Crate of Cervical dilation)
↓ <
Epidural analgesia YES NO
(x)cm/hr) (lcm/h)
* sedatives

↓If notoptions ↓
· Wait & Watch Are contractions

adequate
W ↑ ~

Yes No
13 contr./10 mins,
Sm"1 45sec) (310 mins)
(220-250 Montevides units AUGMENTATION LABOR.
OF
# ARM
Assess for CPD/0p
↓
min
gap
=30 min
still slow/already ruptured.
↓ [occipitoposterior]
① Max 8IV in Mult
-
By doing or examination Occytocin (1-220) It IV in Primi

(look for Triangular Fontanelle)

Contractions
adequate
#
Assess for CPD/0p
↓ [occipitoposterior]
By doing or examination
(look for Triangular Fontanelle)
↓
Ifπ >
Delivery

1
↓
TRIAL OF
LABOR - end Fetal Distress
points: ->

- Caesarian
Section
Arrest
of Labor
If C.S.
not done

OBSTRUCTED
↓ ↑
LABOR
A
E ST
LABOR
OF

& Arrest
of ACTIVE PHASE OF LABOR
⑦
No change in
= cervical dilatation
even AFTER 4 HRS
of
adequate uterine contractions
OR GHRS of inadequate uterine

contractions

& Arrestof SECOND

STAGE
No descent
=

of head adequate sterine

with contractions
for 3 has primigravida
in && has in
multigravida
(With epidural analgesia -
This in primigravida and 3 his in
multigravida
done above ONLY IfFrm IS NORMAL
Waiting
* is as

CIf FHR Abnormal direct- Section)

Above criteria is
* AFTER RUPTURE
OFMEMBRANES

Arrestcan
* be a XONLY in Active Phase or second stage.

* Mxof Arrest CAESARIAN SECTION

=
Pathological Retraction
Ring Constriction Rina
(Bandl's ring) (Schroeder's Ring③

·
PROLONGED 2nd
Occurs in
Stage Occurs in 1st, 2nd on
and stage
·
Always biw upper & lower at. Seg At any level of uterus

· Rises up Position does NOT change

· felt & seen ABDOMINALLY FELT only VAGINALLY

·
Uterus is TONICALLY RETRACTED, Uters isn't tonically retr.
tender & getal partsCANNOT befeltfetal parts CAN be felt.

· MATERNAL DISTRESS & FETAL Maternal & fetal Distress

DISTRESS or Death may NOT
be
prevent
·
Relieved ONLY by DELIVERY May be relieved by
FETWS
OF ANTISPASMODICS &
Anaesthetics
#S
PELNS0.
OF
sUApe INLE
of

=RCODthropoid
a

Android nalypad end

[z2m.c.->
20%] common]
[Least
↓

↓ (50%)
↓ H (500)
HEART-SHAPED
INLET.
AlmostCIRCULAR Anteroposteriorly TRANSVERSLY OVAL

shape of Inlet OVAL #

aka FLAT Pelvis
Colour of amniotic fluid
↳
Early Pregn. =Colourless
↳ Near Term: Straw Coloured (Pale yellow)

↳ Green: MSAF: Fetal Distress

↓
Meconeum (Bilepig) Hyposcia
- ↓
↑Intest. Motility & Bradycardia --Vagal +

↳ Greenish -

Yellow/ Saffron => In Postmaturity

↳Golden coloured AF =

Conditions of Hemolysis
· Rh Incompat
· Parvovirus B-19
CMV
·

↳ Dark-Red AF =
Abruptio Placentae

↳ Dark Brown: In Fetal Demise (old UbA

Dobacco juice
GROWTH FITUS:(Depends
OF on fetal Insulin)

↳ Weight
300 gm - 20 weeks

500 gr
-> 22 weeks

600 gr
- weeks
24

1.2kg in India
1 -> 28 wks (Period of viability
-

1.8 kg ->
32 weeks

2.5-3.5kg - 37weeks

> 4kg -> > 42 weeks

↓

Abortion
* Termination
before 20 weeks

↳ Low Birth Weight:

LBW:<2.5 kg

Nery) VLBW:<1.5kg

(Extremely) ELBW:<1 kg

Gestational
* V w

Preterm Term Post-Term

weeks
1/ 11

<3 37-42 wks >42wky

↓
L
↳
weeks
+
Early Late Early Term
->

37
=
weeks to 38
Preterm Preterm -> Term =

39 was to 40+6 weeks

17 11 · Late Term 41 to 42 weeks
=

<34 Wk 34 to 36 was
Non-steroidal contraception:
Saheli = Chhaya (newest)
-Centchroman - has Ormeloxifence (SERM)

↳ CDRI Lucknow - Introduced in 1992

↳ M.O.A: It makes Endometrium out of phase

N

its
Implantation
↳ Sle: Delay in the Menstrual cycles
& Each tab =
30mg - use twice a week for
1st 3 months
H
then 1 Pill / week

best
Ans: I per week
Investigations in precocious puberty

1) Wrist radiograph for tone age

Se.
2)
FSH, LH, Ec levels
3) Sr. TSH levels
4) USG Pelvis
5) Skull MRI

Additional investigations in a
girl with virilization:
·
NHEAS
·
Tartaterone
· 17-x Hydroxy progesterone
·
Androstenedione
·
11-Deoxycortisol
STAGING of La Cervix
- F1G0
(Clinical Staging)

MRe) can be done for Cancer staging

cervix

BestIto
* look for Parametrial
spread?
=> MRI

* BestIXto look for Lymph Node spread?

=> PET -
CT

BestIto
* look spread?
for Wreteric
=> CT

↑GE-1 =

Confined to Cervice

*A -> I12:Depth of spread 13 mm

(Simple Extra fascial)

↳
Microscopic) ↓

(5mm) D.0.C.:CONIZATION / MYSTERECTOMY (Type -1)

(Type A)
-

1A2 >3mm but 5mm

↓ (TYPE B) -

D.O.C TYPE-2 HYSTERECTOMY

=

Mysterectomy) I
Modified Radical
#
=

are
Wertheines
PELVIC LYMPHADENECTOMY

RE:
>smm up a co
to

& Mx TYP2-2
=
HYSTERECTOMY
>2cm but 4cm

IB3 > 4cm

↑GE-2 Upper =

zed of vagina is invaded.

2A =
Parametrium Involvement
Without

2A1 < 4cm

2A2 >4 cm

2B With Parametrium Involvement

=

⑨
G7 3 -

3A = Lower bed of Vagina

pelvic
BrReachinglateral
3 all

3C CNs
= tve

3C1 tve
=
Pelvic
(N

3C tve
= Paracortic N

↑GE
4 -

&A Invaded Bladder / Rocturn

=

/Cystoscopy shows bladder edema of mucosa

NOT considered as 4A)

LB Distant Spread (Inguinal
=
(N Distant
=
spread)

When Tumor
* <acm Involves surrounding struct.
or

corange highlighted ones)

#
R.O.C. =
CHEMORADIATION
*Forgreenhighlightedonespectomy Radical
-
miss
# Type
=
-
C

PELVIC LYMPHADENECTOMY
Twin gestation and time of division of inner cell mass

(6-sign/twin-peak sign)
(T-sign on US()

L L
* Remnants:

1) Of Nmb.vein Ligamentum
=
teres

Distal Medial Umbilical ligament

2) Of Wmb. Artery >
part:
↓
[Mediran Umb.ligament
Primal part Wrachus
=
remnant]
Superior Vesical
=

artery

calmediarlelated
m
25 mb ligaments

3) of Ductus Arteriosus Ligamentum

= Arteriosus

4) of Ductus
Venosus Ligamentum
=

venosum

5) of Foramen Ovale:Fossa ovalis >Flor;Septum

Primum
· Secundum
Edges:Septum
(Anatomical closure of Favale at
1 year of life)
SIGNS OF PREGNANCY
1) Jacquemier's Sign / Chadwick sign:

Bluish discoloration
=

of Vagina & Vestibute respectively

Jacquemier's (Chadwick)
↓
Due to
venous congestion
(from 8th week)

