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Obg Rapid Revision 2 Only@Prepladdernotess6

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317 views88 pages

Obg Rapid Revision 2 Only@Prepladdernotess6

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mahnra
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LABOUR Stages of labour First | From onset of true labour pains to full cervical dilatation Second _| Full cervical dilatation to delivery of baby Third | Delivery of baby to delivery of placenta Fourth | Stage of observation, till 1 hour after delivery of placenta First stage is further divided into Cx dil <= | Tocolysis in preterm labour em given only in this phase Cx dil >= 4 | Partograph is plotted in om this phase (First point marked at 4 em dilatation on alert line) Further divided into 3. Acceleration phase 2. Phase of maximunn slope Deceleration phase Protraction disorders (prolonged labour) Natlipara Muttipara Prolonged latent phase >20 kes > 44 hes Active phase Protracted dilatation 2.2 om/hr LS whe Protracted descent 2 hrs Arrest of dilatation No dilatation for > 4 hr PRETERM LABOUR Onset of labour before 37 weeks Causes: > Infections: UTI, asymptomatic bacteriuria, chorioarnnionitis > Anatomical: uterine anomalies, cervical incompetence > Overdistended uterus: twins, polyhydramnios Prediction > Cenvieal length: < 2.5 em (on a second trimester scan) > Shape of cervical canal: T (normal), opening of cervical canal with bulging of membranes into cervix causing Y > V > U (in this order) B PrepLadder Ky Y' U > Vaginal secretions: presence of fetal fibronectin from 22 ~ 37 weeks (normally present in vaginal secretions before 22 weeks and then after 37 weeks as it is responsible for sticking amniotic sac to uterine cavity) Role of tocolyties > Only for pregnancy < 34 weeks > Only in latent phase (cervical dilatation < Sem) > To buy time for steroids to act to achieve lung maturity Class Drugs: Important points Beta agonists | Salbutamol + Side effects: tachyeardia, pulmonary edersa Terbutaline Ritedrine Ieoxsuprine Calcium channel | Nifedipine Drug of choice blockers Safer Calcium Mgso4 Neuroprotective antagonist Drug of choice For caraiae patients Least incidence of pulmonary edewma Side effect: neonatal hypotonia PG synthetase Not to be given beyond 32 weeks, risk of PDA in inhibitor baby Specific vole: preterm in polyhydramnios Oxytocin No proven reduction in neonatal morbidity antagonist Progesterone Safest More for prophylaxis than treatment Nitric oxide NTG patches Not commonly used donor Tests for lung maturity 2. LiS vatio > 2:4 (23: 4 precisely) 2. Phosphatidyl glycerol: best indicator (NOTE: phosphatidyl glycerol (PQ) is only a minor constituent of surfactant when compared with phosphatidyl choline (PC) but is stil a better indicator because PC is made from 24 weeks onwards and is also present in maternal and fetal serum besides amniotic fluid, whereas PG is present only in amniotic fluid and is the storage form of PC, hence is released into amniotic Fluid only when lungs are completely mature) shake test , Foam Stability index and Tap test: assess presence of fat in amniotic fluid. addition of saponifying agents forms bubbles 4. Nile blue sulfate test: Fetal skin cells shed in ananiotic Fluid contain fat in response to lung maturity. Addition of nile blue sulfate > color change to orange (>50%. cells become orange implies lung raturity) (NOTE: do not confuse with nitrazine paper test: it is a test for PROM, differentiates normal vaginal discharge from anwniotic fluid in vagina ~vaginal discharge acidic > paper turns ved = amniotic Aud > alkaline > paper turns blue ) ECTOPIC PREGNANCY Incidence: 2-2 % With ART: 5% + After 1 ectopic : 15% «After 2 ectopies : 30% Etiology + PID «History of infertility treatment = wep © H/0 tubal surgery + H/0 endometriosis Most and least common + MC site: tube «Least common site: cervical © MC site in tube: ampulla + Earliest tubal site to rupture : isthenus (4-6 weeks) + Last tubal site to rupture: corneal/ interstitial (12-16 weeks) Fate of ectopic + Most common: vascular insufficiency at the ectopic site > drop in HCG > drop in progesterone > withdrawl bleeding from uterus due to shedding of decidual cast ‘+ Tubal abortion: second most common + Rupture of tube Presentation + Most common : pain > bleeding + Syncope + Shock, (hermoperitoneurm > Cullen's sign: periumbilical bruising and Gray turner sign: Flank bruising) + Abdominal distension Diagnosis # TVS: look for ectopic gestational sac ‘Any gestational sac whether intrauterine or extrauterine should be visible by Diserivainatory zone (bHCG | Gestational sac Cardiae activity level at which sac should be seen) Tvs _| 2500 wiv 4+ weeks (5% week) | 5+ weeks (6 week) TAS. | 6500 mit ‘Se weeks (6 week) | 6+ weeks (7% week) + Serum beta HCG Normal pregnancy | Ectopic pregnancy | Abortion Doubles in 2 days Doubles in 5-7 days | Falling levels ‘+ Serum progesterone Normal pregnancy | Ectopic pregnancy | Abortion 25 ng/dl. EFW/ FL 5 (ponderal index) | 8.3 (maintained) a in late onset, first parameter to be affected is AC (abdominal civcursference) followed by femoral length, last to be affected is brain (HC and BPD) Management Rest in left lateral position Adequate dict (however malnourishment in mother is usually never a cause of UGR, as baby derives all