ONE Touch Obstetrics & Gynecology For NEET/NEXT/FMGE/INI-CET [1 ed.] 9390619300, 9789390619306

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IMPORTANT TOPICS 1. SPERMATOGENESIS AND

Spermatogenesis

O0GENESIS

Oogenesis

2n Spermatogonium

Primordial germ cell

Mitosis

2n Primary spermatocyte

2n

Enters the gonad of female and differentiates into

Meiosis I (Zn

(Ln Secondary spermatocyte

Oogonium (44+XX)

Meiosis I| Zn

Mitosis occurs

(2n) Ln Spermatid

Primary oocyte (44+XX)

Spermiogenesis

(At birth, no more

mitosis occurs and all

oogonia are replaced

by primary oocyte) Spermatozoa

Enter 1st meiotic division

(Sperm) Arrested in prophase-in Diplotene stage Ist meiotic division is

Important Points

Begins at puberty.

completed after puberty, just prior to ovulation releasing

Spermatogenesis takes place in seminiferous tubules

Time taken for spermatogenesis: 74 days (70-74 days). Spermiogenesis: Transformation of spermatids

oocyte (22+X) 2nd meiotic division

to sperm. There is no mitosis or meiosis. Size of sperm: 50-60 um

Fertilizable life span: 48 -72 hours.

Sperms attain Maturity: Proximal part of|

Epididymis Sperms attain Motility: Distal part of Epididymis

First polar body (22+X)

Secondary

Arrested in

metaphase The division is cowmpleted at the time of fertilization

Time for spermiogenesis: 10-14 days Time for capacitation: o-8 hours

Site for capacitation: Female Reproductive

tract-cervix

Ovum

(22+X)

2nd polar

body (22+X)

One Touch

Obstetrics and

Gynecology by Dr Sakshi

Arora Hans

Oogenesis ingportant Points of

intrauterine life Oogenesis: Begins in arrested in: Diplotene Lst nmeiotic division is stage of prophase arrested in: Metaphase 2nd meiotic division is completed at: Puberty division meiotic 1st completed at: Tine of 2nd meiotic division

fertilization 120-130 um (lt is the Size of mature ovum:

largest cell in the body).18-20 mm .Size of mature follicle: hours. Fertilizable life span of ova: 12-24

intrauterine month of 1. Sth life (20 weeks)

6-7 million (maxm)

1-2 million 4 lakhs-5 lakh

2. At Birth

3 At Puberty Events Time Table of Event

It is completed by

3. SIGNS IN PREGNANCY Presumptive Probable signs signs Amenorrhea

Nausea/

vomiting Fatigue

@ 14 weeks

e 22-24 weeks

Urinary

|frequency Breast

2. FERTILIZATION BASICS

changes

Quickening fallopian tube " Fertilization occurs: Ampulla of Zygote " Fertilization occurs on Day 14 of cycle After 20-30hours

2-celled zygote " 8-16 celled zygote is called morula

4-celled zygote

Zona pellucida prevents

8-celled zygote (Surrounded by zona pellucida)

polyspermy

L6-celled zygote (Day 3 after fertilization) MCQ:

Hegar's sign-softening of uterine

isthmus. On Bimanual palpation,

Hearing fetal

heart sounds

vaginal and abdominal fingers touch

Palpation of vaginaa and vulva (Jacguemier's sign) fetal parts Chadwick's bluish discoloration of

Osiander'ssign-lateral vaginal

fornix pulsations

Fetal skelecton seen on X-ray

Image 1: Hegar's sign

Palmer's rhythmic uterine contractions

Piskacek's-unegual growth of uterus

Positive pregnancy test lncreased pigmentation Also Know

Von Braun-Fernwald's sign Landin sign McDonald's sign Hartman's sign/Placental sign

Quickening

Softening of fundus Softening of Mid part of isthmus Easy flexibility of uterus over cervix Bleeding at time of implantation Perception of first fetal wnovement by mother Primi = 16 weeks

