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GOB
INDEX
Topics Pg. Nos.
20 Heart Disease in Pregnancy 83 - 86

21 Abruptio Placenta 86 - 88
22 Torch 89 - 92
23 Placenta Previa 93 - 94
24 Preterm Labour 94 - 96
25 Rh Isoimmunisation 97 - 98
26 Polyhydramnios 98
27 Pcod 99 - 101
28 Prolapse of Uterus 101 - 107
29 Iugr 107 - 108
30 PPH 109
31 Endometriosis 110 - 112
32 Induction of Labour 112 - 113
33 Bacterial Vaginosis 113 - 115
34 Instrumental Delivery 115
35 NST 116 - 117
36 Twins 117 - 118
37 Carcinoma Vulva 119
38 Gonococcus and Chlamydia 120 - 121
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TOPIC - 1 CONTRACEPTION l The continuous administration of analogues
of GnRH causes a fall in the sperm count and
l Mirena lUCD sperm motility
l loss of libido and osteoporosis makes this
„contain LNG progestogen in a silastic
reservoir regime unacceptable over a long period.
n Medroxyprogesterone acetate
„ 20 microgram hormone is eluted in 15
n Desogestrel
minutes after its insertion (MCQ)
„ peak level reaches in a few hours.
Suppression of ovulation (hor monal
m
„ The hormone does not get absorbed into the

contraceptive agents)
n In 1956 , Pincus first brought out an oral
general circulation (or minimal amount) so the
side effects of systemic administrations contraceptive drug
n three types of hormonal oral contraceptives,
are not seen.
l combined oral pills
„ It does not suppress ovulation(MCQ)
l triphasic combined pills
„ Its effect is mainly on the endometrium
l minipills.
and cervical mucus.
n Combined oral pills
„ Because of this, Mirena is also used in
l contain a mixture of ethinyloestra-diol
(MCQ)
® dysfunctional uterine bleeding
(EE2) in a dose of 20 to 30 mcg and an orally
(DUB) active progestogen which is a 19-
® endometrial hyperplasia
norsteroid(MCQ)
GOB
l OCPs available free of cost in India.
® in HRT
„ Mala-D contains 0.5 mg of d-norgestrel
® in a woman on tamoxifen for breast
cancer to combat hyperplasia of (MCQ)
„ Mala-N contains 1 mg norethisterone;
endometrium caused by oestrogen.
„ The pregnancy rate is 0.5 per 100 woman
(MCQ)
l Regime of taking COCs
years (equal to that of tubectomy).
„ tablets are taken starting on the second day of
„ Teratogenic if pregnancy occurs with
Mirena in situ due to progestogen. (MCQ) the cycle for 21 days. (MCQ)
„ A new course of tablets should be
CONTRACEPTION
„ Incidence of ectopic pregnancy 0.02%.
„ As compared to tubectomy, Mirena is an
commenced 7 days after the cessation
effective contraceptive but is reversible, reduces of the previous course. (MCQ)
„ starting the pill on the first day of the cycle
dysmenorrhoea and menorrhagia unlike
tubectomy. (MCQ) has reduced the failure rate
„ They should be taken at a fixed time of
„ Mirena, since it cures menorrhagia and is
as effective as tubectomy, is expected to the day, preferably after a meal.
l Mechanism of action of COCs
reduce the number of hysterectomies
„ COC suppresses pituitary hormones, FSH
and tubectomy operations in future.
m Suppression of spermatogenesis
and LH, peak and through their
n Gossypol(MCQ)
suppression prevents ovulation (MCQ)
„ At the same time, progestogen causes
l use as a male contraceptive
l a yellow pigment isolated from cottonseed
atrophic changes in the endometrium and
oil. prevents nidation.
„ Progestogen also acts on the cervical
l action is directly on the seminiferous tubules
inhibiting spermatogenesis without altering mucus making it thick and tenacious and
FSH and LH levels. (MCQ) impenetrable by sperms.
„ It also increases the tubal motility, so the
l side effects such as weakness,
hypokalaemia (MCQ) fertilized egg reaches the uterine cavity
l permanent sterility in 20% cases limit its
before the endometrium is receptive for
use. implantation.
l Pregnancy rate with COC is 0.1 per 100
n Testosterone enanthate
l effective through negative feedback
woman years, which is the lowest of all
mechanism. contraceptives in use today. (MCQ)
n GnRH
Join free today www.news4medico.com 3
l During the first cycle of use, ovulation may „ Reduced incidence of ectopic pregnancy
not be suppressed and the patient is advised to is due to suppression of ovulation and
use an addi-tional method to prevent reduction in PID. (MCQ)
pregnancy. „ It protects against rheumatoid arthritis.
l If she forgets to take a tablet, she should (MCQ)
take 2 tablets the following day. (MCQ) „ Reduces the risk of anorectal cancer by
l If she forgets to take the tablet more than 30 to 40%.(MCQ)
once in a cycle, she is no longer adequately „ It is useful in acne, PCOD and
protected and must use a barrier method during endometriosis. (MCQ)
that cycle. (MCQ) l Side effects and contraindications
l The majority of failure with COCa are due l Intermenstrual spotting is common
to the failure to take the pills regularly. in the first 3 months of the start of the
l With proper compliance, most women have pills but it gradually disappears. (MCQ)
regular 28-day menstrual cycles. l Heavy spotting can be stopped by increaing
l The bleeding is less in amount and shorter in the dose for a few months.
duration than,a normal menstrual period. l Menstrual bleeding
l In a non-lactating woman, OC can be „ can become very scanty and occasionally
started after three weeks of delivery, but a woman becomes amenorrhoeic causing
can be given soon after an abortion, MTP or undue fear of pregnancy
an ectopic pregnancy. (MCQ) „ Amenorrhoea of 6 months requires
GOB
l Following hydatid mole, one should start on investigations.

OC only after serum Beta-hCG is „ Post-pill amenorrhoea is not related to the
negative. (MCQ) type, dose or duration of pill intake. (MCQ)
l HIV antiviral drugs reduce effectiveness of „ Those with previous menstrual
OC but combined with condoms it is irregularity (oligomenorrhoea) are likely
protective against pregnancy. to suffer amenorrhoea.
l Benefits of combined pills (MCQ) l Genital tract
„ As it causes regular and scanty „ associated with monilial vaginitis.
menstruation, it is useful in menorrhagia „ Carcinoma of the endocervix has
CONTRACEPTION
and polymenorrhoea. (MCQ) been reported if used for more than 5 years
„ By virtue of non-ovulation, it can relieve cervical dysplasia is more frequent. (MCQ)
dysmenorrhoea and premenstrual „ No adverse effect is noted on uterine
tension. (MCQ) fibroids
„ It prevents anaemia by reducing the l Breast.
menstrual loss. „ COCs should not be offered to a woman
„ It has proved to lower the incidence of suffering from cancer of the breast.
benign breast neoplasia. (MCQ) „ Some have reported the breast cancer in
„ It reduces the incidence of functional a nulliparous woman who has taken
ovarian cyst (50%) and ovarian and COCs before the age of 24 years for
uterine malignancy. (MCQ) over a period of 4 years(MCQ)
„ The incidence of ovarian cancer is „ If at all breast cancer develops, it is well
reduced by 40% and uterine malignancy differentiated with good prognosis
by 50% if taken for 1 year, and this effect „ The risk of malignancy disappears after 10
lasts as long as 10 years after stoppage. years of stoppage. (MCQ)
„ The incidence of PID is reduced, though l Pituitary adenoma was attributed to the use
it does not reach the same low level as seen of the pill
with the barrier method. (MCQ) l Lactation is suppressed with combined pills.
„ This effect is due to the thick cervical „ The combined pills are therefore
mucus caused by progestogen, contraindicated in a lactating mother.
preventing the organisms entering into „ the risk of thromboembolism is high during
the uterine cavity. puerperium.
„ Libido varies and may not be related to the
pills. (MCQ)
„ Nausea and vomiting are mainly due to risk of venous thromboembolism than the
oestrogen pills containing LNG. (MCQ)
„ It can be avoided by taking the pills at l Sickle cell anaemia can cause thrombosis
bedtime. and crisis.
l Liver l A woman who wears contact lenses should
„ Adenomas have been reported be warned of oedema and irritation of
„ hormones are metabolized in the liver, eyes (thrombosis of optic vessels)—it is a
chronic liver diseases and recent relative contraindication
jaundice contraindicate the use of pills. (MCQ) l COC pill does not protect a woman against
„ Gall bladder function may be adversely HIV and STIs(MCQ)
affected. (MCQ) l No adverse effect on thyroid.
l COCs are contraindicated or cautiously given l COCs are contraindicated in:
to a diabetic woman. (MCQ) „ Cardiac disease, hypertension, smoker over
l Lipid metabolism. 35 years.
„ Oestrogen increases the HDL and „ Diabetes. (MCQ)
lowers LDL(MCQ) „ History of thrombosis, myocardial infarct, sickle
„ Some progestogens have a reverse effect cell anaemia, severe migraine. (MCQ)
l Drugs interfering with COC (MCQ) „ Chronic liver diseases such as cholestatic
„ Tetracycline ,anticonvulsants , jaundice of pregnancy, cirrhosis of liver, adenoma,
Rifampicin porphyrias.
GOB
„ antifungal, cephalosporin and „ Breast cancer, thyroid disease.
phenobarbital „ Gross obesity.
l Headache, migraine, depression, irritability, increased „ Patient on enzyme-inducing drugs like
weight and lethargy due to progestogen. rifampicin, and antiepileptic except sodium valproate.
(MCQ) „ 4 to 6 weeks prior to planned surgery.
l Thromboembolic disorders (MCQ)
„ Pulmonary embolism and cerebral „ Lactating woman.
thrombosis „ Monilial vaginitis. (MCQ)
„ both venous and arterial, are seven to ten l Return of menstruation and fertility
CONTRACEPTION
times more frequent in the pill users than „ 90% will have normal menstmal cycles
in the non-users. within 6 months of stopping OC(MCQ)
„ caused by the oestrogen component of „ no evidence of fetal malformation or
the pill. increased rate of abortion in those who
„ The effect is dose-dependent conceive while on pills.
„ reduction of the oestrogen content of „ Ninety per cent ovulate within 3 months of
the pill from the original 100 to 30 pg, (MCQ) stoppage of drug. (MCQ)
l Newer oral pill - Femilon n Triphasic combined pills
„ contains desogestrel 0.15 mg, ethinyl l The triphasic preparations of EE2 and LNG
estradiol 0.02 mg. (MCQ) contain (MCQ)
„ 20 micrograms EE2 improves safety and „ during the first 6 days of the cycle 30 mcg
tolerance profile(MCQ) EE2 plus 50 mcg LNG
„ high-risk cases for this complication of „ for the next 5 days 40 mcg EE2 plus 75
thromboembolic disorders due to mcg LNG
pills(MCQ) „ during the last 10 days 30 mcg EE2 and
® A woman over 40 years 125 mcg LNG
® a woman with stroke „ followed by one medication-free week.
® heavy smoker l These pills have no adverse effect on
® cardiac and hypertensive patient carbohydrate and lipid metabolism(MCQ)
® a woman with famlial l can be prescribed to diabetic women and
hyperlipoproteinaemia without expecting any increased risk of
l The pills containing desogestrel and myocardial infarct. (MCQ)
gestodene (third generation) carry a higher l They are as effective as the monophasic oral
pills
l They are not recommended in menorrhagia n The calender method or the rhythm method
and for other indications. n avoidance of sexual intercourse around
n New ORAL PILLS ovulation
l Once-a-month pill n In a 28-day cycle
„ contains 3 mg quinestrol and 12 mg l ovulation normally occurs on the 14th day
megestrol acetate(MCQ) of the cycle
„ Two tablets in first month are followed by l ovulation may occur anytime between the
one tablet monthly. 12th and 16th day (MCQ)
l EE2 + drospirenone (Yasmin, Tarana, Janya) l Spermatozoa deposited in the female genital
contain 21 tablets in a packet, but Janya tract may survive for 24 hours
contains 24 tablets (gap of four tablets in a l ovum itself may live for 12 to 24 hours
cycle). (MCQ) l intercourse between the 11 th and 17th day
l EE2 + cyproterone acetate (Dianette). may result in a pregnancy. (MCQ)
(MCQ) n Safe period
l Drospirenone l first day of the menstrual period until the
„ an analogue of spironolactone 10th day of the cycle
„ is anti-mineralocorticocoid and with l from the 18th to the 28th day(MCQ)
anti-androgenic activity(MCQ) n Risk period,
„ It inhibits ovulation, cures acne and l from 3 days before ovulation to 3 days after ovulation.
hirsutism l In a 35-day menstrual cycle
GOB
„ It reduces fluid and sodium retention „ ovulation will occur on the 21st day (that
„ it has no adverse effect on bone mineral is 14 days before the next period)
density „ risk period is from day 18 to day 24.
„ It also prevents obesity and maintains (MCQ)
good lipid profile. (MCQ) n Calendar method.
„ Because of this and cure of acne, it is also l Ogino-Knaus method
known as’beauty pill. (MCQ) l fertile peiod is determined by subtracting
„ Side effects are: (MCQ) 18 days from the shorest cycle and 10 days
® Potassium retention. from the longest cycle which gives the first
CONTRACEPTION
® It is contraindicated in renal and liver disease and the last day of fertile period,
and in a woman with previous respectively. (MCQ)
thromboembolism. l Failure rate : 25 pregnancies per 100 woman
l Different generations of oral pills(MCQ) years.
„ First generation contained norethindrone. n Mucus method (billings or ovulation
„ Second generation contained LNG. method).
„ Third generation contained gestodene, l Under oestrogen influence
desogestrel, norgestimate. „ the mucus increases in quantity
„ Fourth generation contains spironolactone „ becomes progressively more slippery and
and cyproterone acetate. elastic until a peak is reached
l Janya contains 24 tablets, each containing 20 l under the influence of progesterone
ug EE2 and 3 mg drospirenone. (MCQ) „ after peak under estrogen influence ,
l Yasmin contains 30 ug EE2 with same dose mucus becomes thicker, scanty and dry until
of latter. (MCQ) the onset of menses
l Intercourse is considered safe during the ‘dry
days’ immediately after the menses until mucus is
m Definition of contraception detected. T
n A method or a system which allows intercourse l thereafter the couple must abstain until the
and yet prevents conception is called a fourth day after the ‘peak (MCQ)
contraceptive method. n Temperature method.
m Failure rate of any contraceptive method is l Progesterone is known to exert a thermogenic
described in terms of pregnancy rate per 100 woman effect on the body.
years (Pearl index). l BBT chart will be biphasic in an ovulatory
m Abstinence during the fertile phase cycle
l day of temperature shift indicates the time of l remain effective for 1 to 2 hours after the
ovulation. application. (MCQ)
n Symptothermal method. l By causing irritation and abrasions in
l This combination method is more effective. chronic use, they can cause vaginal ulceration
l The first day of abstinence is predicted either and perhaps increase the risk of HIV
from the calender, by subtracting 21 from the spread rather than prevent it. Therefore, the
length of the shortest menstrual cycle in sper-micidal agents should not be recommended
the preceding 6 months, or first day mucus to HIV couples. (MCQ)
is detected, whichever comes first. (MCQ) l A new spermicidal cream, Tenofovir,
l The end of the fertile period is predicted by prevents viral attachment to the vaginal
use of the ‘basal body temperature’ chart. mucosa and is non-irritant and is under
l The woman resumes intercourse 3 days development. (MCQ)
after the thermal shift. n Ocdusive diaphragms
n Withdrawal method (coitus interruptus) l diaphragm liberally covered with spermicide
l Failure rate : 25 per 100 woman years. can be inserted at any convenient time left in
(MCQ) position for a minimum of 8 hours after
l The main cause of the failure is not that coitus. (MCQ)
ejaculation occurs inside the vagina but that l It causes no discomfort
prostatic fluid secreted prior to ejaculation, frequently l no douching is required
contains active spermatzoa. l A refitting of the diaphragm is always required
GOB
m Breastfeeding after childbirth, and this can be done about 6
n Regular breastfeeding with at least one feed to 8 weeks after confinement. (MCQ)
at night is shown to prevent pregnancy for 6 months l The Dutch cap or diaphragm.
n failure rate of only 0.5 to 1.5%. (MCQ) „ ones in common use range between 65
m Barrier methods and 80 mm
n Condoms „ fit obliquely in the vagina, stretcing from just
l water-based spermicides should be used with latex behind the pubic ramus into the pos¬terior
condoms fornix, thus covering the cervix.
l Because of irritation by latex in some women, „ It is held in position by the tension of the
CONTRACEPTION
non-latex polyurethane condoms are avail- spring rim
able. (MCQ) „ Contraindications to use of diaphragm
l They however slip and break easily and are more (MCQ)
costly than the latex condoms. ® prolapse, cystocele, rectocele because
l Latex condoms prevent STDs such as HIV accurate fitting is not possible
l less protective against STD transmitted ® recurrent urinary tract infection
from skin-to-skin contact such as human ® allergy to rubber or spermicidal agent.
papilloma vims and herpes virus. „ Toxic shock syndrome (TSS)
l Nirodh brand is distributed free of cost in ® occur if the diaphragm is left in the
the government hospitals in India. vagina for a long period
l pregnancy rate of 10 to 14 per 100 woman ® caused by staphylococcal pyogenic
years. (MCQ) infection.
l Other uses of condom „ failure rate of the Dutch cap is about 4 to
„ following vasecomy for 12 ejaculates 6 per 100 woman years
(MCQ) l Cervical cap.
„ in immunological infertility „ It fits closely to the cervix
„ to prevent transmission of gonococcal, „ suitable where the cervix is long and firm.
chlamydia, syphilis, trichomonad and „ When a woman has a prolapse of uterus
fungal infection, HIV. (MCQ) and vagina, a cervical cap is preferred
n Spermicidal agents to the vaginal diaphragm.
l contain surfactants, such as nonoxynol-9, „ Chronic cervicitis, erosion and cervical
octoxynol and menfegol (MCQ) laceration contraindicate its use.
l failure rate - 30 per 100 woman years. „ available in four sizes, varying from 22 to
(MCQ) 31 mm
l Dumas cap absence of the device in the pelvis can be
„ It is a cup-shaped rubber with a thickened easily detected by radiograph.
rim l Biologically inert devices
„ fits well into the vault of the vagina so „ indude Lippes loop and Saf-T-Coil.
that it encloses the cervix(MCQ) „ They can be left in situ for several years,
„ size varies from 55 to 75 mm diameter. provided they cause no side effects
l Femshield (female condom). l Copper carrying devices
„ known as ‘FEM’ or Femidom „ copper wire of surface area 200 to 250
„ It is a loose-fitting 15 to 17 cm long sheath mm is wrapped round the vertical stem of
„ made of polyurethane a polypropylene frame. (MCQ)
prelubricated(MCQ) „ Copper T 200, Copper 7, Multiload Copper
„ It has the combined features of a 250, CopperT380, CopperT220 and
diaphragm and a condom NovaT.
„ It covers the entire vagina, cervix as well „ have an effective life of about 3 to 5
as the external genitalia. years(MCQ)
„ It is highly protective against spread of „ It is estimated that about 50 microgms of
STDs, and AIDS in particular(MCQ) copper is eluted daily in the uterus. (MCQ)
„ It can be removed immediately after intercourse. „ Paraguard
(MCQ) » Copper T 380A (MCQ)
„ Advantages of the Femshield (MCQ) » has a lifespan of 10 years. (MCQ)
GOB
® it is coital-independent and can be „ Nova T

worn well in advance of the sexual act » has silver added to the copper wire
® it does not slip off easily, and the failure (MCQ)
rate is expected to be low, » lifespan is 5 years. (MCQ)
® it is stronger than the condom and l Progestasert and levonova.
does not burst easily „ Progestasert
® it can be worn during the puerperal ® a T- shaped device
period unlike the diaphragm. ® carry 38 mg of progesterone in silicon
„ Failure rate is 5 to 15 per 100 woman oil reservoir in the vertical stem. (MCQ)
CONTRACEPTION
years. (MCQ) ® It releases 65 micrograms of the

„ Femshield is expensive, costing 2 to 3 hormone per day. (MCQ)
dollars per piece ® Mechanism of contraceptive effect.
„ It is not re-usable
l Today » Hormone released in the uterus forms
„ It is a mushroom-shaped polyurethane a thick plug of mucus at the cervical
dispo-sal sponge os which prevents penetration by the
„ contains 1 g of nonoxynol-9(MCQ) sperms
„ It can remain effective for 24 hours. ® Menstrual problems like menorrhagia
(MCQ) and dysmenorrhoea noticed with
„ Failure rate - 9 to 30 per 100 woman Copper T are less with this device (40%
years(MCQ) reduction). (MCQ)
„ expensive, coital-dependent ® Requires yearly replacement
„ may cause TSS if left over a long period. „ Levonova
n Intrauterine contraceptive devices » Contains 60 mg of levonorgestrel
l an effective, reversible and long-term method of (LNG)
contraception » releases the hormone in very low
l it does not require replacement for long periods doses (20 micrograms/day).
l it does not interfere with sexual activity. (MCQ)
l It is commonly made of polyethylene » It is longer-acting (5 years) (MCQ)
(MCQ) » It has a low pregnancy rate of 0 to
l It is impregnated with barium sulphate to 3 per 100 woman years(MCQ)
render it radiopaque so that the presence or » incidence of ectopic pregnancy is
sixfold to nine-fold higher in women who
do become pregnant as compared to „Previous ectopic pregnancy(MCQ)
failures amongst Copper T users. „ Preferably avoid its use in unmarried and
(MCQ) nulliparous patient because of the risk
» It can be safely recommended for of PID and subsequent tubal
nursing mothers. (MCQ) infertility(MCQ)
„ Mirena „ LNG IUCD in breast cancer (MCQ)
» contains 52 mg LNG(MCQ) „ Abnormally shaped uterus, septate
» elutes 20 microgram daily. (MCQ) uterus(MCQ)
» It can be retained for 5 years(MCQ) l Mechanism of action
» It has a failure rate of 0.1 to 0.4 per „ The presence of a foreign body in the
100 woman years uterine cavity renders the migration of
„ Frameless IUCD spermatozoa difficult.
® IUCD under trial. „ A foreign body within the uterus provokes
® contains several copper cylinders tied uterine contractility through
together on a string prostaglandin release
® anchored 1 cm deep into fundus „ It increases the tubal peristalsis (MCQ)
l IUCDs are a good contraceptive choice „ the fertilized egg is propelled down the fallopian
for tube more rapidly than in normal it fertilized
„ Low risk of STD egg reaches the uterine cavity before the
„ Multiparous woman (MCQ) development of chorionic villi and thus is
GOB
„ Monogamous relationship unable to implant.
„ Desirous of long-ter m reversible „ The device in situ causes leucocytic
method of contraception, but not yet infiltration in the endometrium. (MCQ)
desirous of permanent sterilization „ Copper T
„ Unhappy or unreliable users of oral » elutes copper which brings about
contraception or barrier contraception. certain enzymatic and metabolic
l Uses of IUCD changes in the endometrial tissue
„ As a contraceptive which are inimical to the implantation
„ Postcoital contraception (emergency of the fertilized ovum. (MCQ)
CONTRACEPTION
contraception) „ Progestogen-carrying device
„ Following excision of uterine septum, » causes alteration in the cervical
Asherman’s syndrome(MCQ) mucus which prevents penetration of
„ Hormonal IUCD (Mirena) in sperm, in addition to its local action.
» menorrhagia and » It also causes endometrial
dysmenorrhea(MCQ) atrophy(MCQ)
» hormonal replacement therapy » It prevents ovulation in about
in menopausal women(MCQ) 40%.(MCQ)
» In a woman on tamoxifen for breast l Complications(MCQ)
cancer, it can be used to counteract „ Immediate
endometrial hyperplasia. (MCQ) » Difficulty in insertion
l Contraindications of IUCD » Vasovagal attack
„ Suspected pregnancy » Uterine cramps
„ Pelvic inflammatory disease (PID) „ Early
„ lower genital tract infection » Expulsion (2 to 5%)
„ Presence of fibroids—because of » Perforation (1 to 2%)
misfit(MCQ) » Spotting, menorrhagia (2 to 10%)
„ Menorrhagia and dysmenorrhoea, if » Dysmenorrhoea (2 to 10%)
Copper T is used » Vaginal infection
„ Severe anaemia » Actinomycosis
„ Diabetic women who are not well „ Late
controlled—because of slight increase in » PID—-2 to 5%.
pelvic infection(MCQ) » IUCD does not prevent transmission of
„ Heart disease—risk of infection(MCQ) HIV.
» Pregnancy— 1 to 3 per 100 woman „ If the IUCD is in the uterine cavity, it can
years (failure rate) be retrieved with Shirodkar’s hook, a
» Ectopic pregnancy curette or through a hysteroscope.
» Perforation „ In case of perforation, a laparotomy is
» Menorrhagia needed, because Copper T causes adhesions to
» Dysmenorrhoea. the omentum or a gut and cannot be
l IUCD can be inserted in HIV-positive retrieved easily through a laparoscope.
woman on medication. (MCQ) l Pregnancy.
„ Long-term follow-up of women wearing „ occurs with IUCD in situ in 1 to 3 per 100
IUCD has shown no ill effects on systemic woman years.
diseases. „ If this happens, it is important to do
„ There is no evidence that the device ultrasound and rule out ectopic
predisposes to either cervical or endometrial pregnancy(MCQ)
cancer. „ The uterine pregnancy can cause severe
l Perforation infection
„ can occur at the time of insertion, particu- „ It is therefore mandatory to remove the
larly during puerperium IUCD if the tail is visible through the os.
„ rare with withdrawal than push-in While doing so, the risk of abortion
technique(MCQ) should be explained to the woman.
l Menorrhagia is controlled with NSAID „ If the thread of the IUCD is not seen,
GOB
drugs. termination of pregnancy is offered, not

l Expulsion because IUCD has any teratogenic effect
„ may occur in 5 to 15% but because the risk of uterine infection
„ due to small size of IUCD is considerable. (MCQ)
„ common during the puerperal period or l Ectopic pregnancy
following MTP of a large gestation size. „ It occurs in 1:30 pregnancies in woman
(MCQ) wearing IUCD.
l PID „ because IUCD has a local contraceptive
„ occurs usually in the 4 weeks of insertion action on the uterus and prevents a uterine
CONTRACEPTION
„ Actinomycosis is an infection commonly pregnancy but does not protect against tubal
associated with IUCD. or ovarian pregnancy
l Misplaced IUCD „ Progestasert has the highest incidence
„ the tail of the IUCD is not seen through the of ecto-pic pregnancy (six to nine times
os more than Copper T). (MCQ)
„ causes are(MCQ) „ PID also contributes to the occurrence of an
» uterus has enlarged through ectopic pregnancy.
pregnancy l Advantages of IUCD
» thread has curled inside the uterus „ It is coital-independent. (MCQ)
» perforation has occurred „ newer IUCDs being as effective as oral
» IUCD is buried in the myometrium contraceptives.
» it has been expelled „ hree per cent failure rate at the end of 1
„ A plain radiograph or pelvic ultrasound year is reduced to less than 1% at the end
is used to diagnose of 5 years.
„ If it is inside, the uterine sound or another „ There is no user failure. (MCQ)
IUCD inserted in the uterine cavity will ® There is no evidence of reduced fertility
show on radiograph its proximity to the following its removal.
misplaced IUCD and perforation can be ® About 75% women conceive within 6
diagnosed months of its removal
„ Abnormal shape or location of IUCD „ almost 90% conceive within a year. (MCQ)
on radiograph indicates likely perforation. „ There are no systemic ill effects, unlike
„ Hysteroscopy is useful not only to locate it oral contraceptives
but also for its retrieval „ No adverse effect on lactation is
observed.
„ Copper T is inserted free of cost in n Those with focal migraine
government hospitals in India. (MCQ) n Intolerant to oestrogen or oestrogen contraindicated
n Diabetic, hypertensive woman, sickle cell
n Minipill/progestogen-only pill (POP) anaemia.
m The low-dose POP (MCQ) m As regards to return of fertility, it is faster than
m norethisterone 350 mcg, norgestrel 75 mcg or in COC users because ovulation is not
LNG 30 mcg suppressed in all cases (suppressed in 40%).
m tablet is taken daily without a break(MCQ) n Cerozette
m The pill should be started within 5 to 7 days of m contain 75 mcg desogestrel (MCQ)
the menstrua-tion m Advantages over other POPs: (MCQ)
m taken at the same time with a leeway of 3 hours n Stringent time compliance not necessary, as it
on either side of the fixed time each day. (MCQ) supresses ovulation in 97%, through
m If this regime is not observed any day, the pituitary hormone suppression
woman cotinues with POP but observes extra precaution n No androgenic effects like acne.
for 48 hours. (MCQ) n No ectopic pregnancy
m POP is started 21 days postpartum and soon n no effect on carbohydrate or lipid metabolism.
after abortion. n Failure rate only 0.21 per 100 woman years
m woman needs to take precaution in the first 48 n It acts through metabolite etonogestrel which
hours in the first cycle. binds to progesterone receptors
m it is well suited for lactating women ,some m Complications of desogestrel are(MCQ)
GOB
progestogens, in fact, increase milk secr-tion. n Deep venous thrombosis
m it has a pregnancy rate of 2 to 3 per 100 woman n Pulmonary embolism, breast cancer, liver disease apart
years which is higher than that of the COCs from common complications of progestogens.
though comparable to an IUCD and is higher in n Depot injections
obese women(MCQ) m Include (MCQ)
m Drawbacks(MCQ) n Depotmedroxyprogesterone acetate
n Strict daily compliance is a drawback (DMPA) given in microcrytalline aqueous
n irregular bleeding (20%), amenorrhoea suspension
n depression, headache n norethisterone enanthate (NETO) in castor
CONTRACEPTION
n migraine and weight gain, oil solution
n ectopic pregnancy, besides a higher failure rate. m both by deep intramuscular injection (not
m The use of newer generation of synthetic subcutaneous).
progestogen, namely desogestrel, has been m A monthly injection of DMPA 25 to 50 mg,
encouraging. combined with 5mg oestradiol is considered to
m It has no androgenic effect(MCQ) be effective.
m no adverse effect on carbohydrate and lipid m Other preparations in use are
metabolism(MCQ) n DMPA 150 mg three-monthly
m considered to be safe, especially for women n DMPA 300 mg six-monthly
over 40 years and lactating women. incidence of n NETO 200 mg two-monthly.
thromboembolism is higher with these m After stoppage, the contraceptive effect of
progestogens. DMPA lasts longer than that of NETO. (MCQ)
m Contraindications to POP (MCQ) n Menstrual irregularity is accepted by
n previous ectopic pregnancy, ovarian cyst puerperal woman as physiological.
n breast and genital cancers n injection should be started within a month of delivery
n abnormal vaginal bleeding, active liver and in a non-lactating woman and during the third month
arterial diseas in a lactating woman because ovulation is delayed
n porphyria, liver tumour up to at least 10 weeks in lactating mothers.
n valproate, spirono-lactone and m Pregnancy rate is (MCQ)
meprobamate. n 0.4 per 100 woman years for DMPA
m Advantages of POP are that they can be n 0.6 per 100 woman years for NETO.
recommended to: (MCQ) m The injection should be administered within 7 days
n Lactating women of menstruation with grace period of 2 weeks
n Women over 35 and smokers for DMPA and 1 week for NETO (12 to 14 weeks
of first injection for DMPA and 8 to 9 weeks for m have no ‘nuisance value’ of continuous
NETO). compliance which often adversely affects
m Advantages(MCQ) motivation.
n are easy to administer and there is no worry m non-oral system avoids ‘hepatic first pass effect
over ‘missing pill’. and systemic side effects’. (MCQ)
n The compliance is good and the woman remains m Norplant II
under regular medical supervision. n consists of two rods each containing 70 mg
n The side effects of lipid and carbohydrate LNG.
metabolism are avoided. n daily release of hormone is 50 mcg
n DMPA is least androgenic. (MCQ) n provides contraception for 3 to 5 years.
n It is suited to lactating women. (MCQ)
n The incidence of PID, ectopic pregnancy and n main action is suppressing endometrium.
functional ovarian cysts is low, so also n The implants suppress ovulation in 50%
endometrial cancer. n implants are inserted on the (MCQ)
n Avoids oestrogenic side effects. l first day of the menstrual cycle
n Can be given to a woman with sickle cell l within 5 days of abortion
anaemia. l 3 weeks after the delivery.
n Return of fertility is slightly delayed in DMPA n The woman needs to use barrier contracep-
group compared to NET, but 80% conceive in tion or abstain in the first 7 days of insertion.
1 year. (5 months for DMPA and 3 to 4 months (MCQ)
GOB
for NETO). n It is best inserted on the medial aspect of the

n Coital independent upper arm under local anaesthesia.. (MCQ)
m Disadvantages(MCQ) m Implanon
n Once administered, the side effects, if any, n single rod,
need to be tolerated until the progestogenic n contains 67 mg desogestrel(MCQ)
effect of the injection is over n It elutes 30 mcg of the hormone daily
n Menstrual irregularity occurs and n effect lasts 3 years. (MCQ)
amenorrhoea is reported in 20 to 50% at end n It prevents ovulation
of 1 year, more with DMPA than NET n Fertility reversible within 1 month of removal
CONTRACEPTION
n Heavy bleeding is reported in 1 to 2% users. m Capronor

n There is a delay in return of fertility but 80% n a biodegradable single capsule (MCQ)
are expected to conceive by end of 1 year. n contain LNG (MCQ)
l With DMPA, ovulation returns in 5 months n does not require removal.
l with NETO, within 3 months of the last n Ten per cent women request removal at the end
injection. of 1 year because of side effects.
n The side ‘effects of weight gain, depression, n return of fertility occurs in - 90% conceive in
bloated feeling and mastalgia can occur 2 years.
with injectable progestogen. m Contraindications of implants are
n Prolonged DMPA use, by virtue of n Breast cancer, liver .disease, arterial disease
antioestrogenic action, may reduce bone density n porphyria and previous ectopic pregnancy
mass and induce osteopenia. m Advantages of implants are:
n Contraindicated in breast cancer(MCQ) n They are long-acting with sustained effect—
n It does increase LDL but does not adversely affect the compliance is good.
blood pressure. n Coital-independent with no ‘nuisance’ of daily
n Because of risk of osteopenia, this contraceptive oral or frequent injections.
is(MCQ) n Pregnancy rate
l contra-indicated in adolescents l Varies between 0.2 and 1.3 per 100 woman
l not more than 2 years should be in use in years
others l higher in obese women weighing more than
70-kg.
n Subdermal implants n Systemic side effects are few
n first pass effect on the liver avoided.

n Can be used by lactating mothers and over n The drug can also be used as a postcoital
the age 40. (MCQ) pill(MCQ)
m Disadvantages of implants are n given in 60 mg dose within 24 hours of coitus
n Breakthrough bleeding, irregular cycles n 2 tablets repeated 12 hours later (MCQ)
n Amenorrhoea occur as with other n failure rate of 1%
progestogenic contraceptives. (MCQ) n Side effects
n Ectopic pregnancy is reported in 1.3% l Headache, nausea, vomiting:
n Local infection may occur l Gain in weight.
n The implants are expensive and cost Rs 10,000. l Some delay in return of fertility.
n Infertility is seen in a few cases. n Contraindications(MCQ)
m Silastic vaginal rings (SVR) l During 6 months of lactation.
n The ring is 50 to 75 mm in diameter a l PCOD, hepatic dysfunction, cervical dysplasia
n releases 20 mcg of LNG daily. (MCQ) l Allergy to the drug
n contraceptive effect is mainly on the cervical n Postcoital contraception (interceptives) (MCQ)
mucus. m Postcoital contraceptive agents interfere with
n It is kept in situ for 3 weeks and removed postovulatory events leading to pregnancy and
for a week, thus bringing about regular are therefore known as interceptives.
menstrual cycles m also known as ‘emergency contraception’
n failure rate is 1.8/100 woman years. method used to prevent pregnancy after an unprotected
n Nestorone ring (MCQ) intercourse
GOB
l releases 150 mcg progestogen plus 15mcg m Yuzpe Regimen (MCQ)
oestradiol daily n Two tablets of relatively high doses of
l one ring remains effective for 1 year. combined pill containing 100 mcg EE2 and
n Nuvaring(MCQ) 1 mg norethisterone, or 500 mcg LNG,
l 120 ug etonogestrel + 15 ug EE2 daily taken within 72 hours of intercourse followed by 2
l release can be removed during intercourse tablets taken 12 hours later (Yuzpe and
but not for more than 3 hours at a time. Lancee, 1977).
m Centchroman n Failure rate—3.2 per 100 woman years.
n released in India under the name of Saheli. m Haspels Method
CONTRACEPTION
(MCQ) n Ethinyloestradiol 1 mg daily for 5 days, starting
n a synthetic non-steroidal contraceptive within 72 hours of exposure
(MCQ) n Failure rate - 0 to 1.5%
n taken as a tablet 30 mg started on the first m LNG
day of menses n Mechanism
n taken twice weekly for 12 weeks and weekly l delay ovulation if taken soon after intercourse
there-after l cause corpus luteolysis(MCQ)
n half-life is 170 hours l bring about cervical mucus changes and
n It prevents implantation through endometrial endometrial atrophy.
changes. n Levonorgestrel (LNG) tablet contains 0.75 mg
n It exhibits a strong anti-oestrogenic and a LNG.
weak oestrogenic action peripherally at the l One tablet should be taken within 72 hours
receptor level. of unprotected intercourse and another 12
n The return of-fertility occurs soon after hours later(MCQ)
stoppage of the drug (within 6 months). l Alternately two tablets can be taken as a
(MCQ) single dose(MCQ)
n not teratogenic or carcinogenic n The failure rate is 1.1%.
n exerts no pharmacological effect on other organs. n The tablets can be offered up to 120 hours
n The only side effect noted is prolonged but its efficacy decreases with the longer coital-
cycles and oligomenorrhoea in 8% cases. drug interval.
(MCQ) n Side effects are those of progestogens.
n This is due to prolonged proliferative phase n The hormone is not teratogenic in case
n Pregnancy rate is 1.83 per 100 woman years. pregnancy does occur but risk of ectopic
pregnancy remains. (MCQ)
n Advantages TOPIC - 2
l It has no oestrogen and its associated side effects.
TUBECTOMY VASECTOMY MTP
l It can be offered to hypertensive, cardiac
and diabetic woman. (MCQ) n Vasectomy
l It can be offered to a lactating woman.
m consists of dividing the vas deferens and
l It can be given as late as 120 hours after the
disrupting the passage of sperms
unprotected intercourse. (MCQ) m It is done through a small incision in the scrotum,
l Single-dose therapy is an advantage.
under local anaesthesia.
n The drug is contraindicated in a woman with
m The sterility is not immediate
history of thrombophlebitis and migraine. n sperms are stored in the reproductive tract for
m RU 486 (mifepristone) up to 3 months. (MCQ)
n RU 486 is a steroid with an affinity for progesterone
n Approximately, 20 (twenty) ejaculates clear
receptors the semen of all sperms. (MCQ)
n It does not prevent fertilization (MCQ)
n Two semen analysis reports must confirm
n It blocks the action of progesterone on the
the absence of sperms before the man can be
endometrium it causes sloughing and shedding of declared sterile. (MCQ)
decidua and prevents implantation. (MCQ) m No-scalpel technique has been now adopted.
n It is not teratogenic.
m One single incision is made with a special forceps
n A single dose of 10 mg is effective in preventing
and skin stitch is not required.
pregnancy in m Clips and plugs can be applied over the vas
GOB
n Failure rate- 0.9%

instead of cutting
n It causes delayed menstruation
m Riscus (Reversible inhibition of sperms)
n Ectopic pregnancy is not avoided.
(MCQ)
m Ulipristal n experimented by AIIMS and IIT
n Ulipristal is a synthetic progesterone
n A polymer gel is injected into the vas.
hormone receptor modular(MCQ) n Reversibility is possible by flushing the vas with
n attaches to progesterone receptor and
sodium bicarbonate.
prevents/ delays ovulation and suppresses endometrium, m Complications
prevents implantation(MCQ)
n Local pain, skin discolouration, bleeding,

n A 30 mg tablet should be taken within 5 days
haematoma formation (1 to 2%)
n Failure rate - Two per cent
n Infection (1%),
m Centchroman n trauma to the testicular artery causing gangrene
n Two tablets (60 mg) taken twice within 24
n Antibody formation and autoimmune disease
hours of intercourse can prevent implantation (40%).
(MCQ) n Failure rate of 0.15/100 woman years at the
n Failure rate - one percent
end of 1 year.
m Copper-IIUCD n Granuloma formation in 0.1 to 3% cases.
n Inserted within 5 days of intercourse can
n Spontaneous recanalization. (MCQ)
prevent implantation of a fertilized ovum. n Formation of spermatocele. (MCQ)
(MCQ) n Decreased libido or impotency are mainly
n Advantages of Copper T as emergency
psychological
contraception (MCQ) m Advantages
l It can be inserted as late as 5 days after the
n It is an OPD procedure
unprotected intercourse. (MCQ) n Local anaesthesia is adequate.
l It is cheap.
n It is a minor surgical procedure and the man
l Failure rate is 0.1%.
can resume duty after rest of 1 or 2 days.
l It can remain as ongoing contraceptive
m Disadvantages
method for 3 to 5 years. n Haematoma and infection sometimes occur
(1%).
n Spontaneous recanalization may occur
years after vasectomy.
n Spermatocele formation is not uncommon.
(MCQ)
n Autoimmunity through formation of n Pomeroy method
antispermal antibodies is occasionally reported. n Madlener method
n Failure of surgery. n Irving method
n Does not prevent transmission of HIV, STD n Aldridge method
infections. n Cornual resection
n Granuloma (0.3%). n Uchida method
n Restoring the fertility by anastomosis of the two cut n Fimbriectomy
ends of the vas gives 60 to 70% success rate. m Minilaparotomy
(MCQ) n Pomeroy
m Plugs n Madlener
n A device called ‘SHUG’ consists of two flexible n Aldridge
silicon plugs connected by a nylon thread which n Uchida
lies outside the vas. n Fimbriectomy
n This thread prevents migration of plugs and m Vaginal route
allows easy removal through a small incision. m Laparoscopy
(MCQ) m Hysteroscopy
m Contraindications to vasectomy are: n Laparotomy
n Local skin infection m Laparotomy sterilization is performed when the
n Varicocele, hernia abdominal incision extends well over 5 cm
n Undescended testis (MCQ)
GOB
n Female sterilization m done during caesarean section and during gynaecological
m Postpartum sterilization surgery.
n done within the first week when the patient is n Minilaparotomy
already hospitalized m The operation is performed through a small
m Interval sterilization suprapubic incision
n done when the woman is not pregnant or any m Pomeroy method.
time after 6 weeks of delivery. (MCQ) n fallopian tube is identified on each side,
n It can be combined with caesarean section brought out through the incision, and the middle
and MTP. portion is formed into a loop which is tied at the

n The interval surgery should preferably be done base with catgut and excised. (MCQ)
in the preovulatory phase to avoid the n The failure rate is only 0.4% and it is mainly
potential risk of pregnancy in the due to spontaneous canalization. (MCQ)
postovulatory period. (MCQ) n Advntages
m Indications l operation is simple
n Multiparity(MCQ) l requires short hospitalization
n Obstetrics—three caesarean deliveries l does not require sophisticated and expensive
n Medical diseases at high risk of pregnancy equipment like a laparoscope
n Psychiatric problems l can be performed in PHCs by a doctor
n Breast cancer (MCQ) trained in this procedure.
n Eugenic conditions—Repeat fetal m Madlener operation
malformations such as haemophilia, Rh n A loop of the tube is crushed and ligated with a
incompatibility, Wilson’s disease, Tay-Sach’s non-absorbable suture
disease and Marfan’s syndrome. n Failure rate of 7% (MCQ)
m Contraindications (MCQ) n occurrence of ectopic pregnancy are
n Young woman less than 25 years (as dictated unacceptable(MCQ)
by the Government of India). m Irving
n Parity less than two children (as per the n The mid-portion of the tube is ligated and
Government rule). the intervening portion excised (MCQ)
n Local infection. n The proximal end is buried in the
n Prolapse—Tubectomy can be done at the time myometrium and the distal end is buried in
of repair surgery. the broad ligament (MCQ)
n Methods of sterilization n It is a reliable method but irreversible and
m Laparotomy may require a laparotomy incision.
m Aldridge method n It can be done under local anaesthesia in the
n A hole is made in the anterior leaf of the outpatient department.
broad ligament and the fimbrial end is buried into n It is highly reversible, with a success rate of
this. (MCQ) 70% or more.
n The high failure rate is due to the fimbrial n Complications
end popping out and restoring the patency of m Abdominal wall emphysema due to wrong
the tube. placement of the needle.
m Cornual resection m Bleeding from superior epigastric vessel by
n The cornual portion of the tube is resected trocar injury. ,/
between clamps m Tearing of the mesosalpinx and bleeding.
n The technique is complicated and the uterine m Uterine perforation.
end tends to bleed heavily. m Wrong application of the ring, e.g. putting the
n it may also require a laparotomy incision.. ring on round ligament/meso salpinx/utero-
m Uchida method. ovarian ligament will cause operation failure.
n The tubal serosa is stripped off the muscular layer in m Failure rate - 0.4 and 2.5%. (MCQ)
the midsegment of the tube, which is then n cauterization carries a failure of 0.8%,
excised. n Hulka dip has a failure rate of 2.3% (MCQ)
n The proximal end is ligated and buried in the broad n Falope ring 0.8%. (MCQ)
ligament n Most failures occur within 2 years of
n The minimal excision of the tube preserves operation.
GOB
the potential for tuboplasty n At the end of 10 years, failure is reported in