his nourishment from the mother even if the mother is deprived) Increase in surveillance : most important, to improve fetal outcome by carrying the pregnancy to as close to term as possible ANTEPARTUM SURVEILLANCE DFMC ( Daily fetal movement count): >40 in 22 waking hours NST (non stress test): should be reactive after 32 weeks Reactive NST: at least 2 accelerations of at least 25 bpmn lasting for at least 15 sec over a period of 20 mins NON REACTIVE NST Biophysical profile: 2 points each for + NST * Fetal movement: + Fetal tone + Fetal breathing AF Single pocket Oligohydtravanios em Polyhydramnios >3 cm Total 0 points of BPP 4. Modified Biophysical profile: NST + AFL 5. Doppler Doppler of umbilical artery and uterine artery ~ Flow pattern showing systolic anc diastolic low uniformly Doppler of umbilical artery VAST ~ Vibro Acoustic stimulation test We give vibrations with probe along with loud notice (sound box) to baby — baby startles and wakes up form sleep — HR Ht = It isnot a part of BPP Contraction stress test / Oxytocin challenge test = Used to Assess possibility of normal delivery in (UGR ~ We administer and watch for HR in baby with respect to uterine contractions Interpretation: ~ oxytocin administration ~ Contraction causing 44, HR of baby — withhold normal delivery = Contractions does not cause 44 HR of baby - normal delivery can be done INTRAPARTUM SURVEILLANCE Fetal heart rate ~ stethoscope, Doppler Fetal scalp pH - >7.2 (normal) Fetal ECG Cardiotocography ~ best Assessing FHR along with uterine contractions ‘Types of Decelerations + Early decelerations: due to head compression n~ Normal in active labor + Late decelerations — it is seen in placental insufficiency ~ due to calcific vessels Note:~ Sinusoidal pattern is vare entity, but is associated with high rates of fetal morbidity and mortality. It indicates: = Severe fetal hypoxia = Severe fetal anemia inunediate C-section = Fetal maternal hemorrhage + Variable decelerations ~ Associated with umbilical cord compression \ VV > M/C form of deceleration and is associated with deceleration and recovery <20 sec. ~ IP it is >60 see, then it is abnormal pattern of variable deceleration NORMAL AND ABNORMAL LABOUR Presentation pole of the fetus lying in the lower segment = Head is lower segment of uterus - cephalic presentation Breech in lower segment ~ breech presentation Shoulder in lower segment ~ shoulder presentation LIE ~ the vertical axis of baby in relation to vertical axis of mother ~ Cephalic and Breech presentation has vertical lie-can be vaginally delivered ~ Shoulder presentation has transverse lie- always C- section is done, even if baby is dead. Scenario:~ At 37 weeks, uterus relaxed (woman not in labour): = Breech and shoulder presentation (transverse lie), external cephalic version (ECV is tried, to make them cephalic. Around 37 weeks liquor is reducing and baby is increasing in size so if turned, it says in that position. = ECV (external cephalie version) not done around 30-32 weeks, baby can turn back to prior position. Im the case of Transverse lie ~ If patient in labour ~ C ~ section ~ If patient presents as 37 weeks (not in labour) - try ECV Note: only in 2™ Twin in T-lie (uterus is relaxed) ~ internal podalic version (IPV). Otherwise (IPV) is contraindicated in T-lie due to risk of rupture of uterus. Presenting part — the part of the presentation at internal os is presenting part. If presentation is cephalic. = Attitude — flexed head = Presenting part — vertex = Diameter of Engagement ~suboccipitobregmatic 9.5 em = M/C positions of vertex ~ left occipital anterior (LOA) and left — occipito transverse (LOT). ‘Steps of labor in normal vertex and flexed head Engagement ~ head enters the pelvie floor Descent Flexion (ongoing) Internal rotation — head hits the pelvic floor (levator ani) and rotates internally and pretntng prt comes ver vgn © Delivery by extension Restitution — correction of internal rotation of head and neck after deliver . External rotation — rotation of head outside due to shoulder rotation inside (women posterior hits the pelvic floor. MC rnalposition is right occipitoposterior — (ROP) MC presentation is cephalic MC malpresentation is breech 80% times OP (occipitoposterior) ~becomes OA -Delivers normally 15-46% times OP- Stay OP ~ delivers as face to pubis. 2-B% becornes ~ occipitotransverse (OT) an gets stuck and known as Deep Transverse Arrest (DTA) In DTA- can try manual rotation and extract by forceps and best ynanaged by “C-section”. Deflexed head -(Straight head) = Presentation ~ Brow 4 ~ Diameter of engagement ~ mentovertical (MV) (14cm) And always do C-section Extended head — presentation — face Diameter of engagement — submentobregmatic (4.5cre) Submentovertical (10ci) M/C position of face — left Mento-anterior In right Mentoposterior — diameter of engagement is sternobregmatic (17.5em) — cannot deliver. Mentoanterior — face delivery happens @ PrepLadder If it becomes mentoanterior — delivery = Mentoposterior << Pelvie diameters Palpate the sacral promontory with tip of middle finger Uf stays entoposterior ~ C — section Pelvic inlet ‘And mark the level of lower border of pubic symphysis At base of thumb. This distance between tips of middle Finger to base of thumb is diagonal conjugate (DC) Diagonal conjugate:- distance between lower part of symphysis pubis and top of