Multi = 18 weeks

Day 4: Morula enters uterine cavity

Morula enters uterine

Day 5: Zona pellucida lost (Zona hatching)

cavity: (a) 3-4 days (b) 4-5 days (c) S-6 days (d) 2-3 days

Fetus seen on

ultrasound

each other (see Image 1)

4 weeks

@ 12 weeks

Positive signs

6 weeks)

@3 weeks 6 Weeks

Goodell's sign--so ftening of cervix

(1st sign to become positive

|Time (ln weeks)

Germ cells reach genital

ridge yolk sac Germ cells reach Oogonia formed formed | Primary oocyte Follicle formation begins by

OBSTETRICS

Number of folliclo

Time

Morula becomes blastocyst Day 6: lmplantation begins (in form of blastocyst)

(Day 6 after fertilzation = Day 20 of cycle)

Ans: a (Not b)

gestational age.

The entire duration of pregnancy is divided into three trimesters:

1. First trimester: Till 13 weeks + 6 days

|2. Second trimester: 14 weeks till 27 weeks +6 days 3. Thind trimester: 28-40 weeks

Important Terminology

Implantation " Site: Upper posterior wall of uterus

"Implantation window = Day 20 - Day 24 of cycle " Implantation ends = Day 10-11 after fertilization (Day 24-25 of cycle)

Refer to Table 22 of obs for Events of early

months and 7 days Duration of pregnancy: The duration of pregnancy is 1O lunar months or 9 calendar period. This is called as or 280 days or 40 weeks, calculated from the first day of the last menstrual

pregnancy.

Preterwm pregnancy

42 weeks

Obstetricsand One Touch

Arora Hans Gynecologyby DrSakshi

4. PREGNANCY DATING

A. Pregnancy

Dating for

OBSTETRICS S.

Natural Conception

Antenatal visits ldeal:

ANTENATAL CARE IN PREGNANCY

Till 28 weeks = 1/month 28-36 weeks =1 in 2weeks

|If cycle is regular butthan cycle length is more

Regular 28-day cycle

28 days, e.g., 32 days

|Ifcycle is Regular but Cycle length is less than 28 days, e.g., 25 days

Caloric Requirement

>36 weeks = 1/week WHO: 8 visits

Government of(minimum) lndia: 4 visits (minimum)

Park = +350 kcal

trimester

Recommended Weight Gain in Pregnancy

in all

National guidelines: (lmp.)

In

normal BMI 11- 12.5 kq females

T1 = +70

T2 = +230kcal/day kcal/day +400 kcal/ day

females with low females) = 12.5 - 18BMIkg(thin In females with BMI >30 (obese) = 7 kg (5-q kg)

ACOG/International Instituonly) te Medicine (For INI-CET

of

T1 = o 1. Calculate

|Naegele's formula

presumptive EDD

EDD = 1st day of LMP. 7 days + 9 months

using Naegele's Formula

2. 32-28 = 4 days

Note: If LMP is in

3. Now add 4 days to presumptive EDD to get actual EDD

February; first add 9months and then 7 days.

keal/day

T2 = +350

2. Calculate

T3 = +450

presumptive EDD

=

In

kcal/day

kcal/day

using Naegele's Formula

2. 28-25 = 3 daus 3. Now subtract 3 from

presumptive EDD to get actual EDD

ANTENATAL CARE IN PREGNANCY

In rest all cases

add 7 days first and then 9 months

If cucles are

1. Iregular 2. Female conceived while on OCP

3. Female conceived during lactation 4. If fenmale is nSure about LMP

Best method for dating of pregnancy is USG using crown rump langth Not Naegele's Forwmula

B. Pregnancy Dating for IVF Cycles A For Fresih Cycle To the date of oocute retrieval +266 = EDD. 8. For Frozn Cycle with D3 transfer: Date of DS transfer +263

C For Frozen

Cucle

Rafer to Table 19 of obs for Score ard Gravida and Parityobstetric

Folic Acid in Pregnancy To prevent NTD = 400 mcq/ day; Start 1 month before conception and continue till 3 months after conception To prevent recurrence of NTD =

RDA in Pregnancy

4 mg/day; start 3 months before conception or from the day a female

lodine (l,) req. = 250 mcg/day Calcium req. = 100O0 mg/day

plans pregnancy and 3 months after

conception To treat folic acid deficiency=1 mglday In diabetic patients who are pregnant =

400 mcg/day In patients on antiepileptic =

Before conception: 400 mcg/day

After conception: 4 mg/day =

EDD.