m Fimbriectomy. 1.8%.
n Excision of fimbria results in permanent n Spontaneous recanalization occurs if
sterilization and leaves no potential for cauterization is incomplete.
reversibility. (MCQ) m Ectopic pregnancy is reported in 0.2 to 0.3%.
n Laparoscopic sterilization m Hydrosalpinx formation if the tube is occluded
m A small subumbilical incision is made at two places some distance apart.
m pneumoperitoneum created by inserting a Verres n Contraindications.
needle and introducing CO2. (MCQ) m In a patient with a cardiac or pulmonary

m failure rate with this technique is 0.6 per 100 disease, head low position and CO2 are
woman years. (MCQ) contraindicated. (MCQ)
m earlier cauterization technique has now been m Previous abdominal surgery exposes the patient
replaced by the to the risk of intestinal trauma in case parietal
n silastic Falope ring adhesions are present.
n Hulka dip m Puerperal cases. (MCQ)
n Filshie clip m Fallopian tubes are oedematous and vascular
m Monopolar cauterization is liable to cause acddental and may easily get torn.
intestinal burns and destroy a considerable part of m The uterus is soft and can get easily perforated
the tubal structure, a disadvantage if with the uterine manipulator.
recanalization is required at a later date. m Extreme obesity, diaphragmatic or umbilical hernia.
m The Falope silastic ring destroys 2 to 3 cm of the m The increased risk of interstitial injury in these
fallopian tube. (MCQ) cases.
m The Hulka and Filshie dips destroy a smaller m In PID, fallopian tubes may not be easily visible
segment (3 to 4 mm), thus preserving the potential amongst the adhesions.
for successful reversal surgery. (MCQ) m Due to associated morbidity, the government of
n The failure rate varies between 0.2 and India has forbidden (MCQ)
1.5%.(MCQ) n laparoscopic sterilization combined with MTP
m Falope ring n laparoscopic sterilization in the puerperal
n introduced by Yoon in 1974 period.
n is impregnated with barium sulphate for n Hysteroscopic sterilization
radiological visualization. m ‘Essure permanent device’ (MCQ)
m Advantages n This device is a dynamically expanding
n Subumbilical scar is small and nearly invisible. microinsert
n A layer of terephthalate fibre initiates local n Progesterone copper device is recommended
tissue reaction responsible for occlusion of the if the woman has heavy periods with
fallopian tubes. dysmenorrhoea.
n It takes 3 months for the device to be m Hormonal contraceptives
effective(MCQ) n COC pills can be safely prescribed to adolescents
l the woman needs to use other contraceptive n One must remember the possibility of breast
precautions during this period cancer at a later date if the young nulliparous
l hysterosalpingogram is needed to confirm woman below 24 years of age takes COC for more
the tubal blockage. than 4 years. (MCQ)
m Adiana catheter system (under trial) (MCQ) n POPs are not preferred over COC, because
n delivers bipolar energy to superficial of the irregular bleeding, amenorrhoea and
endosalpinx a higher failure rate.
n destroys only 1 cm of the medial end of the m Sterilization
tube and may have this advantage over ‘Essure n should not be offered to young couples.
system’. n Government of India has passed a law that the
n Failure rate of sterilization (Common MCQ surgical procedure should not be performed
in Exam) in a woman less than 20 years with two or
m 0.4% in Pomeroy technique (MCQ) less children and the youngest child less than
m 0.3 to 0.6% by laparoscopic method (MCQ) 2 years old. (MCQ)
m 7% by Madlener method. (MCQ) n Contraception for Parous women
GOB
n Mirena versus tubectomy m counselled on sterilization or vasectomy
m Lately, Mirena is emerging as a better m done any time after 24 hours of delivery
alternative to tubectomy in a young woman who m Minilaparotomy is a simple and a quick procedure
may want to retain fertility and avoid a permanent done under local or a short general anaesthesia.
method. (MCQ)
m Mirena is used in (MCQ) m Because of the possible risk of thrombosis and
n Mainly in DUB embolism, many prefer to avoid tubectomy until
n Dysmenorrhoea 6 weeks after delivery.
n Pelvic endometriosis m COC pills are contraindicated in the puerperium,

n HRT—oral oestrogen + Mirena instead both because of
of oral progestogens m its adverse effect on milk secretion in a lactating woman
n A woman on tamoxifen , m increased risk of thromboembolic episode.
n Contraceptive for 5 years (MCQ)
m Mirena causes deddualization of endometrial m COC can be prescribed to a non-lactating
stroma and atrophy of glands(MCQ) woman 3 weeks after delivery. (MCQ)
m The ovulation is not suppressed(MCQ) m POP is safe in a lactating woman and can be started
m Causes no menopausal symptoms even if the woman 6 weeks onwards. (MCQ)
develops amenorrhoea. m LNG is safer than desogestrel and gestagen
n Contraception for adolescents from thrombosis point of view.
m Barrier method m Intramuscular and progestogen implants can
n It is the best method in young girls. be prescribed 6 weeks after delivery.
n If the man refuses to use condoms, a married m IUCD
woman can use TODAY sponge with n should not be inserted in the puerperal woman, as the
spermiridal cream. (MCQ) risk of infection, perforation and expulsion is
m IUCD high.
n While IUCD may not be a suitable contraceptive n It should be inserted 3 months after delivery.
device in the unmarried and recently married m Regarding the barrier methods, female condoms and
nulliparous women, it is a long-term coital- Today sponge may not be reliable with a patulous
independent method suited to young parous vagina and laxity of the perineum.
women, provided no contraindication exists for m Male condoms with spermicides are safe.
its use. n Contraception for Lactating woman
n It is one of the best methods for spacing m Regular lactation with one feed at night delays
childbirth. (MCQ) ovulation and pregnancy for up to 6 months,
provided she remains amenorrhoeic. n contraindicated in elderly women.
m POP n A woman with medical disease
n does not suppress lactation or alter the m If the risk is negligible, sterilization provides the
quantity and quality of milk (MCQ) permanent method to prevent a pregnancy.
n It can be started after 6 weeks of delivery. m Vasectomy would be ideal, with no risk to the
m IUCD should not preferably be inserted in the 3 woman.
months after delivery. m IUCD is carefully considered in cardiac and
n Contraception for a woman with AIDS or diabetic women, because of the possibility of
positive HIV pelvic infection.
m Condoms are the best in prevention of m COC is contraindicated in a hypertensive,
transmission of infection from one partner to cardiac and diabetic women, as well as a
the other. woman with breast cancer, liver disease and
m Female barrier methods are not as effective as male previous thromboembolism (MCQ)
condoms. m An epileptic woman and a woman on
m Since the failure rate with condom is high, dual antitubercular drugs like rifamycin may face a
method of using hormonal contraceptives higher failure rate due to interaction with rifamycin
(COC) or IUCD is desirable. and antiepileptic drugs except sodium valproate.
m IUCD m POP (MCQ)
n can be inserted provided the woman has not n contraindicated in liver diseases, vascular
suffered from PID. (MCQ) disorders and breast cancer
GOB
n The screening for other STD becomes part n It is safe in sickle cell anaemia
of screening procedures before inserting an m Psychiatric disorders
IUCD. n If a woman is considered unfit to bear children,
m Surgical procedures are not contraindicated and permanent method considered, a written
in these women. opinion regard-ing psychiatric problem should
n Contraception for women over the age of 35 be obtained.
years n The written consent should be obtained from
m Women over the age of 35 years constitute 20% the husband or guardian, as the psychiatric
of the contraceptive users patient may not be mentally aware of the nature
m A woman after 35 years may become obese, of sterilization.
hypertensive and diabetic and likely to suffer DUB. m Emergency contraception is no bar to a woman
m Sterilization with a medical disorder, as only two tablets are given
n In a woman nearer the menopause with a in 24 hours. (MCQ)
fewer years of fertility, surgical procedure
may not be a wise proposition, and temporary
methods will be cost-effec-tive as well as safe, with
emergency contraception and MTP as a back-
up method.
m COC pills are safe, if the woman is thin, non-smoker
without any medical disease up to the age of
45 years. (MCQ)
m Whereas POPs may be safer than COC
(MCQ)
n its adverse effect on bone density and occurrence of
osteoporosis must be borne in mind if given
over a prolonged period.
n Besides, they cause irregular bleeding.
m IUCD may be suitable and effective.
m If the woman suffers from menorrhagia,
Mirena may be inserted and is effective for 5 years.
(MCQ)
m Desogestrel and gestodene (MCQ)
n cause thromboembolism

TOPIC - 3 OVARIAN TUMOR n Family history of breast, ovarian or colonic
cancer
n Ovarian tumour n May be bilateral and solid, fixed.
m The most common are the epithelial tumours n Ascites may be present.
(80% ) (MCQ) n Metastatic nodules may be felt per abdomen.
m 80% are benign tumours and 20% malignant. n Nodules in the pouch of Douglas(MCQ)
(MCQ) n Often solid and bilateral fixed with internal
m Of all the malig-nant tumours, echoes, ascites may be present

n 90% are epithelial in origin (MCQ) n Metastatic noduies may be seen
n 80% are primary in the ovary n Doppler ultrasound(MCQ)
n 20% secondary from breasts, gastrointestinal l increased vascularity
tract and colon l Pulsatile index <1. 1
m Benign tumours can become secondarily l Resistance index <4
malignant. n Metastatic and enlarged lymph nodes may
n Mucinous cyst becomes malignant in 5% be detected

n papillary cystadenoma becomes malignant in n CA-125 raised more than 35IU/ml(MCQ)
n Fixed solid tumour, often bilateral - with
50% if left untreated. (MCQ)
m Unfortunately patients with ovarian tumours are
blood-stained ascites
n Metastatic growth over the omentum and
often symptom-free for a long time
m By the time ovarian malignancy is estab-lished,
peritoneal cavity(MCQ)
GOB
n Lymph nodes may be enlarged
about two-thirds of these are already far
advanced and the prognosis in such cases is
unfavourable. n Pathology
m WHO classification of ovarian tumours (major
m An ovarian tumour in adolescent and
groups)
postmenopausal women is more often malignant
m Common epithelial tumours:
than benign.
n Serous tumours
m Most of the germ cell tumours occur in young
n Mucinous tumours
girls (MCQ)
n Endometrioid tumours
OVARIAN TUMOR
m Benign ovarian tumours
n Clear cell (mesonephroid tumours)
n Not related to age or parity, (MCQ)
n Brenner tumours
n most common during childbearing period
n Mixed epithelial tumours
n Slow-growing tumour, no pain.
n Undifferentiated carcinoma
n No menstrual disorder unless it is a feminizing
n Unclassified epithelial tumours
tumour
m Sex cord (gonsdal stromal) tumours:
n Usually unilateral, cystic, well-defined and
n Granulosa-stromal cell tumours
mobile.
n theca celltumours
n No ascites (except in Meig syndrome.)
n Androblastomas
n No nodules in abdomen or pouch of
n Sertoli-Leydig cell tumours
Douglas(MCQ)
n Gynandroblastomas
n Doppler ultrasound- No increased
n Unclassified
vascularity
m Lipid (lipoid) cell tumours
n CA-135 - normal(MCQ)
m Germ cell tumours:
n Well-defined ovarian cystic or solid tumour.
n Dysgerminoma
(MCQ)
n Endodermal sinus tumour
m Malignant ovarian tumour
n Embryonal carcinoma
n Seen most commonly in adolescents and
n Polyembryoma
elderly women
n Choriocarcinoma
n mostly after 50 years of age.
n Teratoma
n Low parity or infertile woman(MCQ)
n Mixed forms
n Rapidly growing tumour, pain in advanced
m Gonadoblastoma:
stage.
n Pure
n Postmenopausal bleeding(MCQ)

n Mixed with dysgerminoma or other germ cell m Serous cystadenomas occur in the third, fourth
tumours and fifth decades of life
m Soft tissue tumours not specific to ovary m In about half of the cases they are bilateral.
m Unclassified tumours m Delicate papillary excrescences may be seen
m Secondary (metastatic) tumours on the sur¬face and within the loculi in a benign
m Tumour-like conditions cyst. (MCQ)
n Epithelial ovarian neoplasms m Histologically the benign variety shows cystic
m arise from the mesoepithelial cells on the ovarian spaces, and the lining of the tumour consists of
surface. tall columnar ciliated epithelium resembling the
m constitute about 80% of all ovarian cancers. endosalpinx. (MCQ)
(MCQ) m The loculi contain a serous straw-coloured fluid,
m most common histologic type is the papillary which may be blood stained when malignant
serous cystadenomas and carcinomas transformation occurs. (MCQ)
m degree of cellular differentiation of the n Mucinous tumours
epithelial ovarian neoplasm expressed as histologic m multiloculated cysts lined by epithelium
grade has an important prognostic significance resembling the endocervix
as well as in identifying malignancy. (MCQ) m cut surface shows multiloculi and honey-
m Stage I Grade ‘0’ tumours is more than 90% combed appearance.
n Borderline ovarian tumours or ovarian epithelial m can grow to a large size and often weigh as
tumours of low malignant potential (LMP) much as 5-10 kg
GOB
m Patients have a high survival rate. m often pedunculated. (MCQ)

m Tumours run a typical indolent course. m may be combined with a dermoid cyst or a
m Spontaneous regression of peritoneal Brenner tumour (MCQ)
implants is known to occur. m usually unilateral
m Multiple sections must be examined to m essentially benign
exclude invasion. m Mucinous ovarian cyst is often uni-lateral.
m occur in younger women (35-55 years), 10 years m Bilateral tumours are often metastatic from the
younger than their malignant counterparts. gastrointestinal tract, mainly mucocele of
m Risk factors (MCQ) appendix or primary adenocarcinoma of
OVARIAN TUMOR
n Low parity and failure to lactate appendix. (MCQ)

n Unopposed oestrogen and obesity m occur in women between 30 and 60 years
n Smokers m If the tumour ruptures, it may lead to formation
n Induction of ovulation of pseu-domyxoma peritonei
m borderline ovarian tumours are mainly serous m Appendicectomy at the time of primary sur-gery
(intest-inal and endocervical type) prevents pseudomyxoma peritonei(MCQ)
m Management n Endometrioid tumours
n Conservative sur-gery m mostly malignant
l ovarian cystectomy, ovariotomy or m lined by a glandular epithelium resembling the
salpingo-oophorectomy (MCQ) endometrium.
n In mucinous bor-derline tumour, it is prudent m In 15% of cases ovarian endometriosis may
to perform appendicectomy coexist(MCQ)
l because many believe this ovarian tumour is m associated with endometrial cancer in
sec-ondary to appendix. 20%.(MCQ)
l Appendicectomy avoids occurrence of n Mesonephroid tumour
pseudomyxoma peritonei(MCQ) m also called clear cell carcinoma
n No adjuvant chemotherapy or radiotherapy is m composed of large cuboidal epithelial cells
necessary with abundant clear cyto-plasm
n but follow-up is mandatory, as recurrence of m characteristically form tubules, glands, small
10-30% is reported. cystic spaces lined by clear cells showing large
n Serous cystadenoma and cystadenocarcinoma dark nuclei protruding into.the lumen
m most common of cystic ovarian neoplasm(MCQ) (hobnail cells). (MCQ)
m account about 50% of all ovarian tumours m The tumour is highly malignant.
m 60-70% are benign n Brenner tumour
m it resembles a fibroma of the ovary l epidermoid carcinoma occurs in 1.7%
m cut surface appears gritty and yel-lowish grey n Solid teratoma of the ovary
m generally unilateral, small to moderate in size, l cut surface has a peculiar trabeculated
m essentially benign appearance
m have no endocrine function. l Most are malignant tumours because of
m generally seen in women around meno-pause, sarcomatous change
and causes postmenopausal bleeding. (MCQ) n Struma ovarii
m pseudo-Meig syndrome(MCQ) l consists of thyroid tissue similar to that of
n Brenner tumor associated with ascites and a thyroid adenoma.
hydrothorax l Some cases develop thyrotoxicosis.
m Walthard cell rests (MCQ) m Carcinoid tumours
n Histologically, the tumour shows a background n argentaffmoma
of fibrous tissue: interspersed within it are nests n sometimes primary and sometimes metastatic
of transi-tional epithelium (MCQ) n histological property of reducing silver salts
n These cells demonstrate a longitudinal groove derived from the specialized Kulchitsky cells
resembling puffed wheat. (MCQ) of the intestine
n this tumour may be com-bined with a n produces 5-hydroxytryptamine which causes
mucinous adenoma of the ovary. (MCQ) attacks of flushing and cyanosis.
m Dysgerminoma
n Germ cell tumours n corresponds to the seminoma of the testis
GOB
m about 95% are benign cystic teratomas, also n average incidence at the age of 20.
called dermoids. (MCQ) n usually unilateral
m Below the age of 20 years, 60% of the tumours n occsionally undergoes torsion
are of germ cell origin n associated with ascites.
m in girls under the age of 10 years almost 85% n The tumour consists of large cells arranged
are of germ cell origin and are invariably in bunches or alveoli
malignant. n Diagnostic histologic finding : (MCQ)
m Teratoma l Lymphocytes and giant cells are always
n divided into three categories: found amongst the tumour cells.
OVARIAN TUMOR
l mature (benign), e.g. dermoid cyst l appearance of large dark-staining nuclei
l immature (essentially malignant), e.g. solid with clear, almost translucent, cytoplasm
teratoma and lymphocytic infiltration of the fibrous
l monodermal or highly specialized, e.g. struma septa is diagnostic (MCQ)
ovarii. n The tumour is neutral and does not secrete
n Dermoid cysts either male or female sex hormones
l usually unilocular with smooth surface n secretes (MCQ)
l seldom attain more than 15 cm in diameter l placental alkaline phosphatase (PLAP)
l contains sebaceous material and hair l lactate dehydrogenase (LDH)
l wall is lined in part by squamous epithelium l Beta-hCG.
which contains hair follicles and sebaceous n Association of dysgerminoma of the ovary and
glands(MCQ) genital abnormality(MCQ)
l Teeth, bone, cartilage, thyroid tissue and l hypoplasia or absence of some part of the genital
bronchial mucous membrane are often tract
found in the wall l pseudohermaphrodites.
l Sometimes the sebaceous material collects n malignancy rate is 30-50%
together in the form of small balls n suggestive findings at laparotomy
l Frequently (40% ) arise in association with l A unilateral tumour confined to one ovary
mucinous cystadenomas (MCQ) is relatively benign.
l Multiple dermoid cysts in the same ovary l The presence of active invasion of the
l Extraovarian der moid cysts arise pelvic viscera is of poor prognosis.
occasionally in the lumbar region, l The presence of extra pelvic metastases in
uterovesical area, parasacral region and the general peritoneal cavity, lymph
rectovaginal septum. (MCQ)
glands, omentum or liver renders the „ small cyst-like spaces are characteristic
outlook hopeless. features of the granulosa cells of the
n Conservative surgery is recommended in graafian follicle. (MCQ)
young girls. „ Most granulosa cell tumours are
n highly radiosensitive(MCQ) encapsulated
n ovarian destruction contraindicates „ clinically benign.
radiotherapy in young girls(MCQ) l metastases are interesting
n Postoperative chemotheapy yields 90% „ opposite ovary first becomes involved
success. „ then metastases develop in the lumbar
n Chemotherapy comprises: (MCQ) region
l bleomycin „ secondary deposits become scattered in
l etoposide the mesentery, the liver and mediastinum.
l cisplatin l Association of carcinoma of the
n Alternate chemotherapy endometrium with granulosa cell
l VAC (vincristine, adriamycin and tumours(MCQ)
cyclophosphamides) (MCQ) „ theca cell tumour is four times more commonly
l VBP (vincristine, bleomycin and cisplatin) associated with endometrial cancer than the
(MCQ) granulosa cell tumour
l Carboplatin and ifosfamide n Theca cell tumour
n Radiotherapy is employed only for residual l usually arises after the menopause
GOB
and recurrent tumour. (MCQ) l nearly always unilateral and forms a solid mass.
n Sex cord stromal tumours l cut surface is yellow in colour and, if stained
m originate either from the selectively, lipoid material is
n sex cords of the embryonic gonad characteristically present. (MCQ)
n stroma of the ovary l tumour consists of spindle-shaped cells
m Since theca cells are the source of ovarian steroids, reminiscent of an ovarian fibroma (MCQ)
many of these are functional and exert l tumour is intensely oestrogenic and causes
feminizing effects. postmenopausal haemorrhage
m Feminizing functioning mesenchymoma l both granulosa cell tumours and theca
OVARIAN TUMOR
n Granulosa ceil tumour cell tumours may show luteinization of their

l observed in 80% of women over 40 years cells, (MCQ)
and in 5% of prepubertal girls. (MCQ) „ progesterone is secreted
l main clinical features depend upon the „ secretor y hypertrophy can be
oestrogenic activity of the tumour (MCQ) demonstrated in the endometrium.
l When occurring before puberty, they cause n Arrhenoblastoma
precocious puberty(MCQ) l secrete androgens
l When occurring in adult life the l cause defeminization followed by
hyperoestrogenic effects(MCQ) masculinization.
„ exaggerated proliferative pattern with l incidence of malignant transformation is
cystic glandular hyperplasia rated to be higher than with feminizing
„ amenorrhoea, followed by prolonged tumours. (MCQ)
bleeding. n Complications of ovarian tumours
„ metropathia haemorrhagica. (MCQ) m Axial rotation: Torsion
„ In the postmenopausal patient, the most n Chocolate cysts and malignant ovarian
remarkable feature is postmenopausal tumours (MCQ)
bleeding l usually fixed by adhesions
l The cells are arranged either in cords or in l very rare for these ovarian tumours to
trabeculae, and are often surrounded by undergo torsion
structureless hyaline tissue, which resembles the n paraovarian cysts and the broad ligament
glass membrane of an atretic follicle. cysts (MCQ)
l Call-Exner Bodies(MCQ) l most likely pelvic tumours to undergo torsion
l they develop in the outer part of the broad
ligament
l come to lie above the infundibulopelvic n a myoma,
fold and above the pelvic brim n ascites
n In most cases, the cyst is about 10 cm or over m Full bladder
in diameter when it undergoes torsion. (MCQ) n Full bladder is (MCQ)
n Because of the high incidence of mucinous l tense and tender, fixed in position
cystadenomas, torsion is most frequently seen with l anterior to the uterus
this tumour. (MCQ) l project anteriorly more than an ovarian cyst
m Rupture l a catheter should be passed to establish the
n may be traumatic or spontaneous. diagnosis.
n most interesting cases of spontaneous rupture m Myoma
are those arising with actively growing n A myoma is usually hard or firm, without the
mucinous cystadenomas. (MCQ) tense cystic consistency of a typical ovarian
m Pseudomyxoma of the peritoneum cyst.
n findings at laparotomy almost exactly resemble m encysted tuberculous peritonitis with ascites
boiled sago pudding. n history of oligomenorrhoea or amenorrhoea
n material cannot be removed completely at operation can be elicited.
because of its attachment to bowel, n tympanic note over the tumour suggests
n condition tends to recur after operation intestinal adhesions over the cyst.
n usually occurs with a mucinous cystadenoma n patient loses weight, is pyrexial with other signs
of the ovary of tuberculosis in the body.
GOB
n also been reported with a m A benign cyst is characteristically (MCQ)
l mucocele of the appendix n unilateral, unilocular or multilocular with a
l carcinoma of the large intestine in men. thin wall and thin septa of less
n prognosis is bad, even after the ovaries and n than 5 mm in a multilocular cyst
the appendix are removed(MCQ) n cavity is non-echogenic.
m Infection n normal CA-125 level below 35 U/ml indicate
m Extraperitoneal development benign nature
n Some ovarian tumours burrow extraperitoneally m A raised CA-125 level is also reported in (MCQ)
during their development and may spread n Abdominal tuberculosis
OVARIAN TUMOR
upwards into the perinephric region n pelvic endometriosis.
m Secondary malignancy m only 50% Stage I epithelial ovarian malignant tumours
n occur in 50% serous cystadenomas, 5% in present raised CA-125 level levels. (MCQ)
mucinous cystadenomas, but only in 1.7% of m A solid tumour suggests malignancy except
dermoid cysts. (MCQ) in a fibroma and Brenner tumour. (MCQ)
m A menopausal ovary measures not more
n Clinical examination than 2 x 1.5 x lcm in size (volume 8 ml). (MCQ)
m Ovarian tumour versus ascites (MCQ) n A size more than this is suspicious of an ovarian
n on percussion it is dull over the centre of the growth.
tumour but resonant in the flanks which are m A malignant ovarian tumour is suspected if
occupied by the displaced large and small bowel. ultrasound reveals (MCQ)
n This sign is reversed in ascites. n bilateral (may be unilateral) or a solid
m An ovarian cyst may simulate very closely a tumour with ascites.
cystic degenerated myoma n tumour wall is thick with echogenic areas within
n cardinal sign that distinguishes a mobile ovarian the tumour.
tumour from a uterine tumour is when the ovarian n The septum is more than 5 mm thick with
tumour is raised up by the abdominal hand papillary projections from its wall. (MCQ)
the cervix remains stationary to the vaginal n Except in Meig’s syndrome, the presence of
fingers. ascites as shown on ultrasound strongly points
n Differential diagnosis to malignant nature of the tumour.
m abdominal physical signs of an ovarian cyst may n Colour flow Doppler technology,
be simulated by a l indicates increased blood flow to the
n full bladder tumour and probability of the tumour being
n a pregnant uterus malignant.
l Low pulsatile index also suggests increased l emoved in early puerperium to avoid torsion
blood flow in a malignant tumour and infection(MCQ)
m CEA (carcinoembryonic antigen) more than n Malignant ovarian tumours
5 mg/1 is seen in mucinous ovarian tumour(MCQ) l malignant ovarian tumour requires
n Treatment laparotomy at the earliest, irrespective of the
m Laparotomy is required in every case duration of pregnancy.
m Even a benign ovarian tumour requires removal; m Ovarian cyst in a menopausal woman
m Open laparotomy is preferred to laparoscopic n A simple unilocular cyst measuring less than
excision 5 cm (MCQ)
m Prophylactic oophorectomy(MCQ) l can be observed with repeat ultrasound and
n Bilateral removal of ovaries at hysterectomy CA-125 every 3 months
is also desirable in a woman with family history l Many resolve in 6 months
of(MCQ) n A persistent cyst
l ovarian cancer l removal laparoscopically or by laparotomy.
l colonic and breast cancer n Aspiration of the cyst is contraindicated
l previous hyperstimulation of ovaries in because of
infertility l low yield of malignant cells (false-negative)
l in a woman carrying BRCA-1 and BRCA-2 l possibility of spread of malignancy if the
genes. cyst proves malignant histo-logically;
m Benign ovarian tumours n Many perform bilateral oophorectomy and
GOB
n The treatment comprises: hysterectomy.

l Abdominal hysterectomy and bilateral salpingo- n Does the preserved ovary continue to function
oophorectomy after hysterectomy?
l Unilateral ovariotomy l It is obser ved that following
l Ovarian cystectomy hysterectomy, ovarian blood supply is compromised
l Laparoscopic cystectomy-ovariotomy and at best it may retain its function for
l Laparoscopy/ultrasound-guided aspiration of the cyst. about 4 years.
n Abdominal hysterectomy and bilateral n Following oophorectomy, is HRT effective?
salpingooophorectomy (MCQ) l Though effective, it is advisable not to
OVARIAN TUMOR
l recommended in a perimenopausal continue HRT for more than 5 years

women, because of the risk of breast cancer.
l Done even if the tumour is benign and m Ovarian remnant syndrome
unilateral. n follows hysterectomy in 1.4% cases
n Ovariotomy/cystectomy(MCQ) n caused by ovarian adhesions to the vaginal
l In a young woman, irrespective of parity, vault
conservation of healthy ovary is highly desirable. n causes cyclical abdominal pain and deep
l ovarian tumour should be enucleated dyspareunia.
(cystectomy) n It requires oophorectomy.
m Ovarian tumours associated with pregnancy m Ovarian tumours in adolescents
n The ovarian tumour discovered during n Before the age of 20 years(MCQ)
pregnancy is an l 60% are germ cell tumours
l enlarged corpus luteal cyst l 65% of these are malignant.
l a benign tumour. n Why epithelial tumours are extremely rare during
l malignant tumour. adolescent period(MCQ)
n Corpus luteal cyst l epithelial tumours are related to ovulation
l regresses after twelfth week (MCQ) l ovulation occurs only after puberty,
l can therefore be observed. n Dysgerminoma (MCQ)
n Benign tumour l commonest tumour in adolescents
l should be removed in the second trimester l causes amenorrhoea.
l removed between fourteenth and n Conser vative surgery followed by
sixteenth week. (MCQ) chemotherapy is effective in young girls.
n The tumour discovered late in pregnancy (MCQ)

TOPIC - 4 n Spontaneous regressionoccurs in a significant
CERVICAL INTRAEPITHELIAL number of patients
NEOPLASIA n allows for expectant management with serial
cytologic smears in the reliable patient.
n Cervical intraepithelial neoplasia m A certain percentage of all dysplasias, especially
m Lower genital tract squamous intraepithelial high-grade lesions, will progress to an invasive
neoplasia cancer if left untreated
n often multicentric m it is recommended that all patients with CIN
n affects multiple anatomic sites which II and CIN III be treated when diagnosed.
embryologically are derived from the same (MCQ)
anogenital epithelium n The only exception to this recommendation
l cervical intraepithelial neoplasia (CIN) concerning adolescents, in whom CIN II may

l vaginal intraepithelial neoplasia (VAIN) be followed, as spontaneous regression is
l vulvar intraepithelial neoplasia (VIN), substantial and the risk of cancer is almost nil
l perianal intraepithelial neoplasia (PAIN). m Epidemiology & Etiology
m Cervical intraepithelial neoplasia (CIN) – is n CIN is most commonly detected in women in
disordered growth and development of the their 20

epithelial lining of the cervix. n the peak incidence of carcinoma in situ is in
m Various degrees of CIN. (MCQ) women ages 25–35 years, incidence of

n Mild dysplasia, or CIN I, cervical cancer rises most significantly after the
GOB
l disordered growth of the lower third of the age of 40 years. (MCQ)
epithelial lining (MCQ) n The epidemiologic risk factors for CIN
n Moderate dysplasia, or CIN II. (MCQ)

l Abnormal maturation of the lower two- l multiple sexual partners
thirds of the lining is called (MCQ) l early onset of sexual activity
n Severe dysplasia, CIN III l a high-risk sexual partner
l encompasses more than two-thirds of the „ history of multiple sexual partners
epithelial thickness with carcinoma in situ „ HPV infection,
(CIS) „ lower genital tract neoplasia
CERVICAL INTRAEPITHELIAL NEOPLASIA

l represents full-thickness dysmaturity „ prior sexual exposure to someone with
(MCQ) cervical neoplasia

m cytologic smears are classified according to the l a history of STDs
Bethesda system, (MCQ) l cigarette smoking (MCQ)
n atypical squamous cells are divided into those l HIV infection
of undetermined significance (ASC-US) l AIDS
n atypical squamous cells of a high grade lesion l other forms of immunosuppression
(ASC-H). l multiparity(MCQ)
n Low-grade squamous intraepithelial lesion l long-term OCP use.
(LSIL) encompasses n Condoms are not as protective against HPV
l cytologic changes consistent with koilocytic as they are against other STDs as transmission
atypia can occur from labial-scrotal contact.
l CIN I. n High-risk HPV - types 16, 18, 31, 33, 35, 39,
n High-grade squamous intraepithelial lesion 45, 51, 52, 56, 58, 59, 68, 73, and 82(MCQ)
(HSIL) denotes cytologic findings m Pathology
corresponding to n Adenocarcinoma in situ (ACIS) i
l CIN II l defined as the presence of endocervical
l CIN III glands lined by atypical columnar

m CIN epithelium that cytologically resembles the
n suspected because of an abnormal cytologic cells of endocervical adenocarcinoma, but
smear that occur in the absence of stromal
n diagnosis is established by cervical biopsy. invasion.
m CIN I(MCQ) l diagnosis of ACIS can be made only by
cone biopsy.
m Clinical Findings n What is Reflex HPV testing (MCQ)
n There are usually no symptoms or signs of l refers to the concurrent collection of a specimen
CIN for cervical cytology and HPV testing,
n diagnosis is most often based on biopsy with the HPV testing being performed
findings following an abnormal routine cervical only in case of an abnormal cytologic
cytology smear. screen.
m Indications for pelvic examination and collection l For ASC-US, this approach is the most cost-
of a cytologic smear. (MCQ) effective
n all women who have reached age 21 years l Women with an ASC-US smear and a
n who are 3 years past coitarche negative HPV test are followed with a
m The cervical cytology smear should be performed cervical cytology smear at 1 year
(MCQ) m HPV testing combined with a cer vical
n annually in case of conventional Papanicolaou cytology smear
(Pap) smears n approved as a primary screening approach in the
n biannually if using liquid- based cytology patient age 30 years and older, who still has
m Once a patient is age 30 years or older and has her uterus and has no immunosuppression
had 3 consecutive negative smears, the time l Situation : 1 - If both results are negative,
interval between cervical cytology smears can be combined screening should not be repeated for
extended to every 3 years (MCQ) 3 year(MCQ)
m Cervical cytology screening may be discontinued l Situation : 2 - If cytology and HPV testing
GOB
(MCQ) are positive, triaging to colposcopy is as

n at age 70 years if the patient had 3 or more outlined above. (MCQ)
consecutive normal smears in the preceding 10 years. l Situation : 3 - If cytology is normal, but
n if the patient has undergone a total HPV test is positive, repeat cytology and
hysterectomy, unless it was done for the HPV test in 6–12 months is recommended, with
treatment of cervical dysplasia or cancer. colposcopy at that point if either test is
m Repeat Cervical Cytology(MCQ) abnormal. (MCQ)
n 3 acceptable initial evaluation steps for patients m Schiller Test (MCQ)
with minimally abnormal cervical cytology n Principle
smears (eg, ASC-US): l normal mature squamous epithelium of

l accelerated serial cytology smears the cervix
l triage to colposcopy based on a positive „ contains glycogen, (MCQ)
HPV testing result „ glycogen combines with iodine to produce a
l immediate referral to colposcopy. deep mahogany-brown color
m Who should be referred for immediate n Nonstaining, constitutes a positive Schiller test
colposcopy. (MCQ) -, indicates (MCQ)
n All patients with ASC-H, LSILs, HSILs l abnormal squamous (or columnar) epithelium,
n atypical glandular cells (AGCs) l scarring,
n smears suspicious for cancer l cyst formation,
m Conditions that might contribute to an atypical l immature metaplastic epithelium
smear(MCQ) n Lugol’s solution is an aqueous iodine
n infections preparation and is commonly used for the
n atrophic vaginitis Schiller test. (MCQ)
m The cervical cytology smear should be repeated
every 6 months until there are two consecutive normal n Colposcopic Examination
smears. m primary technique for the evaluation of an
m A second abnormal smear (atypical squamous abnormal cervical cytology smear.
cell [ASC] or worse) should be evaluated by colposcopy. m Indications for colposcopy are: (MCQ)
m HPV Testing n Abnormal cervical cytology smear or HPV
n For patients with ASC-US, reflex HPV testing;
testing is the preferred approach, with triage n Clinically abnormal or suspicious-looking
of women who test positive for high-risk HPV to cervix
colposcopy. (MCQ)
n Unexplained intermenstrual or postcoital l epithelium that stains white after the
bleeding application of acetic acid.
n Vulvar or vaginal neoplasia n Mosaicism or punctation (MCQ)
n History of in utero DES exposure. l reflects abnormal vascular patterns of the
m Normal colposcopic findings are those of: surface capillaries.

(MCQ) n capillary thickness and intercapillary
n The original squamous epithelium distances (MCQ)

l extends from the mucocutaneous vulvovaginal l as a general rule, correlate with the severity of
junction to the original squamocolumnar the lesion

junction. l tend to be larger and coarser in higher-grade
n The columnar epithelium of the endocervical lesions.

canal. n Atypical vessels with bizarre capillaries with
n The transformation zone(MCQ) so-called corkscrew, comma-shaped, or

l metaplastic squamous epithelium between the spaghetti-like configurations suggest early
original squamocolumnar junction and the stromal invasion(MCQ)
active squamocolumnar junction m A colposcopically directed punch biopsy of
l Cer vical neoplasia almost invariably the most severely abnormal areas should be done.
originates within the transformation zone m Nonvisualized portion of the endocervical
n original squamocolumnar junction (MCQ) canal

l junction between the stratified squamous n The transformation zone extends into the
GOB
epithelium of the vagina and ectocervix, and endocervical canal beyond the field of
the columnar epithelium of the endocervical vision in (MCQ)
canal l 12–15% of premenopausal women
m Squamocolumnar junction(MCQ) l a significantly higher percentage of
n original squamocolumnar junction is located on postmenopausal women.

l ectocervix- in two-thirds of female infants, n Evaluation of the nonvisualized portion of
l endocervical canal - in close to a third the endocervical canal by endocervical

l vaginal fornices- in a very small subset out curettage (ECC) should be performed using
in the. a brush or curette in every case in (MCQ)
l which colposcopy is unsatisfactory

n During a woman’s life cycle the
squamocolumnar junction “migrates” l where the lesion is extending into the
(MCQ) endocervical canal

l Following menarche, SCJ is generally found l where the colposcopic impression does not
on the ectocervix explain the cervical cytology findings

l further eversion of SCJ ioccurs during l where ablative therapy is contemplated.
pregnancy n ECC is not indicated in pregnancy(MCQ)
l In the postmenopausal patient, the SCJ is n Diagnostic Conization -Indications(MCQ)

frequently within the endocervical canal. m if colposcopy is unsatisfactory
m When do you call the colposcopic examination m if the lesion extends into the cervical canal
satisfactory(MCQ) beyond the view afforded by the colposcope

n If the new SCJ is visualized in its entirety m if there is dysplasia on the endocervical
m When do you call the colposcopic examination curettage

unsatisfactory m if there is a significant discrepancy between the
n if the new SCJ cannot be fully visualized histologic diagnosis of the directed biopsy specimen
m Abnormal findings indicative of dysplasia and and the cytologic examination
carcinoma in situ (CIS) are those of: (MCQ) m if adenocarcinoma in situ is suspected
n Leukoplakia or hyperkeratosis, (MCQ) m if microinvasive carcinoma is suspected.
l an area of white, thickened epithelium n Natural History

l appreciated prior to the application of acetic m majority of CIN I lesions will spontaneously
acid regress without treatment. (MCQ)

l may indicate underlying neoplasia. n it is generally reasonable to expectantly follow
n Acetowhite epithelium(MCQ) the compliant patient with CIN I using

surveillance with
l serial cervical cytology smears at 6-month
intervals or
l an HPV test at 12 months.
n In the adolescent patient, observation is the
preferred management approach.
m majority of high-grade lesions will persist or
progress
n immediate treatment is generally warranted.
n Treatment
m Treatment options fall into one of two main
categories:
n Ablative techniques -procedures that ablate the
abnormal tissue and do not produce a tissue
specimen for additional histologic
evaluation - (MCQ)
l cryotherapy
l laser ablation
n Excisional procedures - procedures that excise
the area of abnormality, allowing for further
histologic study. (MCQ)
GOB
l cold knife conization

l laser cone excision
l LEEP
m If the intraepithelial lesion is confined to the
ectocervix, treatment is appropriate with
n Cryotherapy
n laser ablation
n a superficial excision by the loop electrosurgical
excision procedure (LEEP).
m Deeper LEEP or cone biopsy with inclusion

of endocervical canal - indications(MCQ)
n If the lesion extends into the endocervical canal
n the endocervical curettage contains dysplastic
epithelium
n colposcopic examination is otherwise
unsatisfactory
m Therapeutic Conization procedure –other
indications(MCQ)
n significant discrepancy between cervical
cytology and colposcopy/biopsy results
n cases of suspected microinvasive carcinoma
n cases of suspected adenocarcinoma in situ.

