Gynecology

and obstetrics
General
• Antidepressants safe in pregnancy---------> Fluoxetine + Citalopram
• Antidepressant contraindicated in pregnancy-------> Paroxetin
• Steps of treatment of uterine atony------->
• Gestational diabetes--------------> 24 weeks G. DM screening
• Cervical incompetence surgery-------------> 12-14 weeks
• Most important thing to do in antenatal visit---------> Pelvic examination
• Screening with mammogram------->
- From 50 to 74 years old------> Every 2 years
- Less than 50---------→ Every 1 year
• Solid ovarian mass + High Ca 125--------> Gynecologist oncology referral
• Best time to confirm the gestational age with US--------> 11-13 weeks
• Most important investigation in the 1st visit in pregnancy--------> CBC for anemia
• Diagnosis of embryonic pregnancy---------> Follow up to 4 weeks Anembryonic
• Pregnant before 24 weeks + High glucose--------> Do HbA1c
• Cervical mass + Hemoptysis---------> Malignancy
• Safe vaccine in pregnancy------> Influenza
• Risky vaccine in pregnancy-----> Rubella
• Vaccine to reduce incidence of stillbirth------→ Rubella but should be given before
pregnancy
• Painless genital ulcer + Rash -----> Secondary syphilis
• Postoperative fever:
- 0-2 days -----> Atelectasis or pneumonia
- 3-5 days -----> UTI
- 5-7 days -----> DVT
- > 7 days -----> Wound infection
• Jaundice in newborn (Mother Rh -ve and baby Rh +ve) -------> Auto-antibodies against
fetal RBCs
• Mother Rh -ve and baby (or husband) Rh +ve -------> Give Anti-Rh
• Painful genital ulcer + Rash + Conjunctivitis -------> Gonorrhea
• HBV husband ------> Wear condom
• Pregnant with HBV ------> Secondary prevention
• Baby of HBV mother what to give in the first 12 hours? ------> HBV vaccine + Ig
• Rupture of membranes with history of herpes before ------> Speculum examination ---
→ In confirmed start Acyclovir
• Female with recurrent genital herpes (Painful vesicles in the labia and cervix) ------>
Give Acyclovir
• Active herpes with before labour ------> Caesarian section
• Dyspareunia + bleeding after intercourse ----> Bleeding from cervix or uterus
• Treatment of valvular wart in pregnancy ------> Cryotherapy
• Organism causing wart? -------> HPV 6-11
• Female with multiple sexual partners and valvular lesion ------> Condyloma lata
(Secondary phase of syphilis) -----→ Treponema pallidum
• Female with multiple sexual partners and small papule with central pitting ------->
Molluscum contagiosum
• Type of immunity that the baby get from the mother -----> Passive natural
• Hyperthyroidism in pregnancy upto 12 weeks --------> Propyl thiouracil
• Hyperthyroidism in pregnancy after 12 weeks --------> Carbimazole
• Hydroxychloroquine -------> Safe in pregnancy but reduced efficacy with smoking
• Asthma in pregnancy --------> Safe to take all her medications ??
• Uterotonic agent contraindicated in asthma --------> Carboprost F2 alpha
• Prevent hypercalciuria stone --------> Thiazide diuretics
• Previous preterm labour + Cervix >25 mm ------> Progesterone
• Previous preterm labour + Cervix <25 mm ------> Circulage
• Previous preterm labour >=3 times ------> Circulage
• Vitamin deficiency associated with polished rice --------> B1
• Essential supplement for pregnancy -----> Folic acid
• Most important drug in epileptic pregnant woman ------> Folic acid
• Asthma in pregnancy-----> Short-acting B-agonist ------> Inhaled steroid ------> Long-
acting B-agonist + Steroid
• Atypical endometrial hyperplasia -----> Trial oral progesterone ------> If failed --->
Surgery
• UTI in 1st and 2nd trimester ------> Nitrofurantoin
• UTI in 3rd trimester -----> Amoxicillin or Cephalexin
• Anti-thyroid drugs in pregnancy------> Usually will need to increase the dose
• Antidote of MgSO4 -----> Calcium gluconcate
• Bleeding due to ovulatory dysfunction -------> Give OCP
• Estrogens in females:
• Which drugs to avoid in Familial Mediterranean fever in pregnancy ----> Macrolids +
Verapamil
• Newly married female without cycles for 2 months + bleeding ------> Source of bleeding
is the tube (Ectopic pregnancy)
• Ectopic pregnancy refusing surgery -------> Medical treatment + consent
• Post-delivery with exclusive breast feeding asks for long term contraception ------>
Depo- provera injection
• Treatment of hepatic adenoma caused by OCP :
- <5 cm -----> Stop OCP
- >5 cm -----> Surgical excision
• Most common site of post-coital bleeding --------> Cervix
• Post-coital bleeding -----> Examine vagina + Cervix
• Post-coital bleeding + Cervical mass ------> Do Cone biopsy
• Urine leaks during intercourse and after micturation -------> Urethral diverticulosis
• Triad of dysuria + dyspareunia + incontinence -----> Urethral diverticulosis
• Irregular menses + Abnormal uterine bleeding -----> Give Medroxyprogesterone
• Amenorrhea after menarche --------> Give Medroxyprogesterone
• Abnormal uterine bleeding or Irregular menses -------> Give Medroxyprogesterone
