09/22/2017

GYNAECOLOGY AND OBSTETRICS mci screening test and indian medical pg examz high yield important topics study tips

By Live Dr - Wed Feb 11, 3:45 am

*TOTAL 13

6-13 -favourable

5 or less is unfavourable

FETAL HEART RATE deceleration type causes
Early deceleration Head compression
Late deceleration Placental insufficiency, PIH, fetal distress
Variable deceleration Cord compression

*Baseline variability with or without periodic acceleration of the fetal heart rate is a sign of fetal well being

Increasing baseline variability (salutatory pattern) represents early compromise of fetal oxygenation

*Bpd is the single best parameter for estimation of fetal age in second trimester

Femur length is the single best parameter for estimation of fetal age in third trimester

Diagnostic criteria of PIH

Hypertension An absolute rise of blood pressure of atleast 140/90 mm of Hg,

Or a rise in systolic blood pressure of atleast 30 mm of Hg, or arise in diastolic pressure of atleast 15 mm of Hg, over the previously known blood pressure

A rise of 20 mm of Hg MAP over the previous reading,

Or when the MAP is 105 mm of Hg, or more.

The rise of blood pressure should be evident at least on two occasions, atleast 4 hours apart

Edema Pitting edema over the ankles, after 12 hours of bed rest

Or rapid gain of weight of more than 1 pound/week, or more than 5 pound a month

Proteinuria Protein in 24 hours urine, of more than 0.3 gm or more than 1 gm per litre, in  2 or more midstream specimens, obtained 6 hours apart,  in the absence of UTI

QUOTE CORNER

It does not matter how slowly you go so long as you do not stop.- Confucius

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             128

Pritchard’s regime

Magnesium sulphate- 4 gm IV and 10 gm deep IM 5 gm, in alternate buttocks 4 hourly.

Repeat injection only after checking-

Urine output is more than 30 ml/ hour

Respiration rate is > 12 / minute

Knee jerk is present.

Therapeutic level of serum magnesium is 4-7 meq/l

Treatment is to be stopped 24 hours after the last seizure

*HELLP syndrome

A complication of pih.

Hemolysis

Elevated Liver enzymes

Low Platelet count.

*Prognostic factor of PIH

Blood uric acid level > 3.6 mg/dl, suggestive of bad prognosis

Hasse’s rule

Calculating age of fetus

During first 5 months During next 5 months
Length in cm is square of the age in lunar months Length in cm is 5 times the age in lunar months

WHO criteria for diagnosis of gestational diabetes mellitus

Time Normal values Impaired tolerance Diabetes
Fasting <105 105-139 140 or more
2 hours post glucose < 160 160-199 200 or more

Classification of gestational diabetics

a Gestational diabetics
b Overt diabetics without vasculopathy
c Diabetics with vasculopathy
Effects of diabetes on mother Effects of pregnancy on diabetes
Chorioamnionitis.

Endometritis

Postpartum bleeding

More insulin is required

Progression of diabetic retinopathy

Worsening f diabetic nephropathy

Increased risk of death in patients with diabetic cardiomyopathy.

TRIVIAL TRUTH

The average person is about a quarter of an inch taller at night.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             129

*Hb A1c estimation

Less than or equal to 8.5 -least chances of fetal malformation

9.5 % or more – greater chance of fetal malformation

Screening for gestational diabetes is done at 24-28 weeks

*In rheumatic heart disease,

The fetal outcome is usually good,

In cyanotic group of diseases, there is an increased chance of fetal loss and growth retardation.

*Anticoagulants in heart disease

If the woman is on Warfarin, then she should stop it as soon as pregnancy is detected,

It should be replaced by heparin, upto the end of first trimester,

After first trimester, heparin is replaced by Warfarin, till term.

At term heparin should once again replace Warfarin, till a week postpartum, after which Warfarin should be continued.

Indication of medical management in ectopic pregnancy
Hemodynamically stable patient

Unruptured

Sac size < 3.5 cm in diameter

B hcg < 2500 iu / ml

Methotrexte  is used

characteristics constriction ring retraction ring
Eponym Schroeder’s ring Bandl’s ring
Cause Undue irritability of uterus Obstructed labor
Location Usually at the junction of  upper and lower segment

May occur at other places

Position doesn’t alter

Always at junction of upper and lower segments

Progressively moves upward

Tenderness Absent Present
Palpation Fetal parts felt

Ring not felt

Round ligament not felt

FHS present

Fetal parts not felt

Ring felt

Round ligaments felt

FHS  usually absent

Vaginal examination Ring is felt Ring is not felt
Management To relax ring after delivery of body To relieve obstruction

QUOTE CORNER

Learn as though you would never be able to master it; Hold it as though you would be in fear of losing it- Confucius

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             130

*Encirclage is done at 14 weeks or 2 weeks earlier than lowest period of previous circlage