GOB

n Cryotherapy m done in the operating room under local or general
m an office procedure not requiring anesthesia anesthesia
m nitrous oxide or carbon dioxide is used as the m Complications (MCQ)
refrigerant for a supercooled probe. (MCQ) n Bleeding
m blanching of the cervix extends at least 7 mm n Infection
beyond the probe in all directions n cervical stenosis
m advantages of cryotherapy n cervical incompetence.
n ease of use m Advantage of Cold knife conization over LEEP
n low cost, widespread availability and laser conization(MCQ)
n low complication rate. n it results in a specimen devoid of any thermal
m Side effects of cryotherapy artifact that may complicate the histologic
n mild uterine cramping diagnosis and margin assessment seen with
n a copious watery vaginal discharge for LEEP and laser conization.
several weeks(MCQ) n This becomes particularly important with
n Infection suspected microinvasive carcinoma and
n cervical stenosis adenocarcinoma in situ
m Follow-up colposcopic examinations can be m Pregnancy
unsatisfactory because of the inability to visualize l Colposcopy is performed for the same
the squamocolumnar junction. indications as in the nonpregnant patient.
n Carbon dioxide (CO2 ) laser l Endocervical curettage is not performed in
GOB
m can be used either to (MCQ) pregnancy

n ablate the transformation zone l The physiologic changes of pregnancy render
n as a tool for cone biopsies. the transformation zone easily accessible for
m both precise and flexible satisfactory colposcopy by 20 weeks’ gestation in
m Posttreatment vaginal discharge may last 1–2 almost all women. (MCQ)
weeks l pregnancy may produce changes in the
m bleeding that requires reexamination can occur cervical epithelium that mimic those of cervical
in a small percentage of patients. dysplasia
Loop electrosurgical excision procedure (LEEP) l Although the gravid cervix is more vascular,
n
(MCQ) directed ectocervical biopsies can be performed
m LEEP is the procedure of choice for treating safely with minimal increase in the risk of
CIN II and CIN III (MCQ) significant bleeding.
o Advantages l Even high-grade lesions discovered during
n ease of use pregnancy have a high rate of regression in the
n low cost postpartum period.
n provision of tissue for histologic evaluation l Conization during pregnancy is indicated only
m Complications are less frequent than with cold if early invasive disease is suspected. (MCQ)
knife conization and include (MCQ) l Treatment is deferred into the postpartum
n Bleeding period
n infection, m Atypical glandular cells on cervical cytology
n cervical stenosis. smear
n Cold knife conization of the cervix n Thay have a up to 50% risk of having high-
m excision of a cone-shaped portion of the cervix grade cervical neoplasia
m technique can be individualized to accommodate n The underlying lesion is most commonly CIN
the cervical anatomy and the size and shape II or III, (MCQ)
of the lesion – Tailor made(MCQ) n Given the high risk for significant pathology,
n a wide, shallow cone specimen can be obtained from any patient with glandular cell
a young patient whose squamocolumnar abnormalities on a cervical cytology smear
junction is on the ectocervix requires immediate evaluation, which includes,
n In an older patient, in whom the at a minimum, colposcopy with careful
squamocolumnar junction tends to move more evaluation of the endocervical canal.
cephalad into the endocer vical canal, a n Assessment of the endometrium is
narrower, deeper cone is preferable. recommended in all patients(MCQ)
l older than age 35 years almost always within 1 cm of the
l in patients at any age with abnormal squamocolumnar junction of the cervix either
bleeding, on the portio vaginalis of the cervix or slightly higher in
l in women with AGC (endometrial cells), the endocervical canal. (MCQ)
l in women with AGC (nonspecified cell n Clinical presentation
type) m The most common symptom of cervical cancer
n Diagnostic conization is indicated in is abnor mal vaginal bleeding or
l all cases of AGC-favor neoplasia, AIS, or suspected discharge(MCQ)
adenocarcinoma m Abnormal bleeding may take the form of
l persistent atypical glandular cell–not otherwise n postcoital spotting
specified (AGC-NOS), n intermenstrual bleeding
m Adenocarcinoma in situ n heavy menstrual bleeding (menorrhagia)
n Adenocarcinoma of the cervix represents 25% m Serosanguineous or yellowish vaginal
of all cervical cancers (MCQ) discharge, at times foul smelling, may occur with
n ACIS is a precursor lesion particularly advanced and necrotic carcinomas.
n Half of the women with ACIS have concomitant m Extension to the pelvic side wall may cause
squamous CIN sciatic pain or back pain associated with
n Conization is required to make the diagnosis. hydronephrosis(MCQ)
n Conservative management should be m Metastatic involvement of the iliac and para-
undertaken only in the young patient with a aortic lymph nodes can extend into the
GOB
negative conization margin who is fully lumbosacral nerve roots and also present as
counseled and desires to maintain her fertility. lumbosacral back pain.
n In all other patients, hysterectomy should be m Bladder or rectal invasion by advanced-stage
performed as a definitive therapeutic disease may produce urinary or rectal symptoms
intervention (e.g., hematuria, hematochezia).
n Physical findings.
TOPIC - 5 CARCINOMA CERVIX m Cervical carcinoma most commonly appears as
an exophytic cer vical mass that
n Cancer of the cervix characteristically bleeds on contact.
CARCINOMA CERVIX
m HPV 16 is the most prevalent HPV type in m In these cases, bimanual examination may reveal a
squamous cell carcinoma (MCQ) firm, indurated, often barrel-shaped cervix.

m HPV 18 the most prevalent in adenocarcinoma. n Spread of disease
(MCQ) m Direct extension
m Other associated risk factors (MCQ) n Paracervical and parametrial extension.
n Immunosuppression (MCQ)
n infection with HIV l The lateral spread of cervical cancer occurs
n history of other sexually transmitted diseases, through the cardinal ligament

n tobacco use, high parity l significant involvement of the medial portion
n oral contraceptive use. of cardinal ligament may result in ureteral

m HPV obstruction.
n epitheliotropic. l Tumor cells commonly spread through
n How does integration of HPV into the human parametrial lymphatic vessels to expand and
genome is associated with cell immortalization replace parametrial lymph nodes.
allowing for malignant transformation. n Vaginal extension.
l Causes upregulation of the viral oncogenes l The upper vagina is frequently involved (50%
E6 and E7. (MCQ) of cases) when the primary tumor has

l These oncoproteins interfere with cell- extended beyond the confines of the cervix. (MCQ)
cycle control in the human host cell. l Anterior extension through the vesicovaginal
l E6 and E7 have the ability to complex with septum is most common, and often the
the tumor suppressor genes p53 and Rb, dissection plane between the bladder and
respectively. underlying cervical tumor is obliterated,
m At least 90% of squamous cell carcinomas of the which makes surgical therapy difficult or
cervix develop from the intraepithelial layers, impossible.
l A deep posterior cul-de-sac can represent l Spread to distant organs
an anatomic barrier to direct tumor spread from m The most notable changes were for stage IA1
the cervix and vagina to the rectum posteriorly. (microinvasive carcinoma), which is now
n Bladder and rectal involvement. defined as stromal invasion no greater than 3.0
l Anterior and posterior spread of cervical mm in depth and no wider than 7.0 mm. This
cancer to the bladder and rectum is new definition reflects data indicating that patients
uncommon in the absence of lateral parametrial with less than 3.0 mm of invasion are at very low
disease. risk of metastatic disease and may be treated
m Lymphatic spread more conservatively(MCQ)
n most commonly involved, in descending order m FIGO’s clinical staging system for cervical
of incidence, are the obturator, external iliac, carcinoma is based on (MCQ)
and hypogastric lymph node groups n clinical evaluation (inspection, palpation,
n Staging (A very important High yield topic for colposcopy)
MD Entrance exam) n radiographic examination of the chest, kidneys,
m FIGO revised the clinical staging of cervical and skeleton
carcinoma (MCQ) n endocervical curettage and biopsies as needed.
n IA1 m Findings that should not be used for clinical
l Confined to the cervix, diagnosed only by staging
microscopy with invasion of < 3 mm in n Lymphangiograms
depth and lateral spread < 7 mm n Arteriograms
GOB
n IA2 n CT scan findings

l Confined to the cervix, diagnosed with n MRI
microscopy with invasion of > 3 mm and n laparoscopy and laparotomy findings
< 5 mm with lateral spread < 7mm m Tumor characteristics.
n IB1 n Clinical stage of disease at the time of
l Clinically visible lesion or greater than A2, presentation is the most important
< 4 cm in greatest dimension determinant of subsequent survival regardless
n IB2 of treatment modality
CARCINOMA CERVIX
l Clinically visible lesion, > 4 cm in greatest n For all stages of disease, when both pelvic and
dimension para-aortic lymph nodes are negative, 5-year
n IIA1 survival is 75.2%. (MCQ)
l Involvement of the upper two-thirds of the n Survival decreases to 45.6% with positive
vagina, without parametrial invasion, < 4 pelvic nodes, whereas involvement of para-
cm in greatest dimension aortic nodes lowers 5-year survival to 15.4%.
n IIA2 n Patients with bilateral pelvic lymph node
l 4 cm in greatest dimension involvement have a worse prognosis than those
n IIB with unilateral disease
l With parametrial involvement n Lesion size is an important predictor of survival,
n IIIA independent of other factors.
l Tumor involves lower third of the vagina, n Survival is also strongly correlated with depth
with no extension to the pelvic wall of tumor invasion into the stroma,
n III B m Pathology
l Extension to the pelvic wall and/or n Microinvasive carcinoma (MICA).
hydronephrosis or non-functioning kidney l MICA is a lesion not apparent clinically
n Stage IV l it is diagnosed by histologic examination of
l The carcinoma has extended beyond the a cone biopsy or hysterectomy specimen
true pelvis or has involved (biopsy proven) that includes the entire lesion. (MCQ)
the mucosa of the bladder or rectum. l Findings that preclude a diagnosis of MICA
l A bullous edema, as such, does not permit a „ Involvement of the cone margins by
case to be allotted to Stage IV invasive carcinoma
n IVA „ a high-grade intraepithelial lesion
l Spread of the growth to adjacent organs l Histologically, MICA is characterized by the
n IV B presence of irregularly shaped tongues of epithelium
projecting from the base of an m Follow-up of cervical carcinoma
intraepithelial lesion into the stroma. n Patients are examined every 3 months for the
l Lesions fulfilling the FIGO criteria of first 2 yr, then every 6 months in yr 3–5, and yearly
MICA have virtually no potential for either thereafter. (MCQ)
metastases or recurrence Therefore, this n An exam consists of a history, physical, and
definition appears to be the most useful for Pap.
guiding clinical management. n A chest x-ray and CT scan of abdomen are
n Invasive squamous cell carcinoma. performed annually.
l Squamous cell carcinoma is the most common Recurrent cervical carcinoma
histologic type of cervical cancer n Thirty percent of patients treated for cervical
n Grade. cancer will have a recurrence.
l Grade 1 tumors n Recurrence of cancer can occur anywhere, but
„ well differentiated with mature squamous occur mainly in the pelvis (vagina, cervix,
cell or lateral pelvic wall).
„ often form keratinized pearls of epithelial n Screening for recurrence
cells. m Look for:
„ Mitotic activity is low. n Vaginal bleeding.
l Grade 2 tumors n Hematuria/dysuria.
„ Moderately well-differentiated n Constipation/melena.
carcinomas have higher mitotic activity and n Pelvic and leg pain.
GOB
less cellular maturation n Fistulas (in bladder or bowel).
„ accompanied by more nuclear n Sacral backache or pain in sciatic distribution.
pleomorphism n Costovertebral angle and flank pain.
l Grade 3 tumors m Cause of death
„ poorly differentiated n Uremia is the major cause of death in cervical
„ smaller cells with less cytoplasm and often cancer (found in 50% of patients). (MCQ)
bizarre nuclei. n Excretory urogram can identify periureteral
„ Mitotic activity is high compression by tumor.
CARCINOMA CERVIX
n Subclassification. n Treatment of cervical cancer by stage: (MCQ)
l large cell keratinizing A very impotant topic
l large cell nonkeratinizing, m 0–1: (MCQ)
l small cell types. n Laser or cryotherapy (endocervix);
m Treatment of invasive cervical cancer n loop electrosurgical excision
n Radical surgery(MCQ) n procedure (LEEP)
l Radical hysterectomy with lymph node n cold knife cone biopsy (ectocervix)
dissection. n total abdominal hysterectomy (TAH; if
l Done only in patients with low-stage completed childbearing)
disease (IB–IIA). n conization or cryo (if patient wants to retain
n Radiation therapy(MCQ) uterus).
l High-dose delivery to the cervix and vagina, m 1a–2a: (MCQ)
and minimal dosing to the bladder and rectum: n Radical hysterectomy or radiation
§ External-beam whole pelvic radiation. n pelvic lymphadenectomy
§ Transvaginal intracavitary cesium: n para-aortic lymphadenectomy.
Transvaginal applicators allow significantly m 2b–4b: (MCQ)
larger doses of radiation to surface of n Chemotherapy (cisplatin) and radiation.
cervix. n General principles of treatment:
m Treatment of bulky central pelvic disease m Patients may undergo definitive treatment only
n Radical hysterectomy with adjuvant or if disease is confined to pelvis. (MCQ)
neoadjuvant radiation therapy. m Patients with local recurrence after radical
n Tumor cytoreduction: hysterectomy are treated with radiation. (MCQ)
l Use of cytotoxic chemotherapy before m Patients previously treated with radiotherapy
definitive treatment with radiation or radical are treated only by radical pelvic surgery. (MCQ)
surgery. n Chemotherapy:

m Response rates are higher with combination n Radiation cannot be given during pregnancy,
therapy. only chemotherapy. (MCQ)
m Most combinations include platinum. (MCQ) l In early-stage disease a diagnostic CKC
m Response rates: 50–70% for 4–6 months of life. (cold-knife conization) can be done if the
n Cervical cancer in pregnancy patient has a Stage IA1 cancer.
m Three percent of all invasive cervical cancers occur l If the stage is > Stage IA2, then after delivery,
during pregnancy. treatment can be instituted.
m Symptoms n Second-trimester treatments can include
n One-third of pregnant patients with cervical platinum-based chemotherapies, which
cancer are asymptomatic. would allow prolongation of pregnancy for
n Symptoms in pregnancy include vaginal fetal maturity. (MCQ)
bleeding and discharge. n A cold knife conization during pregnancy
m Screening can lead to severe complications such as
n Cervical cytology should be performed at the hemorrhage and loss of pregnancy. (MCQ)
initial obstetric visit (if?? 21 years old). (MCQ) n Third-trimester treatments include radical
l ASCUS and LGSIL in patients > 21 years hysterectomy and pelvic lymphadenectomy
old managed as in nonpreg-nant patient, after high classic cesarean delivery. (MCQ)
although colposcopy may be deferred until n Delays in treatment have not been reported to?‘!
6 weeks postpartum. (MCQ) recurrence rates in stage I disease. (MCQ)
l Atypical squamous cells with possible m Delivery
GOB
high-grade squamous intraepithelial n Consideration of possible tumor hemorrhage

lesion (ASC-H), high-grade squamous and size/shape influence delivery method.
intraepithelial lesion (HG- SIL), and n Patients with small-volume stage IA tumors
atypical glandular cells (AGCs) require may be candidates for vaginal delivery. (MCQ)
colposcopy with biopsy (endocervical n Episiotomies should be avoided due to case
curettage [ECC] contraindicated). (MCQ) reports of cancer implantation at such sites.
l If antepartum colposcopy is negative, n Patients with > Stage IA1 cancer, require a
repeat colposcopy at 6-week post- cesarean section for delivery, and then treatment.
CARCINOMA CERVIX
partum visit. (MCQ)

n Therapeutic conization is contraindicated n Adenocarcinoma of cervix
during pregnancy m Makes up 10–15% of cervical cancers.
n Diagnostic conization is reserved for patients m Affects women aged 16–27; median age—19 yr.
in whom an invasive lesion is suspected m Carcinomas mainly arise from the endocervix;
but cannot be confirmed by biopsy and the lesions are “endophytic.”
results will alter the timing or mode of delivery. m Overall survival rate: 80%.(MCQ)
l Otherwise, conization is perfor med m Five-year survival rate for stage I disease: > 90%.
postpartum. m Screening of DES-exposed women(MCQ)
n Cone biopsy, if necessary, should be performed n Annual Pap smear.
in the second trimester. (MCQ) n Careful palpation of vaginal walls to rule out
l Complications are common including adenosis or masses.
hemorrhage and preterm labor. m Treatment
n Clinical staging unchanged, except magnetic n Similar to treatment of squamous cell carcinoma
resonance imaging (MRI) should replace CT of cervix.
scans. n Preferred treatment is radical hysterectomy
m Treatment and pelvic lymph node dissection for stage
n Definitive treatment is incompatible with IB or IIA. (MCQ)
pregnancy continuation. n Vaginectomy if vagina is involved.
n Therapy should be influenced by gestational age, m Disease recurrence
tumor stage, and metastatic evaluation. If the n Most DES-related clear cell carcinomas recur
patient chooses to continue the pregnancy, after 3 yr of initial treatment.
therapy can be postponed until after delivery n Pulmonary and supraclavicular nodal
or the pregnancy can be terminated. metastasis common
n A pregnancy can be terminated to begin n yearly screening chest x-ray recommended.
34
treatment.
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TOPIC - 6 INFERTILITY l Morphology: Normal > 40%.
m Treatment for abnormal semen analysis
n Depends on the cause.
n The monthly conception rate is 20% in a group of normal
n Refer to urologist.
fertile couples.
n Smoking and alcohol cessation.
n Infertility ‘!?with increasing age of the female partner.
n Avoid lubricants with intercourse.
n Affects 15% of couples.
n Clomiphene 25 mg/day for 25 days, with 5
n Female factors account for 40–50% of infertile
couples. (MCQ) days of rest (for the male partner). (MCQ)
n Artificial insemination (with partner or donor
n Male factors account for 23% of infertile couples.
n In 40% of infertile couples, there are multiple causes.
sperm):
n Intrauterine insemination: Sperm injected
n The inability to conceive after 12 months of
unprotected sexual intercourse. through cervix.
n Intracytoplasmic sperm injection.
n Types
n If semen analysis is normal, continue workup
m Primary infertility: Infertility in the absence of previous
pregnancy. of other factors.
m Secondary infertility: Infertility after previous
Methods of assessing ovulation
n
m History of regular monthly menses is a strong
pregnancy.
n Evaluation of Infertile Couple
indicator of normal ovulation.
n Basal body temperature (BBT):
m Multifactorial: 40%.(MCQ)
n Body temperature rises about 0.5 –1 F during
o o
m Unexplained: 28%.
the luteal phase due to the ↑ level of
GOB
m Anovulation: 18%.
m Tubal disease: 14%.
progesterone. (MCQ)
n Elevation of BBT is a good indicator that
m Endometriosis: 9%.
m Abnormal sperm function.
ovulation is taking place.
m Serum progesterone:
m Abnormal sperm production.
n May be low if the corpus luteum is not
m Obstruction of ductal system (seminiferous
tubules to urethral oriface). producing enough.
m Day 3 FSH: (MCQ)
n Infertility workup
n Elevated if patient is anovulatory.
m Male factor: Semen analysis.
m Endometrial biopsy:
INFERTILITY
m Ovulation factor: Serum progesterone, day 3
n Determines histologically the presence/absence
FSH, prolactin, endometrial biopsy.
m Cervical factor: Postcoital test.
of ovulation.
n Possible causes and treatments of
m Uterine factor: Ultrasonography,
hysterosonogram, hysterosalpingogram, anovulation
m Pituitary insufficiency:
hysteroscopy.
n Treat with intramuscular luteinizing
m Tubal factor: Hysterosalpingogram, laparoscopy.
m Endometriosis: Laparoscopy.
hormone/ follicle-stimulating hormone
n Male Factor
(LH/FSH) or clomiphene.
m Hyperprolactinemia:
m Semen analysis
n Administer bromocriptine, a dopamine
n Performed after at least 48 hr of abstinence
(MCQ) agonist, which supresses prolactin.
m PCOS:
n examination of the sperm within a maximum
n Treat with clomiphene +/– metformin,
of 2 hrs from time of ejaculation (for those
who prefer to collect at home). (MCQ) weight loss.
m Other causes:
n Two properly performed semen analyses
n Hyper/hypothyroid, androgen excess, obesity/
should be obtained at least 4 weeks apart.
n The analysis reflects sperm production that
starvation, galactorrhea, stress.
m Internal architecture study
occurred 3 months ago. (MCQ)
n analysis of uterus and fallopian tubes is
n Characteristics (A very important MCQ)
l Volume: Normal > 2 mL.
performed
n conducted if ovulation analysis and semen
l Semen count: Normal > 20 million/mL.
l Motility: Normal > 50% with forward
analysis are normal
m Hysteroscopy:
movement.
n A hysteroscope is an telescope that is n Lysis of adhesions via laparoscope.
connected to a video unit with a fiber-optic n Microsurgical tuboplasty.
light source. m Neosalpingostomy (blocked tubes are opened).
n It is introduced through the cervix and allows m Tubal reimplantation for intramural obstruction.
visualization of the m In vitro fertilization (IVF).
n uterine cavity. m Tubal blockage: Tubal flushing.
n It is diagnostic and therapeutic. n If the evaluation up to this point is within
n Hysteroscopy is useful in: (MCQ) normal limits, then a diagnostic laparoscopy
l Asherman syndrome (lyse intrauterine should be done.
adhesions). m Laparoscopy is diagnostic and therapeutic.
l Endometrial polyps (polypectomy). n Causes and treatments for peritoneal factor
l Congenital uterine malformations (eg, infertility
excise a uterine septum). m Adhesions: Lysis of adhesions via laparoscopy.
l Submucosal fibroids (resect). m Endometriosis: Excision or ablation of implants.
m Hysterosalpingogram: n Assisted reproductive technologies (ARTs)
n Radiopaque dye is injected into the cervix and m Intrauterine Insemination
uterus. n Washed sperm is injected into the uterus.
n Dye passes through the fallopian tubes to n Must have a normal tube for fertilization to
the peritoneal cavity. take place.
n It should outline the inner uterine contour m In Vitro Fertilization (IVF) and Embryo
GOB
and both fallopian tubes when imaged with Transfer

fluoroscopy. n Egg cells are fertilized by sperm outside the
n Allows visualization of uterus and fallopian uterus.
tubes. n Consists of ovarian stimulation, egg retrieval,
n Performed during follicular phase (avoid fertilization, selection, and embryo transfer into uterus.
possibility of pregnancy). n Success rate of IVF is about 20%.
n There is a risk of salpingitis from the injection. m Intracytoplasmic Sperm Injection (ICSI)
n An interventional radiologist can use catheters n Subtype of IVF.
to open the fallopian tubes that are occluded proximally. n Injection of spermatozoan into oocyte
m Sonohysterogram: cytoplasm.
INFERTILITY
n Fluid is instilled in the endometrial cavity n Revolutionized treatment of infertility in men

concurrently with a pelvic with severe (MCQ)
ultrasound. l Oligospermia (low number)
n Outlines intrauterine pathology (ie, polyps, l azoospermia (absence of live sperm),
submucosal fibroids). l asthenospermia (low motility),
n Can be done with an ultrasound in an office l teratospermia (abnormal morphology).
setting. n Pregnancy rate: 20% per cycle.
m Ultrasound: n Multiple pregnancy rate: 28–38%.
m Laparoscopy: n Not influenced by cause of abnormal sperm.
n Can visualize outside of the uterus to assist in n Can use spermatozoa from testicular
diagnosis of some mullerian malformations. biopsies.
n Causes and treatments for uterine factor infertility m Gamete Intrafallopian Transfer (GIFT)
m Submucosal fibroid: (MCQ) n Eg g and sperm are placed in a nor mal
n Resection, myomectomy. fallopian tube for fertilization.
m Intrauterine septum: (MCQ) n Success rate is about 25%.(MCQ)
n Hysteroscopic resection of septum. m Zygote Intrafallopian Transfer (ZIFT)
m Uterine didelphys: (MCQ) n Zygote created via fertilization in vitro and
n Metroplasty—a procedure to unify the two placed in fallopian tube, where it proceeds
endometrial cavities. to uterus for natural implantation.
m Asherman syndrome: (MCQ) n Success rate is about 30%. (MCQ)
n Hysteroscopic lysis of intrauterine adhesions. m Artificial Insemination with Donor Sperm
n Causes and treatments for tubal factor infertility n Success rate is 75% in six cycles. (MCQ)
m Adhesions: n Donor sperm is used for ARTs.

n Controlled ovarian hyperstimulation and n The disadvantages of this protocol include
protocols for IVF (MCQ)
m The agents most commonly used to stimulate l premature luteinization
multiple ovarian follicles are CC, hMG, and l spontaneous LH surges that result in high
purified FSH. cancellation rates
m Clomiphene-only regimens l multiple gestations.
n given on days 5–9 of the menstrual cycle. m Gonadotropin-releasing hormone analogs/
(MCQ) agonists (GnRHa)
n Response may be followed by BBT n used via a flare-up protocol or a luteal phase
measurement, ultrasonography, and protocol.
measurement of LH and estradiol levels n flare-up protocol
n CC has a low risk of ovarian l causes an elevation of FSH in the first 4 days,
hyperstimulation syndrome (OHSS). which increases oocyte recruitment.
n However, it creates a low oocyte yield (one l After 5 days of administration, the GnRH
or two per cycle) with frequent LH surges agonist then down-regulates the
that lead to high cancellation rates in IVF cycles and pituitary to prevent premature luteinization and
low pregnancy yield. a spontaneous LH surge(MCQ)
n Most treatment regimens start with 5 (MCQ) n The luteal phase protocol
0 mg/day for 5 days l involves starting GnRHa administration on
n If ovulation fails to occur, the dose is increased the seventeenth to twenty-first menstrual
GOB
to 100 mg/day. day. (MCQ)
n The maximum dose is 250 mg/day. l GnRHa increase the number, quality, and
n Human chorionic gonadotropin (hCG), 5000 synchronization of the oocytes recovered per cycle
IU to 10,000 IU, may be used to simulate an and thereby improve the fertilization rate,
LH surge the number of embr yos, and the
n Eighty percent of properly selected couples will pregnancy rate.
conceive in the first three cycles after n Successful ovulation rates are 75% to 85%.
treatment. n GnRHa
n Potential side effects (MCQ) l more complex to use
l vasomotor flushes, blurring of vision, l can lead to OHSS. (MCQ)
INFERTILITY
urticarial m GnRH analogs/antagonists
l pain, bloating, and multiple gestation (5– n block LH secretion without causing a flare-up effect.
7% of cases, usually twins). n They are administered in a
m Clomiphene/hMG combinations l single dose on the eighth menstrual day
n used to increase the number of recruited l in smaller doses over 4 days. (MCQ)
follicles n Because they block the periovulatory LH
n The hMG and purified FSH are useful in surge, fewer gonadotropins are required to
patients(MCQ) stimulate ovulation, and side effects are decreased.
l who do not achieve pregnancy with CC m Oocyte retrieval, culture fertilization, and
l with endometriosis or unexplained transfer
infertility. n The two major techniques of oocyte retrieval
n hMG (MCQ) are
l is a combination of LH and FSH l ultrasonographically guided follicular
l is given for 2–7 days after the clomiphene. aspiration
l can lead to life-threatening OHSS. l laparoscopic oocyte retrieval.
n Follicle maturation is monitored using n Ultrasonographically guided oocyte
sonography and serial measurement of retrieval
estradiol levels. l Most widely used technique
n To complete oocyte maturation, hCG needs to be l Usie a 17-gauge needle passed through the
given once the follicles have reached 17–18 mm vaginal fornix
in diameter. (MCQ) l performed 34–36 hours after hCG
n Aspiration of follicles should be timed 35–36 injection. (MCQ)
hours after the hCG injection. (MCQ) l The procedure is done under heavy sedation.

l Potential complications include risk of bowel TOPIC - 7
injury and injury to pelvic vessels. DIABETES AND PREGNANCY
m Oocyte fertilization.
n Sperm are diluted, centrifuged, and incubated
n In 85–90% of all pregnancies complicated by
n 50,000–100,000 motile spermatozoa are added to
diabetes, the DM is gestational.
each Petri dish containing an oocyte. (MCQ)
n Of the women who develop GDM
n Fertilization is documented by the presence of
m more than 40% will later develop overt diabetes in
two pronuclei and extrusion of a second
the subsequent 15 years after the index pregnancy
polar body at 24 hours. (MCQ)
(MCQ)
n At that stage, most embryos are cryopreserved
m 50% will have recurrent GDM in any future
for an unlimited period, with a survival rate of
pregnancy.
75%. (MCQ)
n The Priscilla White classification system
m Embryo transfer
m provides an estimate of the level of
n most commonly carried out 48–80 hours after
microvascular damage present in a patient
retrieval at the four- to ten-cell stage. (MCQ)
m assist in effective management during the
n In general, no more than two embryos are
pregnancy.
transferred to limit the risk of multiple gestation
m Classification
and to optimize pregnancy rates.
n There are 2 classes of gestational diabetes
n It is common practice to supplement the luteal
(diabetes which began during pregnancy):
phase with progesterone given by vaginal
(MCQ)
GOB
suppository, beginning the day of oocyte release and

l Class A1: gestational diabetes; diet controlled
continuing into the twelfth week of pregnancy.
l Class A2: gestational diabetes; medication
m Retrieval and pregnancy results.
controlled
n Most programs have deliver y rates of
n The second group of diabetes which existed before
approximately 20% for women under the age
pregnancy can be split up into these classes:
of 40 years who are not affected by male factor
(MCQ)
infertility. (MCQ)
l Class B: onset at age 20 or older or with
n The risk of ectopic pregnancy is 4% to 5%,
duration of less than 10 years
n risk of heterotopic pregnancies is less than
DIABETES AND PREGNANCY
l Class C: onset at age 10-19 or duration of

1%.
10–19 years
n Multiple gestation rate is approximately 30%
l Class D: onset before age 10 or duration
(25% twins and 5% triplets). older women
greater than 20 years
commonly use donor oocytes to improve
l Class E: overt diabetes mellitus with calcified
chances of success.
pelvic vessels
l Class F: diabetic nephropathy
l Class R: proliferative retinopathy
l Class RF: retinopathy and nephropathy
l Class H: ischemic heart disease
l Class T: prior kidney transplant
n Pregnancy physiology.
m Glucose is transported to the fetus by means of
facilitated diffusion(MCQ)
m Active transport is needed for amino acids to gain
access to the fetus. (MCQ)
m A state of relative maternal starvation exists in
pregnancy during which glucose is spared for fetal
consumption while alternative fuels are used by
the mother.
m During the second half of the pregnancy, insulin
levels increase in part as a result of diabetogenic
hormones

n predominantly human placental lactogen. m cesarean section
(MCQ) m birth trauma
n Estrogen, progesterone m postpartum infection.
n cortisol, and prolactin n Diagnosis
m Degradation of insulin is also increased during m Gestational diabetes.
pregnancy. n Diagnosis of diabetes during the first half of
n Maternal and fetal morbidity and mortality. pregnancy indicates undiagnosed PDM
n Fetal morbidity n GDM is usually a disorder of late gestation.
m Potential congenital fetal anomalies associated n The universal screening currently
with DM include the following: recommended by the ACOG
n CNS: spina bifida, anencephaly, n Screening during gestational weeks 24–
holoprosencephaly, hydrocephalus 28(MCQ)
n Cardiac (most common): transposition of the n a 50-g oral glucose load is administered,
great vessels, ventricular septal defect, atrial followed by measurement of serum glucose
septal defect, hypoplastic left heart, cardiac level at 1 hour. (MCQ)
hypertrophy, anomalies of the aorta(MCQ) n Screening thresholds are as follows: (MCQ)
n GI: tracheoesophageal fistula, anal/rectal l Threshold of greater than or equal to 140
atresia mg/dL diagnoses 90% of GDM (MCQ)
n Genitourinary: renal agenesis, double ureter, l Threshold of greater than or equal to 135
cystic kidneys mg/dL diagnoses more than 95% of GDM;
GOB
n Skeletal: caudal regression syndrome (most (MCQ)
specific) (MCQ) l If the level is above 190 mg/dL, there are
n Situs inversus two approaches:
m Glycosylated hemoglobin (HbA1C) „ consider the patient to have GDM
measurement „ perform fasting blood glucose testing
n often used to assess risk of fetal anomalies (MCQ)
n its level provides an estimate of the three ® If the level is 126 mg/dL or higher,
previous months of maternal serum glucose the patient has GDM.
levels. ® If the level is below 126 mg/dL,

n Fetal/neonatal sequelae proceed with the 3-hour glucose
m spontaneous abortion and fetal death tolerance test (GTT).
n uncommon but significant outcomes in diabetic n Interpretation of results.
pregnancies l If the patient’s glucose level is equal to or
n not increased in class A1 GDM greater than the threshold value chosen, then
m fetal macrosomia, the 3-hour GTT should be administered.
m fetal shoulder dystocia(MCQ) (MCQ)
m fetal septal hypertrophy l The GTT is performed by administering
m respiratory distress syndrome (RDS) 100 g of glucose orally in at least 400 mL of
m hyperbilirubinemia, (MCQ) water after an overnight fast
m polyhydramnios. (MCQ) l Criteria for diagnosis of gestational diabetes
m The presence of maternal microvascular according to Indian National Diabetes
disease increases the risk of intrauterine fetal Data group(MCQ)
growth restriction. (MCQ) „ Fasting - 105mg/dl
n Maternal complications of PDM (type ½) „ 1 hour - 190mg/dl
m diabetic ketoacidosis (DKA) „ 2 hours - 165mg/dl
m coronary artery disease, „ 3 hour - 145mg/dl
m hypertension l Criteria for diagnosis of gestational diabetes
m infection (increased rate and severity) according to Carpenter and
m nephropathy, polycythemia Coustan(MCQ)
m retinopathy. „ Fasting -95mg/dl
n poorly controlled DM during pregnancy increases „ 1 hour- 180mg/dl
risk of (MCQ) „ 2 hours - 155mg/dl
m Preeclampsia „ 3 hour - 140mg/dl

l If any two or more of the diagnostic l If the patient with GDM type A1 has no
values are met or exceeded, then the diagnosis concurrent disease or obstetric risk
of GDM is made. factors (i.e., hypertension, fetal growth
l In patients with significant risk factors and restriction, previous stillbirth), she needs no
a normal GTT, a follow-up GTT may be antepartum testing beyond that
performed at 32–34 weeks to diagnose late- recommended for a normal pregnancy.
onset GDM. n Women with GDM type A2 usually require
m Pregestational diabetes antenatal testing similar to that recommended

n A fasting glucose level of 126 mg/dL or for PDM
higher confirms the diagnosis. (MCQ) n A 36- to 38-week fetal growth
n Management of gestational diabetes ultrasonographic examination is
m If glucose levels cannot be controlled with diet recommended to assess fetal size. (MCQ)
alone, then insulin therapy should be started. n For all women with GDM (types A1 and A2),
m Diet. deliver y by 40 weeks’ gestation is

n daily intake of 1800–2400 kilocalories. (MCQ) recommended. (MCQ)
m Glucose monitoring (paneling) m Postpartum evaluation.
n The patient should record fasting and 1-hour n a woman with GDM (A1 and A2) should have
(or 2-hour) postprandial glucose values after a follow-up GTT at 6–12 weeks postpartum
each meal to determine the adequacy of to assess for possible PDM. (MCQ)
management. n Preconceptual and pregnancy workup
GOB
m The threshold values for starting insulin m HbA1C levels of 10% or higher are associated
treatment (MCQ) with significant risk of fetal malformations.

n Fasting glucose level : 100–105 mg/dL or m If the HbA1C level is within the normal range,
higher risk appears to be similar to that of nondiabetic

n 1-hour postprandial level : 140 mg/dL or women.
higher m The patient should be started on folate 400 ìg/
n 2-hour postprandial level : 120 mg/dL or day for spina bifida prophylaxis. (MCQ)
higher m The recommended diet for the pregnant woman
m Depending on the recorded glucose levels from consists of 1800–2400 kilocalories made up of
paneling, the insulin dosage should be initiated 15–20% protein, 50–60% carbohydrates, and
as follows. (MCQ) up to 20% fat. (MCQ)
n Calculate 1.1 U/kg (ideal) body weight. n Medical treatment
n Usually do not start at more than 60 U insulin/ m In patients with type 1 DM, insulin requirements
day. are usually increased 50–100% in pregnancy

n Total daily dose should be divided in half, m in patients with type 2 DM, insulin needs usually
given every morning and evening. more than double.

l Morning dose (before breakfast) m ADA recommends the use of human insulin for
„ two-thirds of dose given as neutral pregnant women with DM and for women with
protamine Hagedorn (NPH) insulin DM considering pregnancy.
(peak activity of 5–12 hours) m Patients taking oral hypoglycemic agents or a
„ one-third of dose given as regular insulin regimen of 70/30 mixed (NPH/regular) insulin
(peak activity of 2–4 hours). are switched to human NPH and regular
l Evening dose (before dinner) insulin.
„ one-half of dose given as NPH, m Oral hypoglycemic medications are not
„ one-half of dose given as regular insulin. currently used

n Regular exercise is important in maintaining m Insulin requirements increase throughout
good glucose control. gestation(MCQ)

m Fetal monitoring n 0.7 U/kg (body weight)/day during weeks 6–
n With GDM type A1 the patient usually can be 18,

managed without fetal antenatal testing. n 0.8 U/kg/day during weeks 18–26,
l The patient is typically seen at 2-week intervals n 0.9 U/kg/day during weeks 26–36
for ongoing diabetic management. n 1.0 U/kg/day during weeks 36–40.

m The goals for glucose control for the progressive decline in the systolic/diastolic
preconceptual and pregnant patient are the (S/D) ratio from early pregnancy until term.
following levels: (MCQ) n At 30 weeks, the S/D ratio for the umbilical
n Fasting: 60–90 mg/dL artery should be below 3.0. (MCQ)

n Premeal: less than 100 mg/dL n The uterine artery S/D ratio
n 1 hour postprandial: less than 140 mg/dL l should peak around 14–20 weeks (MCQ)
n 2 hours postprandial: less than 120 mg/dL l then remain below 2.6 to 26 weeks’
n Bedtime: less than 120 mg/dL gestation. (MCQ)

n 2–6 am: 60–90 mg/dL n An elevated umbilical S/D ratio is associated
n Fetal monitoring and pregestational diabetes with

m Triple screen during the second trimester, l fetal growth restriction
(MCQ) l preeclampsia.
n measurement of maternal serum AFP levels, n With increased resistance of the placenta,
along with levels of unconjugated estriol and the systolic pressure of the umbilical artery increases,
hCG which causes an elevated ratio.
n typically performed at 16–18 weeks’ gestation. n Preterm labor and pregestational diabetes
m Ultrasonography m When the patient with DM develops preterm
n usually at 18–20 weeks(MCQ) labor, the choice of tocolytics

n helps to date the pregnancy and evaluate the n Magnesium sulfate is the tocolytic agent of
fetus for genetic abnormalities and other choice in the presence of preterm labor.
GOB
congenital anomalies n Sympathomimetics (i.e., terbutaline sulfate,
m Fetal cardiac anomalies are the most common ritodrine hydrochloride(MCQ)

congenital anomalies with PDM l avoided
n a fetal echocardiogram is recommended at l they exacerbate hyperglycemia and may
19–22 weeks’ gestation. (MCQ) result in ketoacidosis.

m Repeat obstetrical ultrasonographic n Indomethacin (MCQ)
examinations for fetal growth may be l used as long as maternal renal disease or
considered at 28–30 weeks and then at 36–38 poorly controlled hypertension is absent.

weeks. l Indomethacin should not be given after 32
m If the patient has evidence of microvascular weeks’ gestation.

disease, monthly ultrasonographic m Corticosteroids should be given if there is risk
examinations starting at 24–26 weeks may be of preterm delivery.

necessary to closely follow fetal growth to assess
for intrauterine growth restriction (IUGR). n Labor, delivery, and diabetes
m Tests commonly used for fetal assessment are m In many patients with well-controlled DM, labor
n nonstress test, may be induced at 39–40 weeks. .(MCQ)

n biophysical profile m Amniocentesis is recommended before elective
n contraction stress test. delivery for patients without accurate

m Timing of fetal testing gestational dating or for gestations of less
n If patient has extensive complications of than 39 weeks.(MCQ)
DM (i.e., coronary artery disease, nephropathy), n An elevated lecithin/sphingomyelin (L/S)
fetal assessment may begin at 28 weeks’ gestation. ratio (ratio at lung maturity is 2.0 or higher) is
(MCQ) associated with low incidence of RDS a, even
n For those women with good glucose control if phosphatidylglycerol (PG) is absent.
and minimal to no complications, regular (MCQ)
fetal evaluation may begin at 32–34 weeks. n L/S values are affected by blood and
n Typically, fetal surveillance such as the nonstress meconium

test begins around 32 weeks and occurs n If these are present in amniotic fluid, L/S would
twice weekly until delivery. (MCQ) not be a good indicator of fetal lung maturity,
m Doppler umbilical artery velocimetry. in contrast to PG level.
n Umbilical artery waveforms obtained via n PG level is useful if blood, meconium, or other
Doppler ultrasonography should show a contaminants are present in the amniotic fluid.

n Amniocentesis may need to be repeated until l Associated with chronic hypertension,
fetal lung maturity is achieved. preeclampsia, fetal growth retardation,
m It is essential that the patient be euglycemic nonreassuring fetal heart tones, preterm
during the intrapartum period (glucose level of delivery, and perinatal death (fetal and
100 mg/dL or less). .(MCQ) neonatal).
m Mater nal hyperglycemia results in fetal l With intensive management, a fetal survival
hyperglycemia, which then causes fetal rate of over 90% has been reported.
hyperinsulinemia. The neonate is then at n Diabetic patients with ischemic heart disease
increased risk of severe hypoglycemia as it loses l If conception occurs, termination of the
the maternal infusion of glucose from the umbilical cord pregnancy may be considered to preserve
and the hyperinsulinemia persists, which can cause the health of the patient.
seizures and death. n Spontaneous abortion
m During labor and delivery, continuous l Miscarriage among patients with PDM
intravenous (IV) infusion of insulin and l reported to range between 6% and 29%
dextrose is the optimal means of glycemic control. l associated with poor glucose control during
n With elective induction of labor, the patient the periconceptual period. (MCQ)
should receive her normal insulin dose the previous l No increase in incidence of abortion is found
evening in diabetic women with good
n On the morning of her induction, the patient’s periconceptual glucose control. (MCQ)
normal insulin dose should be withheld. n Polyhydramnios
GOB
m Route of delivery l incidence in diabetic patients is 30 times that in

n If fetal macrosomia is suspected, a trial of nondiabetic controls (MCQ)
labor could ensue. n Preterm labor and preterm delivery
n If the estimated fetal weight exceeds 4000 g, l incidence of preterm labor may be three to
the risk of shoulder dystocia and traumatic birth injuries four times higher in patients with DM.
increases. .(MCQ) (MCQ)
n With a suspected birth weight of 4500 g or l An association has been made between poor
greater, a cesarean section is indicated. glycemic control during the second
(MCQ) trimester and an increased rate of preterm

m Diabetes-associated maternal complications delivery.
n Diabetic ketoacidosis (DKA) l Magnesium sulfate is the tocolytic agent
l In pregnant patients, DKA can occur at lower of choice in labor in patients with DM.
blood glucose levels (i.e., less than 200 mg/ (MCQ)
dL) and more rapidly than in nonpregnant l Corticosteroids should be given if indicated
diabetic patients. (MCQ) based on risk of preterm delivery
l Can cause fetal mortality m Fetal and neonatal complications associated
l Antenatal administration of steroids to with diabetes
promote fetal lung maturity can precipitate n Congenital malformations.
or exacerbate DKA in pregnant diabetic l congenital malformations are now the
women. most common contributor to perinatal
n Hypoglycemia. mortality in pregnancies of women with
l The strict glycemic control that is PDM. (MCQ)
recommended during pregnancies l single defect that is considered most characteristic
complicated by diabetes places patients at of diabetic fetopathy is sacral agenesis or caudal
increased risk for hypoglycemic episodes. regression. (MCQ)
l presence of hyperemesis in early l This rare malformation is diagnosed 200–400
pregnancy also predisposes these patients to times more frequently in gestations in
severe hypoglycemia. diabetic patients.
n Retinopathy l A tenfold increase is also seen in the
l Photocoagulation for diabetic retinopathy incidence of CNS malformations, including
is accomplished safely during pregnancy. anencephaly, holoprosencephaly, open spina bifida,
(MCQ) microcephaly, encephalocele, and meningomyelocele.
n Nephropathy (MCQ)
l The rate of cardiovascular anomalies, the l occur due to a delay in in utero liver
most common malfor mations, are maturation among infants of diabetic
increased fivefold in fetuses of diabetic mothers with poor glycemic control.
patients. (MCQ) n Neonatal respiratory distress syndrome
l Defects include transposition of the great vessels, (MCQ)
ventricular and atrial septal defects, hypoplastic left l RDS in infants of diabetic mothers is
ventricle, situs inversus, and aortic anomalies. associated with delayed fetal lung maturation.
l Malformations of the genitourinary and GI l Fetal hyperinsulinemia is thought to
systems suppress production and
„ absent kidneys (Potter’s syndrome), polycystic l secretion of the major component of
kidneys (MCQ) surfactant required for inflation of the lungs.
„ double ureter, tracheoesophageal fistula l The reliability of the L/S ratio as a predictor
„ bowel atresia, and imperforate anus. of lung maturity
n Macrosomia „ For many infants, development of RDS is
l estimated fetal weight greater than the possible, even with an L/S ratio of 2. (MCQ)
ninetieth percentile, or 4000 g (MCQ) „ The presence of PG (MCQ)
l Maternal diabetes is the most significant ® it is associated with the absence of RDS in
single risk factor for the development of both nor mal and diabetic
macrosomia. pregnancies.
l Diabetic macrosomia is characterized „ There a low incidence of RDS can be
GOB
specifically by a large fetal abdominal expected in infants of patients whose
circumference and a decrease in the ratio disease is well controlled who have a
of head circumference to abdominal mature L/S ratio, even in the absence of
circumference PG. (MCQ)
l These changes are due to the increased n Fetal and neonatal cardiomyopathy
subcutaneous fat deposits caused by fetal l Infants of diabetic mothers are at increased
hyperinsulinemia. risk of developing cardiac septal
l Macrosomic fetuses are at risk of hypertrophy and CHF (MCQ)

„ intrauterine death n Birth trauma and perinatal hypoxia
„ hypertrophic cardiomyopathy l Macrosomic infants are at increased risk for
„ vascular thrombosis, „ fractured clavicles, facial paralysis
„ neonatal hypoglycemia „ Erb’s palsy, Klumpke’s palsy
„ birth trauma. „ phrenic nerve injury, and intracranial hemorrhage.
l Their mothers are also more likely to n increased risk for perinatal hypoxic sequelae
undergo a cesarean delivery than mothers
of smaller infants.
n Neonatal hypoglycemia
l Twenty-five percent to 40% of infants of
diabetic mothers develop hypoglycemia
during the first few hours of life. (MCQ)
l The clinical signs of neonatal hypoglycemia
include cyanosis, convulsions, tremor,
apathy, sweating, and a weak or high-
pitched cry.
l Treatment should be instituted when the
infant’s glucose level drops below 40 mg/dL.
n Neonatal hypocalcemia and
hypomagnesemia. (MCQ)
n Neonatal polycythemia. (MCQ)
n Neonatal hyperbilirubinemia and neonatal
jaundice (MCQ)