• Most important Ig in breast milk -------> IgA
• Instructions to HIV mother on HIV medications ------> No lactation but treatment will
decrease the rate of transmission to the baby
• TB mother lactation status ------> Allowed
• HBV mother lactation status -----> Allowed
• No milk after delivery ------> Sheehan syndrome
• The most important risk factor for breast cancer -----> Age
• Amenorrhea + Delayed breast development -------> Hypogonadotrophic hypogonadism
• Amenorrhea + No pubic or axillary hair ------> Androgen insensitivity
• Amenorrhea + Pubic and axillary hair + High testosterone -----→ Mullerian agenesis
• Breast mass and +ve family history of cancer ------> Do BRCA gene (Breast cancer
gene)
• Inflamed breast mass in lactating mother ------> Abscess needs drainage
• Inflamed breast WITHOUT mass --------> Mastitis needs antibiotics only.
• Unilateral breast mass 1st investigation -----> Bilateral breast US
• Bilateral breast lumps that are painful before menses ------> Breast US
• Breast mass with suspected malignancy ------> Mammography NOT US
• Best advise to pregnant smoker ------> Smoking cessation
• Cracked nipple ------> Breast feeding is contraindicated
• Cystosarcoma phyllodes -----> Wide local excision Breast tumor
• Breast feeding mother with inverted slit-like nipple -----> Duct ectasia
• Best timing for breast feeding counseling --------> Before pregnancy
• Breast feeding mother developed breast abscess------> Continue breast feeding from
the other one
• Common sources of vaginal bleeding:
- Married ------> Cervix
 - Suspected pregnancy -------> Ectopic in the tubes
- Elderly -------> Uterus
• Child with breast development but no secondary sexual features ------> Early breast
development NOT puberty
• Endometrial hyperplasia consent ------> Verbal ??
• Fibroid management -----------> Laparoscopic myomectomy
• Fibroid increased in size suddenly ------> Malignant transformation (Leiomyosarcoma)
• Fever + Recurrent bleeding post-labour especially CS ------> Endometritis
• Most characteristic feature of endometrial bleeding ------> Heavy bleeding
• Multiple small masses around the areola in pregnancy ------> Lactiferous ducts
• Risk factor for endometrial cancer ----> Nulliparity
• Treatment of epithelial ovarian cancer ------> Surgery then chemotherapy
• Cancer in labia majora -------> SCC
• Most important step after diagnosing malignant phylloid tumour ------> CT-chest
• Best investigation in family history of breast cancer ------> BRCA gene
• Differentiating normal from malignant ovarian cyst ----→ Malignant is hypoechoic
• Risk factors for ovarian cancer -----> Infertility, nulliparity, early menarche, late
menopause
• High CA 125 ------> High suspension of ovarian cancer
• High LH + High FSH --------> Low estrogen --------> High risk of osteoporosis
• Simple test for turner patient with amenorrhea -------> FSH/LH
• First test in amenorrhea -------> Pregnancy test
• Amenorrhea + Pregnancy test -ve -------> FSH/LH
• Deeply implanted placenta ------> Placenta increta
• Most common morbidity in multiparity -------> Prematurity
• Which Ig cross the placenta? --------> IgG
• Testing for risk of chromosomal anomalies -------> Nuchal translucency test at 11-13
weeks
• Management of placenta previa before 37 weeks :
- Mother and fetus stable -------> Admission and conservative treatment
- Mother and fetus not stable -----> CS
• Management of placenta previa after 37 weeks -----> CS
• Placenta implanted in the uterine wall -------> Placenta creta
• IVC compression by the uterus -------> Hypotension
• Confirmation of labour -----> Examination every 2 hours
• Fetal bradycardia + Painless vaginal bleeding + Amniotomy (Membrane rupture) ----->
Vasa previa (Fetal blood vessels near the internal os)
• Normal cervical length before pregnancy ------> 4-5 cm
• Normal cervical length during pregnancy ------> >3 cm
• Cervical length during pregnancy < 3 cm ------> Risk of preterm labour -----> Give
progesterone
• Lymphatic drainage of uterine fundus -------> Para-aortic LN
• DVT or PE in pregnancy treatment -------> Enoxaparin
• Pregnant + Hx of previous DVT -----> Enoxaparin
• Risk factor for DVT ------> OCP
• Supplementation for planning or early pregnancy ------> Folate
• Fetal death -----> Induce labour
• Lab findings in DIC ------> Prolonged PT, PTT + Low platelets + Low Fibrinogen
• Recurrent miscarriage +- PE or DVT -----> Suspect anti-phospholipid syndrome
• Recurrent spontaneous abortion ------> Suspect anti-phospholipid syndrome
• Bleeding + Everything is normal ------> Threatened abortion (Mostly before 20 weeks)
-----> Bed rest
• Bleeding + Os closed + No fetus ------> Complete abortion -----> No treatment (Fetus
already passed)
• Bleeding + passage of tissues + Os opened -------> Incomplete abortion -----> D&C +
IV fluids
• Bleeding + no passage of tissues + POC (product of conception) seen at the cervix
-----> Inevitable abortion
