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
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|
It does not matter how slowly you go so long as you do not stop.- Confucius
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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
A complication of pih.
Elevated Liver enzymes
Low Platelet count.
*Prognostic factor of PIH
Blood uric acid level > 3.6 mg/dl, suggestive of bad prognosis
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
|b||Overt diabetics without vasculopathy|
|c||Diabetics with vasculopathy|
|Effects of diabetes on mother||Effects of pregnancy on diabetes|
|More insulin is required
Progression of diabetic retinopathy
Worsening f diabetic nephropathy
Increased risk of death in patients with diabetic cardiomyopathy.
The average person is about a quarter of an inch taller at night.
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*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
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
|Palpation||Fetal parts felt
Ring not felt
Round ligament not felt
|Fetal parts not 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|
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
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
|-Wrong gestational age
-Open neural defects
-Anterior abdominal wall defects
Used in detection of downs syndrome
*Acetylcholinesterase- Elevated in open neural tube defects
*Prolonged latent phase of labour
Latent phase exceeds 20 hours in primigravidae and 14 hrs in multigravida.
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
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
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.
Rupture of membranes, occurring beyond 37th completed weeks but before the onset of labour
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|
Hepatitis b and c
Others (syphilis, tuberculosis )
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
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*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.
|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
At one time it was believed that citrus fruits could provide protection against poisons.
ELEVENTH HOUR GYNECOLOGY & OBSTETRICS 133
ABORTION TYPES CONTINUED…
|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.
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
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
|External||Conversion is done by external manipulation only||Breech presentation and Transverse lie.|
Success isn’t permanent and failure isn’t fatal-Mika Ditka
ELEVENTH HOUR GYNECOLOGY & OBSTETRICS 134
|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
After coming head of breech
Low birth weight baby
Post caesarean pregnancy
|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
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.
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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 bleeding disorder
After coming head of breech
Partially dilated cervix
Head not engaged
*Effective vacuum needed for ventouse is 0.8 kg/ cm2
|complications of vacuum|
Subaponeurotic or subgaleal haemorrhage
|Contraindication of caesarean section|
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.
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.
|Central placenta previa-
Severe degree of contracted pelvis
Cervical or broad ligament fibroid
Advanced carcinoma cervix
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.
Malpresentation-transverse lie, brow, mentoposterior position.
Bad obstetric history
Hypertensive disorders- acute fulminating pre-eclampsia, not responding to treatment, uncontrolled eclampsia
Failed surgical induction
Medical gynaecological disorders-chronic hypertension or chronic nephritis.
Uncorrected heart disease
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.
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