06/26/2017

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

GYNAECOLOGY AND OBSTETRICS

DEVELOPMENT OF VAGINA

Upper 4/5th ,  above the hymen is developed from Mucus membrane from endoderm of the canalized sinovaginal bulbs,

Musculature from the mesoderm of two fused Mullerian ducts

Lower 1/5th , below the hymen is developed from Endoderm of the urogenital sinus.
FALLOPIAN TUBE HAS 4 PARTS
Interstitial (narrowest part)

Isthmus

Ampullary (fertilization takes place here)

Infundibulum

*Uterus measures 8 cm and weighs 50-80 gm

*Female urethra measures 4 cm.

*Gland of Cloquet or Rosenmuller- upper most deep femoral gland

Doderlein’s bacillus
It appears on vagina after birth, then disappears by 10-14 days, to reappear at puberty and then disappears at menopause

It converts glycogen present in vaginal mucosa into lactic acid, to maintain acidic vaginal Ph which protects against infection by pathogenic organisms

*Cystic swelling at junction of lower 1/3 rd and upper 2/3 rd of vaginal wall should be Gartner’s duct

Cystic swelling at the junction of posterior 1/3 and anterior 2/3 rd of labium majus should be Bartholin’s cyst

Menorrhagia (Hypermenorrhoea) Excess and / or prolonged bleeding
Epimenorrhoea (Polymenorrhoea) < 21 days
Oligomenorrhoea > 35 days
Hypomenorrhoea Scant bleeding
Metrorrhagia Irregular , Acyclic bleeding

QUOTE CORNER

Only as high as I reach can I grow, only as far as I seek can I go, only as deep as I look can I see, only as much as I dream can I be.- Karen Ravn

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                           116

*Follicular ovarian cyst

Arises due to failure of rupture of follicle

Usually unilateral

Spontaneously disappear within 2 months

*Corpus luteal cyst appears due to failure of regression of corpus luteam in 14 days.

It can cause delayed menses

*LH surge precedes ovulation by 24-36 hours.

Sub nuclear vacuole seen on day 16 is the first sign of ovulation

*Fern test

Cervical mucus shows characteristic fern pattern on microscopic examination, during the estrogenic phase of cycle

It is due to sodium chloride in mucus

It disappears after 21 days.

*Rokitansky Kuster Hauser Syndrome

Congenital hypoplasia or absence of vagina in combination with an abnormal or absent uterus

Second most common cause of primary amenorrhoea

Gonadal dysgenesis is the most common cause of primary amenorrhoea

Precocious menstruation If menstruation starts before the child reaches the age of 10
Precocious puberty Appearance of appropriate secondary characters before the age of 8 years in girls
Delayed puberty Breast tissue and / or pubic hair have not appeared by 13-14 years or menarche has not occurred by 16 years

Degree of retroversion

First degree Fundus is vertical and pointing towards the sacral promontory
Second degree Fundus lies in the sacral hollow but not below the internal os
Third degree Fundus lies below the level of internal os

Degrees of uterine prolapse

First degree uterus descends from the normal position
Second degree external os  protrudes outside the vaginal introitus but the uterine body still remains inside the vagina
Third degree/ procidentia / complete prolapse Uterine body descends to lie outside the introitus

TRIVIAL TRUTH

The first-known contraceptive was crocodile dung, used by Egyptians in 2000 BC.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                          117

indications of pessary treatment
Early pregnancy , upto 18 weeks

Patients unfit for surgery

Patients waiting for surgery

Puerperium

Patients unwilling for surgery

Patients waiting to complete family.

Stress incontinence Leakage of urine coincides with stress

No prior urge to void

Small amount

Patient aware

Micturiation is normal

Urge incontinence Unable to control escape of urine once there is urge to void

Large amount

Patient aware

Urgency and frequency

Detrusor instability Incompetence may occur abruptly without a full bladder

Large amount

Patient not aware

Frequency and nocturia

Triple swab test FOR FISTULAS

Uppermost swab Placed in vaginal vault
second In middle part
Third Placed in the lower part, just above introitus

*Methylene blue dye is instilled in the bladder

Uretero-vaginal fistula Upper most swab soaked with urine but unstained with dye, lower two swabs remain dry
Vesico-vaginal fistula Upper and lower swabs remain dry but the middle swab attained with dye
Urethra -vaginal fistula Upper two swabs remain dry but the lower swab stained with dye.
fistula symptoms
Uretero-vaginal Urge present

Can pass urine normally

Vesico-vaginal Urge absent
Urethro-vaginal Urge present,

Can’t pass urine normally

QUOTE CORNER

Luck is what happens when preparation meets opportunity.- Seneca

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                           118