• Swelling in the vulva ------> Bartholin cyst
• 0 o’clock lesion at the vulva with pus discharge -----> Bartholin duct abscess
• Vaginal bleeding after RTA -----> Check for pregnancy
• Supra-pubic pain + Itching in vulva in newly married female -------> Honeymoon
syndrome
Benign ovarian tumor, ascitis
• Meigs syndrome management ------> Histopathology &pleural effusion
• Severe menorrhagia -------> Medroxyprogesterone
• Large ovarian cyst ------> Laparoscopic or open surgery
• Vulvar itching after using local cream ------> Allergic dermatitis
• Young female (e.g. 13 years old) with recurrent bleeding weekly -----> Menses
“Common to be irregular in the first few months”
• Tanner scale ------> For determination of the grade of puberty and sexual development
• 2ry sexual characters + No menses -------> Look for imperforate hymen
• First test in case of delayed or no menses ------> Pregnancy test
• Irregular cycles + Amenorrhea more than usual +- Spotting -------> Pregnancy test
• LMP 5 months ago ------> Pregnancy test
• First screening test before any pregnancy -------> HPV screening
• 9 months girl with asymmetrical breast enlargement ------> Do pelvic US
• 6 years old girl with vulvar itching + bleeding + offensive smell -------> Foreign body
• Urge incontinence treatment ------> Kegel exercises
• Urge on coughing or sneezing + urge on going to the bathroom ------> Mixed
incontinence
• What prevents the uterus from prolapse ------> Uterosacral ligament
• Mechanism of action of OCP -----> Inhibition of gonadotropines
• Galactorrhea +- Irregular menses ------> Do prolactin level
• High prolactin level -----> MRI brain to view sella turcica
• Infertility + Headache + High prolactin + High TSH ------> Do Brain MRI
• Determine the expected date of delivery -------> US
• Dysmenorrhea in young females without other symptoms or signs -----> Normal
(Primary dysmenorrhea)
• Timing of tubal ligation -------> After menstruation
• What to do for unbooked women ------> US to determine the gestational age
• Turner with amenorrhea ------> Do FSH
• Turner association -------> Coarctation of aorta
• Probability of turner syndrome in next pregnancy ------> 30 %
• 15 years old with young stature and webbed neck -----> Look for chromosomal
disorders
• Screening test for Down syndrome ------> Quadruple test = Quad screen test (AFP,
hCG, Estriol, Inhibin-A) at 2nd trimester
• Most sensitive marker for Down syndrome in 2nd trimester -----> High hCG
• Diagnostic test of pregnancy -----> SERUM B-HCG
• Treatment of primary dysmenorrhea ----> NSAIDs
• Dysmenorrhea not responding to NSAIDs --------> Exercise + Relaxation -----> If not
responding give OCP
• Menorrhagia ------> OCP
• Adnexal mass felt in mid-cycle in healthy female -----> Follicular cyst
• Vaginal discharge and all investigations normal -----> Physiological discharge
• Mother of sickle cell child wants to marry again -----> Do Hb electrophoresis for the
husband
• Relation between LH peak and ovulation ----------> Ovulation after 36 hours of LH peak
(i.e. LH surge triggers ovulation)
• GERD in pregnancy ------> 1st step is lifestyle modifications
• Acid base disorder in fetal asphyxia -----> Metabolic acidosis
• Who should decide contraception? ------> Both the husband and the wife
• Refusing intervention of life-threatening situation -------> Take consent from the
husband ????
• Cervical polyp -------> Removal in the clinic
• Soft tissue projection during hysteroscopy ------> Endometrial polyp not fibroids
• Breast pain during menses + US breast shows multiple cysts ------> Fibrocystic disease
of the breast
 Infertility and PID
• Infertility with regular periods and monophasic basal body temperature----->
Anovulation (Temperature should increase with ovulation)
• When consider couple infertile?-----> 12 months
• Cause of infertility in polycystic ovary--------------> Anovulation
• First thing to look for in case of infertility ---------> General look
• First investigation to order in case of infertility----------> Semen analysis
• Most significant examination in newly married woman--------> Pelvic examination
• Best advise to prevent infertility--------> Eat less fatty food
• Irregular cycles + Anovulation + Atypical endometrial hyperplasia--------> Give oral
progesterone
• First test in case of regular cycles with infertility--------> LH/FSH ratio
• Who to inform in bilateral tubal blockage-------> Both
• Bleeding in late pregnancy--------→ Ask about intercourse
• PID------> Adhesions-----> Bilateral tubal blockage------> Infertility
• Organism causing PID and adhesions-----> Chlamydia
• Infertility secondary to PID-------> Hysterosalpingography
• Cause of infected IUD--------> Actinomycosis
• Chlamydia in pregnancy affects which part of the infant------> Eye
• Strawberry cervix with yellowish to grey discharge-------> Chlamydia trachomatis
• Treatment of infertility caused by chlamydia PID-------> IVF