TOPIC - 8 ECTOPIC PREGNANCY l patients undergoing ovulation induction.
n Other factors
l Intrauterine device (IUD) users (MCQ)
n Ectopic pregnancy
l Smoking
m More than 95% of extrauterine pregnancies occur
l increasing age
in the fallopian tube.
l Multiple previous elective abortions
m incidence of ectopic pregnancy has increased due
to a higher incidence of (MCQ) Time of Rupture
m
n Isthmic pregnancies tend to rupture earliest,
n salpingitis
n an increase in ovulation induction
at 6 to 8 weeks’ gestation (MCQ)
l It occurs because of the small diameter of this
n assisted reproductive technology
n more tubal sterilizations.
portion of the tube
n Ampullary pregnancies rupture later, generally
m Classification & Incidence
n Tubal (> 95%)(MCQ)
at 8–12 weeks. (MCQ)
n Interstitial pregnancies are the last to
l ampullary (55%) (Most common) (MCQ)
l isthmic (25%
rupture(MCQ)
l usually at 12–16 weeks(MCQ)
l fimbrial (17%),
l Reason : myometrium allows more room
l interstitial (2%) (Least common) (MCQ)
n Other (< 5%)—
to grow than the tubal wall
l Interstitial rupture is quite dangerous
l Includes cervical, ovarian, and abdominal
l most abdominal pregnancies are secondary
because its proximity to uterine and ovarian
GOB
pregnancies, from tubal abortion or rupture vessels can result in massive hemorrhage.
and subsequent implantation in the bowel, Clinical Findings
m
n No specific symptoms or signs are
omentum, or mesentery
n Intraligamentous
pathognomonic for ectopic pregnancy, and
n Heterotopic pregnancy
many disorders can present similarly.
n Symptoms
l ectopic pregnancy occurs in combination
l Pain
with an intrauterine pregnancy
„ Pelvic or abdominal pain is present in
n Bilateral ectopic
close to 100% of cases. (MCQ)
ECTOPIC PREGNANCY
m Etiology
„ presence of subdiaphragmatic or
n Tubal factors
l Ectopic pregnancy is 5–10 times more
shoulder pain is more variable, depending
common in women who have had salpingitis.. on the amount of intra-abdominal
(MCQ) bleeding.
l Bleeding
l Other tubal factors
„ Abnormal uterine bleeding, usually
„ adherent folds of tubal lumen due to
salpingitis isthmica nodosa, spotting, occurs in roughly 75% of cases
„ developmental abnormalities of the tube
(MCQ)
„ represents decidual sloughing. (MCQ)
„ abnormal tubal anatomy due to DES
„ A decidua cast is passed in 5–10% of
exposure in utero
„ previous tubal surgery including tubal
ectopic pregnancies and may be mistaken for
ligation products of conception.
l Secondary amenorrhea
„ Adhesions from infection or previous abdominal
l Syncope
surgery
n Signs
„ Endometriosis(MCQ)
l Tenderness
„ leiomyomas
„ abdominal tenderness is present in over
n Zygote abnormalities
l chromosomal abnormalities
80% of ectopic pregnancies. (MCQ)
l Adnexal and/or cer vical motion
l gross malformations
l neural tube defects(MCQ)
tenderness is present in over 75% of cases.
n Exogenous hormones
(MCQ)
l Adnexal mass
l women taking progestin-only oral
„ A unilateral adnexal mass is palpated in
contraceptives (MCQ)
l Patients with DES exposure
one-third to one-half of patients.
l Uterine changes n The presence of an adnexal mass with an
„ uterus may undergo typical changes of empty uterus raises the suspicion for an ectopic
pregnancy, including softening and a slight pregnancy, especially if the Beta -hCG titers
increase in size. are above the discriminatory zone(MCQ)
l Hemodynamic instability— n direct visualization of an adnexal
m Laboratory Findings gestational sac along with a yolk sac or
n Hematocrit: vary depending on degree, of embryo secures the diagnosis
intraabdominal bleeding. n it is more likely to detect a “tubal ring” or
n Beta-hCG: complex mass adjacent to, but separate
l qualitative serum or urine Beta-hCG assay from, both the uterus and ovary.
is positive in virtually 100% of ectopic pregnancies. n If rupture has occurred, a dilated fallopian
(MCQ) tube with fluid in the cul-de-sac may be
l a quantitative Beta -hCG value that, in visualized.
conjunction with transvaginal ultrasound, n The most likely alternative diagnosis to an
can usually make the diagnosis. adnexal mass in early pregnancy is a corpus
l serial titers can be followed that, in the face luteum cyst, which can rupture and bleed, thus
of a normal pregnancy, should double every contributing to a highly confusing clinical picture.
2 days(MCQ) m Laparoscopy—
l Two-thirds of ectopic pregnancies have n useful in certain situations where a definitive
abnormally rising values(MCQ) diagnosis is difficult, especially in the case of
GOB
m Ultrasound a desired, potentially viable intrauterine pregnancy when
n By correlating Beta-hCG titers with a D&C is contraindicated.
ultrasound findings, an ectopic pregnancy n Laparoscopy may also be used as definitive
often can be differentiated from an intrauterine management in early ectopic gestation. (MCQ)
pregnancy m D&C
n ultrasound can help distinguish a normal n confirm or exclude intrauterine pregnancy in
intrauterine pregnancy from a blighted ovum, the case of an undesired pregnancy. (MCQ)
incomplete abortion, or complete abortion. n D&C may interrupt an intrauterine
n A normal intrauterine sac (MCQ) gestation and should not be performed if the pregnancy
ECTOPIC PREGNANCY
l appears regular and well defined on is desired, unless the Beta-hCG titers have
ultrasound plateaued or fallen and the pregnancy is
l has been described as a “double ring,” which definitely abnormal.
represents the decidual lining and the n Clinical conclusions : (MCQ)
amniotic sac(MCQ) l When chorionic villi are recovered, the
n In ectopic pregnancy diagnosis of an intrauterine pregnancy is
l ultrasound may reveal only a thickened, confirmed.
decidualized endometrium l On the other hand, if only decidua is
l With more advanced ectopics, decidual obtained on D&C, ectopic pregnancy is highly
sloughing with resultant intracavitary likely.
fluid or blood may create a so-called m Laparotomy
“pseudogestational sac,” a small and n Indications(MCQ)
irregular structure that may be confused with l when the presumptive diagnosis of ectopic
an intrauterine gestation. (MCQ) pregnancy in an unstable patient necessitates
n An intrauterine sac should be visible by immediate surgery
l transvaginal ultrasound when the Beta - l when definitive therapy is not possible by
hCG level is approximately 1000 mIU/mL medical management or laparoscopy.
(MCQ) m Culdocentesis—
l transabdominal ultrasound approximately n transvaginal passage of a needle into the posterior
1 week later, when the Beta -hCG level is cul-de-sac in order to determine whether free
1800–3600 mIU/mL(MCQ) blood is present in the abdomen
n Thus, when an empty uterine cavity is seen n largely been replaced by transvaginal
with a Beta -hCG titer above this threshold, an ultrasound.
ectopic pregnancy is more likely. o Magnetic resonance imaging
n a useful adjunct to ultrasound in cases where an „ effective in the medical management of
unusual ectopic location is suspected. small, unruptured ectopic pregnancies
n An accurate diagnosis of cervical, cesarean in asymptomatic women.
scar, or interstitial pregnancy urges conservative l Exclusion criteria include (MCQ)
intervention with methotrexate (MTX) in order to „ a patient who is noncompliant or has completed
avoid the potentially catastrophic hemorrhage childbearing
associated with surgical management of these „ peptic ulcer disease
sites „ immunodeficiency
o Pathology „ pulmonary disease
n In tubal ectopic pregnancy(MCQ) „ liver disease, renal disease
l implantation typically occurs in the wall of „ blood dyscrasias
the tube in the connective tissue beneath „ hemodynamic instability,
the serosa. „ free fluid in the cul-de-sac plus pelvic
l There may be little or no decidual reaction pain
l minimal defense against the permeating „ known sensitivity to MTX.
trophoblast l Relative contraindications include (MCQ)
l trophoblast invades blood vessels, causing „ adnexal mass üÿ> 3.5 cm or
local hemorrhage „ an extrauterine gestation with fetal heart
l A hematoma in the subserosal space motion, because of the higher failure rate.
enlarges as pregnancy progresses l 90% of ectopics resolve, taking on average
GOB
n Progressive distention of the tube eventually just under 1 month (MCQ)

leads to rupture. l Beta -hCG levels should decrease by at least
n Vaginal bleeding 15% between days 4 and 7 after MTX
l It is of uterine origin (MCQ) administration. (MCQ)
l caused by endometrial involution and l Failure of MTX therapy (MCQ)
decidual sloughing „ suggested by a persistent rise or plateau in
n Arias-Stella reaction(MCQ) Beta -hCG titer
l Atypical changes in the endometrium „ managed by a second dose of MTX or
suggestive of ectopic pregnancy surgery.
ECTOPIC PREGNANCY
l consists of hyperchromatic, hypertrophic, l Findings that can be part of a normal

irregularly shaped nuclei, and foamy, response to successful MTX treatment
vacuolated cytoplasm. (MCQ) „ A recurrent episode of abdominal pain
l These changes can be seen in normal „ enlargement of the adnexal mass during
pregnancy and in miscarriage and therefore the first week of therapy
are not diagnostic of ectopic pregnancy. l Indications that mandate immediate surgical
l Occasionally, endometrial tissue may be intervention (MCQ)
passed as a so-called decidual cast. (MCQ) „ Persistent and worsening pain in conjunction with
l Superficial secretory endometrium usually a hemoperitoneum on ultrasound
is present, but no trophoblastic cells are seen. „ hemodynamic instability
o Treatment n Surgical treatment
n Expectant management l surgery is now mainly reserved for patients
„ Many ectopic pregnancies resolve with contraindications to medical
spontaneously management
„ Reasonable to manage an asymptomatic, l Conservative surgery (ie, preservation of
compliant patient expectantly if Beta- the fallopian tube) may be indicated in
hCG titers are low (< 200 miu/ml) or hemodynamically stable patient with an
decreasing, and the risk of rupture is low. ampullary pregnancy who wishes to
n Medical management preserve fertility.
l MTX l A linear salpingostomy (MCQ)
„ a folinic acid antagonist „ performed with a small (< 3 cm), intact
„ destroy proliferating trophoblast (MCQ) ampullary pregnancy
„ linear incision is allowed to heal by
secondary intention,
„ it minimizes recurrent ectopics as „ sometimes salpingectomy on the affected
compared to salpingotomy side.
„ Both methods yield similar subsequent l Abdominal pregnancy (MCQ)
pregnancy rates of 40–90%. „ involves delivery of the fetus (sometimes
l both linear salpingostomy and at term) with ligation of the umbilical
salpingotomy can be performed through cord close to the placenta.
the laparoscope, assuming the pregnancy is „ The placenta is usually left in place to
< 3 cm, unruptured, and easily accessible. avoid hemorrhage following removal.
a Beta -hCG titer should be obtained weekly n Emergency treatment
after surgery to ensure adequate removal of l Immediate surgery is indicated when the
trophoblast and rule out a persistent ectopic diagnosis of ectopic pregnancy with hemorrhage is
l In stable patients, laparoscopy is preferred made.
over laparotomy l There is no place for conservative therapy in
l “Milking” the pregnancy out of the distal a hemodynamically unstable patient.
end of the tube is associated with (MCQ)
„ persistent trophoblast l Rho (D) immunoglobulin should be given
„ need for re-exploration to any Rh-negative mother with the diagnosis
„ increased risks of recurrent ectopic pregnancy. of ectopic pregnancy because sensitization
l With an isthmic ectopic pregnancy, may occur.
segmental resection with subsequent
GOB
anastomosis (usually at a later date) is typically TOPIC - 9
recommended. (MCQ) GESTATIONAL TROPHOBLASTIC
„ Reason TUMOR
® As opposed to ampullary ectopics, the
muscularis is well developed, forcing n Gestational trophoblastic neoplasms
the pregnancy to grow in the lumen m include
® More conservative treatment, such as
n hydatidiform mole (complete and partial)
salpingostomy or salpingotomy, would n invasive mole (chorioadenoma destruens)
likely cause scarring and compromise n choriocarcinoma,
GESTATIONAL TROPHOBLASTIC TUMOR

of the lumen n placental-site trophoblastic tumor (PSTT).
® a tubal fistula may result if the tube
m they develop from an aberrant fertilization
were allowed to heal by secondary event and hence arise from fetal tissue within
intention. the maternal host.
l With fimbrial pregnancy, products of
m They are composed of both
conception are often visible at the most syncytiotrophoblastic and cytotrophoblastic
distal end of the tube, which may be cells, with the exception of PSTT, which is
“plucked out.” derived from intermediate trophoblastic cells
l Interstitial pregnancies (MCQ)
(MCQ)
„ pose a high surgical risk
m Hydatidiform mole
„ have potential for massive intra-
n most common for m of gestational
abdominal bleeding. trophoblastic disease
„ Most cases are managed with a cornual
n benign in nature.
wedge resection, uterine n incidence is higher in (MCQ)
reconstruction, and, sometimes, l women younger than 20
salpingectomy on the affected side. l women older than 40 years of age
l Hysterectomy - indications(MCQ)
l in nulliparous women,
„ If extensive tissue damage is present
l in patients of low economic status
„ if the patient is unstable
l in women whose diets are deficient in
„ cervical ectopics may be associated with
protein, folic acid, and carotene.
massive vaginal bleeding with the potential n Blood Group association
for hysterectomy. l blood group A women impregnated by
l Ovarian pregnancy (MCQ)
group O men have an almost 10-fold
„ requires oophorectomy

greater risk of developing choriocarcinoma n This is important given that the cure rate of
than group A women impregnated by group properly treated metastatic gestational
A partners(MCQ) trophoblastic neoplasia approaches
l women with blood group AB tend to have 90%.(MCQ)
a relatively worse prognosis. (MCQ) n Etiology & Pathogenesis
n Hydatidiform mole should be suspected in m Gestational trophoblastic tumors arise in fetal
any woman with (MCQ) rather than maternal tissue.
l bleeding in the first half of pregnancy m Cytogenetic studies
l passage of vesicles n Complete moles (MCQ)
l hyperemesis gravidarum l usually (perhaps always) euploid
l onset of preeclampsia prior to 24 weeks. l paternal in origin(MCQ)
n physical examination findings that further l sex chromatin-positive—46 XX or 46 XY.
support the diagnosis (MCQ) (MCQ)
l Absent fetal heart tones l A complete mole arises when an empty
l a uterus too large for the estimated ovum (with an absent or inactivated nucleus)
gestational age is fertilized by (MCQ)
m Invasive mole „ one haploid sperm that duplicates its
n reported in 10–15% of patients who have had chromosomes
primary molar pregnancy. „ two haploid sperms
n considered a benign neoplasm n partial mole(MCQ)
GOB
n invasive mole is locally invasive and may l triploid

produce distant metastases. „ 69 XXY (70%),
m Choriocarcinoma „ 69 XXX (27%),
n incidence is higher in Asia(MCQ) „ 69 XYY (3%).
n antecedent gestational event of l It arises when an ovum with an active
choriocarcinoma(MCQ) nucleus is fertilized by a (MCQ)
l In about half of all cases of - hydatidiform „ one haploid sperm that duplicates its
mole chromosomes
l One-fourth of cases follow a ter m „ two haploid sperms
pregnancy n Pathology
l remaining one-fourth follow an abortion. m Hydatidiform mole
m PSTT n an abnormal pregnancy characterized grossly by
n may arise either from a (MCQ) l multiple grapelike vesicles filling and
l hydatidiform mole distending the uterus
l less commonly, from a nor mal-ter m l usually it occurs in the absence of an intact
pregnancy. fetus
n The tumor is generally confined to the uterus n Microscopically, moles may be identified by
n metastasizes late in its course. three classic findings(MCQ)
n Syncytiotrophoblastic cells are generally l edema of the villous stroma
absent from this tumor(MCQ) l avascular villi
l minimal secretion of Beta -hCG in relation l nests of proliferating
to tumor burden syncytiotrophoblastic or
n human placental lactogen (hPL) is secreted cytotrophoblastic elements surrounding
and its levels can be monitored to follow villi
response. (MCQ)
m Clinical dictum
n Any woman with a recent histor y of molar
pregnancy, abortion, or normal pregnancy
who presents with vaginal bleeding or a tumor in any
organ should have at least one Beta -hCG assay to
ensure that metastatic gestational trophoblastic neoplasia
is not the cause. (MCQ)

Comparison of complete and Partial Hydatidiform Moles.
Complete Partial
Karyotype Diploid (46, XX or 46 XY) Triploid (69, XXX or 69, XXY)
Embryo Absent Present
Villi Hydropic Few hydropic
Trophoblasts Diffuse hyperplasia Mild focal hyperplasia
Implantation-site trophoblast Diffuse atypia Focal atypia
Fetal RBCs Absent Present
β-hCG High (> 50,000) Slight elevation (<50, 000)
Frequency of classic clinical symptoms 1
Common Rare
Risk for persistent GTT 20-30% < 5%
m Invasive mole (chorioadenoma destruens) m Nausea and vomiting (MCQ)

n occurs in 20% of patients who have undergone n About half of patients will have a uterine size
evacuation of a molar pregnancy. that is greater than that appropriate for their
GOB
n It is essentially a hydatidiform mole that gestational age.
invades the myometrium or adjacent structures m Multiple theca lutein cysts (MCQ)
n It has the potential to completely penetrate n cause enlargement of one or both ovaries
the myometrium and cause subsequent uterine n enlarged ovaries may be a source of pain.
rupture and hemoperitoneum n Involution of the cysts
n it also has the ability to spontaneously n proceeds over several weeks
regress n usually parallels the decline of Beta hCG values.
m Choriocarcinoma (MCQ) n Surgical treatment of these cysts is indicated only
n a pure epithelial tumor if

n composed of syncytiotrophoblastic and l rupture, torsion, or hemorrhage occur,
cytotrophoblastic cells l enlarged ovaries become infected.
n may accompany or follow any type of m Preeclampsia in the first trimester or early second
pregnancy trimester—an unusual finding in normal
n It usually presents as late vaginal bleeding in pregnancy—has been said to be pathognomonic
the postpartum period for a hydatidiform mole(MCQ)
n physical exam findings(MCQ) m Hyperthyroidism
l An enlarged uterus n Occur from stimulation of thyrotropin
l enlarged ovaries receptors by hCG
l vaginal lesions n usually subclinical and most patients remain
n Histologic examination of the tumor asymptomatic.
l sheets or foci of trophoblasts on a n Laboratory findings
background of hemorrhage and necrosis m Beta -hCG.
but no villi. n used for diagnosis, treatment, and follow-up
m Placental-site trophoblastic tumor of the disease process.
n derived from the intermediate trophoblasts n its levels correlate closely with the number of viable
of the placental bed, with minimal or absent tumor cells present
syncytiotrophoblastic tissue(MCQ) n In most instances, the Beta -hCG values exhibit
n Clinical Findings a progressive decline to nondetectable levels
m Abnormal uterine bleeding, usually during the within 14 weeks following evacuation of a
first trimester, is the most common presenting molar pregnancy. (MCQ)
symptom (MCQ) n Ultrasonograph findings
n Three-fourths of these patients present prior m diagnostic method of choice for patients with
to the end of the first trimester. suspected molar pregnancy(MCQ)
m complete molar pregnancy n Current recommendations restrict
n characteristic multiple hypoechoic areas hysterotomy to cases complicated by hemorrhage.
corresponding to hydropic villi (MCQ)
n described as a “snowstorm” pattern. (MCQ) m After the completion of the evacuation, all Rh-
n A normal gestational sac or fetus is not present negative patients should receive Anti-D immune
n Theca lutein cysts may also be seen. globulin. (MCQ)
m Partial mole n Complications
n focal areas of trophoblastic changes m Acute pulmonary insufficiency(MCQ)
n fetal tissue may be noted n The maternal–fetal barrier contains leaks large
m An ultrasonograph should be obtained in any enough to permit passage of cellular and tissue elements
patient who presents with bleeding in the first n As a result, deportations of trophoblastic
half of pregnancy and has a uterus greater tissue to the lungs are frequent.
than 12 weeks gestational size. (MCQ) n A patient can present with dyspnea and
m Even when the uterus is appropriate for cyanosis within 4–6 hours after evacuation
gestational age, ultrasonography can be key in of the molar pregnancy
differentiating between a normal pregnancy and m Pulmonary edema leading to high-output
a hydatidiform mole. congestive heart failure can also result from
n Treatment of Hydatidiform mole n excessive fluid administration
m Evacuation n preeclampsia
n Suction curettage is the method of choice(MCQ) n anemia
GOB
l It is safe, rapid, and effective in nearly all n hyperthyroidism.

cases. n Surveillance Following Molar Pregnancy
n Intravenous oxytocin (MCQ) m Following evacuation of a hydatidiform mole, the
l should be started after a moderate amount of tissue patient should have serial Beta -hCG
has been removed determinations
l may be continued for 24 hours postevacuation if n begin within 48 hours after evacuation
necessary. n then at weekly intervals until serum Beta -
l can be safely accomplished even when the hCG declines to nondetectable levels on three
uterus is the size of a 28- week gestation.. successive assays.
(MCQ) m If titer remission occurs spontaneously within 14

n When a large hydatidiform mole (> 12 weeks weeks and without a titer plateau, the Beta -hCG
in size) is evacuated by suction curettage, a titer should then be repeated monthly for at least
laparotomy setup should be readily available, as 1 year before the patient is released from close
hysterotomy, hysterectomy, or bilateral medical supervision
hypogastric artery ligation may be necessary m in cases of partial moles, Beta -hCG may be
if perforation or hemorrhage occurs. (MCQ) followed for 6–12 months(MCQ)
m Hysterectomy m Factors that predict increase in the risk of
n remains an option for persistent disease. (MCQ)
l good surgical candidates not desirous of future n In general, at diagnosis, the larger the uterus
pregnancy and the higher the Beta-hCG titer, the greater
l older women (who are more likely to develop the risk for malignant gestational trophoblastic
malignant sequelae). disease.
n If theca lutein cysts are encountered at n The combination of theca lutein cysts and
hysterectomy, the ovaries should remain intact, uterine size excessive for gestational age is
because regression to normal size will occur associated with an extremely high risk (57%) of
as the hCG titer diminishes. malignant sequelae
n Hysterectomy does not eliminate the need for careful n Pathologic specimens with marked nuclear
followup with Beta -hCG testing, atypia, presence of necrosis or hemorrhage,
n the likelihood of metastatic disease following and trophoblastic proliferation may also
hysterectomy for gestational trophoblastic m Effective contraceptive measures should be
disease decreases from 20% to 3.5%.(MCQ) implemented
n Oral contraceptives are the most widely used
method. (MCQ)
m If preevacuation chest radiography reveals „ her disease is known to be confined to
pulmonary metastases the uterus.
m chest radiographs n Single-agent chemotherapy using methotrexate
n should be repeated at 4-week intervals until or dactinomycin
spontaneous remission is confirmed n Methotrexate is contraindicated (MCQ)
n then at 3-month inter vals during the l in the presence of hepatocellular disease
remainder of the surveillance period. l when renal function is impaired
m Can the patient can become pregnant later n Categorization of Gestational Trophoblastic
n A patient who has entered into spontaneous remission Neoplasia.
with negative titers, examinations, and chest m Good-prognosis metastatic disease—(MCQ)
radiographs for 1 year and who is desirous of n Short duration (< 4 months).
becoming pregnant may terminate contraceptive n Serum Beta-hCG < 40,000 mlU/mL.
practices. n No metastasis to brain or liver.
n Successful pregnancy is usual, and complications n No significant prior chemotherapy.
are similar to those of the general population. m Poor-prognosis metastatic disease(MCQ)
n Abnormal Beta-hCG regression curve that n Long duration (> 4 months).
mandates treatment during follow up n Serum Beta -hCG > 40,000 mlU/mL.
m The most critical period of observation is the n Metastasis to brain or liver.
first 4–6 weeks postevacuation. (MCQ) n Unsuccessful prior chemotherapy.
m Beta-hCG should normalize by the 8th week n Gestational trophoblastic neoplasia following
GOB
n Indications for initiating chemotherapy during the term pregnancy.
postmolar surveillance period(MCQ)
m Beta -hCG levels rising for 2 successive weeks or
FIGO Anatomic Staging
constant for 3 successive weeks
m Beta -hCG levels elevated at 15 weeks postevacuation
Stage I Disease confined to the uterus
m rising Beta-hCG titer after reaching normal Stage II GTN extends outside of the uterus, but
levels is limited to the genital structures (adnexa,
m postevacuation hemorrhage.
vagine, abroad ligament)
m Treatment should also be instituted whenever there

Stage III GTN extends to the lungs, with or without
is a tissue diagnosis of choriocarcinoma.
n Malignant Gestational Trophoblastic neoplasia known genital tract involvement
m Malignant gestational trophoblastic neoplasia may Stage IV All other metastatic sites
be diagnosed in the setting of invasive mole,
choriocarcinomas, placental-site trophoblastic n Good-prognosis patients
tumors, and plateauing or rising postmolar Beta - m Single-agent chemotherapy is generally
hCG values successful.
n a plateau of 4 values ± 10% over a period of 3 m Methotrexate is considered the drug of
weeks choice(MCQ)
n a rise in Beta -hCG of > 10% of 3 values over a m Dactinomycin or patients who experience severe
period of 2 weeks side effects with methotrexate.
n persistence of detectable Beta -hCG > 6 n Poor-prognosis patients
months after evacuation m EMACO Regime provides the best response rate
m The most common site of metastases is the lung (MCQ)
n Nonmetastatic Gestational Trophoblastic n etoposide, methotrexate
Disease n actinomycin D, cyclophosphamide
m Therapy includes n vincristine
n single-agent chemotherapy n chemotherapy
n combined chemotherapy and hysterectomy m EP-EMA Regime(MCQ)
(MCQ) n Salvage therapy for disease not responsive to
l surgery done on the third day of drug EMACO
therapy - Prerequisites n substitutes cisplatin and etoposide (EP-EMA)
„ the patient does not wish to preserve for cyclophosphamide and vincristine (CO)
reproductive function m Close monitoring of renal function is required

n Nephrotoxicity can occur secondary to n Bleeding is usually menorrhagia, caused by:
cisplatin (MCQ)
n methotrexate is renally excreted. l Abnormal blood supply.
n Placental-Site Trophoblastic Tumor l Pressure ulceration.
m PSTT is generally is resistant to chemotherapy l Abnormal endometrial covering.
m hysterectomy is the recommended route of n Pain: Secondary dysmenorrhea. (MCQ)
treatment. (MCQ) n Pelvic pressure: May be due to enlarging
fibroids.
n Infertility.
TOPIC - 10 FIBROID UTERUS m Diagnosis
n Physical exam (bimanual pelvic and abdominal
n Leiomyomas exams)
m localized, benign, smooth muscle tumors of n Fibroids are usually midline, enlarged,
the uterus irregularly shaped, and mobile. (MCQ)

m hormonally responsive. n Sonography
m Clinically found in 25–33% of reproductive-age n may also be visualized by x-ray, MRI, CT, HSG,
women hysteroscopy.
m They are almost always multiple. n Pap, ECC, endometrial biopsy, hysteroscopy,
m The most common indication for hysterectomy. and D&C can be done to rule out
(MCQ) malignancy. (MCQ)
GOB
m Leiomyomas are most commonly of the m Treatment
subserous type. (MCQ) m No treatment is indicated for asymptomatic
m Rarely do leiomyomas (fibroids) progress( to women, as this hormonally sensitive tumor will
malignancy (leiomyosarcoma). likely shrink with menopause
m Submucosal and intramural types of fibroids m Pregnancy is usually uncomplicated. (MCQ)
usually present as menorrhagia. n Some fibroids may grow in size during
m Subserosal fibroids, which become pregnancy.

pedunculated, may present with acute pain and n Bed rest and narcotics are indicated for pain
torsion. (MCQ) with red degeneration.

FIBROID UTERUS
m Sequelae m Treatment is usually initiated when: (MCQ)
n Hyaline degeneration. n Tumor is > 14 weeks’ gestation size. (MCQ)
n Calcification. n Hematocrit falls.
n Red degeneration (MCQ) n Tumor compresses adjacent structures.
l painful interstitial hemorrhage n Symptoms limit lifestyle.
l often with pregnancy m The treatment for asymptomatic fibroids at 11 weeks’
n Cystic degeneration—may rupture into adjacent size is observation. (MCQ) (MCQ)

cavities. m GnRH agonists can be given for up to 6 months
m Uterine locations of leiomyomas to shrink tumors (ie, before surgery) and control
n Submucous: Just below endometrium; tend to bleeding: (MCQ)
bleed. m Myomectomy:
n Intramural: Within the uterine wall. n Surgical removal of the fibroid in infertile
n Subserous: Just below the serosa/peritoneum. patients with no other reason for infertility.
n Cervical: In the cervix. (MCQ)
n Parasitic: n A myomectomy is for women who desire to
n The fibroid obtains blood supply from another organ retain their uterus for childbearing.
(ie, omentum). n About one-third of fibroids recur following
n Interligamentous: The fibroid grows laterally myomectomy

into the broad ligament. m Hysterectomy:
m Symptoms n Indicated for symptomatic women who have
n Asymptomatic in > 50% of cases. (MCQ) completed childbearing.

n Bleeding +/- anemia: n Definitive treatment for fibroids = hysterectomy
l One-third of cases present with bleeding. o Pregnancy with fibroids carries ‘! relative risk:
(MCQ)
n Abruption: l occurs when both hips are flexed and both
n First-trimester bleeding knees extended.
n Dysfunctional labor m The breech presentation is associated with risk of
n Breech cord prolapse and head entrapment.
n C-section m The risk of cord prolapse is (MCQ)
n 15% in footling breech,
TOPIC - 11 n 5% in complete breech,
ABNORMAL PRESENTATION n 0.5% in frank breech.

m If the fetal neck is hyperextended, a risk of spinal cord
n Malpresentations injury exists.
m A normal presentation is defined by a Risks of vaginal breech delivery. (MCQ)
m
n longitudinal lie, n Patients with fetuses in a complete or frank
n cephalic presentation breech presentation may be considered for vaginal

n flexion of the fetal neck. delivery.
m Risk factors are conditions that (MCQ) n Cesarean section poses the risk of increased
n decrease the polarity of the uterus maternal morbidity and mortality.

n increase or decrease fetal mobility n Vaginal breech delivery, however, poses
n block the presenting part from the pelvis. increased risk to the fetus of the following:
m Risk Factors (MCQ)
n Maternal factors (MCQ) l Mortality
GOB
l grand multiparity „ three to five times greater mortality rate if
l pelvic tumors the fetus is heavier than 2500 g and does

l pelvic contracture not have a lethal anomaly
l uterine malformations. l Asphyxia
n Fetal factors (MCQ) l Cord prolapse
l Prematurity l Birth trauma
l multiple gestation l Spinal cord injuries
l poly- or oligohydramnios „ occur in vaginal deliveries if deflexion is
ABNORMAL PRESENTATION
l macrosomia, present
l placenta previa Vaginal delivery.
m
l hydrocephaly, n A trial of labor may be attempted if the following
l trisomy circumstances exist: (MCQ)

l anencephaly l breech is frank or complete
l myotonic dystrophy. l the estimated fetal weight is less than 3800
n Breech presentation g
m occurs when the cephalic pole is in the uterine l pelvimetry results are adequate
fundus. l the fetal head is flexed
m Major congenital anomalies occur in 6.3% of l anesthesia is immediately available and a
term breech presentation infants compared to 2.4% prompt cesarean section may be performed
of vertex presentation infants. (MCQ) l the fetus is monitored continuously
m occurs in l two obstetricians experienced with vaginal
n 25% of pregnancies at less than 28 weeks’ breech delivery and two pediatricians are
gestation(MCQ) present.
n 7% of pregnancies at 32 weeks’ gestation n A cesarean section should be performed in the
n 3–4% of term pregnancies in labor. event of any arrest of labor.

m There are three types of breech presentation n How do you conduct Vaginal delivery
n Complete breech (5–12%) l The goal in vaginal breech delivery is to
l occurs when the fetus is flexed at the hips maximize cervical dilatation and maternal expulsion
and flexed at the knees. efforts to maintain flexion of the fetal
n Incomplete, or footling breech (12–38%), vertex.
l occurs when the fetus has one or both hips l In breech presentation, the fetus usually
extended emerges in the sacrum transverse or oblique

n Frank breech (48–73%) (MCQ) position.
l As crowning occurs (the bitrochanteric n Cephalocentesis
diameter passes under the symphysis), an l performed if the fetus is not viable.
episiotomy should be considered. n The procedure is performed by perforating
l One should not assist the delivery yet. the base of the skull and suctioning the cranial
l Pinard maneuver (MCQ) contents.
„ When the umbilicus appears, one should place n External cephalic version(MCQ)
fingers medial to each thigh and press out m Indication for performing external cephalic
laterally to deliver the legs version is persistent breech presentation at
„ The fetus should then be rotated to the term
sacrum anterior position, and the trunk m Version is performed to avoid breech
can be wrapped in a towel for traction. presentation in labor.
l Lovsett’s maneuver(MCQ) m Risks include (MCQ)
„ When the scapulae appear, fingers should n cord accident
be placed over the shoulders from the n placental separation,
back. n fetal distress
„ The humerus should be followed down, n fetal injury
and each arm rotated across the chest and n premature rupture of membranes,
out n fetomaternal bleeding
„ To deliver the right arm, the fetus is turned m The most common “risk” is failed version.
in a counterclockwise direction; to deliver the m Success rate for ECV ranges from 35% to 86
GOB
left arm, the fetus is turned in a clockwise m in 2% of cases the fetus reverts back to breech
direction. presentation.
l Mauriceau-Smellie-Veit maneuver(MCQ) m Prerequisites for ECV(MCQ)
„ If the head does not deliver n A gestational age of at least 36 weeks
spontaneously, the vertex must be flexed n reactive nonstress test must be established
by placing downward traction and before the procedure
pressure on the maxillary ridge n informed consent
l Suprapubic pressure may also be applied. m Tocolysis and spinal or epidural anesthesia
l Piper forceps may be used to assist in may be used.

delivery of the head. m Rh-negative patients should receive Rh O (D)
n Vaginal delivery of a breech second twin immune globulin (RhoGAM) after the
n ultrasonography should be available in the procedure because of the potential for
delivery room. fetomaternal bleeding.
n The operator reaches into the uterus and m Factors associated with failure include (MCQ)
grasps both feet, trying to keep the n Obesity
membranes intact. n Oligohydramnios
n The feet are brought down to the introitus, n deep engagement of the presenting part
then amniotomy is performed. n fetal back posterior.
n The body is delivered to the scapula by m Nulliparity and an anterior placenta may also
applying gentle traction on the feet. The reduce the likelihood of success.
remainder of the delivery is the same as that m Contraindications to ECV include conditions
described earlier for a singleton breech. in which labor or vaginal delivery would be
m Entrapment of the head during breech vaginal contraindicated(MCQ)
delivery may be managed by one or more of the n placenta previa
following procedures. n prior classical cesarean section
n Duhrssen’s incisions (MCQ) m Version is not recommended in cases of (MCQ)
l made in the cervix at the 2, 6, and 10 o’clock n ruptured membrane,
positions. n Third trimester bleeding
l Either two or three incisions can be made. n Oligohydramnios
l The 3 and 9 o’clock positions should be n Multiple gestations
avoided due to the risk of entering the n if labor has begun.
cervical vessels and causing hemorrhage. n Abnormal lie.
(MCQ)
m “Lie” refers to the alignment of the fetal spine n Anencephaly accounts for 33% of all cases
in relation to the maternal spine. (most common cause) (MCQ)
m Longitudinal lie is normal, whereas oblique and n Diagnosis.
transverse lies l vaginal examination
m are abnormal. l ultrasonography
m Abnormal lie is associated with (MCQ) l palpation of the cephalic prominence and
n Multiparity the fetal back on the same side of the maternal
n Prematurity abdomen when performing Leopold’s
n pelvic contraction maneuvers. (MCQ)
n disorders of the placenta. n Risk. Perinatal mortality ranges from 0.6% to
m Incidence of abnormal lie is 1 in 300, or 0.33%, 5.0%.
of pregnancies at term. n Management.
m At 32 weeks’ gestation, incidence is less than l The fetus must be mentum (chin) anterior
2%. for a vaginal delivery to be performed.
m Risk. The greatest risk of abnormal lie is cord (MCQ)
prolapse, because the fetal parts do not fill the m Brow presentation
pelvic inlet. n results from partial deflexion of the fetal neck.
m Management. (MCQ)
n If abnormal lie persists beyond 35–38 weeks, n Incidence is 1 in 670 to 1 in 3433 pregnancies.
external version may be attempted(MCQ) n Causes of brow presentation are similar to those
GOB
n An ultrasonographic examination should be of face presentation.
performed to n Risks. Perinatal mortality ranges from 1.28%
n rule out major anomalies and abnormal to 8.00%.
placentation. n Management.
n If an abnormal axial lie persists, mode of l Majority of cases spontaneously convert
delivery should be cesarean section, with to a flexed attitude. (MCQ)
careful thought regarding type of uterine l A vaginal delivery should be considered
incision. only if (MCQ)
n A low segment transverse incision is still „ maternal pelvis is large
possible. „ fetus is small
n However, 25% of transverse incisions will „ labor progresses adequately
require an extension to allow for access to and l Forceps delivery or manual conversion is
atraumatic delivery of the fetal head. (MCQ) contraindicated. (MCQ)
n An intraoperative cephalic version may be m Compound presentation
attempted but should not be tried if ruptured n occurs when an extremity prolapses beside
membranes or oligohydramnios exists. the presenting part.
n A vertical incision may be prudent in cases n Incidence is 1 in 377 to 1 in 1213 pregnancies
with (MCQ) n compound presentation is associated with
l back down transverse prematurity.
l oblique lie with ruptured membranes n Diagnosis.
l poorly developed lower uterine segment. l Suspicion of compound presentation should
o Abnormal attitude and deflexion. be aroused if (MCQ)
n Full flexion of the fetal neck is considered „ active labor is arrested
normal. „ if the fetus fails to engage,
n Abnormalities range from partial deflexion „ if the prolapsing extremity is palpated directly.
to full extension. n Risks.
o Face presentation l Fetal risks are associated with birth trauma
n results from extension of the fetal and cord prolapse(MCQ)
neck(MCQ) l Cord prolapse occurs in 10–20% of cases.
n The chin is the presenting part. (MCQ) l Neurologic and musculoskeletal damage
n Incidence is between 0.14% and 0.54%. to the involved extremity can occur.
n In 60% of cases, face presentation is associated n Management.
with a fetal malformation.
l The prolapsing extremity should not be l Women who remain hyperthyroid despite
manipulated. treatment have higher inci-dence of
l Continuous fetal monitoring is recommended „ preeclampsia,
because compound presentation can be „ heart failure
associated with occult cord prolapse. „ adverse perinatal outcomes (stillbirth,
l Spontaneous vaginal delivery occurs in preterm labor).
75% of vertex/upper extremity presentations. „ Neonatal thyrotoxicosis
l Cesarean section is indicated in cases of ® 1% risk due to placental transfer of
nonreassuring fetal heart tracing, cord thyroid- stimulating antibodies.
prolapse, and failure of labor to progress. „ Fetal goiter/hypothyroid—from
propylthiouracil (PTU).
TOPIC - 12 „ Preterm delivery.
SYSTEMIC CONDITIONS AND „ Stillbirth.
PREGNANCY m Thyroid storm

n An acute, life-threatening, hypermetabolic
Systemic Conditions in Pregnancy state in patients with thyrotoxicosis.

n Often associated with heart failure. (MCQ)
n Thyroid
n Treatment in intensive care unit (ICU) setting:
m Thyroid hormone is essential for the normal
n PTU orally or nasogastric tube.
development of the fetal brain and mental
n Betaβ blocker to control tachycardia.
function. (MCQ)
GOB
n Sodium iodide inhibits release of T3 and T4

m TSH
n Essential for diagnosis of thyroid (lithium if iodine aller- gic). (MCQ)
n Dexamethasone blocks peripheral conversion
dysfunction in pregnancy.
n Unchanged in pregnancy.
of T4 to T3. (MCQ)
n Does not cross the placenta.
m Hypothyroidism
n Hashimoto’s thyroiditis is the most common
m Free thyroxine (T4): Unchanged in pregnancy.
(MCQ) cause of hypothyroidism during
m Thyroid-binding globulin ‘!?in pregnancy(MCQ).
SYSTEMIC CONDITIONS AND PREGNANCY
n Subclinical hypothyroidism is more common

pregnancy(MCQ)
m Hyperthyroidism
than overt hypothyroidism.
n Overt hypothyroidism is diagnosed by ↓TSH
n Twenty-five percent mortality rate.
n Graves’ disease is the most common cause of
and ↑free T4. (MCQ)
n Subclinical hypothyroidism is an ↑TSH with
thyrotoxicosis in pregnancy. (MCQ)
n Precipitating factors are infection, labor, and
normal free T4. (MCQ)
n Diagnosis may be difficult, as many of the
C-section.
n Treatment
symptoms of hypothyroidism (weight gain,
l Ablation with radioactive iodine fatigue, constipation, etc.) are also symptoms of
contraindicated. pregnancy.
n Treatment
l Propylthiouracil (PTU): (MCQ)
l Levothyroxine replacement:
„ Drug of choice for treatment during
l TSH is monitored every 8 weeks after the
pregnancy.
„ Inhibits conversion of T4 to T3.
initiation of treatment or a change in dosage.
„ Small amount transfer across the placenta.
(MCQ)
l TSH is monitored every trimester if no change
l Methimazole:
„ Readily crosses placenta.
in medication is needed due to increased
„ Associated with aplasia cutis in fetus.
thyroxine requirements in advancing
(MCQ) pregnancy. (MCQ)
l Complications
l Thyroidectomy:
„ Preeclampsia
„ Seldom done in pregnancy.
„ Placental abruption
„ For women who fail medical
„ Cardiac dysfunction
management.
„ Low birth weight
n Complications
„ Still births

n Respiratory disorders l Severe disease may require Beta-lactams +
m The adaptations to the respiratory system during macrolide (amoxicillin-clavulanate), or
pregnancy must be able to satisfy the ↑O2 third-generation cephalosporins
demands of the hyperdynamic circulation and the (ceftriaxone). (MCQ)
fetus. l Vancomycin is added for community-
m Advanced pregnancy may worsen the acquired methicillin-resistant
pathophysiological effects of many acute and Staphylococcus aureus (MRSA) (MCQ).
chronic lung diseases. n Renal and urinary tract disorders
m Asthma m Pregnancy causes hydronephrosis
n Asthmatics have a small but significant ↑in n dilatation of renal pelvis, calyces, and ureters;
pregnancy complications. R > L(MCQ)
n Fetal growth restriction ↑with the severity of n Pregnant uterus compresses the lower ureter.
asthma. (MCQ) n Hormonal milieu ↓ureteral tone.
n Arterial blood gases analysis provides m May cause urinary stasis and ↑vesicoureteral
objective information as to severity of asthma. reflux leading to symptomatic UTIs
n Epidemiology m Asymptomatic Bacteriuria
l One to four percent of pregnancies are n Five percent incidence.
complicated by asthma. n If untreated, 25% will develop pyelonephritis.
l Twenty-five percent of asthmatics worsen (MCQ)
in pregnancy. n Routine screening at the first prenatal visit
GOB
l Twenty-five percent improve. recommended.
l Fifty percent have no change. m Pyelonephritis
n Treatment n Acute pyelonephritis is the most common
l Generally, asthma is exacerbated by serious medical complication of pregnancy.
respiratory tract infections, so killed n Unilateral, right-sided > 50% of the time.
influenza vaccine should be given. (MCQ)
l Pregnant asthmatics can be treated with n Escherichia coli cultured 80% of the time.
Betaβagonists, epinephrine, and inhaled (MCQ)

steroids (same medications used outside of n Bacteremia in 15–20% of women with acute
pregnancy). (MCQ) pyelonephritis.
m Pneumonia n Complications
n Complications l Renal dysfunction: ↑creatinine.
l Premature rupture of membranes. l Pulmonary edema: Endotoxin-induced alveolar injury.
l Preterm delivery due to acidemia. l ARDS.
n Management l Hemolysis.
l Any pregnant woman suspected of having l Preterm labor.
pneumonia should undergo chest radiography n Differential diagnosis
(CXR) with an abdominal shield. (MCQ) l Preterm labor
l Abnormalities seen on CXR may take up l Chorioamnionitis
to 6 weeks to resolve. (MCQ) l Appendicitis
l Pneumococcal vaccine (MCQ) l Placental abruption
„ not recommended for healthy pregnant l Infracted myoma
pa-tients. n Management
„ Use in patients who are l Hospitalization.
immunocompromised or have severe l IV antibiotics usually cephalosporins.
cardiac / renal / pulmonary disease. l IV hydration for adequate urinary output.
l Influenza vaccine is recommended for l Consider long-term antibiotic suppression
prevention in all trimesters. (MCQ) for remainder of pregnancy for recurrent
l For bacterial pneumonia empirical therapy pyelonephritis.
with erythromycin IV then PO is reportedly n Gastrointestinal disorders
effective in 99% of uncomplicated m Differential Diagnosis of Acute Abdomen
pneumonia cases. n Pyelonephritis
n Appendicitis

n Pancreatitis l The fetus is at risk for megaloblastic
n Cholecystitis anemia. (MCQ)
n Ovarian torsion n Treatment
n Ectopic pregnancy (early pregnancy) l Folic acid supplementation should be
n Labor taken by those women taking an-
m Appendicitis ticonvulsants.
n Appendicitis is the most common surgical l Carbamazepine, or lamotrigine in doses
condition in pregnancy under 200 mg/day, when used as
n Incidence is same throughout pregnancy monotherapy, are the anticonvulsant drugs
n rupture is more frequent in third trimester of choice in pregnancy(MCQ)
(40%) than first (10%).(MCQ)
n Symptoms of appendicitis, such as nausea, n Thromboembolic disorders
vomiting, and anorexia, may also be a part m Deep Vein Thrombosis (DVT)
of normal pregnancy complaints, making m Signs and symptoms
diagnosis difficult. n Calf/leg swelling.
n Uterus displaces the appendix superiorly and n Calf pain.
laterally n Palpate cords in leg.
n Pain may not be located at McBurney’s point m Diagnosis
(RLQ). (MCQ) n Venography: Gold standard. (MCQ)
n Complications l Many complications, time consuming,
GOB
l Abortion. cumbersome.
l Preterm labor. n Impedance plethysmography:
l Maternal-fetal sepsis → neonatal neurologic l Better for larger veins.
injury. n Compression ultrasonography:
n Treatment l Test most often used currently.
l Immediate appendectomy. m Complications
l Laparoscopy (early pregnancy when uterus n Pulmonary embolism develops in about 25%
is small). of patients with untreated DVT.