the sacrum — 22 om Antaomical conjugate (OC)- from pubic tubercle to top of sacrum — (DC-2em)= 10 cm = Narrowest diameter of pelvie inlet = 10.40 em ~ contracted inlet Mid pelvis From lower border of symphysis pubis to ischial spine laterally and S4-S5 posteriorly is plane of mid pelvis. = (ISD) interspinous diameter is the narrowest (10.Sev) and is station = When Biparietal diameter (BPD -9.5cme) negotiates the ISD, that time occiput felt per-vaginally is at +2 station (20m below ischial spine) = Im adequate pelvic ~ baby easily reaches +2 station and beyond = ISD <20 em ~ senall pelvis, <8 cm — contracted pelvis Outlet Distance between ischial tuberosities <# cm — contracted outlet (outlet contracture) ‘Types of pelvis Gynecoid pelvis Anthropoid pelvis = M/C type = Slightly narrow side walls - Rounded cavity ~ OP in anthropoid has no space to rotate = OA presentation is seen = So, it delivers by face to pubis >. Cees >) Pet ( J ve Android pelvis = Male type of pelvis = Spacious posteriorly, becomes narrow anteriorly = OP in android can rotate to OT, but cannot rotate to OA So, DTA is seen Platypelloid /Flat pelvic - - Rarest type <3% ~ Oblong compressed from front and back ~ Face presentation is seen Flexed (complete) extended (Frank) ~ can deliver normally Footling (incomplete) - C- section © MC type of breech — extended breech © Best type of breech for vaginal delivery — extended breech (not extended head) © Type of Breechvaginal delivery done ~ assisted Breech vaginal delivery:~ Here we do not touch the baby till umbilicus is seen and delivers on own. For extended legs in Breech delivery ~ Pinard’s Maneuver can be done- Middle Zindex finger is used to tap the popliteal Fossa at legs and flexing of extended legs is done. For extended arms — Lovset's maneuver ~ For after coming head 2 Can do malar flexion and shoulder traction oo Jaw flexion and shoulder traction known as Mariceau Swmelliee Viet (MSV) © Pipers forceps ean be used ~ safest © Burns Marshall technique Note: -Burns Marshall Technique ~ Baby allowed hanging by its own weight And when nape of neck is visible, both Feet are held and swing Ina long are upwards. Head is born by flexion in this maneuver. Placenta Variations of Placenta Normal Placenta - Two Arteries and one vein ~ Normally right vein gest obliterated ‘Types of placenta Bilobate Marginal placenta aka Battledore placenta Succenturiate placenta ~ can present with secondary PPH Bilobed placenta — associated with polyhydraminos and can also have abruption Cireumvallate placenta ~ extra chorial placenta ~ doubling of Amnion and chorion around periphery of placenta Cireuna marginate placenta — also type of extra chorial placenta © Thin membrane. along with fibrin deposits around the periphery © Association with abruption and IUGR Velamentous placenta — there is problern of Torrential hemorrhage of fetal origin while delivery in vasa previa © Velamentous cord when present at OS. tt is called “Vasa Previa” © Im >50% cases of vasa previa, baby dies. Note: ~Doppler in third trimester can pick up vasa previa best Scenario: Distinguish between maternal blood and fetal blood in case of bleeding PV-> to rule cout either it is placenta previa or Vasa Previa + APT test is done (Qualitative test) Blood sample» Alkaline denaturation of Hb NaOH Fetal RBC Resists Alkaline denaturation of HB Colourless/ Yellow blood sample ‘Maternal blood loss confirmed Quantitative test for assessing fetal blood — Kleihauer Betle test — done for Fetornaternal hevnorrhage assessment in Rh (SO inwmaunization Ex:~ Mother (A-) and baby (At) ~ mother get contaminated with “D” (Rh) antigen from. blood of baby and Anti-D Ab’s are made, then in next pregnancy All Anti D-Ab are going to act against baby with D (Rh) antigen present resulting in fetal RBC hemolysis = Hydrops fetals. Mx- Anti- D administration after delivery of first baby-within 72. hours Dose = 300mg Anti-D will neutralize 30m of fetal blood /2 wl off fetal RBC We get fraction of fetal origin cells in slide with respect to mnaternal RBC — we can adjust the dose of “Anti-D” according to that Anti — D is also given prophylactically at 28 weeks ~ 1# dose 1 At 34 weeks ~ Another dose ¥ After delivery ~ another dose within 72. hours. According to American guidelines: 1 dose given at 28 weeks-2™ dose within 72 hrs after delivery. Ante partum Hemorrhage — Any bleeding in genital tract after 28 weeks till delivery. Causes ~ Vasa previa ~ Placenta previa - Abruption ete. Placenta previa Zs = Complete and partial cowering OS are major types and cause bleed ~ If placenta is in lower segment but > 2 em away from OS-Low lying placenta Scenario: = Term pregnancy (37-42 weeks) complete /partial PP + bleeding — Mx= Cesarean section = Term pregnancy +PP (no bleed) — if totally covering OS — Mx = cesarean section © If partially covering OS - PV examination done under Anesthesia (under TIVAMlight GA) in OT If placenta is not present within 10 cm range of PV examination that is placenta is moved away due to effacement — Mx = Trial of normal delivery PP + bleeding at <4 weeks of gestation — Mx Rest, sedation and observation in high visk ward after resuscitation of patient — “Meafee Johnson regime” 0% of bleeding stops after First episode of PP bleeding but if bleeding continues ~ ¢. section is done Steroids are given ASAP when patient come for