*Vesicovaginal fistula is the commonest genitourinary fistula, most commonly caused by obstructed labour in developing countries and following operative injury in developed countries

DIAGNOSTIC CRITERIA OF PCOS
major
Chronic anovulation

Hyperandrogenism

Clinical signs of hyperandrogenism

Exclusion of other etiologies

minor
Insulin resistance

Perimenarchal onset of Hirsutism and obesity

Elevated lh to fsh ratio

Intermittent anovulation associated with hyperandrogenism

ultrasound criteria
Increased ovarian area/ volume

10-15 microcytes organized in a peripheral rosary pattern

Increased echogenicity of ovarian stroma

Stein Levinthal syndrome
Increases androgens

Increased estrogens

Increased lh

Increased gnrh

Decreased fsh

Hirsutism and Amenorrhoea

Decreased ovarian follicular maturation

HAIR-AN syndrome-hyperandrogenism, insulin resistance, acanthosis nigricans

LH: FSH ratio is > than 3:1

*Treatment-

Clomiphene

Surgical resection

Turner syndrome
45 X

Gonads are streak

Sex chromatin study is negative

Hypergonadotrophic hypogonadism

Presents with primary amenorrhoea with delayed appearance of secondary sexual characteristics

TRIVIAL TRUTH

The condom – made originally of linen – was invented in the early 1500s.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             119

Klinefelter syndrome
Sex chromatin is positive

Karyotype is xxy or xxxy

Small and underdeveloped male genitalia

Eunuchoid appearance

Gynecomastia

Azoospermia

Androgen insensitivity syndrome/ testicular feminization
X-linked recessive inheritance

Testicular feminization syndrome is the most common form of male intersex

Primary amenorrhoea phenotypically and psychologically females with adequate breast development

Absence of axillary and pubic hair

Normal external genitalia

Short and blind vagina

Testes are placed in labia, inguinal canal or abdomen

Sex chromatin is negative

Karyotype is 46, XY

Normal testosterone level

pap smears is used to diagnose
hpv lesion

Herpes infection

Trichomoniasis

Cervical cancer

*It is taken from posterior part of vaginal wall

*For hormonal cytological evaluation it is taken from lateral part of vaginal wall

Carl Exner bodies Granulose cell tumor
Reinke’s crystal Hilus cell tumor
Signet ring Krukenberg tumor
Schiller Duval bodies Endodermal sinus tumor
Psammoma bodies Serouscystadenocarcinoma

*Meig’s syndrome-Fibroma

Pseudo-Meig’s syndrome-Brenner tumor

*Clue cells- diagnostic of bacterial vaginosis

Strawberry appearance of vagina is seen in Trichomoniasis

QUOTE CORNER

Courage doesn’t always roar. Sometimes courage is the quiet voice at the end of the day saying, “I will try again tomorrow”.- Mary Anne Radmache

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             120

*Metropathia hemorrhagica / Schroeder’s disease

Cystic glandular hyperplasia

Swiss cheese appearance of endometrium on microscopy

*Endometrial biopsy is done between 21st – 23rd days of menstrual cycle

If cycle is irregular then, it is done within 24 hours period.

*Fibroid is the most common pelvic tumour.

*Mucinous cystadenoma -is the largest benign ovarian tumour

*Commonest site of endometriosis is ovary

*Premature ovarian failure, when before 40 years

ocp progestin oestrogen
Mala N Norgestrol 30 µg Ethinyl estradiol 30 µg
Ovral L Levonorgestrel 15 µg Ethinyl estradiol 30 µg
Mala D D Norgestrel 30 µg Ethinyl estradiol 30 µg
Femilon Desonorgestrel 15 µg Ethinyl estradiol  20 µg

Contraindications to use of OCP

Absolute Relative
Thromboembolism

Active liver disease

Liver adenoma

Gall bladder disease

Cholestatic jaundice

During pregnancy

Surgery within 1 month

Genital / breast carcinoma

Focal migraine

Hypertension

Diabetes

Epilepsy

Smokers over 35

Age over 45

Obesity

Lactation

Past liver disease

Recent history of depression

Adolescence

Sickle cell disease

Hyperlipidemia

OC pills

Tumors associated Provides protection
Cervical cancer

Hepatic adenoma

Pituitary adenoma

Ovarian tumors

Uterine tumors

Benign breast disease

TRIVIAL TRUTH

In England the chance of a woman having twins has doubled since World War II. At this rate every pregnancy will result in twins by the year 2060!

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             121

Centchroman /  saheli
Nonhormonal ocp

Dose 30 mg/ twice weekly for 3 months then once a week

Weak estrogenic and potent antiestrogenic effect

Suppresses endometrial proliferation

Interferes with nidation of embryo

No effect

Can be used in dub and emergency contraception.