l Laparotomy in later pregnancy. m Treatment
m Cholelithiasis and Cholecystitis n Anticoagulation with unfractionated or low-
n Incidence of cholecystitis is 1 in 1000 molecular-weight heparin (LMWH) during

pregnancies pregnancy.
n more common than nonpregnant n Heparin should be suspended during labor
n Same clinical picture as nonpregnant. and delivery and restarted after 12–48 hr,
n Medical management unless common bile duct depending on the degree of trauma to the genital
obstruction or pancreatitis develops, in which tract. (MCQ)
case a cholecystectomy should be performed. n Convert to warfarin postpartum (do not use
n High risk of preterm labor. (MCQ) warfarin when pregnant).

n Neurologic disorders n Anticoagulation ↓the risk of pulmonary
m Seizure disorder embolism to less than 5%. (MCQ)

n Complications m Pulmonary Embolism (PE)
l Women with epilepsy taking anticonvulsants n Symptoms: Dyspnea, chest pain, cough,
during pregnancy have double the general syncope, hemoptysis.

population risk of fetal malformations n Signs: Tachypnea, tachycardia, apprehension,
and preeclampsia. (MCQ) rales, hypoxemia.

l Women with a seizure disorder have an ↑risk n Diagnosis: Spiral CT. (MCQ)
of birth defects even(MCQ) n Complications include maternal death.
l when they do not take anticonvulsant n Treatment: Anticoagulation with heparin/
medications. LMWH.
l Pregnant epileptics are more prone to n Half of women presenting with a DVT will
seizures due to the associated stress and have a “silent” PE.

fatigue of pregnancy. m Thrombophilias

n ↑risk of thrombus formation and associated l Fetal growth restriction , Stillbirth
complications. n Management
n Antithrombin III deficiency l Supplementation with 4 mg/day of folic
l The most thrombogenic of the heritable acid to accommodate for rapid cell turnover.
coagulopathies. (MCQ) (MCQ)
n Protein C deficiency: l IV hydration and pain control for crises.
l 6- to 12-fold ↑risk of first venous l Oxygen given via nasal cannula
thromboembolism (VTE) in pregnancy. administered in an attempt to ↓sickling.
n Protein S deficiency: n Prophylactic blood transfusions throughout
l 2- to 6-fold ↑risk of first VTE in pregnancy are controversial.
pregnancy. m Anemia
n Factor V Leiden mutation: n Physiologic anemia is normal anemia in
l Most common heritable thrombophilia; pregnancy due to hemodilution from volume
(MCQ) expansion.
l 5–8% of the general population. n Anemia for a pregnant woman is a drop in
l Heterozygous inheritance. hemoglobin below 10 g/dL or hematocrit
l Four to eightfold ↑risk of first VTE in < 30%.(MCQ)
pregnancy. n Twenty to sixty percent of pregnant women;
n Antiphospholipid antibodies: n 80% is iron deficiency type. (MCQ)
l Commonly seen in patients with lupus. n Complications(MCQ)
GOB
n Prothrombin G20210A mutation. l Preterm delivery.
n Hyperhomocysteinemia. l Intrauterine growth restriction (IUGR).
n Complications l Low birth weight.
l Preeclampsia/eclampsia. n Treatment
l HELLP syndrome (hemolysis, elevated l Two hundred milligrams of elemental
liver enzymes, low platelets). iron daily from either ferrous sulfate,
l Fetal growth restriction. fumarate, or gluconate. (MCQ)
l Placental abruption. m Antiphospholipid syndrome

l Recurrent abortion. n Diagnosis
l Stillbirth. l Clinical Criteria
n Treatment - Heparin or LMWH. „ Arterial and venous thrombosis.
m Sickle cell disease „ Pregnancy morbidity: (MCQ)
n Red cells with hemoglobin S undergo sickling ® At least one otherwise unexplained
with ↓oxygen leading to cell membrane fetal death at or beyond 10 weeks.
damage. ® At least one preterm birth before 34 weeks.
n Sickle-cell crisis: Pain due to ischemia and ® At least three consecutive spontaneous abortions
infarction in various organs. before 10 weeks.
l Infarction of bone marrow causes severe „ Puerperium:
bone pain. „ Fe deficiency.
l Crisis more common in pregnancy. „ Acute blood loss.
l Acute chest syndrome: Pleuritic chest pain, l Laboratory Criteria(MCQ)
fever, cough, lung infiltrates, hypoxia. „ Lupus anticoagulant.
n Pregnancy complications „ Medium to high titers of anticardiolipin
l Thromboses (cerebral vein thrombosis, antibody.
DVT, PE). „ Anti-Beta 2 glycoprotein.
l Pneumonia. „ Each of these findings must be present in
l Pyelonephritis. plasma, on at least two occa-sions > 12
l Sepsis syndrome. weeks apart. (MCQ)
l Gestational HTN. n Management
l Preeclampsia., Eclampsia. l Ranges from no treatment to daily low-dose
n Delivery complications aspirin to heparin, depending on the patient’s
l Placental abruption past history of thrombosis and pregnancy
l Preterm delivery morbidity.
m Systemic lupus erythematosus m Free T4 and TSH do not change in pregnancy
n Complications and are the most sensitive markers to detect thyroid
l Preeclampsia. disease. (MCQ)
l Preterm labor. m In normal pregnancy, total T3, T4, and thyroid-
l Fetal growth restriction. binding globulin (TBG) are elevated, but free
l Anemia. thyroxine levels do not change = euthyroid.
l Thrombophilia. (MCQ)
n Neonates may have symptoms of lupus for m Hyperthyroidism (↑free T4, “!?TSH) are noted
several months after birth. in hyperemesis gravidarum and gestational
l Congenital heart block may be seen in the trophoblastic disease. (MCQ)
offspring of women with anti-Ro (SS-A) m Hypothyroidism: ↑TSH, ↓Free T4(MCQ)
and anti-La (SS-B). (MCQ) m Subclinical Hypothyroidism: ↑TSH, normal
n Management free T4
l Patients should be counseled to get pregnant m Overt hypothyroidism is often associated with
while their disease is in remission. infertility and higher miscarriage rates.
l Monitor for disease flares and hypertensive m Blood pressure is dynamic during pregnancy
episodes. a. It normally ↓in T2. (MCQ)
l Unless there is evidence of fetal compromise, b. If a patient with chronic hypertension is seen for
the pregnancy should progress to term. the first time in T2, she may appear
l High-dose methylprednisolone can be normotensive.
GOB
given for a lupus flare. c. Development of complications may require

l Azathioprine is an immunosuppressant that the delivery of a very premature infant.
can be used safely in pregnancy. m α-Methyldopa (centrally acting agent): One of
l Cyclophosphamide, methotrexate, and the most common antihypertensives used in
mycophenolate mofetil should be avoided, pregnancy. (MCQ)
or at least not started until after 12 weeks m Pain control of choice during labor and delivery:
gestation. (MCQ) Epidural anesthesia. (MCQ)
m Pruritic urticarial papules and plaques of m F-series prostaglandins exacerbate asthma, so
pregnancy (PUPPP) (MCQ) avoid in pregnancy

n Incidence m Severe pneumonia is a common cause of ARDS
l The most common pruritic dermatosis in m Pregnant women with asymptomatic bacteriuria
pregnancy. (MCQ) should be treated because of their ↑risk of
l One in 200 singleton pregnancies, ↑to 8 in developing pyelonephritis.
200 with multiples. m Hydronephrosis: Usually R >L(MCQ)
l Seldom occurs in subsequent pregnancies. m Highest incidence of asymptomatic bacteriuria:
n Clinical signs and symptoms patients with sickle-cell trait.
l Intensely pruritic cutaneous eruption m Most common cause of septic shock in
l usually appears late in pregnancy. pregnancy: Urosepsis. (MCQ)
l Erythema, vesicles, and eczematous m Increased estrogen in pregnancy →increased
target lesions may be seen. cholesterol saturation in bile →increased biliary
l Begins on the abdomen and spread to arms stasis and gallstones(MCQ)
and legs. m Most common cause of persistent pyelonephritis
l Rarely may in-volve face, palms, and soles. despite adequate therapy: Nephrolithiasis.
n Treatment (MCQ)
l Oral antihistamines and topical steroids m Most common indications for surgery in
are the mainstays of treatment. pregnancy: (MCQ)
l May require systemic corticosteroids for l Appendicitis
severe pruritus. l Adnexal masses
l Rash usually disappears shortly before or a l Cholecystitis
few days after delivery. m Contrast venography is the gold standard for
Clinical Pearls – High yield Facts for MD Entrance diagnosis of lower-extremity DVT.
m Warfarin is a terotogen, so not used in pregnancy.
Can breast-feed with it postpartum.
m Pulmonary embolus may originate in the iliac l Ureaplasma urealyticum ,Mycoplasma
veins rather than the calf in pregnancy. hominis
m Antithrombin deficiency: Most thrombogenic of l Listeria monocytogenes
the heritable coagulopathies. (MCQ) l Chlamydia , Gonorrhea
m Most common thrombophilia: Factor V Leiden n Structural Abnormalities
mutation, often diagnosed when an asymptomatic l Septate/bicornuate uterus: 25–30%.(MCQ)
woman starts combination oral contraceptive pills. l Cervical incompetence.
m How do you treat a pregnant woman with a deep l Leiomyomas (especially submucosal).
vein thrombosis (DVT)? (MCQ)

i. Heparin or low- molecular-weight l Intrauterine adhesions (ie, from previous
heparin. Do not use coumadin. curettage).

m The two most common causes of anemia n Endocrine Abnormalities
during pregnancy and the puerperium are iron l Progesterone deficiency. (MCQ)
deficiency and acute blood loss. l Polycystic ovarian syndrome (PCOS).
m Presence of anti-Ro (SS-A) and anti-La (SS- l Diabetes—uncontrolled.
B) are associated with fetal congenital heart block. n Immunologic Factors
(MCQ) l Lupus anticoagulant.
m Rule of thumb for pregnant patients with l Anticardiolipin antibody (antiphospholipid
lupus: one- third get better, one-third get worse, and one- syndrome).
third remain the same. (MCQ) n Environmental Factors
GOB
l Tobacco: ??14 cigarettes/day ‘!?abortion rates.
TOPIC - 13 ABORTION (MCQ)

l Alcohol., Irradiation , Trauma.
n Bleeding in the first trimester : Differential l Environmental toxin exposure. ,Caffeine: > 5
diagnosis cups/day. (MCQ)

n Spontaneous abortion. ,Ectopic pregnancy. n Types of spontaneous abortion
n Hydatidiform mole. ,choriocarcinoma, m Threatened Abortion
n cervical cancer , Trauma. l Threatened abortion is uterine bleeding from
n Spontaneous abortions a gestation that is < 20 weeks without

m Abortion cervical dilation or passage of tissue.
ABORTION
n intentional or unintentional termination of a (MCQ)
pregnancy < 20 gestation or weight of < l Pregnancy may continue, although up to 50%
500 g. (MCQ) may result in loss of pregnancy. (MCQ)

m Completed spontaneous abortion l It increases the risk of preterm labor and
n spontaneous expulsion of all fetal and placental tissue delivery.

from the uterine cavity before 20 weeks n Diagnosis
gestation. (MCQ) l Speculum exam reveals blood coming from
n Occurs in 30% of all recognized pregnancies. a closed cervical os, without amniotic
n Most are unrecognized because they occur fluid or products of conception (POC)
before or at the time of the in the endocervical canal. (MCQ)
n next expected menses (70–80%). l US will show an empty uterus if gestation
m Etiologies very early, gestational sac, or fetus with

n Chromosomal Abnormalities cardiac activity.
l Majority of abnormal karyotypes are l If uncertain of diagnosis, can follow serial
numeric abnormalities as a result of errors hCGs; should ↑by a minimum of 60%

during gametogenesis, fertilization, or the every 48 hr if normal pregnancy (peaks at
first division of the fertilized ovum. ~10 weeks). (MCQ)
l Trisomy: 50–60%.(MCQ) n Management
l Monosomy (45,X): 7–15%. l Observation, pelvic rest.
l Triploidy: 15%. m Inevitable Abortion
l Tetraploidy: 10%. n Inevitable abortion is vaginal bleeding,

n Infections cramps, and cervical dilation at < 20 weeks
l Toxoplasma gondii ,Herpes simplex

gestation without expulsion of POC. l Observe patient for further bleeding and
(MCQ) signs of infection.
n Expulsion of POC is imminent. m Missed Abortion
n Diagnosis n Missed abortion is fetal demise before 20 weeks
l Presence of menstrual-like cramps. of gestation without expulsion of any POC.
l Speculum exam reveals blood coming from (MCQ)
an open cervical os. n Diagnosis
l Fetal cardiac activity may or may not be l The pregnant uterus fails to grow, and symptoms
present on US. of pregnancy have disappeared.
n Management l Intermittent vaginal bleeding/spotting/
l Surgical evacuation of the uterus if fetal brown discharge and a firm, closed cervix.
cardiac activity is absent. l Quantitative β ετα-hCG may decline,
l Expectant management if fetal cardiac platue, or continue to ↑.
activity is present. l US confirms absent fetal cardiac activity
m Incomplete Abortion or empty gestational sac.
n Incomplete abortion is the passage of some, but not n Management
all, POC from the uterine cavity before 20 l Expectant management.
weeks gestation. (MCQ) l Most women will spontaneously deliver a
n Increased risk of: fetal demise within 2 weeks.
l Ongoing bleeding requiring a blood l Risk of incomplete or septic abortion that
GOB
transfusion. may require a D&C.

l Ascending infection, septic abortion. l Concern for coagulopathy if dead fetus is
n Diagnosis not delivered.
l Continued cramping and bleeding. (MCQ) l More so for fetal demise in T2 and T3.
l Enlarged, boggy uterus; dilated internal os. (MCQ)
(MCQ) l Suction D&C. (MCQ)
l POC present in the endocervical canal or l Cervical dilators with prostaglandin E1
vagina. suppositories.
l POC retained in the uterus may be seen n Septic Abortion
with US. n Infected POC are present.
ABORTION
n Management n Can be threatened, inevitable, or incomplete

l Assess hemodynamic status and stabilize (IV type of abortion.
fluids, blood transfusion). n The infection is usually polymicrobial.
l Suction dilation and curettage (D&C) to n Infection can spread from endometrium,
remove the POC from the uterus. (MCQ) through myometrium, to
l Send POC to pathology. n parametrium and sometimes to peritoneum.
l Karyotype POC if recurrent abortion. n Septic shock may occur.
m Complete abortion n Diagnosis
n complete passage of POC. l Fever, hypotension, tachycardia, generalized pelvic
n The cervical os is closed after the abortion is discomfort, uterine tenderness, signs of peritonitis.
completed. (MCQ) l Speculum exam: Malodorous vaginal and cervical
n Diagnosis discharge.
l Pain has ceased. l Leukocytosis.
l Uterus is well contracted. l US shows retained POC.
l Cervical os may be closed. (MCQ) n Management
l US shows empty uterus. l Vaginal discharge culture, blood culture, check CBC,
n Management urinalysis (UA), serum electrolytes, liver function tests
l Send POC to pathology to verify intrauterine (LFTs), blood urea nitrogen (BUN), creatinine, and
pregnancy. coagulation panel.
l Between 8 and 14 weeks, curettage is often l Broad-spectrum IV antibiotics that has
performed due to ‘!?likeli-hood that the anaerobic bacteria coverage.
abortion was incomplete. (MCQ) l Hemodynamically stable patient(MCQ)

„ D&C after adequate tissue level of n Induced abortion
antibiotics (2 hr) n Intentional termination of pregnancy, before
l Hemodynamically unstable patient 20 weeks gestation.
(MCQ) n Assessment of the Patient
„ start IV fluids and antibiotics l USG - uses
„ perform D&C when patient adequately „ Important in confirming gestation age.
stabilized. „ If there is a discrepancy between dates and
„ Hysterectomy if unable to evacuate the uterine size.
infected uterine contents. „ Ectopic pregnancy suspected.
m Recurrent Abortion „ Leiomyomata present—uterus may feel
n Two or more successive clinically bigger.
recognized pregnancy losses prior to 20 „ Critical for T2 abortions for dating—
weeks GA constitutes recurrent abortion. miscalculation of gestational age (GA) can lead to
(MCQ) complications.
n Women with two successive spontaneous „ Can help during the procedure.
abortions have a recurrence risk of 25–30%. l Blood type and Rh type:
n Etiology „ If patient is Rh negative, anti-D
l Parental chromosomal abnormalities immunoglobulins should be administered
(balanced translocation is the most common). prophylactically.
(MCQ) n Indications for Therapeutic Abortion (Not an
GOB
l Anatomic abnormalities: (MCQ) Exhaustive List)
„ Uterine didelphys, septate uterus l Maternal
„ bicornuate, and unicornuate uterus. „ Cardiovascular disease.
l Acquired defects: „ Genetic syndrome (eg, Marfan).
„ Intrauterine synechiae (Asherman „ Hematologic disease (eg, TTP)
syndrome), „ Metabolic (eg, proliferative diabetic
„ leiomyomas. retinopathy).
l Cervical incompetence: „ Neoplastic (eg, cervical cancer; mother
„ Painless cer vical dilation leads to needs prompt chemotherapy).
second-trimester abortions. (MCQ) „ Neurologic (eg, berr y aneur ysm;
ABORTION
„ Treat with cervical cerclage. cerebrovascular malformation).
l Endocrinologic abnormalities. „ Renal disease.
l Infections: „ Intrauterine infection.
„ Chlamydia, Ureaplasma, Listeria, „ Severe preeclampsia/eclampsia.
„ Mycoplasma, Toxoplasma, or syphilis. l Fetal
l Autoimmune conditions (classically, „ Major malformation (eg, anencephaly).
antiphospholipid syndrome [APA] in which „ Genetic (eg, spinal muscular atrophy).
thrombosis results in fetal demise). n Methods of Abortion
l Unexplained in a majority of cases. n Pharmacologic agents
l Maternal thrombophilia (genetic mutations l Abortions in T1 and T2 can be performed
that increase the risk of thrombi formation). with pharmacologic agents.
n Management - Potentially useful tests include: l Hypertonic solution instilled in the
l Karyotype of abortus. amniotic cavity
l Parental karyotypes: Balanced translocation „ Infrequently used.
in parents may result in unbalanced l Prostaglandin E2, E1, F2?:
translocation in the fetus. „ Can be administered orally or vaginally,
l Sonohysterogram, hysteroscopy: depending on the type of prostaglandin.
l Evaluate uterine cavity. (MCQ)
l Luteal-phase endometrial biopsy not very „ Given every 2–6 hr until uterus evacuated.
helpful. (MCQ)
l Anticardiolipin and antiphosphatidyl serine antibodies. „ Advantages:
l Lupus anticoagulant (antiphospholipid workup). ® Easy to use
l Factor V Leiden.

® can be safely used in women with prior l Preeclampsia. ,Placental infarction.Placental or
cesarean delivery. (MCQ) membrane infection.
„ Disadvantages: l Twin-twin transfusion syndrome. (MCQ)
® Diarrhea, fever. l Nulliparity. , Advanced maternal age(MCQ)
l Mifepristone (RU 486) and misoprostol: n Causes of Fetal Death Based on Trimester
„ Antiprogestin mifepristone is followed l T1 (1–13 weeks)
by misoprotol 48 hours later. (MCQ) „ Chromosomal abnormalities. (MCQ)
„ Ninety-two percent successful for „ Environmental factors (eg, medications,
pregnancy 7 weeks smoking, toxins).
„ Seventy-seven percent successful for „ Maternal anatomic defects (eg, mullerian
pregnancy 8–9 weeks defects).
n Surgical method „ Endocrine factors
l Dilation and curettage (D&C) (MCQ) ® progesterone insufficiency, thyroid
„ Used most often in T1. dysfunction,
„ It involves dilating the cervix and using a ® diabetes ,
suction apparatus to remove the contents „ Unknown.
of the uterus. l T2 (14–27 weeks)
l Dilation and evacuation (D&E): (MCQ) „ Anticardiolipin antibodies. ,
„ Used most often in T2. Antiphospholipid antibodies.
„ It involves dilation of cer vix and „ Chromosomal abnormalities.
GOB
extraction of fetal parts using various „ Anatomic defects of uterus and cervix.
instruments. „ Erythroblastosis. (MCQ)
„ Advantages: „ Placental pathological conditions (eg,
o Less emotional stress for patient circumvallate placentation, placenta
® avoid hospitalization, , greater previa).
convenience. l T3 (28 weeks–term)
„ Disadvantages: „ Anticardiolipin antibodies.
® Need technical expertise, trauma to the „ Placental pathological conditions (eg,
cervix. circumvallate placentation, placenta previa,
l Hysterotomy. abruptio placentae).
ABORTION
l Hysterectomy: „ Infections (eg, toxoplasmosis, CMV,

„ Consider if patient has concurrent fibroids parvovirus).
or carcinoma in situ of the cervix. l Time nonspecific
n Intrauterine Fetal death „ Trauma.
n Death of the fetus > 20 weeks gestation, „ Cord accident.
prior to complete expulsion or extraction from the „ Maternal systemic disease (eg, diabetes,
mother. (MCQ) hypertension).
n It can result in a spontaneous abortion or a „ Maternal infection (eg, chorioamnionitis).
missed abortion. „ Substance abuse (eg, cocaine).
n Etiology/risk factors l Diagnosis
l Fetal growth restriction: „ In late pregnancy, absent fetal movement detected
„ Significant ↑in the risk of stillbirth. by the mother is usually the first sign.
„ Fetal aneuploidies , Fetal infection ,Maternal „ Absent fetal heart tones by Doppler.
smoking „ Real-time US showing absent fetal heart movement
„ Hypertension ,Autoimmune disease, is the diagnostic method of choice.
Obesity, Diabetes (MCQ)
l Chromosomal and genetic abnormalities: l Management
Found in up to 8–13% of fetal death. „ D&E may be used if fetal death occurs in
(MCQ) T2.
l Multiple gestation. ® D&E has “!?maternal mortality compared to
l Placental abruption is a common cause of PGE2 labor induction(MCQ)
fetal death. ® It has the risk of uterine perforation.
l Maternal cocaine and other illicit drug use.

„ Labor induction if fetal death occurs in l Endometrial cancer
T3 l a malignancy arising from the lining of the
® Induction of labor with vaginal uterus.
misoprostol is safe and effective even in l Because endometrial cancer usually presents
patients with a prior cesarean delivery with obvious symptoms, it is most often
with a low transverse uterine scar. diagnosed at an early stage. (MCQ)
(MCQ) l Lifetime risk is 3%.
„ Every attempt should be made to avoid a l Age at diagnosis: > 50 yr: 80%(MCQ)
hysterotomy. (MCQ) l Two types:
n Type I (most common): (MCQ)
TOPIC - 14 l An estrogen-dependent neoplasm that
ENDOMETRIAL CARCINOMA begins as proliferation of normal tissue.

l Over time, chronic proliferation becomes
Endometrial hypertrophy hyperplasia (abnormal tissue) and, eventually,

m A precancerous condition. neoplasia.
m Types include: n Type II: (MCQ)
n Simple (cystic hyperplasia without atypia): l Unrelated to estrogen or hyperplasia.
l Glandular and stromal proliferation. l Tends to present with higher-grade or more
l One percent progress to cancer (most well aggressive tumors.

differentiated). l Clinical presentation
GOB
m Complex (adenomatous hyperplasia without n Abnormal bleeding is present in 90% of cases:
atypia): (MCQ)
l Only glandular proliferation of the n Bleeding in postmenopausal women
endometrium. (classic).
l Three percent progress to cancer. n Meno/metrorrhagia (in premenopausal cases).
m Atypical: l Abnormal Pap smear:
l Simple atypical (10% progress to cancer). n Pap smears are not diagnostic,
l Complex atypical (29% progress to cancer). n a finding of abnormal glandular cells of
ENDOMETRIAL CARCINOMA
(MCQ) unknown significance (AG- CUS) warrants
l Proliferation with cytologic atypia. further investigation
m Diagnosis of endometrial hyperplasia l Differential diagnoses of postmenopausal
n Endometrial biopsy (gold standard). (MCQ) bleeding(MCQ)

n Pap smear: If endometrial cells are found on a n Exogenous estrogens.
pap suspect endometrial pathology. n Atrophic endometritis/vaginitis.
n Other procedures might pick it up: n Endometrial cancer.
l Endocervical curettage (ECC). n Endometrial/cervical polyps.
l Transvaginal ultrasound to evaluate the n Coagulopathy.
endometrial stripe in a postmenopausal woman. n Endometrial hyperplasia.
l Hysterocopy with uterine curettage if l Risk factors (MCQ) A FREQUENTLY
endometrial biopsy is inadequate. ASKED MCQ

m Treatment n Endogenous unopposed estrogen (ie,
n Simple hyperplasia with abnormal bleeding: polycystic ovarian syndrome [PCOS]).

(MCQ) n Estrogen-producing tumors (ie, granulosa cell
l Cyclical progestin therapy. tumors).

n Complex hyperplasia or simple atypical n Liver disease (a healthy liver metabolizes
hyperplasia: (MCQ) estrogen).

l Cyclical or continuous progestin therapy n Previous radiation (sarcomas).
l hysterectomy if uterine preservation is not n Obesity (2–5 times risk).
desired n Early menarche/late menopause.
n Complex atypical hyperplasia: (MCQ) n Nulliparity (2–3 times risk; most likely when
l Continuous high-dose progestin therapy associated with anovulation).

if uterine preservation is desired; n PCOS (chronic unopposed estrogen
l hysterectomy if uterine preservation is not stimulation).
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n Diabetes mellitus (2.8 times risk). n III: Local and/or regional spread of the
n Hypertension. tumor
n Endometrial hyperplasia (highest risk is with l IIIA: Invasion of uterine serosa and/or
complex atypia). adnexa
n Tamoxifen treatment for breast cancer (2–3 l IIIB: Invasion of vagina and/or
times ‘!?risk). parametrial involvement
n Unopposed estrogen stimulation (eg, l IIIC: Mets to pelvic/para-aortic lymph
menopausal estrogen replacement: 4–8 times nodes
‘!?risk). l IIIC1: Positive pelvic nodes
n Familial predisposition. l IIIC2: Positive para-aortic lymph nodes
l Protective factors (MCQ) with or without positive pelvic lymph nodes
n Regular ovulation. n IV: Tumor invades bladder and/ or bowel
n Combined oral contraceptives. mucosa, and/or distant mets
n Cigarette smoking. l IVA: Invasion of bladder and/or bowel
n Multiparity. mucosa
l Diagnosis for postmenopausal bleeding l IVB: Distant invasion, including intra-
(MCQ) abdominal mets and/or inguinal lymph
n Endometrial biopsy. nodes
n D&C hysteroscopy, if endometrial biopsy, is m Grading is determined by the tumor histology:
inadequate. n G1 - Well differentiated -< 5% solid pattern
GOB
l Histologic Subtypes n G2 - Moderately differentiated -5–50% solid

n Endometrioid (ciliated adenocarcinoma): 75– pattern
80%. (MCQ) n G3 - Poorly differentiated -> 50% solid pattern
n Papillary serous: 5–10%: m Treatment
l Poor prognosis. n Basic treatment for all stages (surgical staging
l No history of elevated estrogen. is always the first step): (MCQ)
l Acts like ovarian cancer. l Total abdominal hysterectomy (TAH).
l Typically presents in late stage (stage IV). l Bilateral salpingo-oophorectomy (BSO).
ENDOMETRIAL CARCINOMA
n Clear cell: < 5%. l Pelvic and para-aortic lymphadenectomy.

l Poor prognosis. l Peritoneal washings for cytology (“loose or
n Sarcomas free cancer cells”).
n Poorly differentiated carcinomas n Adjuvant therapy
l Poor prognosis l After the above steps in treatment, adjuvant
m Staging of endometrial cancer (MCQ) therapy depends on the stage.
n Endometrial cancer is staged surgically. l Stages I–II (MCQ)
n The stage of an endometrial cancer is „ Adjuvant radiation therapy (includes internal
determined by and external radiation).
l The spread of tumor in the uterus. l Stages III–IV (MCQ)
l The degree of myometrial invasion. „ External beam radiation
l The presence of extrauterine tumor spread. „ Hormone therapy:
n This assessment is accomplished through a ® Progestin therapy is often used as
surgical staging operation (similar to ovarian adjuvant hormonal therapy:
cancer). » If the cancer is progesterone receptor
n The staging of a patient’s disease directs positive—
treatment and predicts outcome ö 70% have a 5-yr survival.
l Staging (MCQ) A FREQUENTLY » If the cancer is progesterone receptor
ASKED MCQ negative—
n I: Tumor confined to the uterus ö 15–20% have a 5-yr survival.
l IA: No or less than half of myometrium „ Adjuvant chemotherapy: (MCQ)
l IB: Invasion equal to or more than half of ® Doxorubicin
the myometrium ® Cisplatin
n II: Tumor invades cervical stroma, but does ® Carboplatin and paclitaxel (Taxol)
not extend beyond uterus**
TOPIC - 15 n Endometriosis: Occasionally presents as
A DISORDERS OF MENSTRUATION premenstrual spotting.
n Traumatic vaginal lesions.
n Systemic:
n Polymenorrhea
l von Willebrand disease can cause ‘!?bleeding
m Uterine bleeding occurring at regular intervals of
< 21 days. (MCQ) due to coagulopathy.
l Prothrombin deficiency. , Leukemia. ,
n Menorrhagia
m Prolonged (> 7 days) or excessive (> 80 mL)
Sepsis.
l Idiopathic thrombocytopenic purpura. ,
uterine bleeding occurring at regular intervals
(MCQ) Hypersplenism.
l Thyroid dysfunction:
n Oligomenorrhea:
„ Hypothyroidism causes anovulation and is
m Uterine bleeding occurring at intervals > 35 days.
(MCQ) frequently associated with menorrhagia
n Metrorrhagia: and intermenstrual bleeding.
„ Cirrhosis:
m Bleeding occurring at frequent, irregular
® Excessive bleeding secondary to the
intervals.
n Dysfunctional uterine bleeding: reduced capacity of the liver to
m Bleeding that occurs after organic, systemic, and
metabolize estrogens.
n Iatrogenic:
iatrogenic causes have been ruled out
l Anticoagulation medications.
m Two types anovulatory and ovulatory.
GOB
l Oral or injectable steroids used for
n Abnormal uterine bleeding: reproductive age
m A normal menstrual cycle occurs every 21–35
contraception.
l Hormone replacement therapy (HRT).
days (28 ± 7 days) with menstruation for 2–7
l Tranquilizers and psychotropic drugs:
days. (MCQ)
m The normal blood loss is less than 80 mL total
(MCQ)
„ Interfere with neurotransmitters
(average 35 cc), which represents 8 or fewer
soaked pads per day with usually no more than responsible for inhibition and release of
2 heavy days(MCQ) hypothalamic hormones, leading to
A DISORDERS OF MENSTRUATION
m Etiology
anovulation and AUB.
n Organic: Reproductive tract disease.
n Dysfunctional uterine bleeding (DUB):
m Ovulatory:
n Accidents of pregnancy
n After adolescence and before perimenopausal
l threatened, incomplete,
l missed abortion; ectopic pregnancy
years.
n Usually menorrhagia and/or intermenstrual
l trophoblastic disease
n Malignancy:
bleeding.
n Due to abnormal endometrial hemostasis
l Most commonly endometrial and cervical
cancers(MCQ) for any reason.
n The diagnosis of ovulatory DUB is made by
l Estrogen producing ovarian tumors like
the granulosa-theca cell tumors may endometrial biopsy (EMB). (MCQ)
l On the fourth day of flow, the EMB reveals
present with excessive uterine bleeding.
(MCQ) both proliferative and secretory endometrium.
n Infection:
(MCQ)
m Anovulatory:
l Endometritis presents with episodic
n Predominant cause of DUB.
intermenstrual spotting.
n There is continuous estradiol production
l Cervicitis and severe vaginal infections can
present with bleeding. without corpus luteum formation or
n Structural causes : fibroids, polyps,
progesterone production.
n This steady state of estrogen stimulation results
adenomyosis
n Foreign bodies:
in constant endometrial proliferation without
l Tampons retained in the vagina
progesterone-mediated maturation and
l intrauterine devices for contraception can
shedding.
n Fragments of overgrown endometrium sheds
cause bleeding.
sporadically
n Anovulation can manifest in: n Hysterectomy:
l Polycystic ovarian syndrome (PCOS). l Reserved for women with other indications
l Obesity. for hysterectomy, such as leiomyomas or
l Adolescents (perimenarchal). uterine prolapse. (MCQ)
l Perimenopause. l Hysterectomy should be used to treat
m Diagnostic tests persistent ovulatory DUB only after all
n Pap smear. medical therapy has failed. (MCQ)
n Pregnancy test: Sensitive hCG. n Postmenopausal bleeding
n Hemoglobin, serum Fe, serum ferritin. m defined as bleeding that occurs after 1 year of
n TSH ,FSH.Prolactin. amenorrhea.
n Coagulation panel: m All vaginal bleeding in postmenopausal women must
n von Willebrand factor for adolescents with be evaluated
menorrhagia. m Etiology
n EMB for women ??35 yrs of age or with n Vaginal/endometrial atrophy
history of unopposed estrogen. (MCQ) l most common cause(MCQ)
n Pelvic ultrasound. l Hypoestrogenism causes atrophy of the
n Sonohysterogram endometrium and vagina.
l pelvic US combined with intrauterine saline infusion l In the uterus, the collapsed, atrophic
to outline the uterine cavity endometrial surfaces contain little or no fluid
n Hysteroscopy to prevent intracavitary friction.
GOB
m Treatment l This results in microerosions of the surface

n Treat organic, systemic, iatrogenic causes epithelium which is prone to light bleeding
n Medical management: or spotting.
l First-line treatment n Postmenopausal HRT: (MCQ)
l Used for women l Many postmenopausal women who take
„ who desire future fertility HRT develop vaginal bleeding
„ those who will reach menopause within n Endometrial hyperplasia:
a short period of time. l Endogenous estrogen production from
A DISORDERS OF MENSTRUATION
l NSAIDs(MCQ) ovarian or adrenal tumors

„ tranexamic acid/mefenamic acid l exogenous estrogen therapy
l Iron supplements. l Obese women have high levels of
l Hormones: endogenous estrogen due to the conversion
„ OCP is the mainstay for anovulatory of androstenedione to estrone and the
bleeding. (MCQ) aromatization of androgens to estradiol, both
„ Combination pill or estrogens are used in of which occur in peripheral adipose tissue.
the acute management of DUB(MCQ) (MCQ)
„ Progestin intrauterine device (IUD) can n Adenomyosis
be used for DUB. (MCQ) l Confirmed by pathologic examination
n D&C : following hysterectomy.
l Indicated mainly for women with heavy l Symptomatic adenomyosis occurs after
bleeding leading to hemodynamic menopause only in the presence of
instability(MCQ) postmenopausal HRT.
l Once the acute episode of bleeding is n Post radiation therapy
controlled, the patient can be placed on l A late effect of radiation therapy.
medical management. (MCQ) l Radiation devascularizes tissue, causes
n Endometrial ablation: sloughing, and bleeding.
l Used as an alternative to hysterectomy l Vaginal vault necrosis causes uncontrolled
when other medical modalities fail or when bleeding and pain.
there are contraindications to their use. n Iatrogenic anticoagulant effect.
l It should not be used in women who wish n Neoplasia:
to maintain their reproductive capacity. l Endometrial cancer.
(MCQ) l Cervical cancer.
n Myomectomy.

„ Vaginal bleeding occurs because the TOPIC - 16 AMENORRHEA
cancer outgrows its blood supply.
„ The necrotic and denuded tissue bleeds
n Primary amenorrhea:
easily and causes a malodorous discharge. n Absence of menses by age 16 with normal growth
l Vulvar cancer.
and secondary sexual characteristics. (MCQ)
l Estrogen-secreting ovarian tumor.
n Absence of menses by age 14 in a girl with no
l Leiomyomata uteri. (MCQ)
secondary sexual characteristics. (MCQ)
„ The diagnosis of a uterine sarcoma should
n Usually genetic or anatomic causes.
be considered in postmenopausal women n Secondary amenorrhea:
with rapidly growing leiomyomata. n Absence of menses for ??6 months in a woman
l Polyps:
who previously had normal menses. (MCQ)
„ Endometrial growths of unknown etiology.
n Usually caused by underlying medical condition.
„ Growth of polyps can be stimulated by
n Breasts Absent, Uterus Present
estrogen therapy or tamoxifen. (MCQ) n Patients without breasts and with a uterus have
„ They may be benign, premalignant, or
no ovarian estrogen
malignant. n Gonadal dysgenesis (hypergonadotropic
n Infection: Uncommon cause of hypogonadism)
postmenopausal bleeding. l Most common cause of primary amenorrhea
n Trauma.
(MCQ)
m Studies l Most commonly due to chromosomal deletion or
GOB
n Vaginal probes and wet mount for infections.
disorder
n Pap smear for cervical dysplasia, neoplasia.
l Ovaries are replaced by a band of fibrous
n Endometrial biopsy for endometrial
tissue called gonadal streak
hyperplasia or cancer. l Due to the absence of ovarian follicles, there
n Transvaginal ultrasound to assess endometrial
is no synthesis of ovarian steroids
stripe. l Due to low levels of estrogen, breast development
l If endometrial stripe is < 4 mm,
does not occur.
endometrial sampling may be deffered unless l FSH and LH levels are markedly elevated
the patient has persistent bleeding. (MCQ) because the ↓levels of estrogen do not
AMENORRHEA
„ Rationale is thin lining due to atrophy.
provide negative feedback. (MCQ)
(MCQ) l Estrogen is not necessary for mullerian duct
n Diagnostic D&C.
development or wolffian duct regression, so
n Hysteroscopy.
the internal and external genitalia are
m Treatment of postmenopausal bleeding phenotypically female. (MCQ)
n It is dependent on the cause:
n Turner syndrome (45,X):
n Local estrogen cream is used to treat vaginal
l primary amenorrhea and absent breasts
atrophy and postradiation effect limited to the vaginal (MCQ)
region. l short stature (most prevalent)
l webbing of the neck (MCQ)
l short fourth metacarpal
l cubitus valgus
l cardiac abnormality, renal abnormalities
l hypothyroidism.
l At puberty, the patient is given estrogen and
progesterone to allow for secondary sexual
characteristics.
l Patients also receive growth hormone.
n 17α-hydroxylase deficiency
l Can occur in 46,XX (MCQ)
l Patients have ↓cortisol and adrenal/gonadal
sex steroid secretion. (MCQ)
l They have hypertension, hypernatremia, and
hypokalemia due to excess mineralocorticoid.
l These patients need replacement with sex n müllerian ducts regress due to the presence of
steroids and cortisol antimüllerian hormone, (MCQ)
l Despite low levels of sex steroids, pregnancies n wolffian ducts do not develop because they are not
have been achieved with in vitro fertilization/ stimulated by testosterone. (MCQ)
embryo transfer n have no male or female internal genitalia (MCQ)
l Those with karyotype 46,XY and 17α- n have normal female external genitalia (MCQ)
hydroxylase deficiency will have no breasts or n have either a short or absent vagina (MCQ)
female internal genitalia. (MCQ) n have normal breasts and scant or absent axillary
n Hypothalamic-pituitary disorders: and pubic hair.
l Low levels of estrogen are due to low n Intra-abdominal testes or those in the inguinal
gonadotropin release. canal have an ‘!?risk of developing a malignancy
l Lesions: (gonadoblastoma or dysgerminoma), usually
„ Anatomic lesions of the hypothalamus or after age 20. (MCQ)
pituitary can result in low gonadotropin n Treatment
production. „ The gonads should be removed after
„ Congenital: puberty to allow for breast development
® Stenosis of aqueduct, absence of sellar and adequate bone growth.
floor. „ Estrogen is then given.
„ Acquired: „ These patients are raised as females. (MCQ)
® Prolactinoma, chromophobe adenoma m Mullerian agenesis (Mayer-Rokitansky-Kuster-
GOB
® craniopharyngiomas. Hauser syndrome):

n Inadequate GnRH release (hypogonadotropic n patients have no uterus and have a shortened vagina
hypogonadism): n normally ovulating ovaries (MCQ)
l Will have normal levels of gonadotropins if n normal breast development (MCQ)
stimulated with GnRH. n normal axillary and pubic hair. (MCQ)
l These patients should receive estrogen- n have associated renal and skeletal abnormalities
progesterone supplementation to induce breast (MCQ)
development and allow for epiphyseal n should be screened with an ultrasound or MRI.
closure. n They have normal endocrine function
AMENORRHEA
l Human menopausal gonadotropins or n do not need supplemental hormones. (MCQ)

pulsatile GnRH is administered for fertility. n Treatment :
l Clomiphene does not work due to low levels l undergo surgical reconstruction of the vagina
of endogenous estrogen. (MCQ) (MCQ)
n Kallmann syndrome: l use vaginal dilators to make the vagina
l Anosmia associated with low gonadotropins. functional
(MCQ)
l Isolated gonadotropin deficiency (pituitary disease):
l Associated with: (MCQ)
„ Prepubertal hypothyroidism.
„ Kernicterus.
„ Mumps encephalitis.
„ Thalassemia major: Iron deposits in the
pituitary.
„ Retinitis pigmentosa.
n Breasts Present, Uterus Absent
m Androgen insensitivity (testicular feminization):
(MCQ)
n results from the absence of androgen receptors or
lack of responsiveness to androgen stimulus.
n XY karyotype (MCQ)
n normally functioning male gonads that produce
normal male levels of testosterone and
dihydrotestosterone. (MCQ)
Comparison of Androgen Insensitivity and Mullerian Agenesis
Androgen Resistance Mullerian Agenesis
Karyotype XY XX
Breast Present Present
Uterus Absent Absent
Public/axillary hair Absent Normal
Testosterone Normal Male levels Female levels
Further evaluation Need gonadectomy Renal/skeletal abnormalities
m Breasts Absent, Uterus Absent

n 17α-hydroxylase deficiency:
l These patients are XY, have testes (MCQ)
l lack the enzyme needed to synthesize sex
steroids.
l They have female external genitalia (MCQ)
GOB
l Antimullerian hormone causes the regression
of the mullerian ducts. (MCQ)
l Low testosterone levels do not allow the
development of internal male genitalia. (MCQ)
l There is insufficient estrogen to allow breast
development.
l Those with karyotype 46, XX, will have no
breasts, but a uterus will be present. (MCQ)
m Breasts Present, Uterus Present
AMENORRHEA
n This is the second largest category of individuals
with primary amenorrhea (chromosomal/
gonadal dysgenesis #1).
n Imperforate hymen
l transverse vaginal septum.
l present with cyclic pelvic pain due to
menstrual blood not having an egress. (MCQ)
l A hematocolpos (accumulation of menstrual
blood in the vagina from an imperforate
hymen) can be palpated as a perirectal mass on
physical exam (MCQ)
l The treatment is to excise obstruction

GOB
n Secondary Amenorrhea m Pituitary (hypoestrogenic amenorrhea)

m Causes n Neoplasms:
n Pregnancy. l Chromophobe adenomas are the most common
AMENORRHEA
n Hypothalamus (35%). non- prolactin-secreting pituitary tumors.

n Pituitary (19%). (MCQ)
n Ovary (40%). l Treatment may involve suppression with
n Uterus (5%). medication (prolactinomas) or excision.
n Other (1%): Cervical, endocrine. n Lesions:
m Hypothalamic l The pituitary gland can be damaged from
n Low levels of gonadotropins, estrogen anoxia, thrombosis, or hemorrhage
n absent withdrawal bleed with progesterone. l May be associated with ↓ secretion of other
n Lesions: (MCQ) pituitary hormones like ACTH, TSH, LH, and
l Craniopharyngiomas FSH.
l granulomatous disease l The patients may have hypothyroidism and
l encephalitis sequelae. adrenal insufficiency.
n Drugs: n Sheehan syndrome:
l OCPs act at the level of the hypothalamus l Pituitar y cell destruction occurs due to
and pituitary. hypotensive episode during pregnancy
l Postpill amenorrhea can occur up to 6 months l usually due to catastrophic hemorrhage
after stopping the pill. (MCQ)
n Stress and exercise. l Treatment includes replacement of pituitary
n Weight loss/anorexia nervosa: hormones.
l Those who are malnourished have a ↓ m Ovarian (hypergonadotropic hypogonadism)
reproductive ability. n Premature ovarian failure (POF): (MCQ)
l Weight gain will allow menses to resume. l Depletion of oocytes resulting in amenorrhea
n Functional hypothalamic amenorrhea: before the age of 40. (MCQ)
l ↓ GnRH secretion, without other causes.
l May be due to radiation or systemic n Hyper/hypothyroidism.
chemotherapy. n Diabetes mellitus.
l Autoimmune conditions can be present. n Hyperandrogenism (neoplasm, exogenous
l Treatment androgens).
„ hormone replacement (MCQ)
„ Need strategies for bone protection.
„ Surgical: Bilateral salpingo-oophorectomy.
(MCQ)
n Polycystic ovaries:
l Hyperandrogenism.
l Diagnosis: Established if two out of three
of the following are present: (MCQ)
„ Polycystic ovaries on ultrasound.
„ Signs of androgen excess (hirsutism, acne).
„ Oligomenorrhea/amenorrhea.
l Signs:
„ Hirsutism, Acne. Oligomenorrhea/
amenorrhea.
„ Obesity, Acanthosis nigricans
„ Premature pubarche and/or precocious
GOB
puberty.
l Treatment
„ hirsutism – (MCQ)
® spironolactone, eflornithine
„ infertility (MCQ)
® ovulation induction with clomiphene
® Start cyclic or continuous OCPs/hormone
therapy to prevent endometrial hyperplasia/
endometrial cancer and regulate menses.
AMENORRHEA
m Uterine
n Asherman syndrome: (MCQ)
l Intrauterine adhesions can obliterate the
endometrial cavity and cause amenorrhea.
l Most frequent cause is endometrial curettage
associated with pregnancy. (MCQ)
l Adhesions may form after myomectomy,
metroplasty, or cesarean delivery. (MCQ)
l Confirm the diagnosis with hysterosalpingogram
(HSG) or hysteroscopy.
l Treat via hysteroscopic resection of adhesions.
l Estrogens administered to stimulate regrowth
of endometrium.
n Endometrial ablation:
l This procedure may have been performed
for menorrhagia.
n Infection:
l Endometritis or tuberculosis.
m Cervical
n Stenosis due to loop electrosurgical excision
procedure (LEEP) or cold-knife cone
n Treat with cervical dilation.
m Endocrine
n Can cause secondary amenorrhea.