lung maturity Tocolyties are not given in bleeding PP patient and also not given in vasa previa. Abruption Placenta ~ Separation of placenta abruptly before the delivery of baby = Uterus is tender to touch Revealed concealed Couvelaire /bruised Uterus > Uterus is tender to touch = Abruption at term — never a direct indication for LSCS = iFabruption along with fetal distress (HR<220) (Scalp pH<7.2)- CS is done ARM (artificial rupture of membranes) | bleeding because of compression of the placenta. It also releases local prostaglandins that help in induction of labour. Oxytocin is also administered along with it (f abruption at <34 weeks and blood collecting at back of placenta will releaces tissue Thronboplastin © Triggers coagulation cascade-DIC occurs. © There is no role of conservative management Mx= steroids — for lung maturity +ARM is done for Augnsentation of labour. Tocolysis is C/1 im it (we hasten the delivery in Abruptio placenta) Note: If ant maternal problem regarding wellbeing of mother or fetal distress — CS is done Abruptio placenta Placenta previa Tocblytics are C/\ in APH. Vasa previa HTN in pregnancy 8P>140/40 on >2 occasion after 20 weeks of gestation + Proteinuria (>300mg of protein in 24 hour urine or 4+ oF dipstick) Pre-Eclamptic Toxernia + Convulsion Eclampsia ‘Acute on chronic HTN:~ = Chronic HTN +after >20 weeks of pregnancy — superadded HTN of pregnancy = Low platelets <1 lakh ] Happens only in pregnancy not present before = New onset proteinuria Mx of HTN DOC is Labetalol — chronic HTN and Hypertension of pregnancy (200-200mg-Thrice 4 day). Labetalol IV is DOC for HTN emergency also Methyldopa - 250-500mg QiD(S/E-depression and drowsiness) DOC for Eclarnpsia -MgS0x © Pritchard regime —1V+IM © 4gm 20% IV slowly in 3-4 wninutes © Sgm (SOR) in each buttock Note: most important step in Eclampsia — Delivery of baby. CS is NOT C/I MgS04 is administered for 24 hrs after delivery or 24 hours of last convulsion whichever is later. —_knee - knee jerk should be present 5g over 4 hours is given keep check on these signs = RR >44/min ~ Urine output >00ml/4 hours ~ If these signs are absent then discontinue MgSO4 Etiology of Eclampsia ~ Vasospasm of placental vasculature causes | in intra vascular volume > mother BP increases to give more perfusion to fetus — to overcome placental vasculature vasospasin High BP causes: Retinal Hemorrhages Subcapsular hematomas of liver ~ Epigastrie pain HTN Nephropathy ~ Proteinuria Extrudes electrolytes from membranes in brain — irritates Meninges causing Convulsions. Vasespasm in placental vasculature is due to non-development of trophoblastic layer in smooth muscle layer in tunica media of blood vessels of placenta that generally occurs at 20 weeks of gestation. Note: -Furosemide is not given /C/I in HTN of pregnancy GESTATIONAL DIABETES MELLITUS Around 24 weeks or beyond ~ tt sugars (glucose) Occurs due to HPL that has insulinase like action & tt insulin resistance in pregnancy causing high sugars Pre-existing 1% sugars before pregnancy - Overt diabetes 2 Trimester high sugars directly proportional to anornalies GDM does not cause anomalies it is the overt Diabetes that cause Anomalies Metabolic problems, shoulder dystocia, large babies these are common to both - GDM and overt diabetes. Screening for overt diabetes - FBS - HbA2C<6.5 (Normal) Screening for GDM: - "x step test” by American diabetic association Fasting blood glucose (<42 is normal) 75 gm glucose given = Normal value <180 in 3 hr = Normal value <253 in 2 Hr Any abnormal value with respect to normal values ~ confirms GDM Effect of Diabetes on mother:~ 11 obstetric injuries 1.CS/t Forceps and Vaccum deliveries Shoulder Dystocia Association with PIH in 25% cases PROM, Preterm labour Chorioamnionitis Puerperal sepsis ~ Abortion Problems of newborn due to Diabetes:~ Hypoglycemia Hypocaleemia Hypornagnesernia Polyeythernia ‘Anomalies in preexisting diabetes / overt Diabetes:~ ~ M/C group of anornalies — cardiac group of anomalies (TGA is most specific, also seen are VSD, PDA) = NTD-most specific ~ “Caudal Regression syndromes’ aka Sacral agenesis, and Anencephaly Mx of Diabetes = DOC = insulin = OA = (Glyburide, Metformin) — approved for use in GDM. [Bi Preptadder M/C heart disease in pregnancy ~ RHD M/C lesion — vaitral stenosis —Mx:- Around 2 trimester Ballon Valvotomy Failure of heart disease inn Antenatal time is M/C in 30-2 weeks (COt by 50%) and in post Natal time -15 24 hours (COt by 70%) Frusemide after delivery 4 preload and decreases chances of heart Failure DOC for PPH=Oxytocin and avoid giving Methyl Ergometrine because it causes immediate. Contraction of uterus >t BP -> Heart failure In labour avoid straining in 24 stage. Use forceps /Vaccum ~ to cut short the second stage of labour /Valsalva maneuver. Normal delivery is allowed in all heart disease and Morphine is known to decrease incidence of LVF. Epidural analgesic and Morphine administration in heart failure patient is beneficial Heart diseases C/I for pregnancy = Elsenmenger Primary pulmonary HTN Marfan disease ~ involving aortic root Severe aortic stenosis ~Any heart disease which comes in NYHA Ill and IV is C/I for pregnancy ~ Co-aretation is not a C/I of pregnancy can be delivered by C- section. Epilepsy in pregnancy Does not cause fetal anomalies Fate of epilepsy patients in pregnancy: = 