PAP smear and colposcopy

• Screening for cervical cancer using PAP smear: Atypical Squamous Cells of
Undetermined significance
Below 30: - Screening every 3 years starting from age of 21
- If ASCUS -------> Repeat after 1 year (mostly will go away by itself)
Above 30: - Screening every 3 years
- If ASCUS -----> Do HPV -----> If positive do Colposcopy
-----> If negative screening every 3 years
• HGSIL (High grade squamous intraepithelial lesion) in PAP smear---------> Do
Cloposcopy (20 % will progress to cancer)
• Breast tenderness before periods-------> PAP smear
• Last PAP 3 years ago or more------> Repeat
• Previous genital wart-------> Do PAP
• Cervical lesion with irregular borders-----> Excision
• Female with atypical hyperplasia many years ago------> Repeat PAP
• Suspicious lesion on the cervix------> Do PAP
• Postmenopausal with ASCUS------> Local estrogen and reassess after 1 month---> No
resolved-------> Colposcopy
• How to do PAP smear---------> From transformation zone (endocervix)
• First step after diagnosing invasive cervical carcinoma on cloposcopy-----> Staging
• Post-partum clear discharge which is positive for leucocytes and epithelial cells---->
Normal
• Fever after few days of delivery upto 6 weeks-----> Endometritis
• Antibiotic for mastitis-----> Ceftriaxone
• C. Difficile------→ Vancomycin ORAL
• Vaginal bleeding and brown discharge in early pregnancy-------> Normal
• +ve PAP smear + inconclusive Colposcopy ------> Do Cone biopsy
• Post-coital bleeding + Cervical mass ------> Excision in the clinic
• Uterine mass increases during pregnancy without malignant features ----> Polyp
(Increases in size due to pregnancy hormones) -----> Needs monitoring and
reassessment after delivery
• Vulvar tumour in situ (Benign or malignant) ------> Local superficial excision
• Vulvar mass translucent and filled with mucous -----> Vulvar mucinous cyst
• Lichen planus in the vulva ----> SCC
• Tumour that causes Meigs syndrome (Ascites and pleural effusion that resolves after
tumour excision) ------> Benign solid ovarian tumour (Sex cord-stromal tumour)
• Best diagnostic test in suspected cervical cancer -----> Biopsy
• Risk factor for all malignancies -----> Smoking