2) Goodell's Sign Softening of

: cervix
↓ Cue to water retention)
6th week

3) Osiander's sign Lateral formiseal

=
pulsations
on

↓ Binanual exam
8th week (due to dilated uterine arteries)

4) Piskacek's sign On Bimanual examination

=

↓
⑨ 6-10 weeks Assymmetric Inlargementof terus
(due to lateral implantation)
5) Hegar's sign On Bimanual examination
:

↓
& 6-10 weeks empty lower partof uterus
+

Softening of Isthmus

6) Palmer's sign -

interine contractions
Regular, rhythmic
↓ felt on Rimanual escam
& 4-8 weeks
HEMATOLOGICAL CHANGES:
↳ Plasma val ↑ (20 50%) -

+
RBCs
count
(20 30%)
-

·
Hemodilution
in Pregnancy
Yes Placental
Perfusion
↓es blood viscosity TOTAL O2 carrying
capacity
It
↑ RBC
"
cone : there is in TOTAL
Hb come" Id Hb (NotHb conc")
#
Or carrying capacity
of (per unitvol of blood)

↳ WBC Court
↑ (Leucocytosis)
non-pregnant 11,000
=
·
in

· InANC -
15,000

· In Labor - 23-30K
-

Due to NEUTROPHILIA

· EOSINOPENIA
· absolute Lymphopenia

↳ RBC Life span ad to 110 days

↳
Erythropositio ↑↑50 10

↳ Platelet
count of low
to values

↳ All
clotting factors , EXCEPT factors &#
(procoagulant)
Mostimp reason
* of PPH Prevention?

Living Liature (Middle Layer)

TEATMENT of IDA
(<11gm%)
= Pills
2 IfA / day
Target:11gm% Hachieved, I IfA pill /
·
day
M.C. side
* effectof IFA GT UPSET
=

↑ Indications
of Parenteral To Therapy?

9) Non-Compliant pt.

6) Intolerantpt.

2) Severe Anemia
in early Ts (34weeks
d) If only Moderate Anemia given in que (POS not specified)
(generally is or Late in pregnancy is assumed)

Hb
* es at same oral?
rate withingas with

I
table Iron Preparations:

↳ M.C. Fe Sucrose
=
(IV)

Cartrosymaltose
↳ Best Ferric (very costly) (IV)
↑
SUCROSE:
↳
20mg iron
(mL =

(IV)
3 700mL
of NS 100mg Iron Admit
+
for daycare =

410-20 drops/min for 30 mins (to

check for
Hypersensitivity)
How
* much?=> Calculate Total Iron Requirement:

SWt.in
=2.3 x kg Hb
x deficitin gm /0)
#
500 mg for from stores
↑ Indications
for TRANSFUSION:
BLOOD

1) Hb <
5gm% (any POG)
2) Severe Anemia
in Late Ts (734 weeks)
3) Refractory Anemia

4) Anemia
Causing CCF

5) Hemorrhagic
episode (in
a case of anemia)
affecting vitals

6) Inadequate response to oral to (see below)

↳ I packed cell transfusion 1gm% ↑ in
=
Hb
CARDIOVASCULAR SYSTEM changes in pregnancy
1) HR (15 250/)-

2) Stroke Val (20-30%) I Blood val by 45%)

3) (08 (40-50%)
↳ starts from 5th week
ing
Peaks in ANC @ 28-32 wh
↓
Max. peak in Immediata Post-Partum
Period

Highestrisk of failure.
Cardiac

Imm post-partum stage > 32 weeks

of Labor

4) * softsystolic
murmur (Upto Grade-2)

murmur Pathological)
I Diastolic =

5) ECG-leftaxis Der.

6) CXR => Cardiac

shadow (due to rotation)
* Cardiomegaly isPathological
7) BP. PVR t -
- i. BP ↓
-
=> ↑ (ABP SBPd)
-

-
> HA ;

Pulse Pressure & Regn..HyperdynamicCircult)

8) CVp Constant
=

Lower
* limbvenous pressure
#

Pedal
* edema: (In T3) (Uterus presses on common

·
Physiological iliac veins
·
Pitting
· painless
· Relieved or rest (R: Bed rest)
Hypotension Syndrome:
Supie
Due to
failure of developmentof venous anastomosis

-
↓ Preload -
Hypotension
R: Left Lateral Position

Regional distribution
* of Blood flow during pregnancy:
B. F ded in:

·
Uterus
·

Lungs (Pulm. b.f.)