30% cases ~ more convulsions = 20% cases ~ reduction in convulsion = 50% cases ~ unchanged In case of epilepsy in pregnancy: Lamotrigine (DOC), Levetiracetamn Malaria in pregnancy = Worse prognosis = t chance of fulminant hepatic Failure Me: DOC- chloroquine, artesunate & quinine in resistant cases, Appendicitis in pregnancy ~ trupture /perforation /preterm labor /sepsis- so early decision to undergo Sx needed. Rheumatoid arthritis in pregnancy — better prognosis Sarcoidosis - better in pregnancy Ulcerative colitis — unchanged in pregnancy 7B in pregnancy ~ 28 /and/srtpuerperiumn- worst prognosis, In puerperium — worst as there is innmune suppression. Also t demand (lactation) | supply: heat, humidity. ~ More cormmon in low socio Economic Status ABORTIONS Spontaneous abortion— Anything delivering before <28 weeks or less than SOO gums. Note = Any baby delivery >28 weeks ~ viable baby - Term pregnancy — 37-42 weeks = MTP = medical termination of pregnancy <20 weeks 4+ trimester abortion (12. weeks) = Mostly because of chromosomal causes © Trisomy 16,13,21(16 M/C association) © Monosomy 45%0 2m trimester abortion- sostly due to Anatomical causes:~ ~ Incompetent OS ~ Bicornuate uterus ~ Septate Uterus ~ Unicornuate uterus Note: ~ causes leading to abortion in any trimester:— - Diabetes = Torch ~ Hypothyroidisen = Syphilis - SLE = APLA syndrome Recurrent pregnancy losses: ~ 5 losses at any time of pregnancy ~M/C/C - chromosornal = Other causes © Anatomical © DM/APLA/SLE/Hypothyroidism = It can never be due to TORCH group infection; because once they cause pregnancy loss then the wornen becomes immune to the infection. APLA ~ Antiphospholipid Ab syndrome Ab against phospholipid membranes ~ causing thrombosis and blood vessels will get plugged ‘[Thrombosed causing death of baby, Thrombophilias Inherited 2 Anti-Thrombin deficiency © Factor V Leiden mutation 0 Protein S and C deficiency © Prothrombin gene mutation Acquired © APLA © Major Sx/Inumobilization © Malignancy Diagnosis of APLA Clinical ertaria Vascular thrombosis: 2 arterial, venous, or small vessel thrombosis Pregnancy morbidity 4 fetal death (at or beyond the 10% week of gestation) 2 premature birth before the 34% week of gestation because of cclampsia, severe preeclampsia, or placental insufficiency 3 consecutive (pre) embryonic losses (before the 20% week of gestation) Laboratory criteria Lupus anticoagulant positivity on 2 occasions at least 12 weeks apart. Anticardiolipin antibody (IgG and /or (gM) in medium or high titer (ie. >40, or above the 99% percentile), on two or more occasions at least 12 weeks apart. Anti-2. glycoprotein —1 antibody (IgG and /or IgM) in medium or high titer (ie, above the 44% percentile) on two or more occasions at least 12 weeks apart. Note: ~Definite APS is present if at least one of the clinical criteria and one of the laboratory criteria are met. Anatomical defects ~ Only indication of unification of a Bicornuate uterus Abortion — recurrent abortions ~ Septal resection is also done in bicornuate uterus ~ In cervical incompetence, abortion occur at 20-24 weeks ‘And there is painless dilatation of cervix ~ Ie can be diagnosed Antenatally by passing Hegar’s Dilator (8 French) = Ibis also diagnosed with Antenatal sean at 10-23 Weeks ~cervis length <2.5 em (short) Leading to abortion or pre-term labour Mx of cervical incompetence ~ cevelage by 22. weeks and Beyond, M/C used method is McDonald's method. ~ Shorter cervix or Mutilated cervix ~ Mx Shiredkar’ stitch or any ‘Abdominal cerclage ~ removal of Cerelage is done at »37 weeks, or when patient comes with labor. Presentation of Abortion ~ Bleeding (mast commonly), pain = Bulging of membranes ~ On per vaginal examination if OS is closed - Threatened abortion ~ On PV iF OS is opened and products are bulging ~ mevitable abortion ~ IFS opened, H/0 passage of products and stil Few products of pregnancy felt through PV Incomplete abortion ~ closed, uterus is of N size and H/O passage of products ~ complete abortion ~ iF there are no symptoms of Miscarriage, and dead fetus/Embryo is retained in uterus (baby was alive before now dead) ~ Missed Abortion Blighted Ovura (On USG only gestational sac is seen, and no repeated USG after few weeks gestational sac increases in size but no yolk sac or fetus formation. ( Normal sequence of events: yolk sac formation — fetalnode formation — cardiac Activity) ‘Aka Abembryonie Gestation MTP ~ act passed in 1974 and implemented in 1472. Can only be done in govt. Approved centre Done by 0 Gynecologist 0 Doctor — trained for 6 months + Done 25 abortions under supervision of gynecologist. 