Pre-eclampsia
After 20 wk
• Diagnosis--------> BP>140/80 + Proteinuria
• 34 weeks or more-------> Delivery + MgSO4
• Before 34 weeks and stable ---------> Admit for observation + MgSO4
• Before 34 weeks and unstable------> Delivery + Steroids (Immature lungs)
• MgSO4 toxicity (Absent deep tendon reflexes or Dyspnea or Non-reactive CTG)------->
Stop immediately + Calcium gluconate
• HTN before pregnancy increases risk of---------> Pre-eclampsia
• Common cause of IUGR------> Oligohydramnios
• Prevention of convulsions in pre-eclampsia-------> MgSO4
• Indicator of severe pre-eclampsia-------> Low platelets
• Treatment of HTN in pre-eclampsia-------> Hydralazine (for emergency) + Methyldopa
(not in emergency)
• Gestational DM + Nephritis + HTN at risk of what? ---------> Pre-eclampsia
 Vaginitis
• Fishy smell, foul smell, grey discharge, epithelial cells, Clue cells------> Bacterial
vaginitis-------> Metronidazole
• Yellow green discharge, Flagellate-------> Trichomonas vaginalis-------> Metronidazole
• Odourless vaginal discharge, white grey, budding yeast cells, pseudophytes,----→
hyphae -----> Candidiasis-------> Fluconazole or Itraconazole
• Female vaginal discharge + Husband has discharge------> Gonorrhea-----→
Ceftriaxone
• Common predisposing factor to candidiasis--------> DM
• When to treat the male partner-------> Trichomonas only
• Vaginal infection causing incompetence-----> Bacterial
• Testing for bacterial vaginitis------> Gram stain

Menopause
• Postmenopausal bleeding commonest cause ------> Cancer endometrium until proved
otherwise
• Dexa scan result 1.5 – 2.4 ------> Osteopenia
• Dexa scan result 2.5 or more ----> Osteoporosis
• High LH + High FSH ------> Ovarian failure = early menopause ------> Low estrogen
-------> Risk of osteoporosis
• Dx of premenopausal syndrome ------> FSH
• Incontinence in postmenopausal women ------> Pelvic muscles exercises for 8 weeks
• What is hot flushes -----> Increase in core body temperature due to hormones
• Pathogenesis of postmenopausal hot flushes ------> Cutaneous thermoregulators or
low estrogen
• Postmenopausal asks for HRT ----> Refuse
• Postmenopausal C/O itching in vulva + watery discharge + scaly vulva -----> Atrophic
vaginitis
• Postmenopausal bleeding + shiny vulva which bleeds on touch + Dryness ---->
Atrophic vaginitis
• Treatment of atrophic vaginitis ------> Topical estrogen
• Carcinoma in situ in the vulva ----→ Wide local excision OR Superficial vulvectomy
• How to confirm Psoriasis of the vulva -----> Biopsy
• Change of skin color of vulva to brown or black that bleeds on touch ----> Skin tag
• Postmenopausal bleeding + Endometrial hyperplasia -------> Think of cancer
• Tamoxifen + postmenopausal bleeding = Endometrial cancer
• Breast cancer on Tamoxifen developed postmenopausal bleeding -----> Do Biopsy
• Hypoechoic lesion in the uterus -----> Endometrial cancer
• Postmenopausal bleeding + Endometrial hyperplasia +- Atypia ------> Hysterectomy
• Post total hysterectomy + bilateral oophorectomy --------> Give Estrogen only
• Commonest source of postmenopausal bleeding -------> Uterus
• Most important investigation for postmenopausal bleeding ------> Endometrial biopsy
• Postmenopausal with bilateral ovarian tumour -----> Refer to gynecology oncologist

Endometriosis
• Classic triad ------> Dyspareunia + Dysmenorrhea + Dyschazia
• Other presentations ------> Dysuria + Inter-menstrual bleeding + Infertility
• Complications ------> Infertility
• Ovarian endometriosis and no plan for more pregnancy -------> Oophorectomy with
ablation of other lesions
• US uterus showed ground glass appearance ------> Endometriosis
• Dysmenorrhea not relieved by analgesics ------> Suspect endometriosis
• Suspected endometriosis ------> Do Laparoscopic exploration
• Endometriosis cancer risk ------> Epithelial ovarian tumour
• Heavy menses + Infertility -------> Suspect endometriosis
• Severe dysmenorrhea -------> Suspect endometriosis
 Post-partum hemorrhage

• First step in management ---------> Uterine massage

• Most important medication for PPH (Highest success rate) ------> Oxytocin
• Primary PPH -------> 1st 24 hours
• Secondary PPH -----> After 24 hours and before 6 weeks
• Prevention of recurrent PPH -------> Reduce maternal stress + Reduce labour duration
+ Fundus massage
• PPH due to macrosomic baby -------> Oxytocin
• PPH not responding to massage and medications, next step? --------> B-Lynch of the
uterus
• Death rate from PPH ------> 25%
 PCOS (Polycystic ovary)
(Stein Leventhal syndrome)