Most common site of metastasis from choriocarcinoma is lungs

*Couvelaire uterus

There is infiltration of blood and fluid in between the muscles bundles, leading to their necrosis, however it rarely interferes with uterine contractility, and hence is not an indication for hysterectomy

RADIOLOGICAL SIGNS OF IUFD

Blair Hartley’s sign Attitude of hyperextension or hyperflexion of fetal body

Seen after 3-4 weeks

Robert’s sign Gas  translucencies are seen in fetal heart and great vessels

Seen after 12 hours

Halo sign of Deuel Radiolucent halo around fetal cranium , due to edema of pericranial fat

Seen after 2 days

Helix sign Presence of gas in umbilical cord

Maternal serum alpha fetoprotein

RAISED IN
-Wrong gestational age

-Open neural defects

-Multiple pregnancy

-Renal anomalies

-Anterior abdominal wall  defects

-Iufd

LOWERED IN
Trisomies

*Triple test

Used in detection of downs syndrome

Low msafp

High HCG

Low Estriol

*Acetylcholinesterase- Elevated in open neural tube defects

*Prolonged latent phase of labour

Latent phase exceeds 20 hours in primigravidae and 14 hrs in multigravida.

TRIVIAL TRUTH

If you yelled for 8 years, 7 months and 6 days, you would have produced enough sound energy to heat one cup of coffee.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                            131

*Prolonged labour

Combined duration of first and second stage is more than 18 hours

Labour is considered to be prolonged when cervical dilatation rate is less than 1cm/hr; descent is less than 1 cm / hr for a period of more than 4 hrs

*Precipitate labour

Combined duration of the first and second stage is less than 2 hours.

*Prelabour rupture of membranes

Spontaneous rupture of membranes any time beyond 28th week, of pregnancy but before the onset of labour.

*Term prom

Rupture of membranes, occurring beyond 37th completed weeks but before the onset of labour

*Preterm prom

Rupture of membranes, before 37th week

*Examine the collected fluid from the posterior fornix,

Ph- increases as the acidic vaginal secretion is mixed with alkaline amniotic fluid,

Characteristic ferning pattern, on microscopy

Cells stained with Nile blue sulphate show orange blue colored cells

Organisms crossing placenta
Syphilis

Parvovirus

Hepatitis b and c

Toxoplasma

Rubella

Hiv

Cmv

Torch
Toxoplasmosis

Others (syphilis, tuberculosis )

Rubella

Cytomegalovirus

Herpes

QUOTE CORNER

An educational system isn’t worth a great deal if it teaches young people how to make a living but doesn’t teach them how to make a life.- Anonymous

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             132

*Transplacental transmission of toxoplasmosis

First trimester-low incidence of transplacental infection, but disease is more severe

Third trimester-high incidence, but severity is less

*Kassowitz’s law- If a woman having syphilis, has series of pregnancies, the outcome improves in later pregnancies

HYDATIDIFORM MOLE/ VESICULAR MOLE
Complete-have only placental parts, as sperm fertilizes an empty ovum

Complete moles have 46 XX karyotype, the molar chromosomes being derived entirely from the father. (Androgenesis)

Incomplete -focal affection of the chorionic villi. So there is a fetus or an amniotic sac

Vaginal bleeding is the commonest presentation

White currant in red currant juice- blood may be mixed with fluid form the ruptured cysts.

USG -shows snow storm appearance  and Bunch of grapes appearance

High HCG titre.

Risk factors FOR DEVELOPMENT OF CHORIOCARCINOMA
Age > 35 years

Parity > 3

Initial HCG level in urine > 1 lac IU /hr

Histologically proven infiltrative mole

Previous history of molar pregnancy

*Risk of development of choriocarcinoma- 2-10 %

Routine follow up must be done for atleast 1 year, by regularly checking β HCG levels, and chest X rays.

The patient should use contraception, for atleast 2 years, to avoid confusion between fresh pregnancy and choriocarcinoma changes.

ABORTION TYPE CHARACTERISTIC
Threatened abortion Process of abortion has started but has not reached a stage, from where recovery is impossible.

External os is closed

Slight vaginal bleeding.

USG  indicates a healthy fetus

Fetal cardiac movements are present

Complete abortion Products of conception are expelled en masse.

Vaginal bleeding is absent/trace, following expulsion.

Cervical os is closed

TRIVIAL TRUTH

At one time it was believed that citrus fruits could provide protection against poisons.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             133

ABORTION TYPES CONTINUED…

ABORTION TYPE CHARACTERISTIC
Inevitable abortion It’s a clinical type of abortion where the changes have progressed from where continuation of pregnancy is impossible-

Increased vaginal bleeding

Dilated internal os, through which products of conception are felt.

Incomplete abortion Entire products of conception are not expelled but a part of it is left inside the uterine cavity,

Persistence of vaginal bleeding.

Patulous cervical os

Missed abortion/ silent miscarriage When the fetus is dead and retained inside the uterus for a variable period

Persistence of brownish vaginal discharge. absent fetal heart sounds.