GOB
AMENORRHEA

TOPIC - 17 PREECLAMPSIA edema that stretches Glisson’s capsule).
(MCQ)
n Hypertensive disorders of pregnancy include „ ↑ aspartate transaminase (AST), alanine
m gestational hypertension (HTN) transaminase (ALT).

m mild and severe preeclampsia l Pulmonary:
m HELLP (hemolysis, elevated liver enzymes, low „ Edema, cyanosis.
platelets), l Hematologic:
m eclampsia. „ Thrombocytopenia (< 100,000),
n There are four categories of HTN in pregnancy: „ Microangiopathic coagulopathy, hemolysis
m Preexisting or chronic HTN during pregnancy: (‘! LDH).

n Preexisting HTN begins prior to pregnancy l Fetal:
or before the 20th week of gestation.(MCQ) „ IUGR or oligohydramnios. .(MCQ)
n Defined as a sustained systolic BP ≥140 mm m Super imposed preeclampsia:
Hg and/or diastolic BP ≥ 90 mm Hg n Preeclampsia (mild or severe) in patients with
documented on more than one occasion prior chronic HTN in pregnancy.

to the 20th week of gestation.(MCQ) n Twenty-five percent of patients with chronic
n HTN that existed before pregnancy, or HTN HTN in pregnancy de-velop preeclampsia.
that persists > 12 weeks after delivery. . n Patients can have seemingly benign HTN (no
(MCQ) proteinuria or evidence of end-organ damage)

n Usually not associated with significant in early pregnancy and then develop pre-
GOB
proteinuria or end-organ damage if well eclampsia.
controlled. n Increasing proteinuria in the setting of HTN
m Gestational hypertension (most benign): after the 20th week of gestation is

n Also called transient HTN and pregnancy- preeclampsia, regardless of the timing of the
induced HTN. onset of the HTN. .(MCQ)
n A sustained or transient systolic blood pressure n Often occurs earlier in pregnancy
(BP) ≥ 140 mm Hgand / or diastolic BP ≥ n has more severe fetal growth restriction than
90 mm Hg occurs after the 20th week of preeclampsia without chronic HTN

gestation. .(MCQ) n also associated with ↑ risk of placental
PREECLAMPSIA
n No proteinuria or end-organ damage. abruption. (MCQ)
m Preeclampsia: Pathophysiology
n
n Defined as hypertension with proteinuria m Vasospasm in various organs (brain, kidneys, lungs,
after the 20th week of gestation. (MCQ) uterus) causes most of the signs and symptoms
n Mild preeclampsia is defined by:. (MCQ) of preeclampsia
l A systolic BP ≥ 140 mm Hg or a diastolic m Risk Factors for Preeclampsia
BP ≥ 90 mm Hg twice 6 hr apart at bed n Pregnancy-associated factors.(MCQ)
rest. l Chromosomal abnormalities
l Proteinuria: 1+ on dipstick or ≥ 300 mg/24 l Hydatidiform mole
hr. l Hydrops fetalis
l Usually no other subjective symptoms. l Multifetal pregnancy .(MCQ)
n Severe preeclampsia is defined by: .(MCQ) l Oocyte donation or donor insemination
l A systolic BP ≥ 160 mm Hg or a diastolic Structural congenital anomalies

BP ≥ 110 mm Hg twice 6 hr apart at bed rest l Urinary tract infection
n Maternal-specific factors.(MCQ)
with or without the following end organ findings.
l Neurologic: l Age greater than 35 years
„ Frontal headaches, scotomata l Age less than 20 years
„ eclampsia (seizure due to preeclampsia). l Black race
l Renal: l Family history of preeclampsia
„ Proteinuria (≥ 5.0 g/24 hr), l Nulliparity
„ Oliguria (< 500 cc/24 hr). .(MCQ) l Preeclampsia in a previous pregnancy
l Gastrointestinal (GI): n Specific medical conditions:
„ Epigastric or right upper quadrant l Gestational diabetes, type I diabetes, obesity,
(RUQ) pain (hepatocellular ischemia and

l chronic hypertension, renal disease,
thrombophilias
l Stress
l Paternal-specific factors
l First-time father
l Previously fathered a preeclamptic pregnancy
in another woman
l Angiotensinogen gene T235 (homozygous
> heterozygous).
n Complications.(MCQ)
m Abruption.
m Eclampsia with intracranial hemorrhage, blindness.
m Coagulopathy.
m Renal failure.
m Hepatic subcapsular hematoma.
m Uteroplacental insufficiency.
n Treatment
m Indications for Delivery in Preeclampsia.(MCQ)
n Fetal indications
l Severe intrauterine growth restriction
GOB
l Nonreassuring fetal surveillance

l Oligohydramnios
n Maternal indications
l Gestational age of 38 weeks or greater
l Platelet count below 100 X 10 per mm3
3
l Progressive deterioration of hepatic function

l Progressive deterioration of renal function
l Suspected placental abruption
l Persistent severe headache or visual changes
PREECLAMPSIA
l Persistent severe epigastric pain, nausea,or

vomiting
l Eclampsia
m A baseline sonograph should be considered at
25 to 28 weeks of gestation to evaluate fetal
growth in pregnant women at high risk for
preeclampsia. .(MCQ)
n Management algorithm.

GOB
PREECLAMPSIA

m The only cure for preeclampsia and its variants is l 25% of seizures are ( postdelivery (may be
delivery of the fetus. encountered up to 10 days postpartum).
m Preexisting HTN/transient HTN/chronic m Treatment
HTN in pregnancy: n Airway, breathing, and circulation (ABCs).
n Antihypertensive medications vs. close n Rule out other causes:
observation. l Head trauma is a possible confounder
n Antihypertensive medications have not been l others include cerebral tumors, cerebral venous
found to be helpful, and in some cases thrombosis, drug overdoses, epilepsy, and
adversely affect fetal growth. cerebrovascular accidents.
n Magnesium sulfate (MgSO4) n Control seizures with magnesium sulfate (the
l started for seizure prophylaxis when decision only anticonvulsant used).
is made to deliver fetus. .(MCQ) l Magnesium toxicity (7–10 mEq/L)
l It is not a treatment for HTN. .(MCQ) (MCQ)
m Mild preeclampsia: ® is associated with (MCQ)
n Preterm: » loss of patellar reflexes
l Close monitoring for worsening disease. » respiratory depression
l Fetal testing (non-stress tests [NSTs] and » cardiac arrest.
biophysical profiles [BPPs]) to ensure fetal ® Treat with calcium gluconate 10%
well-being. solution 1 g IV.
l Bed rest is not necessary, although “! physical „ Magnesium sulfate prevents seizures in
GOB
activity is recommended. .(MCQ) preeclam psia; does not treat HTN.

n Term: delivery. (MCQ)
l Vaginal delivery is usually attempted „ When patients are put on MgSO4 for
l cesarean delivery for other obstetrical reasons. seizure prophylaxis, they must be closely
l Start MgSO4 for seizure prophylaxis. monitored for magnesium toxicity by
m Severe preeclampsia: obtaining magnesium levels and
n Very preterm (< 28 weeks): .(MCQ) watching for hyporeflexia.
l Close monitoring in hospital in select cases l Calcium gluconate is antidote in the case
only. of MgSO4 toxicity(MCQ)
PREECLAMPSIA
n Preterm or term: Delivery. n Delivery is the only definitive treatment.

l Delivery may not be in the best interest of the (MCQ)
premature baby, but it is indicated to n If diagnosis of eclampsia made, no
prevent worsening maternal disease. expectant management regardless of
l Vaginal delivery is usually attempted gestational age. (MCQ)
l cesarean delivery for other obstetrical n Vaginal delivery is recommended.
reasons. n Women often go into spontaneous labor after
l Start MgSO4 for seizure prophylaxis. onset of seizures, and/or have a shorter duration of
m HELLP Syndrome labor.
n HELLP syndrome is a manifestation of severe n Control BP with hydralazine or labetalol.
preeclampsia with: n Antihypertensive Agents Used in Pregnancy
l Hemolysis, „ Short-term control
l Elevated Liver enzymes » Hydralazine: IV or PO, (MCQ)
l Low Platelets. ö direct vasodilator.
n It is associated with high morbidity, and ö Side effects: systemic lupus
immediate delivery is indicated. It may occur erythematosus (SLE)-like
with or without HTN. syndrome, headache, palpitations.
m Eclampsia » Labetalol: IV or PO(MCQ)
n Defined as seizure or coma without another ö nonselective β1 and α1 blocker.
cause in a patient with preeclampsia. ö Side effects: headache and
n Eclampsia → hemorrhagic stroke → death. tremor.
n Eclampsia: „ Long-term control
l 25% of seizures are ( before labor. ® Methyldopa: PO(MCQ)
l 50% of seizures are ( during labor. (MCQ) » false neurotransmitter.

» Side effects: postural hypotension, TOPIC - 18 DOWN SYNDROME
drowsiness, fluid retention.
® Nifedipine: PO, (MCQ)
n First-Trimester Screen (FTS)
» calcium channel blocker
m performed between weeks 11 and 13. (MCQ)
» Side effects: edema, dizziness.
m The FTS combines a maternal blood screening test with
„ Diuretics are not used in pregnancy because a fetal US evaluation
they ↓ plasma volume and this may be m It identifies risk for (MCQ)
detrimental to fetal growth. (MCQ) n Down syndrome (trisomy 21).
„ Salt restriction also ↓ plasma volume n trisomy 13,
and is not recommended. (MCQ) n Turner syndrome
„ ACE inhibitors are contraindicated n Edwards syndrome (trisomy 18),
because they are teratogenic(MCQ) m It cannot detect neural tube defects (NTDs).
(MCQ)
m FTS
n Maternal serum
l Free or total βετα-hCG, PAPP-A.
n USG
l at 11–13 weeks gestation(MCQ)
l Nuchal translucency (NT)—measurement of
fluid under the baby’s skin at the level of the neck
GOB
(MCQ)
n In the case of Down syndrome,
l βετα-hCG will be ↑(MCQ)
l PAPP-A will be ↓ (MCQ)
n The FTS is considered the most accurate
noninvasive screening method available, with
a sensitivity of 85% for Down syndrome.
m Quad Screen
DOWN SYNDROME
n a screening test of maternal serum
n evaluates the risk a patient has for delivering a
baby with Down syndrome (trisomy 21),
Edwards syndrome (trisomy 18), or NTDs.
n The result does not indicate that the fetus does
or does not have the indicated condition, only the
risk
n Ideally performed at 16–18 weeks gestation
(range is 15–21 weeks). (MCQ)
n Sensitivity: 81%.
n Evaluates four maternal serum analytes:
l Maternal serum α feto protein
l Unconjugated estriol
l Human chorionic gonadotropin
l Inhibin A

Quad Screen Summary
Down (Trisomy 21) Edwards (Trisomy 18) NTD
uE3 ↓ ↓ Normal
AFP ↓ ↓ ↑
β-hCG ↑ ↓ Normal
Inhibin A ↑ ↓ Normal
AFP, α-fetoprotein; β-hCG, β-human chorionic gonadotropin; NTD neural tube defect; uE3, unconjugated
estriol
n Maternal Serum α-Fetoprotein (MSAFP) m High levels are associated with: Trisomy 21.
m MSAFP is first produced in the yolk sac and then (MCQ)
by the fetal gastrointestinal tract and liver. m Low levels are associated with: Trisomy 18,
m Normally, it passes by diffusion through the anencephaly. (MCQ)
chorion and amnion. n Inhibin A
m It begins to rise at 13 weeks and peaks at 32 m This hormone is secreted the placenta and
GOB
weeks. (MCQ) granulosa cells in the female.

m In general, MSAFP levels > 2.0–2.5 multiples m High levels are associated with: Trisomy 21.
of the mean (MOM) (MCQ) (MCQ)
n warrant further investigation m Low levels are associated with: Trisomy 18.
n they are suspicious of NTDs. (MCQ)
m most accurate between 16 and 18 weeks. (MCQ) n Amniocentesis
m High levels are associated with: (MCQ) m most frequently employed technique used to
n Underestimation of gestational age. obtain fetal cells.
DOWN SYNDROME
n NTDs. m Usually done at 15–20 weeks. (MCQ)

n Abdominal wall defects (gastroschisis and m Indications
omphalocele). n Kar yotype: Fetal cells obtained via
n Fetal death. amniocentesis are cultured and an evaluation of
n Placental abnormalities (eg, abruption). the chromosomes is performed in the following
n Multiple gestations. circumstances:
n Others: Low maternal weight, fetal skin n Fetal anomaly suspected on US.
defects, cystic hygroma, sacrococcygeal n Abnormal serum quad screen.
teratoma, oligohydramnios. n Family history of congenital abnormalities.
m Low levels are associated with: (MCQ) n Indicated for patients ≥35 years of age
n Overestimation of gestational age. because they have a higher risk of aneuploidy.
n Chromosomal trisomies: Down syndrome (MCQ)
(trisomy 21), Edwards’ syndrome (trisomy n Fetal lung maturity: Usually done near term
18). in order to deliver the baby.
n Fetal death. n Others: Rule out infection, check bilirubin.
n Molar pregnancy. m Risks:
n High maternal weight. n Pain/cramping.
n Unconjugated Estriol (uE3) n Vaginal spotting (resolves spontaneously).
m Low levels are associated with: (MCQ) n Amniotic fluid leakage in 1–2% of cases.
n Trisomy 21 (Down syndrome). n Symptomatic amnionitis in < 1 in 1000
n Trisomy 18 (Edwards syndrome). patients.
n Possibly low in trisomy 13 (Patau syndrome). n Rate of fetal loss is 0.5% (1 in 200) and is less
n Human Chorionic Gonadotropin (hCG) (MCQ) in experienced hands. (MCQ)
n Chorionic Villus Sampling (CVS)

m a small sample of chorionic villi is taken TOPIC - 19 OVULATION
transcervically or transabdominally and analyzed
m Typically done between 9 and 12 weeks
n A 28-day menstrual cycle.
gestation. (MCQ) m Many follicles are stimulated by FSH, but the
m Information on fetal karyotype.
follicle that secretes more estrogen than
m Biochemical assays or DNA tests can be done
androgen will be released.
earlier than amniocentesis. m This dominant follicle releases the most
m Complications—0.5–1%:(MCQ)
estradiol so that its positive feedback causes an
n Preterm delivery.
LH surge.(MCQ)
n PROM.
m Average menses = 4 days. .(MCQ)
n Fetal injury, especially limb abnormalities if
m More than 7 days is abnormal. .(MCQ)
performed before 9 m Blood loss in menstruation averages 30–50 mL
n Weeks gestation.
and should not form
n Differences between CVS and Amniocentesis m clots; .(MCQ)
(MCQ) m 80 mL is an abnormally high amount of blood
m CVS:
loss. .(MCQ)
n Transvaginal or transabdominal aspiration
m Days 1–14: Follicular Phase
of precursor cells in the intrauterine cavity. n The follicular phase begins on the first day of
n Evaluates chromosomal abnormalities but does
menses.
not evaluate NTDs. (MCQ) n All hormone levels are low.
GOB
n Done at 9–12 weeks. (MCQ)
n Without any negative feedback, GnRH from
n Higher risks (fetal loss has 1% risk, limb
the hypothalamus causes FSH release from
defects if done < 9 weeks) the pituitary.
n diagnosis accuracy is comparable to
n FSH stimulates maturation of granulosa cells
amniocentesis. in the ovary. .(MCQ)
m Amniocentesis:
n The granulosa cells secrete estradiol in
n Transabdominal aspiration of amniotic fluid
response. .(MCQ)
using ultrasound-guided needle. n Estradiol inhibits LH and FSH due to negative
n Evaluates chromosomal abnormalities.
feedback.
n Done at 15–20 weeks. (MCQ)
n In the meantime, the estradiol secretion also
OVULATION
n Indicated if > 35-year-old mother at time of
causes the endometrium to proliferate.
delivery. .(MCQ)
n Risks of fetal loss (0.5%).(MCQ)
n LH
n Cordocentesis l acts on the theca cells to ↑secretion of
m percutaneous umbilical blood sampling (PUBS),
androgens (which are converted to estradiol)
m a spinal needle is advanced transabdominally
.(MCQ)
under US guidance into a cord vessel to sample l prepare the cells for progesterone secretion
fetal blood l cause further granulosa maturation.
m Typically performed after 17 weeks. (MCQ)
n Day 14: Ovulation
m Allows for rapid diagnosis because of the high
m A critical level of estradiol triggers an LH surge.
number of nucleated cells (WBCs) collected m The LH surge causes the oocyte to be released
which require no culturing. (MCQ) from the follicle.
m Indications(MCQ)
m Ovulation takes place 24–36 hr after LH surge
n Fetal karyotyping because of fetal anomalies.
and 12 hr after LH peak.(MCQ)
n To determine the fetal hematocrit in
m The ruptured follicle then becomes the corpus
isoimmunization or severe fetal anemia. luteum, which secretes progesterone. .(MCQ)
n To assay fetal platelet counts, acid-base status, antibody
n Days 14–28: Luteal Phase
levels, blood chemistries, etc. m The corpus luteum secretes progesterone for
only about 11 days in the absence of hCG.
m Progesterone
n causes the endometrium to mature in
preparation for possible implantation.

l It becomes highly vascularized and
↑glandular secretions
n causes inhibition of FSH and LH release..
(MCQ)
m If fertilization does not occur, the corpus luteum
involutes, progesterone and estradiol levels
fall, with subsequent endometrial sloughing
(menses). .(MCQ)
m The hypothalamic-pituitary axis is released
from inhibition, and the cycle begins again.
m The follicular phase is highly variable.
m The luteal phase is usually about 11 days due to
the length of time the corpus luteum (is able
to secrete progesterone. .(MCQ)
m The corpus luteum is maintained after fertilization

by hCG, released by the embryo.
Ovarian Hormone Effect on Uterus

GOB
Ovarian phase Dominant Hormone Uterine Phase

Before ovulation Follicular Estrogen Proliferative
After Ovulation Luteal Progesterone Secretory
OVULATION

TOPIC - 20 n Jugular venous distention
HEART DISEASE IN PREGNANCY n Cardiomegaly or a ventricular heave
m Management of patients with known cardiac
n Cardiovascular disorders in Pregnancy disease

m Hemodynamic changes during pregnancy. n Sometimes, surgical correction during
n Blood volume. pregnancy becomes necessary; when possible,

l By 32 weeks’ gestation, total blood volume procedures should be performed during the
expands by 40%, with an increase in the total early second trimester to avoid the period
plasma volume up to 50%. (MCQ) of fetal organogenesis, but before more
l Because the red cell mass only increases significant hemodynamic changes of
by 20%, dilutional anemia results. (MCQ) pregnancy occur. (MCQ)
n Cardiac output. m Medical management
l Increased stroke volume causes cardiac output n Prophylaxis for endocarditis.
to increase 30–50% by 20–24 weeks’ l majority of obstetric and gynecologic
gestational age. (MCQ) procedures do not require prophylactic

l A marked decrease in cardiac output can antibiotic treatment for subacute bacterial
occur, however, when a pregnant woman is endocarditis because of the low likelihood
in the supine position because of caval of bacteremia (1–5% for a vaginal delivery).
compression. (MCQ)
n Systemic vascular resistance l For patients at high risk of developing
GOB
l decreases during pregnancy (MCQ) endocarditis prophylaxis is optional, both for
l It reaches its nadir during the second vaginal hysterectomies and for vaginal deliveries
trimester and then slowly returns to (MCQ)
prepregnancy levels by term. (MCQ) l Antibiotic prophylaxis consists of
n Redistribution of blood flow. „ 2 g of ampicillin IV or intramuscularly
l During pregnancy, blood flow to the plus 1.5 mg/kg of gentamicin IV or

kidneys, skin, and uterus increases. intramuscularly before the procedure,
l Uterine blood flow reaches as high as 500 followed by one dose of ampicillin 8
hours postpartum.
HEART DISEASE IN PREGNANCY

mL/minute at term. (MCQ)
m Hemodynamic changes during labor. „ In the event of penicillin allergy, 1 g of
n Venous pressure increases during labor because vancomycin IV can be substituted.

uterine contractions cause an increase of n Patients with rheumatic heart disease require
venous return from the uterine veins. either 1.2 million U of penicillin G every
n In turn, this results in higher cardiac output, month or daily oral penicillin or
increased right ventricular pressure, and erythromycin. (MCQ)
increased mean arterial pressure. n If anticoagulation is necessary, heparin
m Postpartum hemodynamic changes. sodium remains the drug of choice due to the
n In the postpartum period, caval compression potential teratogenetic effects of warfarin
decreases, which results in an increase of the sodium (Coumadin). (MCQ)
circulating blood volume. (MCQ) Valvular heart disease
n
n Higher cardiac output ensues, and a reflex m Mitral valve prolapse
bradycardia may occur. (MCQ) n most common congenital heart defect in
n Because of increased blood loss, these young women,

hemodynamic changes become less pronounced in n it rarely affects maternal or fetal outcome.
patients undergoing cesarean section. (MCQ)

n Cardiac diseases in pregnancy m Mitral stenosis
m Warning signs. n most common rheumatic heart disease in
n Worsening dyspnea on exertion, or dyspnea pregnancy

at rest n increased plasma volume of pregnancy
n Chest pain with exercise or activity imposes great stress on the cardiovascular
n Syncope preceded by palpitations or exertion system of a woman with mitral stenosis because
n Loud systolic murmurs or diastolic murmurs of the fixed cardiac output(MCQ)
n Cyanosis or clubbing

n Up to 20% of pregnant patients with mitral n In severe cases, the onset of symptoms usually
stenosis become symptomatic by 20 weeks’ occurs later than in cases of mitral stenosis.
gestation, when cardiac output is at its n Atrial enlargement and fibrillation, as well
maximum. (MCQ) as ventricular enlargement and dysfunction,
n Management. may develop.
l During pregnancy, affected patients should n Administration of inotropic agents may be
limit their physical activity. necessary if left ventricular dilatation and
l If volume overload is present, they should dysfunction are present.
receive careful diuresis. n During labor, patients with advanced disease
l Arrhythmias, especially atrial fibrillation, may require central monitoring.
should be controlled to avoid decreased n The pain of labor may lead to an increase in
diastolic filling time BP and afterload, which cause pulmonary
l If medical management fails, the patient may vascular congestion. Therefore, epidural
require a valve replacement or anesthesia is recommended. (MCQ)
commissurotomy. (MCQ) m Aortic stenosis
n Considerations during labor. n During pregnancy, mortality for patients may
l Cesarean section should be performed for be as high as 17%.
obstetric indications only(MCQ) n Because this disorder is characterized by a fixed
l If significant heart disease exists, especially afterload, adequate end-diastolic volume,
with pulmonary hypertension, invasive cardiac and therefore adequate filling pressure, is
GOB
monitoring with a Swan-Ganz catheter necessary to maintain cardiac output.

should be considered during labor. n Consequently, great care must be taken to
l The patient should undergo labor in the left prevent hypotension and tachycardia caused
lateral position and receive supplemental by blood loss, regional anesthesia, (MCQ)
oxygen. n Patients should be hydrated adequately
l Tachycardia should be prevented because it n placed in the left lateral position to maximize
may lead to decreased cardiac output caused venous return. (MCQ)
by a decreased diastolic filling time. n Affected patients should receive antibiotic
l Verapamil hydrochloride or digoxin may prophylaxis. (MCQ)
be used to slow the ventricular contraction m Aortic regurgitation

rate if an atrial arrhythmia is present. (MCQ) n Because of decreased systemic vascular
l Anesthetics may be useful in slowing sinus resistance during pregnancy, regurgitation often
tachycardia. decreases, and the condition is usually well
l If an epidural anesthetic is used, care must tolerated.
be taken to prevent hypotension. n If a patient shows evidence of left heart
l If necessary, alpha-adrenergic agonists may failure and requires valve replacement,
be used to maintain systemic vascular pregnancy should be delayed until after the
resistance. repair has been completed. (MCQ)
l The second stage of labor may be shortened n If a patient is not yet symptomatic, she should
by performing a forceps deliver y or be encouraged to complete her childbearing early,
vacuum extraction delivery. (MCQ) before the onset of symptoms.
m Mitral regurgitation n During labor, afterload reduction by epidural
n may occur in patients with a history of anesthesia is recommended.
l rheumatic fever n Bradycardia is poorly tolerated because the
l endocarditis increased time of diastole allows more time for
l idiopathic hypertrophic subaortic stenosis regurgitation. (MCQ)
l most commonly mitral valve prolapse. n A heart rate of 80–100 beats/minute should
n Typically a decrescendo murmur is detected. be maintained.
l This murmur, however, is often diminished n Congenital lesions
during pregnancy(MCQ) m Left-to-right shunts
n In most cases, mitral regurgitation is tolerated n If the defect has been corrected, the outcome
well during pregnancy. (MCQ) of pregnancy is usually good. (MCQ)

n If the defect has not been corrected, pregnancy l During pregnancy, the fetus should be
causes only a slight increase in the degree of monitored for intrauterine growth
shunting. retardation.
n If pulmonary hypertension has caused reversal n Coarctation of the aorta.
of the shunt, however, the outcome of pregnancy l Surgical correction during pregnancy is
is dismal, with a high rate of maternal recommended only if dissection occurs. (MCQ)
mortality. l Coarctation of the aorta is characterized by a
n Atrial septal defects fixed cardiac output
l most common congenital heart lesions in l Therefore, the patient’s heart cannot meet
adults. the increased cardiac demands of
l The defects are usually very well tolerated pregnancy by increasing its beating rate, and
unless they are associated with pulmonary extreme care must be taken to prevent
hypertension. hypotension.
l Complications l Two percent of infants of mothers with
„ Include atrial arrhythmias, pulmonary coarctation of the aorta may themselves
hypertension ,heart failure exhibit cardiac lesions. (MCQ)
„ usually do not arise until the fifth decade n Eisenmenger’s syndrome
of life and are therefore uncommon in l carries a maternal mortality rate of 50%
pregnancy. (MCQ) during pregnancy and a fetal mortality rate
n Ventricular septal defects (VSDs) of more than 50% if cyanosis is present.
GOB
l Because of the increased systemic vascular (MCQ)
resistance during labor, epidural anesthesia l 30% of fetuses exhibit intrauterine growth
is recommended. (MCQ) retardation
l If the patient has pulmonary hypertension l termination of the pregnancy is advised
or right-to-left shunt , however, this n Marfan syndrome
decrease in systemic vascular resistance l If a patient’s cardiovascular involvement is
is poorly tolerated because of decreased minor and her aortic root diameter is
perfusion of the lungs. smaller than 40 mm, the risks related to
l Fetal echocardiography is recommended. pregnancy are similar to those of the general

(MCQ) population.
„ The incidence of VSD in the offspring l If cardiovascular involvement is more
of affected parents is 4%; extensive or the aortic root is larger than
n Patent ductus arteriosus 40 mm, the risks of complications during
l usually tolerated well during pregnancy pregnancy and aortic dissection are
unless pulmonary hypertension has significantly increased. (MCQ)
developed. l Hypertension should be avoided and
l Because of increased volume, left heart managed with beta-blockers.
failure and pulmonary hypertension l Beta-blocker therapy should be considered
usually worsen during pregnancy. for patients with Marfan syndrome from the
Therefore, pregnancy is not recommended second trimester until delivery, particularly if the
for patients with large patent ductus arteriosus aortic root is dilated. (MCQ)
and associated complications. (MCQ) l Regional anesthesia during labor is
m Right-to-left shunts considered safe.
n Tetralogy of Fallot n Idiopathic hypertrophic subaortic stenosis
l If the defect goes uncorrected, the affected l Patients’ conditions improve when left
patient rarely lives beyond childhood ventricular end-diastolic volume is
l If pregnancy does occur, however, the maximized.
incidence of heart failure is 40%. shunt l Pregnant patients often fare quite well initially
can also worsen during the immediate because of an increase in circulating blood
postpartum period because of the decreases volume
in systemic vascular resistance and blood l Later in pregnancy, however, decreased
volume. (MCQ) systemic vascular resistance and decreased

venous return caused by caval compression TOPIC - 21 ABRUPTIO PLACENTA
may worsen the obstruction.
l This may cause left ventricular failure as
Abruptio placenta
well as supraventricular arrhythmias from left n Premature separation of the placenta is defined as
atrial distention. separation from the site of uterine implantation
l management points during labor:
before delivery of the
l Inotropic agents may exacerbate obstruction.
n Two principal forms
l The patient should undergo labor in the left
m concealed form (20%),
lateral decubitus position. (MCQ) n hemorrhage is confined within the uterine cavity,
l Medications that decrease systemic
n detachment of the placenta may be
vascular resistance should be avoided or complete(MCQ)
limited n complications often are severe
l Cardiac rhythm should be monitored and
n associated with DIC
tachycardia treated promptly. m external form (80%) (MCQ)
l The second stage of labor should be
n the blood drains through the cervix,
curtailed by operative delivery. n lacental detachment is more likely to be
n Peripartum cardiomyopathy incomplete(MCQ)
l a dilated cardiomyopathy of unknown
n complications are fewer and less severe
cause n Occasionally, the placental detachment involves
l develops in the third trimester of pregnancy
only the margin or placental rim. most
GOB
or the first 6 months postpartum. (MCQ) important complication is the possibility of

l Of the patients who survive, approximately
premature labor(MCQ)
50% recover normal left heart function, but n Approximately 30% of cases of third-trimester
the others retain permanent cardiomyopathy. bleeding are due to placental separation
l Due to the high maternal mortality,
n initial hemorrhage is usually encountered after the
subsequent pregnancy is discouraged. 26th week(MCQ)
l Risk factors include (MCQ)
n 50% of separations occur before the onset of
„ multiparity, increased maternal age
labor(MCQ)
ABRUPTIO PLACENTA
„ multiple gestations
n Predisposing factors (MCQ)
„ preeclampsia or eclampsia.
m common predisposing factor is previous
l Management of peripartum cardiomyopathy
placental separation.
includes m hypertensive states of pregnancy
l bed rest; sodium restriction;
m advanced maternal age
l medical therapy with afterload reducers,
m multiparity(MCQ)
diuretics m uterine distention (eg, multiple gestation,
l inotropics, anticoagulants, or some
hydramnios)
combination of these m vascular disease (eg, diabetes mellitus, systemic
l in cases of advanced disease, lupus erythematosus), thrombophilias
transplantation. m uterine anomalies or tumors (eg, leiomyoma)
l Invasive cardiac monitoring should be
m cigarette smoking(MCQ)
considered during labor until at least 24 hours m alcohol consumption (> 14 drinks per week),
postpartum. m cocaine use,
l Hydralazine hydrochloride, furosemide,
m maternal type O blood.
or digoxin, or some combination of these, n Precipitating causes of premature separation of
may be administered the placenta, (MCQ)
l dopamine or dobutamine hydrochloride
m Circumvallate placenta
are given if necessary. m trauma
l Cesarean section is reserved for obstetric indications.
n external or internal version
n automobile accident
n abdominal trauma directly transmitted to an
anterior placenta
m sudden reduction in uterine volume
n rapid amniotic fluid loss
n delivery of a first twin m about half of these will have high-frequency contractions
m abnormally short cord and half hypertonus
m increased venous pressure m 20% of patients with abruptio placentae will be
n Pathophysiology & Pathology diagnosed erroneously as having idiopathic
m Mechanisms in the pathophysiology of premature labor.
premature placental separation. m Fetal distress will be present in more than 50%
n local vascular injury that results in vascular of cases(MCQ)
rupture into the decidua basalis, bleeding, m 15% will present with fetal demise.
and hematoma formation. n Laboratory
l a spiral artery may rupture, creating a m Why the degree of anemia will be considerably
retroplacental hematoma(MCQ) less than would seem to be justified by the amount
n Abrupt rise in uterine venous pressure of blood loss
transmitted to the intervillous space. n changes in hemoglobin and hematocrit are
m tissue disruption by bleeding may allow delayed during acute blood loss until secondary
n maternofetal hemorrhage, fetomaternal hemorrhage hemodilution has occurred
n maternal bleeding into the amniotic fluid m A peripheral blood smear
n amniotic fluid embolus n reduced platelet count;
m Couvelaire uterus(MCQ) n schistocytes, suggesting intravascular coagulation
n extensive intramyometrial bleeding results in n fibrinogen depletion with release of fibrin split
uteroplacental apoplexy products
GOB
n purplish and copper-colored, ecchymotic, indurated m clot observation test
organ n bedside procedure
n myometrium lose its contractile force because n Failure of clot for mation within 5–10
of disruption of the muscle bundles. (MCQ) minutes or dissolution of a formed clot when
n clinically significant amount of DIC with the tube is gently shaken is proof of a clotting
hemorrhagic diathesis deficiency
m lethal complications due to fibrin deposits in small n Treatment
capillaries along with the hypoxic vascular damage m Expectant therapy
ABRUPTIO PLACENTA
of shock(MCQ) n Expectant management of suspected placental
n acute cor pulmonale abruption is the exception, not the rule.
n renal cortical and tubular necrosis (MCQ)
n anterior pituitary infarction (Sheehan’s n expectant management may be appropriate
syndrome). when the
n Clinical Findings l mother is stable
m 30% of separations are small, produce few or l the fetus is immature
no symptoms l fetal heart tracing is reassuring.
m Larger separations are accompanied by n The patient should be observed in the labor
abdominal pain and uterine irritability. (MCQ) and delivery suite for 24–48 hours to ensure
m Hemorrhage may be visible or concealed that further placental separation is not occurring.
m If the process is extensive, it leads to (MCQ) (MCQ)
n fetal distress n Continuous fetal and uterine monitoring
n uterine tetany, should be maintained.
n DIC n Changes in fetal status may be the earliest
n hypovolemic shock. indication of an expanding abruption.
m Increased uterine tonus and frequency of n tocolytic therapy in preventing an abruption from
contractions may provide early clues of expanding – no conclusive trials
abruption. (MCQ) m Emergency measures
m 80% of patients will present with vaginal n Vaginal delivery
bleeding l Indications(MCQ)
m two-thirds will have uterine tenderness and „ if the degree of separation appears to
abdominal or back pain. (MCQ) be limited
m One-third will have abnormal contractions „ if the continuous FHR tracing is
reassuring
„ When placental separation is extensive n Prognosis
but the fetus is dead or of dubious viability, m unfavorable prognostic factors (MCQ)
l exception to vaginal delivery is the patient in n External or concealed bleeding
whom hemorrhage is uncontrollable and n excessive blood loss
operative delivery is necessary to save the n shock
life of the fetus or mother. n nulliparity
l Induction of labor with an oxytocin n a closed cervix
infusion should be instituted if active labor n absence of labor
does not begin shortly after amniotomy. n delayed diagnosis and treatment
„ In practice, augmentation often is not m Most women die of hemorrhage (immediate
needed because usually the uterus is or delayed) or cardiac or renal failure.
already excessively irritable
l If the uterus is extremely spastic, uterine
contractions cannot be clearly identified unless
an internal monitor is used, and the progress
of labor must be judged by observing cervical
dilatation
n Obstetrical anaesthesia
l Pudendal block anesthesia is
recommended. (MCQ)
GOB
l Conduction anesthesia is to be avoided in

the face of significant hemorrhage because
profound, persistent hypotension may
result(MCQ)
l in the volume repleted patient in early
labor, a preemptive epidural should be considered
because rapid deterioration of maternal or
fetal status can occur as labor progresses.
ABRUPTIO PLACENTA
(MCQ)
n Cesarean section
l Fetal indications for cesarean
section(MCQ)
„ whenever delivery is not imminent for a
fetus with a reasonable chance of survival
who exhibits persistent evidence of
distress
„ if the fetus is in good condition but the
situation is not favorable for rapid delivery in the
face of progressive or severe placental
separation
„ This includes most nulliparous patients
with less than 3–4 cm of cervical dilatation.
l Mater nal indications for cesarean
section(MCQ)
„ uncontrollable hemorrhage from a
contracting uterus
„ rapidly expanding uterus with concealed
hemorrhage (with or without a live fetus)
when delivery is not imminent
„ uterine apoplexy as manifested by
hemorrhage with secondary relaxation of a
previously spastic uterus, or refractory
uterus with delivery necessary (20%).
TOPIC - 22 TORCH „ oligohydramnios, intrauterine growth
retardation
„ premature delivery, inguinal hernias in
n Cytomegalovirus
m CMV infection is the most common congenital
boys
„ chorioretinitis.
infection (MCQ)
„ Nonimmune hydrops
m The virus has been isolated from saliva, cervical
l The severely affected infant may present with
secretions, semen, and urine.
m Infection can also be contracted by exposure to
purpura, “blueberry muffin skin,” and
infected breast milk or blood products. “salt and pepper skin.” (MCQ)
l Approximately one-third of neonates with
m Transmission can occur from mother to child
both in utero and postpartum. symptomatic infection die from severe
m Clinical manifestations
disease, generally with cerebral involvement
l Sixty percent to 70% of these survivors suffer
n Maternal infection.
l In immunocompetent adults, CMV infection
hearing loss; visual disturbances, motor
is silent impairments, language and learning
l symptoms include low-grade fever, malaise,
disabilities, and mental retardation are also
arthralgias, and, occasionally, pharyngitis common.
m Diagnosis
with lymphadenopathy(MCQ)
n Maternal infection
l As in other herpesvirus infections, after
l can be detected reliably only by documenting
primary infection,, CMV becomes latent,
GOB
with periodic episodes of reactivation and maternal seroconversion using serial
shedding of virus. (MCQ) Immunoglobulin G (IgG) measurements
l Mothers determined to be seronegative for
during pregnancy. (MCQ)
l Screening of asymptomatic pregnant
CMV before conception or early in gestation
have a women for seroconversion is not
„ 1–4% risk of acquiring the infection during
recommended
n Fetal infection.
pregnancy
l Ultrasonography may enable the detection
„ a 30–40% rate of fetal transmission.
l most fetal infections are due to recurrent
of the fetal anomalies that characterize CMV
maternal infection. (MCQ) infection.
l Amniocentesis and cordocentesis also
l These infections rarely lead to congenital
TORCH
abnormalities. have been used to diagnosis fetal infection
l Previously acquired immunity confers a
using measurement of total and specific
decreased likelihood of clinically apparent IgM antibodies and viral culture. (MCQ)
m Management.
disease, because partial protection to the fetus is
n Breast feeding is discouraged in women with active
provided by maternal antibodies.
l acquired immunity does not impede
infection.
transmission, but evidently prevents the Varicella zoster virus
n
m The major mode of transmission is respiratory
serious sequelae that develop with primary
m direct contact with vesicular or pustular lesions
maternal infection.
n Congenital infection.
also may result in disease.
m Nearly all persons are infected before adulthood
l Ten percent to 15% of infected infants have
m Clinical manifestations
clinically apparent disease, (MCQ)
n Maternal infection.
l A higher risk of sequelae is seen in fetuses
l Primary varicella infection tends to be
infected earlier in gestation than in those infected
later. more severe in adults than in children.
l Preterm neonates are at greatest risk of
Infection is especially severe in pregnancy.
l The risk of varicella pneumonia appears
infection.
l Common clinical findings in fetal infection
to increase in pregnancy, starting several
include the presence of (MCQ) days after the onset of the characteristic rash.
l When varicella pneumonia occurs in
„ petechiae, hepatosplenomegaly
„ jaundice, microcephaly with pregnancy, maternal mortality may reach
periventricular calcifications,
40% in the absence of specific antiviral n Neonatal therapy is also important when a
therapy. (MCQ) mother develops signs of chickenpox less than
l Herpes zoster infection, or reactivation 3 days postpartum. (MCQ)
of varicella, is more common in older and n Herpes zoster is not associated with fetal
immunocompromised patients. sequelae
l Zoster is not more prevalent or severe in o Laboratory studies.
pregnancy. (MCQ) n Confirmation of the diagnosis may be obtained
n Congenital infection. by examining scrapings of lesions, which may
l Of fetuses born to mothers who had active reveal multinucleated giant cells.
disease during the first 20 weeks of pregnancy, n For rapid diagnosis, varicella zoster antigen
20–40% are infected. may be demonstrated in exfoliated cells from
l The risk of congenital malformation after lesions by immunofluorescent antibody staining.
fetal exposure to primary maternal varicella o Ultrasonography.
before 20 weeks’ gestation is 5%. (MCQ) n Detailed ultrasonographic examination is
l Fetal infection with varicella zoster virus can probably the best means for assessing a fetus for major
lead to one of three major outcomes: limb and growth disturbances.
„ intrauterine infection n Other abnormalities that have been detected
® infrequently causes congenital before 20 weeks’ gestation include
abnormalities l polyhydramnios, hydrops fetalis,
„ postnatal disease l Multiple hyperechogenic foci within the
GOB
® ranges from typical varicella with a liver

benign course to fatal disseminated l limb defects, and hydrocephaly.
infection o Management
„ shingles n Exposure of a previously uninfected
® appear months or years after birth. woman during pregnancy
m Congenital varicella syndrome n An IgG titer should be obtained within 24–
n attributed to the occurrence of infection 48 hours of a patient’s exposure to a person
before 20 weeks’ gestation with noncrusted lesions.
n abnormalities (MCQ) n The presence of IgG within a few days of
l cutaneous scars exposure reflects prior immunity. Absence of
l limb-reduction anomalies IgG indicates susceptibility.
TORCH
l malformed digits, muscle atrophy n Varicella zoster immune globulin. (MCQ)

l growth restriction, cataracts l prevents maternal infection in patients
l chorioretinitis, microphthalmia, without IgG
l cortical atrophy, microcephaly l administered within 96–144 hours of
l psychomotor retardation. exposure(MCQ)
n The risk of this syndrome is estimated to be l dosage of 125 U/10 kg up to a maximum
around 2%. of 625 units, or five vials, intramuscularly (IM).
n Infection after 20 weeks’ gestation may lead l Why is the VZIG administration not
to postnatal disease. (MCQ) currently recommended to pregnant
n If maternal infection occurs within 5 days of women who have been exposed to varicella.
delivery, hematogenous transplacental viral (MCQ)
transfer may cause significant infant morbidity, „ is difficult to obtain serologic test results
incurring infant mortality rates between 10% in a timely manner
and 30%. (MCQ) „ no proven benefit results from
n Sufficient antibody transfer to protect the administration of VZIG for the
fetus apparently requires at least 5 days after prevention of mater nal-fetal
the onset of the maternal rash. (MCQ) transmission or amelioration of
m Women who develop chickenpox, especially maternal symptoms and sequelae
near term l Pregnant women with varicella, however,
n should receive tocolytic therapy if labor begins may be advised to continue with the
before day 5 of the maternal infection. (MCQ) pregnancy because the risk of congenital
varicella is small.
n Vaccination. crisis should be evaluated for parvovirus B19
l Live attenuated live vaccine virus by measuring IgG and IgM titers. (MCQ)
l One dose is recommended for all children n For patients who have had contact with an
between ages 1 and 12, which results in a infected individual, titers should be drawn 10
97% seroconversion rate. (MCQ) days after exposure
l Two doses, given 4–8 weeks apart, are n Parvovirus B19 IgM appears 3 days after the
recommended for adolescents and adults onset of illness, peaks in 30–60 days, and may
without a history of varicella infection. persist for 4 months.
(MCQ) n Parvovirus B19 IgG usually is detected by the
l Use of the vaccine during pregnancy is not seventh day of illness and persists for years.
recommended. m Management.
n Parvovirus B19 n Detection of fetal hydrops.
m Causes erythema infectiosum or fifth disease, occur in l Although hydrops fetalis usually develops
school-aged children. The virus is spread primarily within 6 weeks of maternal infection, it can
by the respiratory route. appear as late as 10 weeks after maternal
m Clinical manifestations infection. (MCQ)
n Maternal infection. n Intrauterine blood transfusion has been
l Adults may present with the typical clinical demonstrated to be a successful therapeutic
features of fifth disease, a red, macular rash measure for correcting the fetal anemia in
and erythroderma affecting the face, which fetal hydrops.
GOB
gives a characteristic “slapped cheek”
appearance. (MCQ) n Rubella virus
l 60% have acute joint swelling, usually with m Transmission results from direct contact with the
symmetrical involvement of peripheral joints nasopharyngeal secretions of an infected person.