·

Kidneys (RBF)
·
skin & mucous membranes - causes symptoms

sense
↑heat sweating stuffy nose

M.C. fetal
* position
in Transverse Lie Dorwoanterior
-
INTRAUEPATIC CHOLESTASIS OF PREGNANCY (IU<p)
↳ cnd M.C.C. of Jaundice
↳ I bile flow (dilated biliary canaliculi)
↳ Alk. Phosphatase (non-specific)
&
SGOT, SEPTIF mildly) (never <2501U(L)
↳ CONJUGATED Bilirubin, but never>5mgo)
↳ M.c symptom=Itching (so aka "Pruritus of Pregnancy")
& Se. Bile acids of (most specific test for 2U(p)

4 DOC = UDCA (Urso -OeocyCholic Acid)

↳IHCP -> can cause MSAF, Fetal Distress

d
:Terminate Pregnancy by -38 weeks
AcUTE FATTY LIVER OF PREGNANCY (AFLP)
1 in 30000 preg.)
↳ M.c.c. of Liver Failure in
Pregnancy
↳ aka "Yellow Necrosis of Liver"

↳
Defect in Metab.of Long chain FA
(LCHAD enzyme defect)
4 S907, sapt of K2 7(L)
↳ Bilirubie P (Conjug + Unconj.]

↳ Seen m.c. between 30-38 weeks (Liver disorder is

m.c.in T3)
↳ IMMEDIATE TERMINATION of pregnancy
is a must

LIVERSUPPORT
↳ High carbs
↳ Low proteins
↳ Low fat
- Joy Vit-K IM

enemaleswaslab
-Lactelose/ Neomycin
tests
VIRAL HEPATITIS IN PREGNANCY :

↳ M.c. (Chronic Hepatitis)

=
Hep. B

3
↳ WORST Viral Hep
Hep. I pregn
↳ Fulminant Hepatitis is m.c. in

↳ Which Hep.virues can cross placenta? - B, C, D

↳Is HBsAg vaccine given to exposed its in pregnancy?

H
Yes. O, I month, a months
If itis
already
↳ HBsAg + ve

do HBeAg (envelope Ags)

↓
Marker of infectivity I transmission

↳
Breastfeeding is NOT C/I in
any Viral Hep.

re
in
↳ DOL for Hep-B? =>
re
Lamivudine

Baby should Active

Passive Immunity
↳ receive +

↓
UBsAgvaccine HB Ig
-

? 4 Not an indice for C-Section

HIV in Pregnancy
↳ All HIV the pregnant patients Give ART
->

4 ART given= 0
TEL, TLD
Tenofovir Efavirenz Lamivudine

-
men? from 1stvisit ->

· For how long? Lifelong

↳ Is HIV an Indication for C-section in India?
N
No. Although (- Section & chance of mother-to-
child
transmission
If ret. ART
*
Is on

Risk of PTCT 1-2%

=

only
↓X
If it has not given If pt. has given if
Breast feeding
. In India: Breastfeeding is NOT c/1 in HIV the

Pregnant women.

* In developed countries:

If viral load -
1000 copies/mL
Indication of Elective C-section
&38 weeks

* Vag. Delivery i

↳
Artif. Ron +c/I
↳ Instrumental delivery -> cII
↳ Invasive fetal monitoring c/2 ->

- Episiotomy -
avoided
&
Occytocin is given to a speed of labor
ab
20th
<Add to * Max risk of transmission during
-

Labor
Pard
NEET
sectors
-

should
I not ->12 wks
↳
Baby receive Nevirapin Prophylaxis ↑ NVp

12 mg/kg for 6 weeks) (7 mother on ART)