1 trimester abortions upto 4 weeks , we can do it by medical abortion by © Methotrexate © Mifepristone followed by Misoprostol (800g) (200mg). Success vate of Mifepristone /Misoprostol:— + First 7 weeks ~ 99% + First 4 weeks - 45% Suction /evacuation is done ideally ~ 8-10 weeks Dilation / curettage is done ideally ~ 8-22 weeks If pregnancy >22 weeks ~ DOC is prostaglandins + Misoprostol - PGE2 - Tablet and used as vaginal, oral, rectal, Sublingual + Dinoprostone ~ PGE2 ~ Gel from and given in vagina + Carboprost — PGF2 a ~ injection from — given iv. Laminaria tents — act by hydroscopie method Hysterotomy: IF there is abortion failure after prostaglandins administration and to remove the dead /macerated fetus —Hysteratomy is done. POST PARTUM HEMORRHAGE (PPH) Any bleed in genital tract after delivery M/C/C — Atonic uterus, mostly due to Trauma (cervical, uterine, vaginal) Other causes © Thrombin deficiency (coagulation defect) © Retained tissue (placental bits) Any bleed 500 val in Normal delivery or >2000 mal in CS in PPH © IF 22000 nl blood loss ~ severe PPH © 4000-2000 is moderate PPH Note- Any bleed which reduces Hb by 2gm % is PPH. ~ M/C/C of maternal mortality ~ obstetric hemorrhage (M/C-PPH) ‘Management of PPH Prevention: ~ Oxytocin $-30 IU/IM (Oxytocin is stored in Refrigerator) = Control cord Traction = Massage of uterus Mx of PPH:~ = BOC ~ oxytocin 10-20 IU by IV drip ~ Methyl ergometrine - IV/IM 0.2, it is C/I in Pre-Eclampsia, toxemia, HTN, twins (before delivery of 24 baby) Rh - ve pregnancy, heart disease (MR, MS, vsp) Carboprost ~ PGF2 «- 250g ina only, upto 8 injections in 24 hours Misoprostol ~ rectal 60-800ug Activated factor Vil Prophylactically ~ Uterine artery Embolization and intra-aortic balloon (In cases like placenta accrete where there is risk of severe PPH). BRACE sutures © B. Lynch © Hayman Uterine artery lation EB Preptadcer Internal iliac artery ligation — anterior division Sub ligature is done ~ sluggish blood flow, so promotes coagulation (Reduces pulse pressure) Obstetric Hysterectomy ‘STOP BLEEDING 1. Syntocinon '5 units by slow intravenous injection (may have repeat dose). (40 units in 500m! Hartman's Solution at 125mUhour). rash Frozen plaama ‘us for every 6 us of ed cals of relentless bleeding or PY APTT >15 x normal (12-15eUKg oftota 1). Exclude trauma to vulva, vagina, cervix, and uterus. Resort to hysterectomy sooner rather than later. Note~ Dinoprostone is not given /regular drug used to control PPH (so if all other drugs given along with dinoprostone in management of PPH except- the mark dinoprostone) Types of PPH 2. PPH ~ PPH within 24 hours of delivery 2 PPH ~ PPH after 24 hour of delivery up to 12 weeks of delivery. tt is mostly due to retained placental bits. Mx = Retained placenta — manual removal of placenta ~ Retained placenta bits ~ curettage, S/E of curettage is Asherman's syndrome Removal of placenta ~ best method — controlled cord traction /Brandt Andrew method. = Forcible separation by squeezing fundus and pulling placenta ~ Credé’s Method — it cause lot of retained bits of placenta and that are managed by curettage: if overly done it results in Ashermann syndrome ~ If no delivery of placenta >30 min ~ MRP under general anesthesia Inversion of uterus = If the placenta is pulled with force Without giving counter traction = Acute inversion of placenta occurs ~ Hemorrhagic shock — M/C/C of death = Neuragenic shock Mx: Reposition of uterus manually or Hydrostatic method Note: - Last part goes first inside ~ Reposition is done under generally anesthesia. Reposition is done under general Anesthesia /Terbutaline © Once reposition is done Oxytocin is administered Morbidly Adhered Placenta /Placenta Accreta. Separation of placenta takes place at “Nitabuch layer” /fibrinoid layer ~ in case this layer — in case this layer is absent - If placenta invades the muscular layer — placenta increta ~ If placenta goes through uterine muscle and found on Serosa — Placenta perereta ~ M/C/C of placenta Accreta /Increta /percreta — low lying placenta / placenta previa Other causes:- 9 USCS © Previous repeated Curettage © Infections Mx of placenta Accreta /Inereta /Parereta = M/e treatment — obstetric hysterectomy ~ UF bleeding is controlled by sutures, it is Followed up by Post op Methotrexate or Actinomycin is given to degenerate Trophoblast that can cause Trophoblastic diseases / Tumours. a4 Trophoblastie Disease Normal reproduction 23x z “—H - > InIVF. day 3 Embryo are used. Generally 2-3 embryo are taken and transferred. E> Inner cell mass. —> Fetus —> Biastocyst- day 5 “WophoE-toderm —> Pracenta Formation of Partial mole ItOvcvte i fertilised by 2 sperms Mipoidy) O~ Partial Mole Partial Mole Fetus that is partly degenerated by vesiles. 1 causes Choriocareinoma in only 25% cases (almost not seen). Better prognosis than complete mole. It ean also be G4XXY, 69XYY, and can never be 64 YY. Complete mole It can be 46 XX (mainly), 46 XY and can never be 46 YY. The degenerated villi formation occurs — start imbibing Fluid and numerous vesicles appear ‘There is 20% risk of chorioearcinona, Difference between partial and complete mole L Complete mole Partial mole Pathology = Fetal or embryology = Absent Present tissue Hydropie swelling of Diffuse Focal villas Trophoblastie Diffuse Focal hyperplasia Imeplantation site Marked atypia Mild atypia trophoblast Karyotype 46 XX (mainly) Triploid L 46 XY EB Preptadder Presentation of complete mole and partial mole Complete mole: M/C ~ bleeding 1 BP ‘48 TSH (HCG similar to TSH) ~ hyperthyroidism Rarely passage of grape like vesicles = Uterine size > POG ~ Hyperemesis (due to HCG 1) Mx: ~ Any size - suction /Evacuation, followed by check curettage by D/C because there might bbe retained bits. Dx — chest X~ ray becouse it is M/C site of Mets = HCG values should be followed for at least 6 months after it comes negative © HCG comes negative in # weeks ~ complete mole © HCG comes negative in 7 weeks ~ partial mole Note: ~ in follow up period of & months, there should not be any pregnancy and we give contraception. Persistence of