• Pathophysiology --------> Increased testosterone level

• Symptoms ------> Hirsutism + Acne + Irregular menses or amenorrhea + Weight gain +
Obesity
• Main lines of treatment -----> Metformin + Weight loss + Clomiphene
• Treatment of infertility in PCOS ------> Clomiphene
• PCOS doesn’t want pregnancy -------> Estrogen + Progesterone
• PCOS + Obese -------> Metformin (Decrease insulin resistance -----> Prevent diabetes)
• FSH/LH ratio in PCOS -----> 1:3
• Irregular menses + Increased LH + Increased testosterone ------> Do Glucose
tolerance test + Lipid profile
• Blood test for hirsutism --------> Testosterone level
• Cause of endometrial hyperplasia in PCOS ------> Unopposed estrogen
• PCOS + Endometrial hyperplasia ------> Induction of 3 monthly withdrawal bleeds with
progesterone
• Amenorrhea + High testosterone -------> Complete androgen insensitivity (No
hirsutism)
• Amenorrhea + High testosterone + Normal breast development + Hirsutism ------>
Mayer Rokitansky Huster Hauser syndrome

Adenomyosis
• Definition ------> Invasion of endometrial glands into the myometrium
• Age --------> 35-50
• Risk factors -----> Fibroids + Endometriosis
• Symptoms -------> Dysmenorrhea + Menorrhagia
• Keyword ------> Bulky or large uterus (+- tender abdomen) OR Menorrhagia with
previous uterine surgery
• Diagnosis -------> Clinical ------> Confirm using MRI not US
• Treatment -------> Hysterectomy

Pregnancy diseases
• Pregnancy + Jaundice + Itching -------> Pregnancy Cholelithiasis
• Midsystolic murmur in pregnancy -------> Physiologic
• Systolic murmur radiating to the carotid ------> AS
• How to assist a mitral stenosis patient ------> Forceps (To avoid straining)
• Brown spots in pregnancy ------> Chloasma of pregnancy
• What is dizygotic? ---------> Di-chorionic + Di-amniotic
• Right lower abdominal pain without pregnancy-related cause ------> Suspect
appendicitis
• Multipara with mid-line bulge -------> Divarication of recti
• Fate of divarication of recti ------> Resolve after delivery -------> If not refer to surgery
• Early pregnancy + vomiting after every meal + weight loss + fatigue ------>
Hyperemesis gravidarum
• Os closed + No abortion + US shows empty sac -------> Anembryonic pregnancy ------>
Follow up after 4 weeks
• How to stop heavy bleeding -------> High dose conjugated estrogen only not OCP
• Clinical confirmation of pregnancy ------> Uterus just above symphysis pubis (Not
higher)
• Incontinence in multipara -------> Do Kegel exercises for 6 weeks and reassess
• When to do cholecystectomy in pregnancy? -------> 2nd trimester (Most safe for any
operation)-------> 1st trimester risk of abortion and 3rd trimester risk of preterm labour
• Symptomatic biliary colic in pregnancy ------> Laparoscopic cholecystectomy in 2 nd
trimester
• Next step after salpingotomy for ectopic pregnancy -------> B-HCG weekly
• Why to do medio-lateral episiotomy? -------> Prevent 4 th degree perineal tear
• Which fetal presentation causes 3rd and 4th degree perineal tear? -------> Occipito-
posterior position
• Which perineal tear affects rectal mucosa? ------> 4 th degree
• Swelling in episiotomy after few hours ------> Sitz bath + dressing
• Management of bleeding from lacerations after delivery ------> Prostaglandin F2
• Prognostic lab result for DM in pregnancy ------> HbA1C
• No bleeding in menses after D&C --------> Removal the stratum basalis layer of the
endometrium.
• Abortion more than 3 times ------> Anatomical cause:
- 1st trimester -----> Septate uterus
- 2nd trimester ----> Arcuate uterus
• Hysterectomy was done by mistake instead of D&C ------> Tell the patient
• HTN before 20 weeks ------> Primary HTN
• HTN after 20 weeks --------> Pregnancy-induced HTN
• Pregnancy-induced HTN which medication to start? ------> Methyldopa
• Common complication of pregnancy-induced HTN ------> IUGR
• AntiHTN in pregnancy --------> Methyldopa (1st line) + Labetalol (2nd line)+ Hydralazine
+ Nifedipine
• ACEIs in pregnancy -------> Absolutely contraindicated
• Pigmentation over body folds e.g. back of neck, axilla and groin ------> Acanthosis
nigricans
• Treatment of DM in pregnancy ------> Insulin
• Safest route of administration of glucose to DM pregnant mother with hypoglycemia
-----> Peripheral venous
• Abnormal glucose tolerance test (GTT) in pregnancy -----> Repeat the test before any
action
• Uncontrolled DM before pregnancy -------> Tight control of DM is advised before
pregnancy
• Repeated vomiting in pregnancy ------> Ketones in urine