Witk Ds transter Date ofDS transter +261 = EDD

To treat sickle cell anemia = 5 mglday

Carbohydrate req. =175 g/day Protein req. = Nonpregnant =45 g/day T1 = NIL (No additional requirement) T2 = +1O 9 T3 = +2O9

Fat req. = 28 g/day Refer to Table 12 of obs for

detailed Nutritional requirement in pregnancy and lactation

One Touch

IN 6. VACCINATION

PREGNANCY

OBSTETRICS

pregnant females should be given to all which Viaceines Tabhle L: Td vaccine females should be given: Al pregnant Td vaccine doses: 2

7. ANEUPLOIDY SCREENING

Nutber of after a gap of 4 weeks at 1st AN Visit and 2nd dose Lst dose Tine: If preanant female was immunized in past3 years and had received 2 doses: then in booster aose is needed Current pregnancy only one

(Tetanus

Diphtheria)

Talapvaccine Tetanus toxoid - reduced Diphtheria toxoid + Acellular pertussis is also recommended during pregnancy.

weeks to all pregnant females to

be given between 27 and 36 At least one Taap should

protect nwborn from Pertussis. All pregnant females, regardless of trimester-during flu season (October to May) should

Infiuarza

receive infiuenza vaccine.

VRCCIna

weeks): in Down t(hchgh \hCa syndrome

PAPP-A ==l

" hCG

This vaccine can be given in any trimester if pregnant female had not received earlier

Vactines which are safe

Vaccines to be given in special Circumstances

Al dead vaccines can be given: E.g.,

Polio

Hepatts 3

Typhoid

test + USG in T1

" Integrated test= T1 and T2 test Integrated test includes:

PAPPA in T1 + USG for NT in T2 + Quadruple test in T2

SSereening test

Rubella ANEUPLOIDY SCREENING

Done in all pregnant females irrespective of age

Chicken pox BCG

HPV vaccine

Intercourse during pregnancy

Air travel in pregnancy

Noninvasive prenatal test e T screening is positive

2. Threatened abortion

T2 Chorionic villus

sampling

Negative

3. Placenta previa

Tissue for karyotyping obtained by

Can be done anytime >10 weeks Highest sensitivity 2qq%

236 wks of pregnancy

2. PTL

Karyotyping (Diagnostic test)

Secondary screening test Cell free fetal DNA

ACOG recommends air travel should not be done at

pregnancy except in case of

4. PROM

Positive

(11-13 weeks)

Amniocentesis

(16-18 weeks) (lImage 4)

(lmage 3)

|Karyotyping diagnostic test patient No further testing needed to reassure the

Sgnficant bleeding Pacenta pravia Rufur ta Table 10 of obs for GOt High risk pregnancy and Table 11

Important Point " Combined test = Biochemical

Mumps

Fabies

Heart asense

"Echogenic intracardiac focus

" Echogenic bowel " Choroid plexus cyst

(Any 2 should be present)

Measles

Meningococcus

Puimonaru disease

"Simian crease

Fetal Echo

Smallpox

Sexual activity is not C/l in

"Sandal gap " Duodenal atresia

Case: If NT on USG (lmage 2) 23 mm and karyotype is normal

contraindicated

FneunococcNs

150 week is recommEnded duringmins/ pregncy

"Absent nasal bone " Short femur/humerus

Next step

Yellow fever

Hepatits A

Enercise in pregnancy Moderate cxeroise tor

‘(KIhibin Increased

(B) USG: Soft tisues " Nuchal fold markers: thickness zG mm

Trisomy 13 Tuner syndrome

Vaccines which are absolutely

Unconjugted Es =

QUADRUPLE lnhibin A= TEST:

Trisomysyndrome 18

Table 2: Vaccines, exercise, intercourse and air travel in pregnancy

SECOND TRIMESTER Biochemical TRIPLE TEST Test " Alpha-Fetoprotein =

+ (A)

"

(B) USG (11-13 weeks + 6 days): Nuchal translucency = 23 mm Indicates = Aneuploidy MIC = Down or congenital heart disease

One dose IM Covid-19 Vaccine

FIRST TRIMESTER (A) Biochemical Test: DUAL TEST (11-13 "

of obs for

Color codes on antenatal card

highest risk of aneuploidy. (mp PYQ's which if present in isolation has One single usG marker in T2 femur. aneuploidy: |Nuchal skin fold thickness >short isolation has least riskof T2 which if present in One single USG marker in

Choroid plexus cyst.

One Touct 10

OBSTETRICS

lnportant lnnages

8. ANTENATAL INVESTIGATIONS

ANTENATAL INVESTIGATIONSs

Chorionic vili At the First Visit

ABO, Rh typing Hb, Hematocrit (CBC)

USG in Pregnancy

Dating/viability scan = 6-8 weeks

Nuchal Translucency scan = 11-13 weeks + 6 days

VDRL

HBSAg

Rubella susceptibility screening Urine routine and microscopy (Every trimester)

NT

Image 3: Chorionic Inage 2: Nuchal translucency

Chorionic villus sampling:

villi sampling

If done at HC

First trimester ultrasound done for:

T3

FL

USG in Pregnancy

Gestational age assessment

Viability of pregnancy Suspected ectopic

chorionicity

o

For threatened abortion

o Nuchal translucency

CRL: Crown-rump length BPD: Biparietal diameter

FL: Femur length

Best parameter for estimation of gestational age-RL AC is best for assessing qrowth of fetus, i.e., in case of macrosomia and IUGR.

CRL can be used till 13 weeks + 6 days, i.e.,

Most accurate gestational age can be determined

by CRL between 7 and q weeks.

Predisposition

CRL (mm) + 42 =Gage in days

to leukemia

Smallest CRL Which can be measured = S mm Mean sac diameter in mm + 3o = Gestational

Gap between first and second toes (sandal gap)

Done = 16-18 wWeeks Fetal loss = VSD > ASD

age in days

Refer to Table 13 of obs for Symphysiofundal height

One Touch Obstetrics

12 9.

and Gynecology by

IMPORTANT USG

Dr Sakshi Arora

Hans

IMAGES

OBSTETRICS

Uterus SAG U

Double decidual Sac SIgn A

mage b. lntradecidual sign

1st sign of pregnancy USG indicatina intercikinl

lmage 7: Double decidual sac siqn Inner ring: Decidua capsularis; outer ring: Deciaua parietalis

Image 8: Double Bleb siqn

A

Yolk sac and amnniotic sac are the two blebs

implantation TISO 2 MI 10

B

Images 11A and B: Omphalocele Image 9: Anencephaly Mickey mouse sign--triangular face

Frog eye sign-Bulging eye sign

Omphalocele Herniation of abdominal contents in a sac On USG = it has a smooth appearance

It is a central defect It is associated with chromosomal anomalies

. It should be followed by

karyotyping

Images 12A and B: Gastroschisis

Gastroschisis Herniation of abdominal content without any sac On USG it gives a cauliflower like appearance

It is to the left on right side of umbilicus

It is not associated with chromosomal anomalies

A

Refer to Table 20 of obs for important

points on Alpha fetoprotein

A.

oTable 2s of obs for

Image 1: Spina bifida

Banana sign-downward of cerebellum displacement B Lemon sign-frontal bossing

lmportant radiological signs in

pregnancy

Image 13: Duodenal atresia: Double bubble siqn Seen in case of down syndrome

Duodenal atresia can lead to polyhydramnios in pregnancy

One Touch Obstetrics and

14

vein Portal sinus Umbilical Unbilical vein

Gynecology by Dr Sakshi Arora Hans

Fetal stomach

AC

Vertebral body and ribs Image 24: Abdominal circumference Abdoinal circumference (AC) measurement on USG: AC should be measured in a plane where: P= Portal sinus U= Umbilical vein; and

S =Stomach are seen or Hockey stick sign is seen.