Trophoblastic tissue is confirmed by:- Continuous bleeding occurs High HCG 7200000 Persistently tt HCG + 40% of pervious value Bulky /Enlarged uterus If there is confusion at HPE of Molar / Complete Mole or partial Mole — P K4P-2 immuno staining is done, and this P is innmune staining only seen with maternal contribution in the Karyotype? Complete mole not shows P K2P-2. staining High Risk of Chorio carcinoma is seen with: - HCG >10 ~ Very large uterus = Theca Lutein cysts (HCG) rem size era repens Se rope ae Invasive mole = Does not follow normal pregnancy Marker - HCG = Surgery is maintaining of treatment Chorio-Carcinoma - Marker — HCG = Chemotherapy is treatment of choice = For older women hysterectomy can be done Placental site trophoblastic tumor = Marker — HPL ~ Hysterectomy is best management Choriocarcinoma cHORIQgARCNOMA 60s as] ast Vesieler le Abortion Normal prog. [worst 20% e <8 prognost] Risk factors of choriocarcinoma WHO classification for risk assessment/prognosis Risk Factor | ° Age = 34 ‘Antecedent pregnancy Hydatidiform. Mole Interval (months) from 4 antecedent pregnancy Human chorionic gonadotrophin (Hea) (w/e ‘ABO blood group (Fernale x male) Largest tumor mass, including uterine (com) Site of Metastases Number of metastases Prior chemotherapy = Low Risk score <7 = High Risk score >8 WHO classification was used earlier, which includes Blood group also. But now it has been replaced by FIGO classification, which do not include blood group as a risk factor FIGO SCORING FIGO SCORING Age (years) Antecedent pregnancy Interval months From end of index pregnancy to treatment Pretreatment 304-<105 serum hCG (1U/), Largest tumour size, including uterus (cr) site of Spleen, kidney | Gastro — Liver, brain metastases intestinal ‘Number of | 24 5-8 28 metastases Previous failed Single drug chemotherapy Staging of trophoblastic Disease (Choriocarcinoma) ‘Site of Metastasis | Prognosis ‘Management Uterus Good ‘Single Agent Chemo Pelvis Based on scoring If Low seore— single agent cheno Lung Based on scoring IF High score— Multi agent chemo Distant Metastasis | Poor ‘Multi agent chemo is used MC site of metastasis is lungs an MC site of metastasis = vagina (sub urethral nodule) ~ This appears as a bluish spot in the vaginal area and if you take biopsy of this area, severe hemorrhage can occur, which cannot controlled by suturing & urgent Radiotherapy needs to be given to control it. MANAGEMENT OF CHORIOCARCINOMA su o RISK ASSESSMENT a LOW RISK {Score <7) HIGH RISK (score >=8) SINGLE AGENT CHEMOTHERAPY <= asa COMBINATION CHEMOTHERAPY stance Choice of contraception in various situations ~ For vesicular mole, contraception needs to be given — best choice is COCP and UCD is C/ as it can causes perforation. For heart ds patient ~ (UCD here COCP is C/I as they cause fluid retention For DM patient — Both IUCD & COCP are safe For uncontrolled DM patients — barrier with spermicidal jelly For STD prevention ~ barriers (double barvier is controversial) Newly married couple: COCP Couples staying in separate cities: (UCD Lactational Amenorrhoea ~ POP Postnatal period >6 weeks - 1UCD Post placental IUCD (IUCD place immediately after placental expulsion)~ expulsion rate is less than 12% ace. to WHO. Sickle cell anemia — POP “Wwo separate Oocytes feriised by separate sperms. ‘areal Wepltis ater 8 days than (8-12 days {Momo twins) Dichorionic iamniatic spits > 12 days Ht spltis in 3-8 days (40% cormmones)- | Conjoined Twins Monochorionic Diamiotic (because embryonic plate deady formed), pe, S77 ® ® = Monozygotic Twin ~ Identical Twins and 1/250 (ess common) = Dizygotie Twin — Not identical so Fraternal Twins, always Dichorionic Diamniotic and 4/60-20 (more common), Note: Dichorionic Diamniotie pregnancy can also be seen in monozygotic twins if split happens before 3 days as seen above. Complications in Twin pregnancy = in case of Monochorionic pregnancy there is sharing of blood between the two babies via deep arterio-venous anastomosis © The receiving baby — Plethorie High Hb more weight © The fiving baby — Thin & weak, anemic = tn case of Monoavaniotic Pregnancy: 2 Cord accidents 2° Abruption © Single baby demise leading to DIC © Premature Rupture of membranes © Preterm labor Diagnosis of Twin pregnancy ~ USG ~ Done at 12% week of pregnancy to find out chorionicity ~Chorionicity sean Tee “Twin Peas Sign Se > ‘chorion ating tom ook ha pea ‘so sopuate paca ‘eon Dosis Done Presrarey ~ But it still does not tell about the Zygosity of pregnancy ie whether it is dizygotic or Monozygotic = If there is no invagination of tissue seen there is no invagination of issue seen CY) 4 ‘Tiss sign seen in Monochorionte Diarnioe Pragnaney, Emergency Contraception ~ Contraception given to prevent pregnancy, within 72. hours of unprotected intercourse. ~ Abortion is not a method of emergency contraception FSH ~ estrogen LS ~ Progesterone ~ Combined oral contraceptive pills (COCs) Estrogen +Progesterone v Negative feedback to pituitary (NO FSH and LH to act on ovary) 4 ‘Suppresses Estrogen +Progesterone formation by ovary ~ COC's cause artificial menstruation in the female. © Cycles are regular, anovulatory ~ Dose of Estrogen is low in COC (Max-0.03mg), so it © Reduces bleeding © Control aneenia © Since Estrogen is ess ~ ovarian cancers, endometrial cancers and fibroids are less. For emergency contraception, best