Placenta abruption

• Painful bleeding in pregnancy ------> Placental abruption

• Painless bleeding in pregnancy ------> Placenta previa
• Bleeding + Pain + rapid uterine contractions + uterine tenderness + Fetal heart rate
abnormalities -------> Placental abruption
• Smoker with painful bleeding ------> Placental abruption
• Abdominal trauma + painful bleeding -----> Placental abruption
• What improves mortality in baby with acidemia due to placental abruption -----> Mild
hypothermia
• DIC + Severe bleeding + Placental abruption -----> Call multidisciplinary team + Rapid
response team
• Placental abruption + stable fetus ------> Normal delivery
• Placental abruption + unstable fetus -----> CS
• Placental abruption + unstable mother -----> CS
• Placental abruption + contraindication to vaginal delivery ------> CS
• Mechanism of DIC in placental abruption -----> Excessive arterial bleeding leads to
consumption and loss of coagulation factors
• First investigation in vaginal bleeding in pregnancy ------> US abdomen
• Massive bleeding from placental abruption ------> 2 peripheral IV cannulae + blood
transfusion

CTG
• Decreased fetal movement -------> Do CTG
• Early deceleration (At the beginning of uterine contractions) -----> Head compression
• Variable deceleration causes -----> MgSO4, Cord compression
• Late deceleration (At the end of uterine contractions) -------> Uteroplacental
insufficiency --------> Fetal hypoxia or asphyxia ------> Metabolic acidosis
• CTG indications for stopping oxytocin -----> Late deceleration , Decreased or absent
contractions
• Contraindications to ECV (External cephalic version) ------> CTG variable deceleration,
Oligohydramnios
• Fetal bradycardia during general anaesthesia -----> Stop anaesthesia
• Fetal bradycardia ------> Change mother’s position
• Common complications of epidural anaesthesia ------> Hypotension, Fetal bradycardia
• Reduced Variability in CTG -------> MgSO4
• Decreased uterine contractions ------> Fetal distress
• No contractions in CTG during labour + Dilated effaced cervix ------> Wait and check in
2 hours
• Prolonged labour -----> Indication to use vacuum extraction
• Key points:
- Epidural anesthesia ------> Prolonged decelerations
- Fetal bradycardia ------> Prolonged decelerations
- MgSO4 ------> Decreased variability
- Oxytocin ------> Late decelerations
- Cord compression -----> Variable decelerations
- Head compression or inappropriate position ------> Early deceleration
- Placental insufficiency or abruption ------> Late deceleration
• Sinusoidal pattern in CTG -----> Fetal anemia
• Biophysical profile (10/10):
- 8-10------> Normal
- 6-7 --------> Equivocal
- <6 ------> Abnormal
• Flat fetal heart in CTG -----> Sop MgSO4
• Fetal bradycardia in CTG after PROM in polyhydramnios ------> Cord prolapse
• CTG of fetal distress + sudden stopping of uterine contractions in stable mother ----->
Change mother’s position

PROM
(Premature rupture of membranes)
• If 34 weeks or more ------> Antibiotics then delivery
• If < 34 weeks ------> Antibiotics + Steroids + Delivery at 34 weeks
• When to deliver PROM before 34 weeks?
- In labour
- Intra-amniotic infection
- Cord prolapse
- Significant abruption of placenta
- Non-reassuring fetal heart tracing