Cu- T 200/ Cu-T 200B

Multiload cu 250

3 years
Cu T-380 A 10 years
Nova T 5 years
Progestasert 1 year
lng –  ius 5 years
Timing for iucd insertion
Postmenstrual day 4/5

Postabortal after MTP

Postcoital upto 5 days after unprotected coitus

Postpartum 6 weeks after delivery.

Contraindication of laparoscopic tl

Absolute Relative
Associated large abdominal masses

Decompensated heart disease

Severe respiratory dysfunction

Hiatus hernia

History of abdominal surgery

Postpartum

Postabortal

Obesity

Pelvic adhesions

Previous pid

Previous pelvic surgery

METHODS OF FIRST TRIMESTER MTP METHODS OF SECOND TRIMESTER MTP
Menstrual regulation

Dilatation and curettage

Cervical softening prior to dilatation and suction evacuation

Medical methods

Surgical evacuation

Intra-amniotic instillation of drugs

Intrauterine insertion of devices

Extra-uterine methods

QUOTE CORNER

Talent is cheaper than table salt. What separates the talented individual from the successful one is a lot of hard work.- Stephen King

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             122

Indications for mtp
s– Social

h-Humanitarian

e-Eugenic  fetal anomalies

l-Life saving

f-Failure of contraception.

INDICATIONS OF THERAPEUTIC TERMINATION OF PREGNANCY
Primary pulmonary hypertension

Eisenmenger’s syndrome

Pulmonary veno-occlusive disease,

IMMUNOLOGICAL TEST OF INFERTILITY

Specific immunological problem in couple Wife’s mucus abnormal Immunological problem in male Problem in both
Wife’s cervical mucus +fertile donors semen + +
Fertile donor’s cervical mucus+ husband’s semen + +

+ Penetration of sperm with shaking movements

– No penetration of sperm with shaking movements

Normal sperm values

Volume > 2 ml
Sperm concentration > 20 million / ml
Motility > 50 %
Morphology >30 % normal forms
Aspermia Means failure of formation or emission of semen
Oligospremia/ Oligozoospermia Count is less than 20 million spermatozoa per ml
Polyzoospermia When the count is more than 350 millions per ml
Azoospermia No spermatozoa in the semen
Asthenospermia Means reduction in the vitality of spermatozoa
Necrospermia/ Necrozoospermia Condition in which the spermatozoa are dead or motionless
Teratospermia/ teratozoospermia Presence of high number of malformed spermatozoa in the semen

TRIVIAL TRUTH

On average women say 7,000 words per day. Men manage just over 2000.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             123

*Normal Ph 7.5

Seminal vesicle contributes to the bulk of volume.

Also contributes fructose, which is source of energy.

Prostate alkalinizes semen, contributes clotting enzyme and fibrinolysin.

*Infertility is inability of a couple to achieve conception after 1 year of unprotected sex

Clomiphene
Indicated in Contraindicated in
Anovulatory infertility

Polycystic ovarian disease associated with infertility

In In-vitro fertilization, gift technique and art

Ovarian cyst

Chronic liver disease

Scotoma

Anteversion Long axis of the uterus is bent forward on the long axis of vagina , making an angle of 90 degree
Anteflexion Long axis of the body of uterus is bent forward at the level of internal os with the long axis of the cervix, making an angle of 120 degrees

*Mc-Cune Albright syndrome-

Sexual precocity

Multiple cystic bone lesions

Endocrinopathies

Café-au-lait spots on the skin

Pregnancy signs

sign description
Jacquemier’s sign / Chadwick’s sign Dusky hue to the vestibule/ anterior vaginal wall
Osiander’s sign Increased pulsation of lateral fornices
Goodell’s sign Cervical softening
Piskacek’s sign Asymmetrical enlargement of uterus
Hegar’s sign On bimanual palpation, vaginal and abdominal fingers meet
Palmer’s sign Regular, rhythmic uterine contraction

*Total weight gain during a normal singleton pregnancy–11 kg

1 kg in first trimester

5 kg each in second and third trimester

QUOTE CORNER

Ability may get you to the top, but it takes character to keep you there.- John Wooden

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             124

*Naegle’s formula-

If the periods are regular,

Add 9 months and 7 days to the first day of the last menstrual cycle.

If the cycle length is more than 28 days, then extra days are to be added, if less, then they should be substracted.

Manning’s score
Non stress test

Breathing movement- atleast 1 in 30 minutes for 30 seconds duration

Atleast 3 fetal movements in 30 minutes

Fetal tone- atleast 1 in 30 min.

Adequacy of amniotic fluid

*Maximum score- 10

10-8 -Normal

6- Equivocal

4 or less – Abnormal.