given is~ Levonorgestrel (LNG) - 0.75mgx2 tablets - 12 hours apart of 1.5mgxt Tab. MOA:- - timplantation by making endometrium too fluffy or hypersecretory, = stubal motility = ovulation (by suppressing LH surge) COCP- Yuxpee regime (outdated)-2 Tab (morning) 200Ug - 42 hrs apart 2x Tab (evening) - 100ug MOA ~\ ovulation = 4 implantation Mifepristone: RU 486- dose ~ 25-50 mg; MOA:~ = Antiprogestin = 4 implantation wep - Effective upto 5 days unprotected intercourse = Most effective method but no DOC Note:~ drugs of emergency contraception are not prescription drugs, these are “Over the Counter” drugs Ulipristal acetate = Selective progesterone receptor modulator (SPRM) ~ Equally effective upto 5 days of unprotected intercourse. CONTRACEPTION wep 48 generation — Lippes loop 2M generation ~ Cu7, Cu 380 Au/Ag (380-surface area of cu in mm on device). ~ Paragard — Effective upto 10 years rd generation — Progesterone containing devices:~ = Progestasert - 38 mg, releasing 65 meg/day ~ LNG devices (MIRENA) - 52 mg, releasing 20 meg/day Also used for management of:- 0 Menorrhagia © Endometriosis © Endometrial hyperplasia ‘MOA of IUCD:- - Foreign body action - Endometrium non receptive - 44 Ovulation Note: ~ Progestasert is having above actions: also act by thickening of cervical mucous (main action). Lung also makes cervical mucosa thick but main action is making endometrium non-receptor. Side Effects of UCD ~ M/C ~ bleeding >Pain - Perforation at insertion Note: for first three months of bleeding after IUCD we give prophylactically NSAIDS and ‘Tranexamic acid to some patients Extra: ~ scenario 4~ IUCD patient got pregnant Mxz if patient wants to abort, do MTP If patient wants to continue: Remove UCD if thread is visible if thread are not visible then explain that there are SO% chances of abortion Note: ~Overall chances of ectopic pregnancy is more with patient having IUCD as compared to normal women having pregnancy. Scenario 2 Lost device /IUCD. ‘Mx: ~ First step — Exploration in OPD with artery forceps, if not found then do USG and locate device. 4 if not Found Radiography (X-ray)- Rule out pregnancy first beforehand. a = in lateral view if the Uterine sound and copper device are in same plane ~ Copper T is inside. Sterilization Vasectoray — failure rate 3mm and 5 mm (greater than stage 1A), lesion limited to the cervix uteri © IBA invasive carcinoma >Sram depth of stromal invasion of <2. ems in greatest dimension © 1B2 invasive carcinoma >2cnn and <4 cm in greatest dimension © IBS invasive carcinoma >4 cm in greatest dimension New changes A= wwieroscopic cancer; Transverse spread is not included (earlier classification used transverse spread as well) 2B = clinically obvious ~ Now 28 is further divided into 181, 182, 163 Stage tt “The carcinoma beyond the uterus but has not extended onto the lower third of the vagina or to thee pelvic wall + WA involvement limited to the upper two ~thirds of the vagina without parametrial involvement WAZ Invasive carcinoma <4 cm in greatest dimension © 1A2 invasive carcinoma >4 em in greatest dimension + 1B with paramsetrial involvement but not up to the pelvic wall Stage lll “The carcinoma involves the lower third of the vagina and /or extends to the pelvic wall and Zor causes hydronephrosis or non-functioning kidney and/or involves pelvic and paraaortic Iyraph nodes LWA carcinoma involves the lower third of the vagina, with no extension to the pelvic wall LUIB extension to the pelvic wall and /or hydronephrosis or non-functioning kidney (unless known to be due to another cause). IC involvement of pelvie and /or paraaortic lymph nodes, irrespective of tumor size and extent (with r and p notations) © MICE pelvie lymph node metastasis only 2 INIC2 paraaortie lymph node metastasis Tips to remember:~ { A ~ upper 2/3% of vagina NA. lower 3/30 of vagina { NB = parametrial involvement short of pelvic wall WB = Parametrial involvement till pelvic side wall = Full growth from cervix till the pelvic side wall (no cancer free area in between) Whole area of parametrium is involved; the ureters get compressed in between leads to + Hydronephrosis NOTE: spread of Ca cervix to uterus does not change staging Stage lNIC: New development in staging of carcinoma cervix = All cancers in gynecology are staged surgically - Cervical cancer staged clinically- on per vaginal & per rectal examination Till September 2018 = Imaging was not required in staging of carcinona cervix ~ From September 2018, imaging is required for staging to look for paraaortie or pelvic [geaph nodes involvenent © Method of imaging can be + USG - cr + MRI + PET-cr + MRI-PET Stage IV: The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A bullous edema, as such, does not permit a case to be allotted to stage IV © IVA spread of the growth to adjacent organs © INB spread to distant organs Epidemiology M/C cancer in fernale genitalia in india = carcinoma cervix M/€ cancer in females overall = Carcinoma breast). ~ M/C associated virus is HPV 26 - Most invasive is HPV 18 Screening for carcinorna cervix = Time to start pap smear screening: 3 years after first exposure To sexual activity (in western countries, itis started at 24 years of age) = Frequency: yearly © If Pap smear negative and HPV DNA Negative, repeat Pap smear after 5 years

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