EXCEPTION:If pt.has already taken Nevirapie

in the past
↓
Replace it by
ZIDOVUDINE For 6 weeks

EXCEPTION:If pt. has taken ART in Antenatal period

for <4 weeks
A
Replace "6 weeks" by "12 weeks"
x Is HIV testing compulsory for pregnant patient?
N
No. It is done only if patient agrees ("Opt-out" method)
b
If pt. disagrees a
Don't force
Atonic PPH
1st = Bimanual Uterine Massage +

Fluid Mx
↓
2nd Vterotonic
=

Agents
↓
LRinger Lactate Zanacamic
(500m2)
+

(1gmIV)
Acid)
InjQaytocin Blood grouping Cross matching
12028 IV diluted) ↓
(Bolus Rcytocin never given) Blood transfusion
* Other:DPGE ( Misoprostal) (800mg)
Ergometrine IM/IV

4
② Juj. 0.25 mg

↓
③ Juj. Methyl Ergo. 0.2 mg In/ev
C12 in
Asthmatic ④ Jnj. (0 E)
Syntometrine +

⑤ Inj. PGF2x (Carhopost) 250mg IM (Maxsinj)

Cartoprost > Methyl Ergo
Powerful Stelatonic
Most
↑ ↑
If fails
Medical Mx eTamponadeone
Balloon
↑ =

Foley's Catheter

⑭mhache
·

·
Sengstaken Blakemore
· BakriBalloon
↓

inmatibon

Uterine Artery Embolization

(Pt should be stable)

fails
↓
I not
available

Surgical Mx
EploratoryLaparotomy
one
=

(if Vag.deliv.)
Haymann's suture
① =>

⑪
⑪ "B-Lynch" Suture (for C-section)

04!f
②

.
⑪Cho Suture Bax stitch
=

Multiple places

↓ failure

Devascularisation
Procedures
·
Utering Artay Ligation
· Branch of OvarianArtery Ligation
·
Ligation
Ant. division of Int. Hiac

failure
↓

Hysterectomy
Obstetric
Concurrentcorrection
of DK is a must
CDC criteria for the diagnosis of PID:
Definitive criteria:
. Histopathologic evidence of endometritis on biopsy
• Imaging studies (TVS/MRI) evidence of thickened
fluid-filled tubes (tubo-ovarian abscess)
• Laparoscopic evidence of PID

Minimum criteria:
• Lower abdominal tenderness
• Adnexal tenderess
• Cervical motion tenderness

Additional criteria:
• Oral temperature of >38.3C
• Mucopurulent cervical or vaginal discharge and cervical
friability
• Raised ESR oF CRP
• Laboratory documentation of positive cervical infection
with Neisseria gonorrhoeae or Chlamydia
HELLP
* syndrome

↳ Dx:Tennesses criteria
Hemolysis
⑦ Bili
S.P.S:
=
1.2

Schistocytes (LD4 >600,x]

Anyaof
Haptoglobin
↳ Severe
25 mg/dL LDH 2 times
anemia, explained
(AST> 70(r/2)
③
Elevated Liver enz

↳ AST/ALT=2x
⑥ Low platelets
↳ Plt<1 lakh/m
Plt
LDH
↳3 grades -
Mississippiclassification
ALT
4
PT, PT, Fibrinogen levels N
=>

(Diff. From DIC =>

PT, PT 4; Fibrinogend)
4 15% women-> have NBP.
.I
Myometrium

Reproductive
-

>35 ys 40-45 yrs

t
age

Imp. component Menorrhagia Irregular bleeding Menorrhagia

presenting complaint (Metrorrhagia) I

Dysmenorrhea
·
Enlarged
Kan grow upto (Usually grows up to
20 weeks size) 10-12 weeks size)
·symmetrically enlarged)
/GLOBULAR Uterus)

· Tender

I.0.2 WSG

see small
I CUSG isthe FIRST
L
Ix)

Thickened junctional
to braidsaFleet
submucosal ene
·

· Narrow base
=12 mm thick
vessels
to be
↓
· Solid · LIKELY
· Broad base Adenomyosis
·
surface vessels
How
* to make Dx?
↓

endomBydagraStaudang
nowre
Will
*