Delivery
• When to give antibiotics for CS ------> Preoperative
• HTN + Seizures not responding to MgSO4 ------> Eclampsia ------> Immediate CS
• IUFD (Intrauterine fetal death) + Previous CS ------> Ask her opinion about CS or
vaginal delivery
• Placenta previa -------> CS
• Face presentation -----> CS
• Prolonged vaginal delivery + Fetal distress ------> CS
• Occipito-anterior presentation -------> Vaginal delivery
• Occipito-posterior presentation ------> CS
• Exhaustion during normal labour ------> CS
• Herniation of fetal tissues in early pregnancy without associated symptoms ----->
Cervical incompetence
• Previous preterm + Cervix opened in early pregnancy ------> Progesterone
• Prolonged labour in primi-gravida ------> Allow more time before CS as soon as the
mother and the fetus are stable
• IUFD in DIC + opened cervix------> Vaginal delivery
• Prolonged first stage + CTG reassuring -----> Recheck after 2 hours
• Incompletely dilated cervix + Mother and fetus stable -----> recheck every 2 hours
• When to use Oxytocin in normal labour -------> Opened effaced cervix with weak or no
contractions
• Feeling uterine contractions + Closed cervix + No effacement + No bleeding ----->
False labour
• Yellowish odourless vaginal discharge during puerperium ----> Normal
• Blue vaginal swelling after vaginal delivery and episiotomy:
- Small------> Rest, Ice, Compression, Elevation (RICE)
- Large -----> Surgical drainage
• Vaginal swelling increases when standing + Needs manual evacuation of urine after
urination -------> Cystocele
• Multipara feeling vaginal mass -----> Cystocele
• Urine passing from the vagina -----> Vesico-vaginal fistula
• Stool incontinence + Flatus from the vagina ----> Recto-vaginal fistula
• Benefit of episiotomy ------> Decreases incidence of perineal tear
• Vaginal tear + Profuse bleeding from above -------> Examine the uterus
• Most important thing to look for before instrumental delivery --------> Cephalopelvic
disproportion
• Stations during vaginal delivery:
• Risk factors for 4th degree perineal tear ------> Legs restrain + Use of metallic
instruments + Squatting position
• Prolonged second stage of labour in fully dilated effaced cervix + Good uterine
contractions -----> Use ventose
• Prolonged second stage of labour in fully dilated effaced cervix + Weak uterine
contractions -----> Use Oxytocin
• Mouth and nose felt during vaginal examination ------> Face presentation
• Best twin position for SVD (Spontaneous vaginal delivery) ------> Cephalic-Cephalic
• Breech presentation flexing the hips and knees -----> Complete breech
• Fetal heart at the level of the mother’s umbilicus ------> Breech presentation
• Contraindication to ECV (External cephalic version) -----> Bicornuate uterus
• Management of breech presentation -----> Trial of ECV if no contraindication -----> If
failed do CS
 Ovarian torsion

• Sudden onset of UNILATERAL lower abdominal pain that worsens over time + Nausea
and vomiting + Tenderness + Adnexal mass ------> Ovarian torsion
• BILATERAL Lower abdominal pain + fever + tenderness ----> Salpingitis
• Fever + Suprapubic pain + Vaginal discharge (Suppurative) ----> Salpingitis
• Torsion refusing surgery ----> Explain then document -----> Respect her wish

Uterine tumours
• Uterine leiomyoma = Fibroid = Benign
• Uterine leiomyosarcoma = Malignant
• Asymptomatic fibroid --------> Follow up after 1 year
• Small fibroids -------> Follow up after 1 year
• Large fibroids ------> Surgical removal due to risk of malignant transformation
• Commonest race for fibroids ------> Africans
• Fibroid increases in size after menopause ------> Leiomyosarcoma
• Endometrial thickening over fibroid -----> Suspect leiomyosarcoma

Ectopic pregnancy
• Commonest site -------> Fallopian tube
• Predisposing factor ------> PID
• Defect in which step -------> Implantation
• Unilateral lower abdominal pain + Vaginal bleeding -------> Ectopic pregnancy
• Unilateral lower abdominal pain + Vaginal bleeding+ Peritoneal irritation ------->
Ruptured ectopic pregnancy (MEDICAL EMERGENCY)
• Diagnostic tests ------> B-HCG + US +- Laparoscopy
• Treatment of stable patients ------> Methotrexate for 4+7 days then reassess B-HCG
level -----> If not decreased give second dose and reassess WEEKLY level (Target B-
HCG is ZERO) -----> If still no response refer to surgery
• Increasing B-HCG without cause ------> Suspect ectopic pregnancy
• Creating an opening in fallopian tube (e.g. for removing ectopic pregnancy) ------>
Salpingostomy
• Removing the fallopian tube (e.g. for ruptured fallopian tube due to ectopic pregnancy)
------> Salpingectomy
• First question before starting medical treatment ------> Accessibility to the hospital
• Lower abdominal pain + Absent or sluggish bowel sounds (Peritonitis) -----> Ruptured
ovarian cyst OR ruptured ectopic pregnancy
• Source of bleeding in ectopic pregnancy -------> Fallopian tubes
• Commonest contraindication to IUD -----> Previous ectopic on IUD

Asherman syndrome

• Adhesions (scarring) inside the uterine walls caused by recurrent D&C

• Presentations ------> Recurrent abortions (No space for the fetus) , Amenorrhea
(Destroyed endometrium) , Bleeding during pregnancy (Beginning of abortion)
 UTI in pregnancy
• 1st + 2nd trimester -------> Nitrofurantoin
• 3rd trimester -------> Cephalexin
• Pyelonephritis ------> Ceftriaxone
• Asymptomatic UTI in pregnancy ------> Must be treated as it can cause abortion or
preterm labour
• UTI during lactation ------> Nitrofurantoin
• Gram -ve bacteremia post-operatively -------> UTI

Breast disorders
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