l arthritis may be severe and chronic m The most contagious period is the few days
l Some adults have completely before the onset of a maculopapular rash
asymptomatic infection. (MCQ)
l Parvovirus B19 may cause aplastic crises m The disease is communicable, however, for 1 week
in patients with hemolytic anemia (i.e., sickle before and for 4 days after the onset of the
cell disease). (MCQ) rash. (MCQ)
n Fetal infection. m The incubation period ranges from 14 to 21 days.
TORCH
l Approximately one-third of maternal m Clinical manifestations
infections are associated with fetal infection. n Fetal infection
l On transplacental transfer of the virus l At least 50% of all fetuses are infected
„ fetal anemia, when primary maternal rubella infection

„ nonimmune hydrops fetalis. occurs in the first trimester, when the greatest
l The likelihood of severe fetal disease is risk of congenital anomalies exists.
increased if maternal infection occurs l Permanent congenital defects include (MCQ)
during the first 18 weeks of pregnancy „ ocular defects such as cataracts,
l the risk of hydrops fetalis persists even when microphthalmia, and glaucoma ,heart
infection occurs in the late third trimester. abnor malities, especially PDA,
l Fetal immunoglobulin M (IgM) pulmonar y arter y stenosis, and
production after 18 weeks gestation atrioventricular septal defects
probably contributes to the resolution of „ sensorineural deafness;
infection in fetuses who survive. (MCQ) „ microcephaly
l parvovirus B19 does not cause congenital „ encephalopathy that culminates in mental
anomalies retardation or profound motor

m Diagnosis impairment.
n A pregnant woman who has been exposed to l As many as one-third of infants
a child with fifth disease, who presents with asymptomatic at birth may develop late
an unexplained morbilliform or purpuric manifestations, including diabetes mellitus,
rash, or who has a known history of chronic thyroid disorders, and precocious puberty(MCQ)
hemolytic anemia and presents with an aplastic
l extended rubella syndrome (progressive l low birth weight, hepatosplenomegaly,
panencephalitis and type 1 diabetes mellitus) may icterus, and anemia
develop as late as the second or third decade l Sequelae such as vision loss and
of life. (MCQ) psychomotor and mental retardation are
n Mortality. in pregnancies complicated by common.
maternal rubella. l Hearing loss
l Spontaneous abortion occurs in 4–9% l developmental delay
l stillbirth in 2–3% l Chorioretinitis (MCQ)
m Diagnosis m Management
n Prenatal diagnosis is made by identification n Spiramycin reduces the incidence of fetal
of IgM in fetal blood obtained by direct infection but not necessarily the severity of fetal
puncture under ultrasonographic guidance at 22 infection. (MCQ)
weeks’ gestation or later. (MCQ) n Pyrimethamine and sulfadiazine. (MCQ)
m Management l Folinic acid is added to prevent toxicity.
n Pregnant women should undergo rubella l During the first trimester, pyrimethamine is
serum evaluation as part of routine prenatal not recommended due to a risk of
care teratogenicity.
n The rubella vaccine n Sulfadiazine is omitted from the regimen at
l Live attenuated live virus, and if the patient is term.
nonimmune, she should receive rubella m Herpes simplex virus (HSV)
GOB
vaccine after delivery. (MCQ) n Primary maternal infection with HSV results
l Contraception should be used for a from direct contact, generally sexual, with
minimum of 3 months after vaccination mucous membranes or intact skin infected
(MCQ) with the virus.
n If a pregnant woman is exposed to rubella, n Fetal infection with HSV can occur via three
immediate serologic evaluation is mandatory. routes.
l If primary rubella is diagnosed, the mother l In utero transplacental transmission
should be informed about the implications l ascending infection from the cervix both
of the infection for the fetus. occur.
l If acute infection is diagnosed during the l direct contact with infectious maternal
first trimester, the option of therapeutic genital lesions during delivery - the most
TORCH
abortion should be considered. (MCQ) common route

l Women who decline this option may be n Clinical manifestations
given immune globulin because it may l Fetal infection is usually the result of a
modify clinical rubella in the mother. primary maternal infection. (MCQ)
l Immune globulin, however, does not n Diagnosis.
prevent infection or viremia and affords no l Tissue culture has 95% sensitivity and very
protection to the fetus. high specificity.
n Toxoplasma l The use of HSV-specific ELISA allows
m Transmission occurs primarily via preliminary diagnosis within 24–48 hours of
n ingestion of undercooked or raw meat culturing. (MCQ)
containing cysts, (MCQ) n Management.
n ingestion of food or water contaminated l Active genital HSV in patients in labor or
by the feces of an infected cat, with ruptured membranes is an indication
n handling of material contaminated by the for cesarian section, regardless of the
feces of an infected cat. (MCQ) duration of rupture. (MCQ)
m Clinical manifestations l Acyclovir may be used to treat HSV infection
n Fetal infection. in pregnancy; however, valacyclovir
l the rate of transmission(MCQ) hydrochloride has been shown to be more
„ first trimester-15%. effective and is more easily tolerated due to a
„ second trimester - 30% twice-daily dosing schedule.
„ third trimester - 60%.
n Infected neonates often have

TOPIC : 23 PLACENTA PREVIA n If there is local bleeding, do a C- section; if
not, palpate for nices to determine if
n Placenta Previa placenta is covering the os.
n The double setup exam is performed only on
m A condition in which the placenta is implanted
in the immediate vicinity of the cervical os. the rare occasion that the US is inconclusive
(MCQ) and there is no MRI.
m Management
m Third trimester bleeding(MCQ)
n Cesarean delivery is indicated for placenta
n Painless bleeding = previa
n Painful bleeding = abruption
previa. (MCQ)
m It can be classified into four types:
n Fetal Vessel Rupture(MCQ)
m Two conditions cause third-trimester bleeding
n Complete placenta previa:
l The placenta covers the entire internal cer-
resulting from fetal vessel rupture
n vasa previa
vical os
n velamentous cord insertion
n Partial placenta previa:
m These two conditions often occur together and
l The placenta partially covers the internal
cervical os. can cause fetal hemorrhage and death very
n Marginal placenta previa:
quickly.
n Vasa previa
l One edge of the placenta extends to the edge
l A condition in which the unprotected fetal
of the internal cervical os.
n Low-lying placenta: (MCQ)
cord vessels pass over the internal cervical
GOB
l Within 2 cm of the internal cervical os.
os, making them susceptible to rupture when
m Etiology
membranes are ruptured. (MCQ)
n Velamentous cord insertion(MCQ)
n Unknown, but associated with: (MCQ)
l Fetal vessels insert in the membranes and
l High parity.
l Older mothers.
travel unprotected to the placenta.
l This leaves them susceptible to tearing
l Previous abortions.
l Previous history of placenta previa.
when the amniotic sac ruptures.
l The vessels are usually covered by Wharton’s
l Fetal anomalies.
jelly in the umbilical cord until they insert
PLACENTA PREVIA
n Five to ten percent associated with placenta
accreta, especially if prior low transverse into the placenta.
l Incidence: 1% of singletons, 10% of twins,
cesarean section. (MCQ)
m Clinical presentation
50% of triplets.
m Clinical presentation
n Painless, profuse bleeding in second or third
n Vaginal bleeding with fetal distress.
trimester. (MCQ)
m Management
n Postcoital bleeding.
n Correction of shock and immediate delivery
n Spotting during first and second trimester that
subsides, and then recurs later in pregnancy. (usually cesarean delivery).
m Diagnosis
n Uterine Rupture
m The disruption of the uterine musculature
m Transabdominal US (95% accurate). (MCQ)
m MRI findings:
through all of its layers, usually with part of the
n Placenta previa is diagnosed on MRI when it is
fetus protruding through the opening.
m Complications
low lying and partially or completely covering
n Maternal: Hemorrhage, hysterectomy, death.
the internal os.
n Fetal: Permanent neurologic impairment, cerebral palsy,
n It is best demonstrated on sagittal images.
m When US reveals that a baby is lying
death.
m Risk factors
transversely,you should suspect Placenta
n Prior uterine scar from a cesarean delivery is
previa(MCQ)
m Double setup exam:
the most important risk factor:
l Vertical scar: 10% risk due to scarring of
n Take the patient to the operating room and
prep for a C-section. the active, contractile portion of the uterus.
n Do speculum exam:
(MCQ)
l Low transverse scar: 0.5% risk.
n Can occur in the setting of trauma.

m Presentation and diagnosis TOPIC - 24 PRETERM LABOUR
n Nonreassuring fetal heart tones or bradycardia:
Most suggestive of uteine rupture. (MCQ) n Preterm Labour
n Sudden cessation of uterine contractions.
m Criteria (MCQ)
n “Tearing” sensation in abdomen.
n Gestational age (GA) < 37 weeks with regular
n Presenting fetal part moves higher in the pelvis.
uterine contractions and any of the following :
n Vaginal bleeding.
l Progressive cervical change
n Maternal hypovolemia from concealed
l A cervix that is 2 cm dilated
hemorrhage. l A cervix 80% effaced
m Management l Ruptured membranes.
n Immediate laparotomy and delivery. (MCQ)
m Risk factors (MCQ)
n May require a cesarean hysterectomy if uterus
n Previous history of preterm delivery.
cannot be reconstructed. n Hydramnios, Abruption.
n Multiple gestations ,Cocaine.
n UTI, Vaginal infections.
m Assessment
n Evaluate for causes such as infection
(gonococcus, bacterial vaginosis),
abruption.
n Confirm GA of fetus (ie, by US).
GOB
m Predictors of preterm labor:

n Transvaginal cervical length measurement:
l 35 mm: Low risk of preterm delivery.
(MCQ)
l < 25 mm (especially with funneling): High risk
of preterm delivery. (MCQ)
n Fetal fibronectin assay: (MCQ)
l Vaginal swab of posterior fornix prior to
PRETERM LABOUR
digital exam.
l If negative, 99% predictability for no
preterm delivery within 1 week.
m Management of Preterm Labor
n Hydration
l Hydration may decrease uterine irritability
l Dehydration causes ADH secretion, and
ADH mimics oxytocin, which causes uterine
contractions.
n Tocolytic therapy
l Tocolytic drugs (MCQ)
„ not been shown to decrease neonatal
morbidity or mortality
„ may prolong gestation for 2–7 days to
allow time for administration of
steroids and transfer to a facility with a
neonatal ICU. (MCQ)
„ It is used when fetus is < 34 weeks
gestation. (MCQ)
m Tocolytic agents
n Magnesium sulfate: (MCQ)
l Suppresses uterine contractions.
l Competes with calcium,
l inhibits myosin light chain. (MCQ)
l Maternal side effects: (MCQ)
„ Flushing, lethargy, headache, muscle weakness, „ Phosphatidylglycerol is present in
„ diplopia, dry mouth, pulmonary edema, cardiac amniotic fluid.

arrest. „ Surfactant-albumin in amniotic fluid at a
l Toxicity is treated with calcium gluconate. ratio > 55.

(MCQ) „ Lecithin-sphingomyelin in amniotic fluid
l Fetal side effects: Lethargy, hypotonia, at a ratio > 2.
respiratory depression. n Prevention of preterm labor
l Contraindications: Myasthenia gravis. l 17α-hydroxyprogesterone is often given as
(MCQ) weekly IM injections starting at 16–20 weeks to

n Nifedipine: Oral calcium channel blocker. women with risk factors or history of
l Maternal side effects: Flushing, headache, dizziness, preterm labor. (MCQ)
nausea, transient hypotension. (MCQ) l Relaxes the myometrium.
l Fetal side effects: None l Prevents rejection of the fetus by suppressing
l Contraindications: lymphocyte production of cytokines.

„ Maternal hypotension, cardiac disease m Braxton Hicks contractions(MCQ)
„ use with caution with renal disease. l irregular, nonrhythmic
„ Avoid concomitant use with magnesium l usually painless contractions
sulfate. (MCQ) l begin at early gestation
n Ritodrine, terbutaline, l ↑as term approaches
l Beta β agonist: l make it difficult to distinguish between true
GOB
l Beta 2 receptor stimulation on myometrial and false labor.
cells m Most infants born after 34 weeks GA will survive
l ↑cyclic adenosine monophosphate (cAMP) (MCQ)

(MCQ) m the survival rate is within 1% of the survival rate
l ↓ intracellular Ca , ↓ contractions: beyond 37 weeks

l Maternal side effects: Pulmonary edema, m Tocolytics have not been proven to prolong
tachycardia, headaches. pregnancy.

l Fetal side effect: Tachycardia. m Contraindications to tocolysis(MCQ)
l Severe Bleeding from any cause
PRETERM LABOUR
l Contraindications: (MCQ)
„ Cardiovascular disease l Severe Abruptio placentae
„ Hyperthyroidism l Fetal Death/life- incompatible anomaly

„ uncontrolled diabetes mellitus. l Chorioamnionitis
n Indomethacin, prostaglandin inhibitors: l Severe pregnancy-induced Hypertension
l Used for < 32 weeks. (MCQ) l Unstable maternal hemodynamics
l Maternal side effects: Nausea, heartburn. m Maternal corticosteroid administration(MCQ)

l Fetal side effects: (MCQ) l Indications:
„ Premature constriction of ductus arteriosus, „ Preterm labor 24–34 weeks
„ pulmonary HTN, reversible ↓ in amniotic „ Preterm premature rupture of membranes

fluid. (PPROM) : 24–32 weeks
l Contraindications: (MCQ) l Fetal benefits:
„ Renal or hepatic impairment „ ↓ respiratory distress syndrome (RDS).
„ peptic ulcer disease „ ↓ intraventricular hemorrhage.
m Corticosteroids
l Given to patients in preterm labor from 24 n Premature rupture
to 34 weeks unless they have an infection. m denotes spontaneous rupture of fetal membranes
(MCQ) before the onset of labor.

l Actions: (MCQ) m This can occur at term (PROM) or preterm
„ Accelerate fetal lung maturity (↓ RDS) (PPROM).

„ reduce intraventricular hemorrhage. m PPROM:
n Assessing fetal lung maturity l Preterm (< 37 weeks) premature rupture
l An amniocentesis may be performed to assess of membranes. (MCQ)

fetal lungs for risk of RDS. m Prolonged rupture of membranes:
l Fetal lungs are mature if: (MCQ)

l Rupture of membranes present for ( > 18 n Amniotic fluid assessment for fetal lung
hr. (MCQ) maturity from vaginal pooling.
m Etiology n Nitrazine test may be falsely positive if
l Unknown but hypothesized: Vaginal and contaminated with blood, semen.
cervical infections. n Consider delivery if mature.
l Incompetent cervix. n US to assess GA, anomalies, presentation of
l Nutritional deficiencies. baby, and AFI.
m Complications n Monitor in hospital for infection, abruption,
l Prematurity: fetal distress and preterm labor.
„ If PROM occurs at < 37 weeks, the fetus n If < 32 weeks gestation, give steroids to ↓
is at risk of being born prematurely with the incidence of RDS. (MCQ)
its associated complications. (MCQ) n Antibiotic coverage to prolong latency period
l Pulmonary hypoplasia: (time between ROM and
„ If PROM occurs at < 24 weeks n onset of labor) to give a premature fetus time
→oligohydramnios →pulmonar y to mature in utero.
hypoplasia. (MCQ) n Fetal testing to ensure fetal well-being.
l Survival at this age is low n Delivery:
l Chorioamnionitis. l If infection, abruption, fetal distress
l Placental abruption. noted.
l Neonatal infection. l Done At 34 weeks gestation. : At this GA,
GOB
l Umbilical cord prolapse. most babies with little risk of RDS; (MCQ)
l Preterm labor.
m Management of all PROM patients
l Avoid vaginal exams if possible to ↓ risk
of chorioamnionitis.
l Evaluate patient for chorioamnionitis
(common etiology of PROM):
„ Fever > 100.4°F (38°C), leukocytosis
„ maternal/fetal tachycardia
PRETERM LABOUR
„ uterine tenderness
„ malodorous vaginal discharge.
l If chorioamnionitis present, delivery is
performed despite GA, and
l broad-spectrum antibiotics (ampicillin,
gentamicin) are initiated.
m Specific management for PROM at term
l Ninety percent of term patients go into
spontaneous labor within 24 hr after
rupture: (MCQ)
l Patients in active labor should be allowed
to progress.
l If labor is not spontaneous, it should be
induced.
l Cesarean delivery should be performed for
other indications.
m Specific management of PPROM
n Fifty percent of preterm patients go into
labor within 24 hr after rupture. (MCQ)
n Generally, one needs to balance the risks of
premature birth against the risk of infection
(which ↑with the time that membranes are
ruptured before birth).

TOPIC- 25 RH ISOIMMUNISATION antigen on them and clear them from the maternal
circulation. .(MCQ)
n anti-Lewis antibodies pose no harm to the fetus m The goal is to prevent the mother’s immune
.(MCQ) system from recognizing the presence of the D

n antibodies that can cause hemolytic disease of the antigen and forming antibodies against it.
newborn (HDN) and be fatal .(MCQ) m Give to D-negative mothers, who have not
m anti-D formed antibodies against D antigen.

m anti- Kell m Not indicated for patients who already have anti-D
m anti-Duffy antibodies and are sensitized. .(MCQ)

m Kell Kills, Duffy Dies, Lewis Lives. m Indicated for patients who might be sensitized
m A critical titer, usually 1:16 at most institutions, to other blood group an- tigens.
is the titer associated with a significant risk for n Management of the unsensitized D-negative patient
HDN.(MCQ) (the D-negative patient with a negative antibody
m Anti-D Isoimmunization screen)
m If the mother is D negative and the father is D m Antibody screen should be done at the initial
positive, there may be a chance that the baby may prenatal visit and at 28 weeks.
be D positive. m If antibody screen negative, the fetus is presumed
m If the mother is D negative and her fetus is D to be D positive, and one dose of anti-D IgG
positive, she may become sensitized to the D immune globulin is given to the mother at 28 weeks
antigen and develop antibodies against the to prevent development of maternal antibodies..
GOB
baby’s RBCs. (MCQ)
m These antibodies cross the placenta and attack m Anti-D immune globulins last for ~12 weeks,
the fetal RBCs, resulting in fetal RBC hemolysis. and the highest risk of sensitization is in T3..
m The hemolysis results in significant fetal anemia, (MCQ)
resulting in fetal heart failure and death. - known m At birth, the infant’s D status is noted.
as hemolytic disease of the newborn (HDN). n If the infant is D negative, no anti- D IgG is
m Sensitization is the development of maternal given to the mother.

antibodies against D anti- gens on the fetus n If the infant is D positive, anti-D IgG is given
RBC. .(MCQ) to the mother within 72 hr of delivery. .(MCQ)

m The dose of anti-D IgG is determined by KB
RH ISOIMMUNISATION
m fetus of the pregnancy when sensitization occurred
usually suffers no harm because the maternal antibody test.
titers are low. m Administration of anti-D IgG at 28 weeks
m The subsequent pregnancies with a D-positive gestation and within 72 hr of birth, reduces
fetus are at significantly higher risk of HDN sensitization to 0.2%..(MCQ)
because the mother has already developed n Management of the sensitized D-negative patient
memory cells that quickly produce anti-D (antibody screen positive for anti-D antibody)
antibodies against the fetus RBCs. m If antibody screen at initial prenatal visit is positive,
m The following conditions can cause fetal-maternal and is identified as anti-D,

bleeding, and lead to sensitization: .(MCQ) m Check the antibody titer. Critical titer is 1:16.
n Chorionic villus sampling. .(MCQ)

n Amniocentesis. n If titer remains stable at < 1:16.(MCQ)
n Spontaneous/induced abortion. l the likelihood of hemolytic disease of the
n Threatened/incomplete abortion. newborn is low.

n Ectopic pregnancies. l Follow the antibody titer every 4 weeks.
n Placental abruption/bleeding placenta n If the titer is ≥1:16 and/or rising.(MCQ)
previa. l the likelihood of hemolytic disease of the
n Vaginal or cesarean delivery. newborn is high.

n Abdominal trauma. l Amniocentesis is done.
n External cephalic version. m Amniocentesis:
n Anti-D immune globulins (IgG) (RHOGAM) n Fetal cells are analyzed for D status.
m When a mother is given a dose of anti-D IgG, m Assessment of Fetal anemia
the antibodies bind to the fetal RBCs that have the D

n Historically, amniotic fluid was analyzed by TOPIC - 26 POLYHYDRAMNIOS
spectral analysis, which measured the light
absorbance by bilirubin. n Normal amniotic fluid volume varies and ‘!?with
l Absorbance measurements were plotted on
gestational age.
a graph to predict the severity of disease. n The peak volume is 800–1000 mL at 36–37 weeks
n The preferred method now is to perform
gestation.(MCQ)
middle cerebral artery (MCA) Dopplers to n In the late T2 or T3, amniotic fluid volume
assess for anemia. .(MCQ) represents fetal urine output. .(MCQ)
m Serial US monitoring for:
n Why is AFI is used as a measure of chronic
n Anatomy scan for hydrops fetalis.
uteroplacental function. .(MCQ)
n MCA Doppler for presence or severity of
m If there is uteroplacental dysfunction and ↓
anemia oxygenation to the fetus, the fetus preferentially
n Consider blood transfusion to fetus if very
shunts blood to the brain and heart, leaving the
premature. fetal kidneys underperfused. This results in ↓fetal
o Delivery: .(MCQ) urine output and, as a result, ↓amniotic fluid.
n Mild anemia: Induction of labor at 37–38
n The AFI is the sum of amniotic fluid measured
weeks. in four quadrants of the uterus via the US. .(MCQ)
n Severe anemia: Deliver at 32–34 weeks.
m AFI > 5 cm: Adequate.
o Most babies > 32 weeks do well in the m AFI < 5 cm: Abnormal (oligohydramnios).
NICU.(MCQ) m AFI 25 cm: Abnormal (polyhydramnios).
3
GOB
n Weigh risks for continued cord blood

n Oligohydramnios:
sampling and transfusions with neonatal m Most common cause: Ruptured membranes. .
risks of preterm delivery. (MCQ)
n Administer steroids to mother to enhance fetal
m Associated with intrauterine growth restriction
lung maturity. 60% of the time.
m Evaluate for genitourinary malformations.
n Kleihauer-Betke test determines the number of fetal n Polyhydramnios: .(MCQ)
RBCs in the maternal circulation m Fetal malformation (anencephaly, esophageal
POLYHYDRAMNIOS
n The standard dose of RhoGAM is 300 µg.(MCQ) atresia).

m It is sufficient for 15 mL of D-positive fetal
m Genetic disorders.
RBCs (30 mL of whole fetal blood). .(MCQ) m Maternal diabetes.
m Kleihauer-Betke (KB) test estimates the number
m Multiple gestation.
of fetal RBCs that are present in the maternal m Fetal anemia.
circulation. m Viruses.
m The dose of anti-D IgG is based on the results
n Polyhydramnios is associated with uterine
of the KB test. overdistention, resulting in: .(MCQ)
m Preterm labor
m PROM
m Fetal malposition
m Uterine atony

TOPIC - 27 PCOD n Normal androstenedione level is 1.3-1.5 ng/
ml.
n Polycystic ovarian syndrome (PCOS) or disease n DHEA > 700 ng/ml suggests adrenal tumour.
(PCOD) (MCQ)
m Polycystic ovarian disease - Stein-Leventhal n Prolactin is mildly raised in 15% cases.
syndrome n Fasting insulin is more than 10 mIU/1 in
m Amongst infertile women, about 20% is PCOS.

attributed to anovulation caused by PCOS. n Thyroid function tests may be abnormal
m PCOS in earlier years lead to later in life (MCQ) (hypothyroidism).

n cardiovascular disease n 17 alpha-hydroxyprogesterone in the
n hypertension, follicular phase > 300 ng/dl suggests adrenal

n endometrial cancer hyperplasia due to 21 hydroxylase deficiency.
n type 2 diabetes (MCQ)
m Aetiology and pathogenesis m Clinical features(MCQ)
n insulin resistance is central key point in the n Young woman
genesis of PCOS. n Central obesity

n BMI >30 kg/cm
2
n Insulin induces LH to cause thecal
hyperplasia and secrete androgens, n Waist line >35
testosterone and epiandrostenedione n Waist over hip ratio > 0.72 is abnormal.
(MCQ) n Oligomenorrhoea, amenorrhoea
GOB
n Epiandrostenedione is converted in the n Infertility (20%)
peripheral fat to oestrone. n Hirsutism
n This leads to rise in the oestrogen and inhibin n Acanthosis nigricans due to insulin resistance.
level. (MCQ) n Thick pigmented skin over the nape of neck,
n These in turn cause high LH surge(MCQ) inner thigh and axilla

n Whereas oestrone level increases, oestradiol level n For the diagnosis of PCOS, Rotterdam criteria
remains normal with the result oestrone/ (2003) suggest that at least two out of three
oestradiol ratio rises. (MCQ) criteria should be present. (MCQ)
n Hyperandrogenism lowers the level of hepatic l Oligo/amenorrhoea, anovulation,
sex homone binding globulin (SHBG), infertility
(MCQ) l Hirsutism
l Ultrasound findings
PCOD
n level of free testosterone rises leading to
hirsutism. (MCQ) m Investigations
n Androgen n Ultrasound is diagnostic of PCOS.
l suppresses growth of the dominant follicle l The enlarged ovaries, their size and increased
l prevents apoptosis of smaller follicles which stroma. (MCQ)

are normally destined to disappear in the late l Twelve or more small follicles each of 2-9
follicular phase. mm in size placed peripherally. (MCQ)

m Associated with Syndrome X (MCQ) l It rules out ovarian tumour.
n diabetes, hypertension l It shows endometrial hyperplasia if present.
n hyperlipidaemia and cardiovascular disease l In case of doubt, abdominal scan will reveal
m Endocrinological changes in PCOD: adrenal hyperplasia or tumour.

n Oestrone/E2 level rises. (MCQ) l Ultrasound should preferably be performed
n LH level is raised over 10 IU/ml. in the early follicular phase.

n FSH level remains normal(MCQ) n Laparoscopy is reserved for therapeutic
n FSH/LH ratio falls. (MCQ) purpose, now that the diagnosis can be based
n SHBG level falls due to hyperandrogenism. on ultrasound findings.
n Testosterone and epiandrostenedione levels m Treatment
rise. n Weight loss.
n Testosterone >2ng/ml l Weight loss of more than 5% of previous
n Free T >2.2pg/ml (Normal level 0.2-0.8 ng/ weight, alone is beneficial in mild hirsutism
ml) and it restores the hormonal milieu
considerably. (MCQ)
n Cigarette smoking should be abandoned. „ off-label letrozole (MCQ)
l It lowers E2 level and raises DHEA and „ Failure to above therapy calls for FSH, LH
androgen level. or GnRH analogues.
n Hormones to control menstruation are: l A woman with insulin resistance
l Oral combined pills (OC) „ requires metformin in addition. (MCQ)
l OC and cyproterone acetate. „ This woman also shows raised level of
n Oestrogen homocysteine in which case N-acetyl-
l suppresses androgens and adrenal hormones cysteine 1.2 g may be added to clo-
(DHEA). miphene therapy.
l raises the secretion of SHBG in the liver, ® N-acetyl-cysteine (NAC) is a
which binds with testosterone, thus reduces mucolytic drug and insulin-sensitizer.
free testosterone. (MCQ) n Metformin
l suppresses LH. (MCQ) l treats the root cause of PCOS
l best given as low-dose combined pills, l rectifies endocrine and metabolic functions
having progestogen with lesser androgenic effect. l improves fertility rate
l Fourth generation of combined pills l is used as insulin sensitizer.
which contains 30 microgms of E2 and 2-3 l It reduces insulin level
mg drospirenone (progestogen with anti- l delays glucose absorption
androgenic action) is best for PCOS (Yasmin, l decreases liver neoglycolysis
Janya, Tarana). (MCQ) l improves peripheral utilization of glucose.
GOB
„ It helps to reduce acne and further l Liver function tests should be performed
development of hirsutism. prior to metformin administration.
n Progestogen(MCQ) l reduces the level of total and free
l required to induce menstruation in testosterone
amenorrhoeic woman prior to initiating l increases the sex hormone binding globulin.
hormonal cyclical therapy. l Ovulation occurs in 70-80%, and pregnancy
n OC with cyproterone is prescribed if the in 30-40%.
woman has hirsutism. l It does not cause hypoglycaemia
n Hirsutism. l does not reduce weight.
l Anti-androgens (MCQ) l It is contraindicated in hepatic and renal
l managed by clindamycin lotion 1% or disease.
erythromycin gel 2% if pustules form. l It causes gastrointestinal disturbances and
PCOD
(MCQ) lactic acidosis.

l For severe acne, isotretinoin is used(MCQ) l If metformin is contraindicated, acarbose
„ it is teratogenic and pregnancy should be 300 mg daily can replace it.
avoided n Octreotide (MCQ)
l Dexamethasone (0.5 mg) at bedtime l a peptide hormone secreted by
(MCQ) hypothalamus
„ reduces androgen production l inhibits growth hormone and insulin.
„ used in some infertile women with l enhances ovulation in clomiphene-resistant
clomiphene. infertility.
n Infertility. m Surgery
l Clomiphene (MCQ) n Surgery is reserved for those in whom (MCQ)
„ first line of treatment if PCOS woman l Medical therapy fails
is to be treated for infertility. (MCQ) l Hyperstimulation occurs
„ induces ovulation in 80% and 40-50% l Infertile women
conceive, but 25-40% abortion rate is l Previous pregnancy losses.
caused by corpus luteal phase defect. n Surgery comprises laparoscopic drilling or
„ Hyperstimulation occurs in 10% cases. puncture of not more than four cysts in each
„ Clomiphene with dexamethasone ovary either by laser or by unipolar
improves fertility rate. electrocautery.
l In a resistant case, n Surgery restores endocrine milieu and
„ tamoxifen (MCQ) improves fertility for a year or so. Thereafter,
pelvic adhesions caused by surgery may again TOPIC - 28 PROLAPSE OF UTERUS
reduce fertility rate.
n Hydrofloatation reduces adhesion formation. Pelvic organ prolapse
n Advantages of surgery are as follows: (MCQ) m Cystocele (MCQ)
l Tubal testing with chromotubation can be
n present when there is descent of the anterior
performed simultaneously. vaginal wall
l Other causes of infertility, i.e. endometriosis
n It is generally caused by
looked for. l separation of the paravaginal attachment of
l One-time treatment.
the pubocervical fascia from the arcus
l Intense and prolonged monitoring not
tendineus fasciae pelvis (MCQ)
required. l tearing of the pubocervical fascia, which
l Cost effective compared to IVF.
results in herniation of the bladder. (MCQ)
l Reduces androgen and LH production
m Rectocele
l Following surgery, single ovulation occurs
n caused by a defect in the rectovaginal
with drugs, and hyperstimulation and septum. (MCQ)
multiple pregnancy are avoided. n results in herniation of the posterior wall of
l Ovulation occurs in 80-90% and pregnancy
the vagina and the anterior wall of the rectum,
in 60-70%. so that they are in direct apposition to vaginal
n Disadvantages of surgery are as follows: epithelium. . (MCQ)
l Adhesions may form postoperatively.
m Loss of perineal body integrity
GOB
l Premature ovarian failure due to
n occurs when the perineal body becomes
destruction of ovarian tissue if cautery is used. detached from the rectovaginal septum and
l For this reason, many now prefer simple
becomes mobile.
puncture of the cysts. n Loss of perineal body integrity can lead to an
inferior rectocele and perineal descent.
m Uterovaginal prolapse
n occurs secondary to damage of the cardinal-
PROLAPSE OF UTERUS
uterosacral ligament complex and
endopelvic fascia that normally support the
uterus and upper vagina over the pelvic
diaphragm.
m Vaginal vault prolapse
n refers to descent of the vaginal apex below
its normal position in the pelvis after a woman
has had a hysterectomy.
m Enterocele
n hernia in which the normal anatomic
endopelvic fascia is absent so that small bowel fills
the hernia sac . (MCQ)
n peritoneum is in contact with vaginal mucosa
n Enteroceles are the result of separation of the
pubocervical and rectovaginal fasciae,
which allows a peritoneal sac with its contents to
protrude through the fascial defect.
n Etiology of pelvic floor damage. . (MCQ)
n Heavy lifting,
n obesity, chronic coughing
n chronic diseases, especially those
accompanied by neuropathy, are associated
with pelvic organ prolapse.
n hypoestrogenic state of menopause
n genetic predisposition
n History.
n Patients with vaginal prolapse commonly l splinting (applying pressure between the
describe aching in the groin or lower back . vagina and the rectum to elevate the rectocele
(MCQ) and facilitate defecation).
l caused by traction on the uterosacral l Unfortunately, as the woman bears down
ligaments to empty the rectum, stool is pushed into the
l discomfort typically resolves when the rectocele, and the harder she strains, the larger
patient lies down the rectocele becomes.
n ulceration on the vaginal wall n Physical examination.
n The symptoms of urethral support are generally n When a patient with pelvic organ prolapse is
those of stress urinary incontinence. . being evaluated, there are four
(MCQ) “compartments” that should be systematically
n When patients have defective support of the assessed
upper anterior vaginal wall, they often l anterior vaginal wall,
complain of difficulty voiding and a sense l uterus and vaginal apex
of incomplete emptying. l posterior vaginal wall
n Sometimes, these patients report that they must l presence or absence of an enterocele
strain or perform a Valsalva maneuver to should be determined.
empty the bladder. n The physical examination should be performed
n Patients with a rectocele complain of the with the patient in the lithotomy position.
l sensation of pelvic pressure n Pelvic organ prolapse defects are best identified
GOB
l feeling that there is a mass or bulge in the vagina using a Sims speculum or the posterior blade
l inability to evacuate the distal rectum without of a Graves speculum
straining n While the other compartments are supported,
the patient is asked to strain forcefully or
cough vigorously. During this time, descent
of the pelvic organs is systematically observed.
Traditional anatomical site prolapse classification.

PROLAPSE OF UTERUS
Urethrpcele Prolapse of the lower anterior vaginal wall involving the urethra only
Cystocele Prolapse of the upper anterior vaginal wall involving the bladder.
Generally there is also associated prolapse of the urethra and hence the term cystourethrocele of often used.
Uterovaginal This term is used to describe prolapse of the uterus, cervix and upper vagina
Prolapse
Enterocele Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
Rectocele Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina

n The Pelvic Organ Prolapse Quantitation system.
(MCQ)
m commonly used to quantify the degree of pelvic
organ prolapse seen during the physical
examination.
m It describes nine measured segments of a
patient’s pelvic organ support. The prolapse of
each segment is evaluated and measured relative
to the hymenal ring, which is a fixed anatomic
landmark.
Stages of POP-Q system measurement

Stage no prolapse is demonstrated
0
Stage the most distal portion of the prolapse is morethan 1 cm above the level of the hymen
1
Stage the most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane
2
Stage the most distal portion of the prolapse protrudes morethan 1 cm below the
GOB
3 hymen but protrudes no further than 2 cm less than the total vaginal length
(for example, not all of the vagina has prolapsed)
Stage vaginal eversion is essential complete
4
PROLAPSE OF UTERUS
Points and landmarks for POP–Q system examination. Aa, point A anterior, Ap, point A posterior, Ba,
point B anterior; Bp, point B posterior; C, cervix or vaginal cuff; D, posterior fornix (if cervix is present); gh,
genital hiatus; pb, perineal body; tvl, total vaginal length

n Diagnostic studies. ® obliterates the cul-de-sac using sutures
m if the patient has defecatory complaints, a dynamic placed sagittally between the uterosacral
MRI can be useful. ligaments.
m A defecating proctogram (quadruple-contrast „ Transverse plication of the uterosacral
study), which is performed under fluoroscopy, ligaments
allows visualization of the small bowel, bladder, vagina, ® used to obliterate the cul-de-sac.
and rectum during defecation. „ In all three of these procedures, care must
n Treatment. be taken to avoid kinking a ureter.
m Nonsurgical l Abdominal sacral colpopexy . (MCQ)
n Hormone replacement therapy. . (MCQ) „ a procedure used to suspend the vagina
l Estrogen replacement therapy to the sacral promontory
l affects postmenopausal urogenital symptoms „ used as a treatment for uterovaginal
l HRT alone will not relieve a patient’s prolapse and vaginal eversion
prolapse. „ It is the procedure of choice for patients
l However, HRT before a surgical repair is who have other indications for
performed is beneficial because it promotes abdominal surgery.
vaginal cellular maturation and improves „ synthetic materials such as polypropylene
symptoms of atrophy. or polytetrafluoroethylene mesh are
n Pelvic muscle exercises. -Kegel exercises. most commonly used for the graft
(MCQ) l Paravaginal repair.
GOB
l aimed at improving muscle tone of levator „ This repair is performed for anterior
ani , can alleviate the symptoms of prolapse vaginal wall prolapse
l the bladder and other pelvic organs are „ accomplished using an abdominal
supported by the levator ani muscles,. (retropubic) or vaginal approach
n Pessaries . (MCQ) „ goal of this repair is to reattach the
l oldest effective treatment for prolapse. anterolateral attachments of the vagina,
l one of the most commonly used for prolapse including the overlying endopelvic fascia,
is the doughnut-shaped pessary. to the arcus tendineus fasciae pelvis.
PROLAPSE OF UTERUS
l Pessaries are placed in the vagina and are n Vaginal

retained above the pelvic floor musculature, l Transvaginal hysterectomy with or
which prevents the smaller uterine cervix from without anteroposterior colporrhaphy .
passing through the introitus. (MCQ)
l Having the patient remove the pessary at „ the operation most commonly performed
night minimizes the vaginal discharge that is for the treatment of uterovaginal prolapse.
commonly associated with pessary use. „ Each patient has different degrees of
l In addition, treatment with estrogen, prolapse in the anterior and posterior
either locally or systemically, helps the compartments.
vaginal mucosa tolerate the foreign body. „ Should there be significant prolapse in either
l Because pessaries can cause erosion and of these compartments, simply removing the
ulceration, patients should be examined uterus will not correct prolapse of the vaginal walls.
periodically. l Anterior colporrhaphy. . (MCQ)
m Surgical „ is performed to repair a cystocele and
n Abdominal cystourethrocele.
l Enterocele repair. - three techniques for „ The objective of anterior colporrhaphy is
the abdominal repair to reduce the protrusion of the bladder and vagina
„ Moschcowitz procedure. (MCQ) „ In this procedure, the layers of the vaginal
® performed by placing concentric muscularis and adventitia overlying the
purse-string sutures around the cul-de- bladder (pubocervical fascia) are plicated.
sac, including the posterior vaginal wall, „ In women suffering from stress
right pelvic side wall, the serosa of the incontinence, a Kelly suture to plicate the
sigmoid, and the left pelvic side wall. bladder neck helps to correct stress
„ Halban procedure . (MCQ) incontinence
n Posterior colporrhaphy . (MCQ)

„ done to correct a rectocele and repair a „ To avoid the obstetric complications of
deficient perineum. Fothergill operation, Shirodkar modified
„ It is commonly combined with an anterior this operation. (MCQ)
colporrhphy, or a vaginal hysterectomy „ The anterior colporrhaphy is performed
requiring pelvic floor repair, and as part as usual

of „ attachment of Mackenrodt ligaments to
l Rectovaginal fascia defect . (MCQ) the cervix on each side is exposed.

„ a procedure in which isolated defects in „ The vaginal incision is then extended
the rectovaginal fascia are identified and posteriorly round the cervix
reapproximated, so that normal anatomy is „ pouch of Dou-glas is opened
restored. „ uterosacral ligaments identified and
l Perineorrhaphy divided close to the cervix.

„ the identification and reconstruction of „ The stumps of these ligaments are crossed
the elements of the perineal body. and stitched together in front of the cervix.
l Fothergill’s repair (Manchester „ A high closure of the peritoneum of
operation) . (MCQ) the pouch of Douglas is carried out. The

„ In this operation, the surgeon cer vix is not amputated and later
® combines an anterior colporrhaphy pregnancy complications avoided.
with amputation of cervix „ The rest of the opera-tion is similar to
® sutures the cut ends of the Fothergill’s operation.
GOB
Mackenrodt ligaments in front of the l Vaginal hysterectomy with pelvic floor
cervix repair
® covers the raw area on the amputated „ suitable for . (MCQ)
cervix with vaginal mucosa and follows ® women over the age of 40 years
it up with a colpoperineorrhaphy ® those who have completed their
„ The operation preserves menstrual and families

childbearing functions. . (MCQ) ® no longer keen on retaining their
„ However, fertility is somewhat reduced childbearing and menstrual functions.
PROLAPSE OF UTERUS
because of the-;amputation of the cervix causing „ The age limit may be relaxed to 35 years
loss of cervical mucus. for women who have . (MCQ)

„ It is suitable for women under 40 years ® additional menstrual problems
who are desirous of retaining their ® uterus is a seat of fibroids,

menstrual and repro-ductive function. adenomyosis.
(MCQ) ® The operation relieves the woman of
„ Some include dilatation of cervix and her prolapse and also of her menstrual
endometrial cuRettage as a preliminary problems.
step in Fothergill repair. „ A Kelly stitch may be necessary to relieve
„ This is optional, but desirable in a woman her of stress incontinence, if this is

complaining of men-strual disorder present.
associated with prolapse. „ Complications . (MCQ)
„ Obstetric complications of Fothergill ® haemorrhage, sepsis, anaesthesia
operation. (MCQ) risks

® Cervical amputation may lead to ® urinary tract infection
» Incompetent cervical os ® rarely trauma to the bladder and
» habitual abortions rectum may occur.

» preterm deliveries. ® Vault prolapse follows as a late sequela
® Excessive fibrosis may lead to cervical in a few cases.

stenosis and dystocia during labour. ® Dyspareunia is caused by a short vagina.
Very rarely, it may cause haematometra. „ LigaSure
® Recur-rence of prolapse may occur ® LigaSure vessel sealing system
following vaginal delivery in some cases. ® used to secure the pedicles in vaginal
l Shirodkar’s procedure hysterectomy.