Placenta succenturiata One or more small lobes of placenta, size of a cotyledon, may be placed at varying distances, from the main placental margin.
Placenta extrachorialis Circumvallate placenta-

The fetal surface of placenta shows a central zone surrounded by a thickened white ring

Ring is composed of double fold of amnion.

Placenta marginata A thin fibrous ring is present at the margin of the chorionic plate where fetal vessels appear to terminate.
Placenta membranecea Unduly large an d thin placenta-

Whole of the ovum is practically covered by the placenta.

Battledore placenta Cord is attached to the margin of placenta
Velamentous placenta Cord is attached to membranes
Placenta accrete Placenta is directly anchored to the myometrium partially or completely without intervening deciduas
Placenta increta Varying degree of penetration of the villi into the muscle bundles
Placenta percreta Penetration of the villi upto the serosal surface

TRIVIAL TRUTH

The largest cell in the human body is the female ovum, or egg cell. It is about 1/180 inch in diameter. The smallest cell in the human body is the male sperm. It takes about 175,000 sperm cells to weigh as much as a single egg cell.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                            125

Types of placenta previa

Type I

(lateral)

Major part of placenta is attached to the upper segment and only lower margin encroaches onto the lower segment but not upto the os, upto 5 cm above the os.
Type II (marginal) Placenta reaches the internal os but doesn’t cover it
Type III

(incomplete central)

Placenta completely covers the internal os when closed but doesn’t entirely do so when fully dilated.
Type IV (central) Placenta completely covers the internal os even after it is fully dilated
mild placenta previa major degree
Type I and II anterior Type II posterior, Type III and IV.

*Dangerous placenta previa

Type II posterior

As it prevents engagement of the head, preventing the compression of the separated placenta to stop bleeding.

placenta previa abruption placenta
Painless, causeless, recurrent Painful, due to pre-eclampsia or trauma, continuous
Bleeding is always revealed Bleeding may be revealed, concealed or mixed
Uterus is soft and relaxed Uterus is tense, tender, and rigid
Fetal heart sounds usually present fetal heart sounds usually absent
Placenta is present in lower segment, so Malpresentation is common Placenta is present in upper segment,  No Malpresentation
amniotic fluid colour cause
Straw Normal
Meconium stained (green) Fetal distress
Thick with flakes (pea-soup) Chronic fetal distress
Golden colour Rh incompatibility
Greenish yellow (saffron) Postmaturity
Dark coloured Concealed accidental hemorrhage
Dark brown (tobacco juice) Intra uterine death
Purulent Chorioamnionitis

QUOTE CORNER

The three great essentials to achieve anything worth while are, first, hard work; second, stick-to-itiveness; third, common sense.- Thomas Alva Edison

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                           126

PROCEDURE PREFERRED TIME
Amniocentesis 14-16 weeks
Chorionic villous sampling 10-12 weeks
Cordocentesis After 18 weeks
Placental villi sampling > 12 weeks

Amniotic fluid indicators of fetal maturity

Physical Osmolarity of 250 mosmol /litre
Chemical L:S  ratio of > 2

Identification of phosphatidyl glycerol

Creatinine> 2 mg/ 100 ml

Cytological Orange colored cells > 50% when stained with 0.1 % Nile blue sulphate
Spectrophotometric Optical density difference at 650 m greater than 0.15
Polyhydramnios Liquor amnii exceeds 2000 ml. OR

afi > 20cm / > 90th percentile for the gestational age

Oligohydramnios Liquor amnii is less than 100 ml. OR

afi < 5 cm/ < 10th percentile for gestational age

pelvis characteristic
Naegle’s pelvis Ala on one side is absent
Roberts pelvis Ala on both sides is absent
diameter size
Suboccipito-bregmatic 9.5 cm
Suboccipito-frontal 10 cm
Occipito-frontal 11.5 cm
Mentovertical 14 cm
Submento-vertical 11.5 cm
Submento-bregmatic 9.5 cm
Biparietal 9.5 cm
Bitemporal 8 cm
Bimastoid 7.5 cm
Lochia rubra (Red) 1-4 days
Lochia serosa (White) 5-9 days
Lochia alba (Pale white ) 10-15 days

TRIVIAL TRUTH

The embryos of tiger sharks fight each other while in their mother’s womb, the survivor being the baby shark that is born.

ELEVENTH HOUR GYNECOLOGY & OBSTETRICS                                                                             127

BISHOP’S CERVICAL SCORING

sign 0 1 2 3
Dilatation Closed 1-2 3-4 5 or more
Length >2 cm 1-2 cm < 1cm Fully taken up
Consistency Firm Medium Soft
Position Posterior Midline Anterior
Station -3 -2 -1, 0 +1 , +2

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