Cervix firm.

Empty gestational sac

Superfecundation Fertilization of two ova released in same menstrual cycles, by separate acts of coitus, within a short period of time.
Superfetation Fertilization of two ova released in different menstrual cycles
physiological causes of hyperprolactinemia
Early morning /sleep

High protein meal

Stress, physical or psychological

Late follicular phase of menstrual cycle

Pregnancy , suckling

Prolonged breast manipulation

Coitus

Exercise

*Sheehan’s syndrome

Severe postpartum hemorrhage, shock, or severe infection, leading to anterior pituitary necrosis, leading to failure of lactation, secondary amenorrhoea, loss of pubic and axillary hair, breast and genital atrophy, lethargy and hypotension

VERSION TYPE MANIPULATION INDICATION
External Conversion is done by external manipulation only Breech presentation and Transverse lie.

QUOTE CORNER

Success isn’t permanent and  failure isn’t fatal-Mika Ditka

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             134

TABLE CONTINUED…

VERSION TYPE MANIPULATION INDICATION
Internal Conversion is done by one hand introducing into the uterus and the other on the abdomen Transverse lie in case of second baby of twins.
Bipolar (Braxton-Hicks) Conversion is done introducing one or two fingers through the cervix and the other hand on the abdomen. Lesser degree of placenta previa when the fetus is dead, deformed or previable.
Indications for forceps application
Delay In the second stage of labour

Appearance of fetal distress

Cord prolapse

After coming head of breech

Low birth weight baby

Postmaturity

Maternal distress

Pre-eclampsia

Post caesarean pregnancy

Heart disease

Conditions to be fulfilled for application of forceps
Suitable presentation and position

Cervix must be fully dilated and effaced

Membranes must be ruptured

Head must be engaged; station must be >+2

No obstruction should be present

Live baby

Uterus should be actively contracting and relaxing

Bladder should be empty.

Advantages of ventouse over forceps Advantages of forceps over ventouse
Can be used in unrotated and ,malrotated Occipito-posterior position

It can be applied through incompletely dilated cervix. (atleast 6cm )

Not space occupying

Lesser traction force required

Can be applied at higher station

Useful in suspected pelvic contraction

Quicker, hence more useful in fetal distress.

Safer in premature babies

Can be used in face presentation and after coming head of breech

Incidence of hemorrhages in fetus is less.

TRIVIAL TRUTH

Most cows give more milk when they listen to music.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             135

Indications of Ventouse
Deep transverse arrest with adequate pelvis

Delay in descent of  head of the second baby of  twins

Delay in first stage due to uterine inertia or primary cervical dystocia

As an alternative to forceps operation.

Contraindication to ventouse
Fetal distress

Pelvic contraction

Prematurity

Fetal bleeding disorder

Face presentation

Transverse lie

After coming head of breech

Partially dilated cervix

Head not engaged

Congenital anomalies

Dead fetus.

*Effective vacuum needed for ventouse is 0.8 kg/ cm2

complications of vacuum
Chignon

Cephalhematoma

Subaponeurotic or subgaleal haemorrhage

Retinal hemorrhage

Contraindication of caesarean section
Dead fetus

Baby so premature that it can’t survive ex-utero

Presence of blood-coagulation disorders.

indications of classical caesarean section
Previous classical caesarean section

Neglected shoulder with anhydramnios

Structural abnormality making approach to lower segment difficult

Constriction ring due to neglected labour

Fibroids in lower segment

Anterior placenta accreta and previa

Postmortem caesarean section

Very preterm fetus, where lower segment is poorly formed.

QUOTE CORNER

Success does not consist in never making blunders, but in never making the same one a second time.- Josh Billings

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             136

Indication of caesarean section.

Absolute indications Relative
Central placenta previa-

Severe degree of contracted pelvis

Cervical or broad ligament fibroid

Advanced carcinoma cervix

Cephalopelvic disproportion

Previous uterine scar

Fetal distress during first stage of labour

Abnormal uterine contraction

In sever degree  of Placenta previa

In lesser degree of placenta previa when bleeding continues despite low rupture of membranes.

Abruption placentae

Malpresentation-transverse lie, brow, mentoposterior position.

Bad obstetric history

Hypertensive disorders- acute fulminating pre-eclampsia, not responding to treatment, uncontrolled eclampsia

Failed surgical induction

Elderly primigravidae

Medical gynaecological disorders-chronic hypertension or chronic nephritis.

Uncontrolled diabetes

Uncorrected heart disease

Pelvic tumours

Vaginal atresia

TRIVIAL TRUTH

Modern obstetrical forceps were invented by Peter Chamberlen around 1600 and kept a family secret for three generations.

When they arrived at the home of the woman in labor, the pregnant patient was blindfolded as to not to reveal the secret, all the others had to leave the room. Then the operator went to work. The people outside heard screams, bells, and other strange noises until the cry of the baby indicated another successful delivery.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                            137

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