® device consists of bipolar ligaments, and then the ends of the tape
radiofrequency generator, reusable were brought forward retroperitone-ally,
hand-piece and disposable electrodes. and attached to the external oblique
® The electrodes melt the col-lagen and aponeurosis.
elastin in the vessel wall to form a seal „ Abdominocervicopexy can be combined with
zone. a . (MCQ)
® The quick surgery with LigaSure is ® Moschcowitz’s repair to obliterate an
an advantage. enterocele
® Vaginal hysterectomy is mainly ® anterior colpor-rhaphy and
perfor med for major degree of colpoperineorrhaphy to correct
uterine prolapse in the elderly woman. additional genital laxity of the vagina.
„ Vaginal hysterectomy is contraindicated
if the uterus is: . (MCQ) l Indian gynaecologists that contributed
® Very bulky (more than 12-14 weeks) signifi-cantly to the operative repair of genital
® Fixed by abdominal adhesions and prolapse.
inflammatory disease „ Virkud’s sling operation
® Abdominal adhesions are likely to „ Mangeshkar’s laparoscopic tech-nique,
be present if the woman had „ Neeta Warty’s laparoscopic modification of
previous abdominal surgery or Shirodkar’s operation.
caesarean section. l Shirodkar’s abdominal sling operation for uterine
GOB
® Other pelvic pathology exists such as prolapse. (MCQ)

endometriosis and ovarian tumour. „ designed to meet the special needs of the
In such cases, proper laparotomy is case of a nulliparous prolapse having
indicated. inherently weak supports.
n Abdominal sling operations l Khanna’s sling operation
l designed for young women . (MCQ) „ In this operation the Mersilene tape is fixed to
„ suffering from second- or third-degree terine the isthmus posteriorly, and the two free ends
prolapse, brought out retroperitoneally to emerge
PROLAPSE OF UTERUS
„ who are desirous of retaining their out at the lateral margin of the rectus
childbearing and menstrual functions. abdominis muscle on either side, and
l The objective of these operations is to anchored to the anterosuperior iliac
buttress the weakened supports spine on either side.
(Mackenrodt and uterosacral ligaments) n Enterocele repair.
of the uterus by providing a substitute in the l McCall culdoplasty procedure
form of nylon or Dacron tapes, used as slings to „ an enterocele is surgically corrected at
support the uterus. . (MCQ) the time of a vaginal hysterectomy
l The advantage of the synthetic tapes is that „ The advantage of this procedure is that it
they are strong and non-tissue reactive. not only repairs the enterocele, but it
l The sling operations are best suited to provides apical support for the vagina
nulliparous prolapse „ Some have recommended performing this
l The operations in common practice include:. procedure with ever y vaginal
(MCQ) hysterectomy to prevent future enterocele
„ Abdominocervicopexy. formation and vaginal vault prolapse.
„ Shirodkar’s abdominal sling operation. m A LeFort partial colpocleisis . (MCQ)
„ Khanna’s abdominal sling operation. l performed to obliterate the vagina.
l Abdominocervicopexy l performed to reduce uterovaginal prolapse
„ Presently, the surgeon uses a 12 inch long l apposes the anterior and posterior vaginal
Mersilene/nylon tape to provide the new walls.
artificial supports for the uterus l It is considered to be an operation of last
„ Purandare and Mhatre improved on the resort, and the patient should understand that
original opera-tion by attaching the tape she will not have a functional vagina.
posteriorly on the cervix close to the
attachments of the uterosacral
l Advantages are that the procedure can be l Inadequate weight gain during pregnancy or
performed quickly and under regional arrested weight gain after 28 weeks is also
anesthesia. associated with IUGR(MCQ)
l This procedure is commonly used in elderly l weight gain goal should be 10-12 kgs for a
patients who are poor surgical candidates. normal-weight woman. (MCQ)
l An underweight woman should be
TOPIC- 29 IUGR encouraged to achieve ideal body weight plus

an additional 20–25 kgs
n Intrauterine growth restriction l Chronic maternal disease can cause growth
m A diagnosis of IUGR is considered when the restriction(MCQ)

estimated fetal weight by sonogram falls below „ chronic hypertension
the tenth percentile for gestational age. (MCQ) „ cyanotic heart disease
m Symmetric growth restriction „ long-standing diabetes,
n has an earlier onset than asymmetric growth „ collagen vascular disease,.
restriction, (MCQ) l All of these conditions place the patient at
n all organs tend to be proportionally reduced risk for superimposed preeclampsia, which
in size. itself can lead to IUGR.
n Factors associated with symmetric restriction n Fetal causes
include (MCQ) l Fetal infection.
l chromosomal abnormalities „ Viral, bacterial, protozoan, and
GOB
l anatomic (especially cardiac) spirochetal infections all have been
malformations associated with fetal growth restriction.
l congenital infection with rubella, „ Rubella and cytomegalovirus are among
cytomegalovirus, or Toxoplasma; the best-known infectious antecedents of

l severe chronic maternal malnutrition IUGR.
l maternal smoking. l A circumvallate placenta or placenta
m Asymmetric growth restriction previa also may impair growth. (MCQ)

n has a later onset(MCQ) l Multiple fetuses. (MCQ)
n some organs are more affected than others. n Diagnosis

n Abdominal circumference is the measurement m If a lag in fundal height of more than 2 cm is
to be first affected (MCQ) found, growth restriction should be suspected and

n femur length may be affected late (MCQ) ultrasonographic examination performed.
IUGR
n head circumference and biparietal diameter (MCQ)
are usually spared. (MCQ) m Third trimester measurements are the least
n Asymmetric IUGR is attributed to placental reliable for determining gestational age because
insufficiency, which can be caused by a variety growth restriction may already have occurred.
of maternal conditions, including (MCQ) (MCQ)
l chronic or pregnancy-induced m Transverse cerebellar diameter has been shown
hypertension to correlate with gestational age in weeks up to 24 weeks

l diabetes mellitus (typically pregestational). and is not significantly affected by growth
m Etiology. restriction.
n Approximately 75% of IUGR infants are m Abdominal circumference is the parameter that
constitutionally small correlates best with fetal weight. (MCQ)

n Maternal causes m In contrast to biparietal diameter, abdominal
l Constitutionally small mothers and circumference is smaller in both symmetric and

inadequate weight gain (MCQ) asymmetric types of IUGR; therefore, its
l Maternal familial factors appear to measurement has high sensitivity for
significantly affect birth weight detecting IUGR(MCQ)
l If a woman weighs less than 50 Kg at m Abdominal circumference,
conception, her risk of delivering a small- n subject to more intraobserver and

for-gestational-age infant is doubled. (MCQ) interobserver variation in measurement than
either biparietal diameter or femur
length(MCQ)
n Variability in abdominal circumference may also l The association of IUGR with
result from fetal breathing movements, oligohydramnios also predisposes the fetus
compression, or position of the fetus. to cord compression and intolerance of
m Femur length generally labor as a result.
n decreased in symmetrically growth-restricted m Fetal outcome.
fetuses n The growth-restricted fetus is at risk for
n normal with asymmetric IUGR. (MCQ) l perinatal hypoxia
n An elevated femur length to abdominal l meconium aspiration
circumference ratio raises suspicion for l hypothermia
asymmetric IUGR. l severe hypoglycemia.
m Other associated findings. n prolonged symmetrical IUGR is likely to be
n An association between oligohydramnios and followed by slow growth after birth
fetal growth restriction has long been n fetus with asymmetric IUGR is more likely to
recognized, in which IUGR is preceded by recuperate with “catch-up” growth after birth.
oligohydramnios. (MCQ) n almost 50% of children born small for
n Detection of a grade III placenta before gestational age were found to have learning
34 weeks’ gestation should alert the clinician deficits at 9–11 years of age. (MCQ)
to the possibility of impending IUGR. (MCQ)
n Management.
m IUGR at or near term.
GOB
n The best outcome for these fetuses is achieved

by prompt delivery.
m IUGR remote from term.
n Structural anomalies should be sought in these
fetuses
n if a chromosomal abnormality is suspected
then amniocentesis,
n chorionic villus sampling, or fetal blood
sampling for karyotyping and viral studies
should be recommended.
n The parents may decide to terminate the
pregnancy based on this information
IUGR
n In cases such as trisomy 13 or 18 in which the

neonate has a short life expectancy, cesarean
section can be avoided.
m Treatment
n In women with a history of recurrent, severe
fetal growth restriction, early antiplatelet
therapy with low-dose aspirin (80 mg taken
orally once a day) may prevent placental
thrombosis, placental infarction, and fetal
growth restriction.
n Delivery
l Confirmation of lung maturity by
measurement of a lecithin to
sphingomyelin ratio of 2 or more or by
identification of phosphatidylglycerol in
amniotic fluid is a clear indication for
delivery. (MCQ)
l fetal growth restriction is commonly the result
of insufficient placental function, which
is likely to be aggravated by labor.

TOPIC - 30 PPH l Prostaglandin F2a—contraindicated:
Asthma. (MCQ)
n Early Postpartum Hemorrhage (PPH) l Misoprostol.: (MCQ)
m Excessive bleeding that makes patient symptomatic l Decrease uterine pulse pressure: (MCQ)
and/or results in signs of hypovolemia. „ Uterine artery embolization.
m Blood loss > 500 mL in vaginal delivery; > 1000 „ Hypogastric artery ligation.
mL for cesarean delivery (difficult to „ Ligation of utero-ovarian ligament.
quantify).(MCQ) n Hysterectomy.
n During first 24 hr: “Early” PPH. l Hysterectomy (additional surgery) should be
n Between 24 hr and 6 weeks after delivery: avoided in setting of coagulopathy.

“Late” PPH. n Coagulopathy
m The most common cause of early PPH is uterine l Consider coagulopathy if persistent
atony where the uterus does not contract as bleeding with above management.
expected. MCQ) l Red top tube for clot retraction test. (MCQ)
n Normally, the uterus contracts, compressing „ Normal coags if clot forms < 8 min.
blood vessels and preventing bleeding. „ Coagulopathy if no clot >12 min.
m Other causes of postpartum hemorrhage MCQ) l Uterine packing until fresh frozen plasma
n Coagulation defect and/or cryoprecipitate available.

n Atony of uterus
n Rupture of uterus
GOB
n Placenta retained
n Implantation site bleeding
n Trauma to genitourinary tract
m Risk factors (MCQ)
n Blood transfusion/hemorrhage during a previous
pregnancy.
n Coagulopathy.
n Trial of labor after cesarean (TOLAC).
n High parity.
n Large infant/twins/polyhydramnios.
n Midforceps delivery.
n Chorioamnionitis.
PPH
m Management
n Manually compress and massage the
uterus—controls most cases of hemorrhage
due to atony.
n Start two large-bore IVs and infuse isotonic
crystalloids
n Type and cross blood. Monitor vitals. Strict
inputs and outputs.
n Carefully explore the uterine cavity to ensure
that all placental parts have been delivered and
that the uterus is intact.
n Inspect the cervix and vagina for trauma/
lacerations.
n If uterus is boggy, suspect atony:
l Give additional dilute oxytocin. (MCQ)
„ Oxytocin should never be given as undiluted bolus
because serious hypotension can
result(MCQ)
l Methergine—contraindicated: HTN.
(MCQ)

TOPIC - 31 ENDOMETRIOSIS l This can explain endometriosis in locations
outside of the pelvis (ie, lymph nodes,
n Endometriosis pleural cavity, kidneys). (MCQ)
n Altered immunity:
m Ectopic endometrial glands and stroma
l There may be deficient or inadequate NK or cell-
ectopically growing outside of the uterus, often
causing pain and/or infertility. (MCQ) mediated response.
l This can explain why some women develop
m Occurs primarily in women in their 20s and 30s
m Common in nulliparous woman. (MCQ)
endometriosis, whereas others with similar
m Accounts for 20% of chronic pelvic pain.
characteristics do not. (MCQ)
n Iatrogenic dissemination:
m One-third to one-half of women affected with
l Endometrial glands and stroma can be
infertility, have endometriosis. (MCQ)
m Pathophysiology
implanted during a procedure (eg, C-section).
l Endometriosis can be noted in the anterior
n The ectopic endometrial tissue is
physiologically functional abdominal wall.
n It responds to hormones and goes through cyclic
m Genetic predisposition
n A woman with a first-degree relative affected
changes, such as menstrual bleeding.
n The result of this ectopic tissue is “ectopic
with endometriosis has a 7% chance of being
menses,” which causes bleeding , peritoneal similarly affected as compared with 1% in unrelated
inflammation, pain, fibrosis, and, eventually, adhesions. persons. (MCQ)
n With a positive family history, a patient may
m Sites of endometriosis
GOB
n Common
develop endometriosis at an earlier age than
l Ovary (bilaterally): 60% (Most common
the family member.
site ) (MCQ) m Clinical presentation
n Pelvic pain (that is especially worse during
l Peritoneum over uterus ,Anterior and
posterior cul-de-sacs. menses, but can be chronic): (MCQ)
n Secondary dysmenorrhea (pain begins up to
l Broad ligaments/fallopian tubes/round
ligaments , 48 hr prior to menses). (MCQ)
n Dyspareunia (painful intercourse) as a result
l Uterosacral ligaments. Bowel.
l Pelvic lymph nodes: 30%.
of implants on pouch of Douglas; occurs
ENDOMETRIOSIS
n Less Common
commonly, with deep penetration. (MCQ)
n Dyschezia (pain with defecation)
l Rectosigmoid: 10–15%. , Cervix.
l Implants on rectosigmoid.
l Vagina. , Bladder.
n Infertility.
l Rare
n Intermenstrual bleeding.
l Nasopharynx. , Lungs. CNS , Arms/legs.
n Cyclic bowel or bladder symptoms
l Abdominal wall. Abdominal surgical scars or
episiotomy scar. (hematuria).
n Up to one-third of women may be
m Theories of etiology
n Retrograde menstruation:
asymptomatic.
n Severity of symptoms (MCQ)
l Endometrial tissue fragments are
l does not necessarily correlate with quantity of
retrogradely transported through the
fallopian tubes and implant there or ectopic endometrial tissue
l may correlate with the depth of penetration
intraabdominally
l Show predilection for the ovaries and pelvic
of the ectopic tissue.
n Long-term complications of endometriosis:
peritoneum.
l Prolonged bleeding causes scarring
n Mesothelial (peritoneal) metaplasia:
l Under certain conditions, peritoneal tissue
(adhesions).
l Adhesions cause infertility, and small bowel
develops into functional endometrial
tissue, thus responding to hormones. obstruction, pelvic pain, and difficult surgeries.
l Congenital anomalies that promote
n Vascular/lymphatic transport
l Endometrial tissue is transported via blood
retrograde menstruation may be a
vessels and lymphatics common associated finding in adolescents.
l Chronic pelvic pain may be a result of
endometriosis
n Signs ® Creates a pseudopregnancy
l Fixed retroflexed uterus, with scarring (amenorrhea).
posterior to uterus. „ Danazol(MCQ)
l Tender uterus or presence of adnexal masses. ® An androgen derivative that suppresses
l “Nodular” uterosacral ligaments or FSH/ LH
thickening and induration of uterosacral ® cause pseudomenopause.
ligaments. (MCQ) „ Oral contraceptives (OCPs): (MCQ)
l Ovarian endometriomas ® Used with mild disease/symptoms.
„ Tender, palpable, and freely mobile n Surgical
implanted masses that occur within the l Conservative
ovarian capsule and bleed. (MCQ) „ Done if reproductivity is to be preserved
„ This creates a small blood-filled cavity in „ Laparoscopic lysis and ablation of
the ovary, classically known as a “chocolate adhesions and implants.
cyst.” (MCQ) l Definitive:
l Blue/brown vaginal implants (rare). „ Total abdominal hysterectomy and bilateral
m Diagnosis salpingo-oophorectomy (TAH/BSO).
n Laparoscopy or laparotomy: (MCQ)
l Ectopic tissue must be biopsied for l GnRH agonist (MCQ)
definitive diagnosis. „ can be used in conjunction with surgical
l The gold standard for diagnosis is treatment.
GOB
laparoscopy with biopsy proven „ It is associated with osteoporosis and
hemosiderin laden macrophages should be used for only six months.
n The colors of endometrial implants vary widely: n Adenomyosis
l Red implants—new. m Ectopic endometrial glands and stroma are found
l Brown implants—older. within the myometrium, resulting in a
l White implants—oldest (scar tissue). symmetrically enlarged and globular uterus.
n Tissue biopsy (cardinal features): (MCQ) m Occurs in 30% of women.
l Positive findings contain endometrial m Usually in parous women in their 30s to 50s
glands, stroma, and hemosiderin-laden m Rare in nulliparous women.
ENDOMETRIOSIS
macrophages. m Often coexists with (MCQ)
n Maximum time on estrogen suppression n uterine fibroids
should be 6 months due to adverse effects. n endometriosis.
m Clinical course n Signs and symptoms
n 35% percent are asymptomatic. m Common
n Symptomatic patients may have increasing n Pelvic pain (usually noncyclical).
pain and possible bowel pain and possible n Symmetrical uterine enlargement.
bowel complications. (MCQ) n Dysmenorrhea (MCQ)
n Often, there is improvement with pregnancy l progresses with duration of disease.
secondary to temporary cessation of menses. l Dysmenorrhea in adenomyosis doesn’t
n May be associated with infertility. occur as cyclically as it does in
m Treatment endometriosis.
n Medical (temporizing). n Menorrhagia(MCQ)
l The primary goal is to induce amenorrhea l 50% of women are asymptomatic.
and cause regression of the endometriotic l The diagnosis is usually made incidentally
implants. by the pathologist, when examining a
l All of these treatments suppress estrogen: surgical specimen.
„ GnRH agonists (MCQ) m Diagnosis
® leuprolide n Either ultrasound or MRI can be used to
® Suppress FSH differentiate between adenomyosis and uterine
® create a pseudomenopause. fibroids.
„ Depo-Provera (MCQ) m Treatment
® progesterone [+/– estrogen] n No proven medical therapy for treatment.

n GnRH agonist, NSAIDs, and OCPs may TOPIC - 32 INDUCTION OF LABOUR
be used for pain and bleeding.
n Hysterectomy(MCQ)
n Induction of Labour
l Definitive therapy if childbearing is complete.
m Indications (MCQ)
l The diagnosis is usually confirmed after
n Maternal:
histologic examination of the hysterectomy l Fetal demise.
specimen. l Prolonged pregnancy.
n Endometrial ablation will not improve
l Chorioamnionitis.
adenomyosis symptoms. l Severe preeclampsia/eclampsia.
n Adenomyosis: versus Endometriosis: l Maternal conditions: Diabetes, renal disease,
m Adenomyosis: (MCQ)
COPD, chronic hypertension, antiphospholipid
n Found in older, multiparous women.
syndrome.
n Tissue is not as responsive to hormonal
n Fetal:
stimulation. l Intrauterine growth retardation (IUGR).
n Noncyclical pain.
l Abnormal fetal testing.
m Endometriosis: (MCQ)
l Infection.
n Found in young, nulliparous women.
l Isoimmunization.
n Tissue is responsive to hormonal stimulation.
l Oligohydramnios.
PHYSIOLOGY
n Cyclical pain
l Postterm.
l Premature ROM.
GOB
n Clinical pearls for MD Entrance Exan m Contraindications

m Endometriosis is the most likely cause of
n Maternal: (MCQ)
infertility in a menstruating woman over the age l Placenta or vasa previa.
of 30, without a history of pelvic inflammatory l Prior uterine surgery/malpresentation.
disease. (MCQ) l Classical cesarean delivery.
m A 39-year-old woman complains of hemoptysis
l Active genital herpes infection.
during the menstrual period. (MCQ) l Previous myomectomy.
n Think: Endometriosis of the nasopharynx or lung.
n Fetal:
m Congenital anomalies that promote retrograde
l Acute distress.
OF LABOUR
menstruation may be a common associated finding l Transverse fetal lie.

in adolescents. l Cord prolapse.
m Chronic pelvic pain may be a result of
m Confirmation of Fetal Maturity
NEPHRON
endometriosis associated with adhesions. n Elective induction and/or cesarean should have
m Classic findings of endometriosis: fetal maturity documented by accurate dating
Dysmenorrhea, dyspareunia, and dyschezia. criteria or amniocentesis.
INDUCTION
(MCQ) n Dating criteria

m The classic findings on physical exam are
l Documented fetal heart tones for:
nodularities on the uterosacral ligament and „ 20 weeks by nonelectronic fetoscope.
a fixed retroverted uterus. (MCQ) (MCQ)
m GnRH treatment and pseudo-menopause
„ 30 weeks by Doppler. (MCQ)
state. (MCQ) l 36 weeks since a positive urine or serum
n The pulsatile fashion of endogenous GnRH
pregnancy test.
stimulates FSH secretion. l Ultrasound of crown-rump length at 6–11
n GnRH agonists cause down regulation of
weeks dates the pregnancy and supports a
pituitary receptors and supress FSH secretion. gestational age of 39 weeks or more
This creates a pseudo-menopause state. (gestational age is determined by the
m Pelvic ultrasounds should be performed to
ultrasound). (MCQ)
differentiate between adenomyosis and uterine l Ultrasound at 12–20 weeks confirms a
fibroids. (MCQ) gestational age of 39 weeks or more
m Adenomyosis is described as an enlarged,
determined by clinical history (LMP) and
globular, “boggy” uterus on physical exam. physical exam (ultrasound gestational age is
consistent with LMP). (MCQ)
m Induction Methods
n Oxytocin TOPIC - 33 BACTERIAL VAGINOSIS
l A synthetic polypeptide hormone that
stimulates uterine contraction. n Bacterial vaginosis (BV)
l Acts promptly when given intravenously.
m most common cause of vaginitis. (MCQ)
l Half-life about 5 min. (MCQ)
m There is no single infectious agent, rather a shift
l Complications(MCQ)
in the composition of normal vaginal flora
„ Potent antidiuretic effects of oxytocin in
with an up to tenfold increase in anaerobic bacteria,
high doses can cause water intoxication including Prevotella species, Gardnerella
(ie, hyponatremia), which can lead to vaginalis, and Mobiluncus species
convulsions, coma, and death m There is decrease in the concentration of
„ Oxytocin is related structurally and
Lactobacilli species.
functionally to vasopressin or antidiuretic m it is not considered to be sexually transmitted.
hormone. (MCQ)
„ Risk of hyperstimulation: Frequent,
m Signs and symptoms.
strong contractions that cause an l The characteristic discharge (MCQ)
abnormality in the FHR. „ thin, homogeneous, and gray-white
n Prostaglandins „ has a fishy odor.
l Misoprostol, a synthetic PGE1 analog:
l The discharge can be copious and is
(MCQ) adherent to vaginal walls on speculum
„ Can be administered intravaginally or
examination. (MCQ)
GOB
orally. l Vulvar or vaginal pruritus or irritation is
„ Used for cer vical ripening and
rare.
induction. m Diagnosis is made by the following methods.
l PGE2 gel and vaginal insert: (MCQ)
l Microscopic identification of clue cells
„ Both contain dinoprostone.
(constituting more than 20%) on a wet smear.
„ Used for cervical ripening in women at
(MCQ)
or near term. l Clue cells are vaginal epithelial cells with
Mechanical
BACTERIAL VAGINOSIS
n
clusters of bacteria adhering to the cell membrane,
l Foley balloon:
which creates a stippled appearance.
„ Passed through the internal cervical os
l Few inflammatory cells or lactobacilli
into the extra-amniotic space, inflated should be noted.
and rested with traction on the internal l The pH of the discharge should be equal to
os to cause dilation. or greater than 4.5. (MCQ)
l Laminaria:
l Positive “whiff ” test, (MCQ)
„ Organic/synthetic material that slowly
„ an amine-like (or fishy) odor is released
hygroscopically expands when placed in with the addition of KOH solution (10%
the cervix. to 20%) to the discharge.
l Erythema of the vagina is rare.
m Recommended Regimens
n Metronidazole 500 mg orally twice a day for
7 days
OR
n Metronidazole gel 0.75%, one full applicator
(5 g) intravaginally, once a day for 5 days
OR
n Clindamycin cream 2%, one full applicator (5
g) intravaginally at bedtime for 7 days
m Recommended Regimens for Pregnant Women
n Metronidazole 500 mg orally twice a day for
7 days
OR
n Metronidazole 250 mg orally three times a day
for 7 days
OR n The severity of symptoms does not correlate with
n Clindamycin 300 mg orally twice a day for 7 the number of organisms. The predominant
days symptom is pruritus, which is often
n Trichomonas infection accompanied by vaginal irritation, dysuria, or
m a sexually transmitted infection (MCQ) both.
m caused by the protozoon Trichomonas vaginalis. n The classic vaginal discharge is white, curd-like,
m Trichomonas is a hardy organism, able to survive and without an odor. (MCQ)
on wet towels and other surfaces, and thus can be n Speculum examination often reveals erythema
nonsexually transmitted (MCQ) of the vulva and vaginal walls, sometimes
m Its incubation period ranges from 4 to 28 days. with adherent plaques. (MCQ)
m Signs and symptoms m Diagnosis
n classic discharge (MCQ) n when a KOH preparation of the vaginal
l frothy, thin, malodorous, and copious. discharge reveals hyphae and buds (a 10% to
l gray, white, or yellow-green 20% solution of KOH lyses red and white blood
n here may be erythema or edema of the vulva cells, which facilitates identification of the
and vagina. fungus). (MCQ)
n The cervix may also appear erythematous and n A negative finding on KOH preparation does
friable. (MCQ) not necessarily rule out the infection. (MCQ)
m Diagnosis n A specimen can be obtained for culture, with
n A wet smear preparation reveals the unicellular results made available within 24–72 hours.
GOB
fusiform protozoon, which is slightly larger m Treatment.

than a WBC. n An oral agent (not recommended during
n It is flagellated, and motion can be observed pregnancy) is fluconazole 150 mg PO (one
in the specimen. (MCQ) dose).
n Many inflammatory cells are usually present. n In addition, clinicians can recommend
n The vaginal discharge should have a pH of consumption of yogurt, which may help
5.0–7.0. (MCQ) replenish lactobacilli to reestablish the normal vaginal
n In asymptomatic patients, the infection may first flora. (MCQ)
BACTERIAL VAGINOSIS
be recognized with detection of Trichomonas n Treatment of male partners is usually not

on a Pap smear specimen. (MCQ) necessary unless the partner has symptoms of
m Treatment consists of yeast balanitis or is uncircumcised. (MCQ)
n metronidazole 2 g by mouth (PO) (one dose)
n metronidazole 500 mg PO twice daily (bid) for
7 days.
n The patient’s sexual partners should be
treated as well
n This treatment should be avoided during the
first trimester of pregnancy (MCQ)
n Candidal vaginitis
m not a sexually transmitted infection.
m Candida
n is a normal vaginal inhabitant in up to 25%
of women
n found in the rectum and oral cavity in an even
greater percentage.
m Candida albicans is the pathogen in 80–95% of
cases of vulvovaginal candidiasis(MCQ)
m Risk factors for infection include
immunosuppression, especially HIV
infection, diabetes mellitus, hor monal
changes (e.g., pregnancy), broad-spectrum
antibiotic therapy, and obesity. (MCQ)

Distinguishing Characteristics of Vaginitis
Bacterial Trichomonas Candidal
Vaginosis Vaginitis Vaginitis
Vaginal pH ≥ 4.5 5.0-7.0 -
Type of Thin, white, Thin, frothy, white, Thick, white,
discharge adherent; a mine grey, yellow, copious curdlike
(fishy) odor with
potassium hydroxide
(KOH)
Wet smear Clue cells, no WBCs Trichomonads, WBCs Hyphae and buds WBC’s
TOPIC - 34 INSTRUMENTAL DELIVERY
n Forceps delivery
n If time permits, the patient should be given
m Classification is by station of the fetal head at
adequate anesthesia.
the time the forceps are applied.
n If forceps delivery is done for fetal distress,
GOB
n Mid forceps. Head is engaged but above the level
someone who is able to perform neonatal
of +2 station.(MCQ)
resuscitation should be available.
n Low forceps. Station is +2 or greater.
m Complications
n Outlet forceps.
n Maternal. .(MCQ)
l Scalp is visible without separating the labia
l Uterine, cervical, or vaginal lacerations
l skull has reached pelvic floor
l extension of the episiotomy
l head is at or on perineum.(MCQ)
l bladder or urethral injuries, and hematomas.
l the occiput is either directly anterior-
n Fetal. .(MCQ)
INSTRUMENTAL DELIVERY
posterior in alignment .(MCQ)
l Cephalohematoma, bruising, lacerations
l does not require more than 45 degrees of
l facial nerve injury
rotation to accomplish this.
l skull fracture and intracranial hemorrhage.
m Indications.
n Soft cup vacuum delivery.
n No indication is absolute.
m Indications, contraindications, and complications are largely
n Indications include .(MCQ)
the same as for forceps delivery.
l prolonged second stage of labor
m The suction cup is applied to the head away from
l maternal exhaustion
the fontanelles
l fetal distress
m Vacuum pressure to 0.7–0.8 kg/cc is
l a maternal condition requiring a shortened
reached,traction is applied with one hand on the
second stage.
vacuum while the other hand maintains fetal flexion
m Prerequisite criteria. .(MCQ)
and supports the vacuum cup. .(MCQ)
n Before forceps delivery is performed, the
m Traction should be applied only during
following criteria should be met.
contractions.
n The fetal head must be engaged in the pelvis.
m The vacuum pressure can be reduced between
n The cervix must be fully dilated.
contractions and should not be maintained for
n The exact position and station of the fetal
longer than 30 minutes.
head should be known.
n Maternal pelvis type should be known, and
the pelvis must be adequate. Cephalopelvic
disproportion is a contraindication for
forceps delivery.

TOPIC - 35 NST n If the fetus is already compromised with low
levels of oxygen, the contraction may cause a
n Non-stress Test (NST) late deceleration in FHR, which reflects
m evaluates four components of the fetal heart rate hypoxemia in the fetus.
(FHR) tracing: m Patient is placed in lateral recumbent position
n Baseline: Normally 110–160 beats/ and contractions are stimulated. .(MCQ)

min.(MCQ) n Administration of oxytocin
n Variability: n Nipple stimulation (2 min self-stimulation
l Beat-to-beat irregularity and waviness of the through clothes every 5 min).

FHR. m Adequate contractions: .(MCQ)
l Presence of variability reflects an intact and n Occur three times in 10 min.
mature brain stem and heart. .(MCQ) n Lasting at least 40 sec.
n Periodic changes: m Unsatisfactory: Fewer than three contractions
l Early deceleration: .(MCQ) in 10 min. .(MCQ)

„ Vagally mediated m Interpreted as the presence or absence of late
„ caused by head compression usually at decelerations: .(MCQ)

cervical dilation of 4–7 cm. n Negative: No late or significant variable
l Variable deceleration .(MCQ) decelerations.

„ caused by cord compression. n Positive: Late decelerations following 50% or more
l Late deceleration: .(MCQ) of contractions.

GOB
„ Reflects hypoxemia. n Equivocal: Intermittent late decels or significant
n Acceleration: variable decelerations.

l At least two accelerations of at least 15 m Contraindications: .(MCQ)
beats/min above baseline for 15 sec in a n Preterm labor patients at high risk of delivery.
20-min period. .(MCQ) n Premature rupture of membranes (PROM).
l Presence of accelerations = fetal well-being. n History of extensive uterine surgery or previous
m Reactive NST = two or more accelerations over 20 cesarean section.

min. n Known placenta previa
n Uterine contractions are also recorded to help n Biophysical Profile (BPP)

interpret the NST. m A biophysical profile (BPP) is the combination of
n Preterm fetuses are frequently nonreactive: the non-stress test and an ultrasound exam
l 24–28 weeks: Up to 50% nonreactive. m It has total of five components: .(MCQ)
NST
l 28–32 weeks: 15% nonreactive. n NST: Appropriate variation of fetal heart rate.
l An NST usually takes 20–40 min to n Breathing:
complete l G ≥1 episode of rhythmic breathing movements of
n If the NST is nonreactive, the baby may be 30 sec or more within 30 min.
asleep n Movement:
l If this is suspected, ask the patient to eat l g > 3 discrete body or limb movements within 30
or drink to make the baby active if not min.

reactive within 1–2 hours, then additional n Muscle tone:
testing may need to be performed. l g >1 episode of extension with return to flexion or
n Contraction Stress Test (CST) opening/closing of a hand.

m measures how the fetal heart rate (FHR) reacts to n Determination of amniotic fluid volume:
uterine contractions l Single vertical pocket of amniotic fluid
m The CST can be performed if the NST is measuring g > 2 cm is considered adequate
nonreactive. or an amniotic fluid index g ≥ 5 cm).
m The FHR and the contractions are recorded m Scoring : .(MCQ)
simultaneously. n Each of the category is given a score of 0 or 2
n During a contraction, the blood flow to the placenta points:

briefly. n 0: Abnormal, absent, or insufficient.
n A well-oxygenated fetus can compensate, and n 2: Normal and present as previously defined.
there are no decels in the FHR. .(MCQ) n Total possible score is 10 points.
n Normal score: 8–10.

n Equivocal: 6. m Most common cause of Oligohydramnios =
n Abnormal: < 4. rupture of membranes.
n In the presence of oligohydramnios (largest m “Brain sparing” may occur in hypoxic fetuses =
pocket of amniotic fluid < 2 cm), further increased ↑S/D in umbilical artery + decreased
investigation is required. ↓S/D in middle cerebral artery. (MCQ)
n Doppler Velocimetry
m Doppler sonography is a noninvasive technique
used to assess fetal hemodynamic vascular TOPIC - 36 TWINS
resistance by imaging specific fetal vessels: .
(MCQ) n Multiple gestation or twins continues to
n Umbilical artery (UA) and umbilical vein. ↑secondary to
n Aorta. m assisted reproductive techniques
n Heart. m advancing maternal age at childbirth.
n Middle cerebral artery (MCA). n Maternal adaptations
m Commonly measured flow indices are: m Cardiac:
n Peak systolic frequency shift (S). n ↑heart rate, ↑stroke volume, ↑cardiac
n Peak diastolic frequency shift (D). output is more secondary to
n Mean peak frequency shift over the cardiac n the ↑myometrial contractility and blood
cycle (A). volume.
n Systolic to diastolic ratio (S/D). n ↑in uterine volume/weight.
GOB
n Resistance index (S-D/S). m Respiratory:
n Pulsatility index (S-D/A). n Further ↑in tidal volume and oxygen
m Flow velocity waveforms differ in normal-sized consumption.
fetuses as compared to those suffering from m Renal: ↑GFR and ↑in renal size.
growth restriction: m Calories:
n Fetuses with normal growth: .(MCQ) n Average to consume 3000–4000 kcal/day
l High-velocity diastolic flow. compared to 2400 kcal/day in singletons.
n Fetuses with restricted growth: .(MCQ) (MCQ)
l ↓ velocity diastolic flow, m Weight gain:
l ↑ flow resistance (↑ S/D) in umbilical artery n Avg/week is 0.5-0.75 kgs ; total gain: 18 – 22
l ↓resistance (↓S/D) in MCA. kgs . (MCQ)
TWINS
n Very severe intrauterine growth n Types of Twins
restriction.(MCQ) m A zygote is the result of fertilization of an ovum
l Flow may be absent or even reversed. with a spermatozoan.
m Abnormal flow is usually the result of placental m Dizygotic twins are more common that
insufficiency and dysfunction, resulting in fetal monozygotic twins. . (MCQ)
hypoxia and acidosis. m Dizygotic twins
m This may induce the phenomenon of brain n result of two ova fertilized by two different sperm. .
sparing: .(MCQ) (MCQ)
n ↑ S/D in umbilical artery (↑ resistance). n Risk factors include fertility drugs, race,
n ↓S/D in MCA (↓resistance). advanced maternal age, and parity.
n These are fraternal twins.
n Clinical Pearls m Monozygotic twins
m Most common cause of size not equal to date— n result of a single ovum fertilized by one sperm
incorrect gestational age. .(MCQ) which subsequently divides.
m A reactive NST has two or more accelerations over n The frequency of 1 in 250 pregnancies
20 min = fetal well-being. .(MCQ) n These are identical twins. . (MCQ)
m When can a baby’s heartbeat be detected with m The timing of cell division within the monozygotic
Doppler? twin determines the amnionicity and chorionicity
m ( 8–12 weeks of gestation Fetal heart starts beating of twins.
at 22–24 days.(MCQ) n Division of the ovum between days 0 and 3:
m Modified BPP (mBPP) = NST + AFI.(MCQ) Dichorionic, diamniotic monozygotic twins. .
(MCQ)
n Division between 4 and 8 days: to underperfusion and the other due to over
Monochorionic, diamniotic monozygotic twins.. perfusion.
(MCQ) m The theoretical cause is unbalanced vascular
n Division between 9 and 12 days: anastomoses.
Monochorionic, monoamniotic monozygotic m US is needed for diagnosis.
twins.. (MCQ) m Treatment is laser coagulation of the
n Division after 13 days: Conjoined twins. . anastomoses.
(MCQ) n A size/date discrepancy when measuring uterine
n Monochorionic twins have more fundal height of > 3 cm should prompt US
complications than dichorionic. . (MCQ) assessment. . (MCQ)
n Monoamniotic twins have more n Differential diagnoses for a size/date discrepancy
complications than diamniotic. . (MCQ) in pregnancy include: . (MCQ)
n Prenatal diagnosis m Twins
m Both monozygotic and dizygotic twins are at m Adnexal mass
↑ for structural anomalies. m Distended bladder
m Multiple gestation have an increased risk of m Fetal macrosomia
aneuploidy. m Hydramnios
m First-trimester serum markers not as valid for m Maternal obesity
multiple gestation. m Uncertain LMP
m Nuchal translucency is the preferred first- m Molar pregnancy
GOB
trimester marker.
n Diagnosis and management of twins
m Physical exam may show a uterine size/
gestational age (GA) difference with size greater
than expected from GA.
m Chorionicity can best be determined in the first
or early second trimester by ultrasound (US).
m Monochorionic twins should undergo US
examination to look for fetal growth every 4
weeks, while dichorionic twins can be scanned
every 6–8 weeks for growth. . (MCQ)
TWINS
m Growth restriction rates are higher among the

monochorionic in comparison to the dichorionic
twin gestation.
m Monochorionic twins may also be at risk for
twin-twin transfusion syndrome. . (MCQ)
m Induction of labor of twins should be strongly
considered when 38 weeks gestation has been
reached, as the rate of stillbirth and growth
restriction?↑ after this GA.
m Breech presentation of Twin A and cephalic
presentation of Twin B
m may causes interlocking twins, and cesarean
delivery should be under taken in this causes.
(MCQ)
n Twin-twin transfusion
m A serious complication of monochorionic
multifetal gestation in which blood/
intravascular volume is shunted from one twin
to another. . (MCQ)
m The major risk is intrauterine fetal demise, in
which one twin develops complications of due

TOPIC - 37 CARCINOMA VULVA l With lymph node metastasis (> 5 mm) .
(MCQ)
n Carcinoma of Vulva l 1–2 lymph node metastasis(es) (< 5 mm), .
m Most often found in women age 60–70.(MCQ) (MCQ)

m Unlike the cervix, the vulva does not have a n IIIB:
transformation zone. .(MCQ) l With 2 or more lymph node metastases (> 5
m Vulvar intraepithelial lesions are less likely than mm)

cervical intraepithelial l 3 or more lymph node metastases (< 5 mm)
m lesions to become high grade or cancers. n IIIC:
m can arise as carcinoma of various types: l With positive nodes with extracapsular
n Squamous (90%)..(MCQ) spread

n Adenocarcinoma (Paget disease, Bartholin’s m STAGE IV:
gland). n Tumor invades other regional (2/3 upper
n Basal cell carcinoma. , Melanoma (4–5%). urethra, 2/3 upper vagina), or distant structures
n Metastasis. Sarcoma. Verrucous carcinoma. l IVA : Tumor invades any of the following:
m Signs and symptoms „ upper urethral and/or vaginal mucosa,
n Pruritus (most common). .(MCQ) bladder mucosa, rectal mucosa, or fixed

n Ulceration. to pelvic bone, or fixed or ulcerated
n Mass (often exophytic). inguino-femoral lymph nodes
n Bleeding. n IVB:
GOB
m Risk factors „ Any distant metastasis including pelvic
n Postmenopausal. .(MCQ) lymph nodes

n Smoking. m Treatment
n Immunodeficiency syndromes. n Stages I–II:
n Age l Radical vulvectomy and

n HPV ,VIN ,HIV lymphadenectomy (wide local excision is
n Vulvar skin disease (dystrophy) sometimes possible for certain small lesions
n Melanoma,Atypical moles < 1 cm). .(MCQ)
CARCINOMA VULVA
n Diagnosis n Stages III–IV:
m Biopsy of the suspicious lesion. l As above, plus removal of affected organs and
n Vulvar Cancer Staging, FIGO Revised.(MCQ) adjunct r diation therapy

m Stage I: Tumor confined to the vulva m Clinical Pearls for MD Entrance
n IA: n Remember that a dark- pigmented lesion could
l Lesions < 2 cm in size.(MCQ) be a melanoma, even in the vulvar region.

l confined to the vulva or perineum n Most common site of vulvar dysplasia is labia
l stromal invasion < 1.0 mm. .(MCQ) majora. .(MCQ)

l No nodal invasion n Pruritus is the most common symptom of
n IB: vulvar cancer. .(MCQ)

l Lesions > 2 cm in size or with stromal n Always biopsy itchy, white lesions on exam.
invasion > 1.0 mm n Most common vulvar cancer is squamous cell..
l confined to the vulva or perineum. (MCQ)

l No nodal metastasis
m Stage II:
n Tumor of any size with extension to adjacent
perineal structures (1/3- lower urethra ,1/3-
lower vagina, anus) with negative nodes
m STAGE III: Tumor of any size with or without
extension to adjacent perineal structures (1/3 lower
urethra, 1/3 lower vagina, anus) with positive
inguino-femoral lymph nodes
n IIIA

TOPIC - 38 m Treatment for coinfection with gonorrhea is
GONOCOCCUS AND CHLAMYDIA recommended using azithromycin dihydrate 2
g PO (one dose).
n The primary pathogens of mucopurulent cervicitis n Gonorrhea
m N. gonorrhoeae
are Chlamydia trachomatis and Neisseria
n a Gram-negative diplococcus
gonorrhoeae, both of which are transmitted sexually.
n infects columnar or pseudostratified
n C. trachomatis
m most common sexually transmitted organism
epithelium; thus, the urogenital tract is a common
m Risk factors include (MCQ)
site of infection. (MCQ)
n incubation period is 3–5 days.
n age younger than 24 years
n low socioeconomic status
n The most common infected site is the
n multiple sex partners
n unmarried status.
endocervix. (MCQ)
m Diagnosis.
m Microbiology.
n Culture with selective medium is the best test
n C. trachomatis (MCQ)
l obligatory intracellular organism
for gonorrhea.
n A sterile cotton swab is inserted into the endocervical
l preferentially infects the squamocolumnar
cells and thus the transition zone of the canal for 15–30 seconds; the specimen is then
cervix. (MCQ) plated on Thayer-Martin medium containing
vancomycin, colistin sulfate, and nystatin,
GOB
n Chlamydial infection is asymptomatic in 30–

which will inhibit growth of contaminants.
50% of cases (MCQ)
n A Gram stain preparation
n Patients with cervicitis may complain of vaginal
l demonstrating intracellular diplococci is
discharge or spotting or postcoital
bleeding(MCQ) diagnostic(MCQ)
l sensitivity is only approximately 60%.
n On examination, the cervix may appear eroded
and friable
n A yellow-green mucopurulent discharge
GONOCOCCUS AND CHLAMYDIA
may be present. (MCQ)

n Gram staining should reveal more than ten
polymorphonuclear leukocytes per oil
immersion field.
m Diagnosis
n A rapid slide test (monoclonal antibody test)
(MCQ)
l provides quicker, cheaper results.
l sensitivity of 86–93%
l specificity of 93–99%.
n DNA probe tests
l use nucleic acid hybridization to identify C.
trachomatis DNA directly from swab
specimens.
l has a sensitivity of 86.1% and a specificity of
99.2%.
n PCR testing
l a simple, accurate, and reliable method
(MCQ)
l detect even in low-prevalence, asymptomatic
patients
l has a sensitivity of 97% and a specificity
of 99.7%.

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GONOCOCCUS AND CHLAMYDIA

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20 Heart Disease in Pregnancy 83 - 86

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„ The hormone does not get absorbed into the

l Following hydatid mole, one should start on investigations.

® it is coital-independent and can be „ Nova T

years. (MCQ) ® It releases 65 micrograms of the

drugs. termination of pregnancy is offered, not

for NETO). n It is best inserted on the medial aspect of the

n Heavy bleeding is reported in 1 to 2% users. m Capronor

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n Failure rate- 0.9%

n Local pain, skin discolouration, bleeding,

TUBECTOMY VASECTOMY MTP

the potential for tuboplasty n At the end of 10 years, failure is reported in

needle and introducing CO2. (MCQ) m In a patient with a cardiac or pulmonary

TUBECTOMY VASECTOMY MTP

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(80% ) (MCQ) n Metastatic nodules may be felt per abdomen.

(MCQ) n Often solid and bilateral fixed with internal

m Of all the malig-nant tumours, echoes, ascites may be present

n 80% are primary in the ovary n Doppler ultrasound(MCQ)

n 20% secondary from breasts, gastrointestinal l increased vascularity

tract and colon l Pulsatile index <1. 1

m Benign tumours can become secondarily l Resistance index <4

malignant. n Metastatic and enlarged lymph nodes may

n Mucinous cyst becomes malignant in 5% be detected

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m Patients have a high survival rate. m often pedunculated. (MCQ)

n Low parity and failure to lactate appendix. (MCQ)

n Granulosa ceil tumour cell tumours may show luteinization of their

n The treatment comprises: hysterectomy.

l recommended in a perimenopausal continue HRT for more than 5 years

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l cervical intraepithelial neoplasia (CIN) concerning adolescents, in whom CIN II may

disordered growth and development of the their 20

m Various degrees of CIN. (MCQ) women ages 25–35 years, incidence of

n Moderate dysplasia, or CIN II. (MCQ)

thirds of the lining is called (MCQ) l early onset of sexual activity

n Severe dysplasia, CIN III l a high-risk sexual partner

l encompasses more than two-thirds of the „ history of multiple sexual partners

epithelial thickness with carcinoma in situ „ HPV infection,

(CIS) „ lower genital tract neoplasia

CERVICAL INTRAEPITHELIAL NEOPLASIA

(MCQ) cervical neoplasia

Bethesda system, (MCQ) l cigarette smoking (MCQ)

n atypical squamous cells are divided into those l HIV infection

of undetermined significance (ASC-US) l AIDS

n atypical squamous cells of a high grade lesion l other forms of immunosuppression

n Low-grade squamous intraepithelial lesion l long-term OCP use.

(LSIL) encompasses n Condoms are not as protective against HPV

l CIN II l defined as the presence of endocervical

l CIN III glands lined by atypical columnar

(MCQ) are positive, triaging to colposcopy is as

smears (eg, ASC-US): l normal mature squamous epithelium of

n History of in utero DES exposure. l reflects abnormal vascular patterns of the

m Normal colposcopic findings are those of: surface capillaries.

n The original squamous epithelium distances (MCQ)

junction to the original squamocolumnar the lesion

n The columnar epithelium of the endocervical lesions.

n The transformation zone(MCQ) so-called corkscrew, comma-shaped, or

n original squamocolumnar junction (MCQ) canal

m Squamocolumnar junction(MCQ) l a significantly higher percentage of