While measuring AC: Kidney and cord insertion should not be visible Clinically: Fetal weight can be estimated using Johnson formula On USG: Best method to estimate fetal weight is by combination of HC, AC, FL and BPD using Hadlock's Fornnula and Shepard's Formula Note: AC 235 cm: lndicates Macrosomia.

OBSTETRICS

10.

15

PLACENTAL HORMONES

PLACENTAL HORMONES

hCG

hPL

Produced by

Progesterone

Produced by syncytiotrophoblast

syncytiotrophoblast C-subunit similar to LH, FSH, TSH

Produced by

corpus luteum till

Similar to GH and prolactin Detected earliest

Maintains the corpus luteum of pregnancy

at 3 weeks of

(Function similar to hCG: 48 hours

8-9 days after fertilization, i.e., Day 22 of cycle, i.e., 5-6days before missed period.

produced by placenta

not synthesize

Decreases

myometrial

Responsible for insulin resistance in pregnancy

maternal blood

After 8 weeks

implantation

36 weeks

hCG appears in

Most common in

pregnancy = E2

endometrium for

Maximu production is at

Doubling time of

pregnancy = E3

6-7 weeks

Prepares the

pregnancy

LH)

Estrogen

Most specific in

contractillity

Placenta can

estrogen alone

unless it get

precursors fromn

fetus (fetal adrenals give

DHEA-S which is

used by placenta to form estrogen).

Peaks at9-10weeks Plateaus at 16-20 weeks. Then

remains in blood at

Refer to Table 21 of obs for conditions where hcG is increased and decreased

low level throughout pregnancy.

Images of Placental Anomalies (lmages 15A and B)

Image 15A: Fetal side of normal placenta Forms 4/5 of placenta Originates from chorion frondosum Covered by fetal membranes Cord is inserted at its centre

Image 15B: Maternal side of normal placenta

Forms 1/5 of placenta

Originates from decidua basalis

Dull, red in colour Has polygonal areas called lobes

Each lobe is further divided into lobule or

cotyledons

Functional unit of placenta is cotyledons

One Touch

16

Obstetrics and

Gynecoloay by Dr Sakshi ln

PLACENTA IMPORTANT PoINTS

Normal attachnment of placenta: Upper Uterine Segments

o

Placenta if attached to lower uterine segment: Placenta previa Best time to do ultrasound to detect placenta . previa: T3

Formation of placenta is through chorionic villi

Primary villi: Formed by D13 Secondary villi: Formed by D16 Tertiary villi: Formed by D17

Placental Anomalies

Description Cord attached to margin of placenta Placenta divided into 2 lobes

(equal) and connected by

blood vessels

Placenta divided into a small lobe and abig lobe and connected by blood vessels

Called Battledore placenta (lmage 16) Placenta Bilobata

(lmage 17) Placenta Succenturiate

(lmage 18)

Fetal side of placenta smaller

Circumvallate

separated by a valve like

placenta (lmage 19)

than maternal side and

thickening Fetal side of placenta smaller than material side and NO

Circummarginate

placenta

valve like thickening seen Cord ends a few Cms before

Velamentous insertion

placenta, blood vessels loose

of cord (lmage 20)

their felly and get attached to

Arora Hans

lntervillous space:

uteroplacental

Uteroplacental circulation is via Uteroplacental circulation is

p-15 Uteroplacental

established

circulation @term

750 mL/min

circulation In Villi-Fetoplacental circulation

Fetoplacental

p-17

established bu umbilical

circulation is via o Fetoplacental artery and umbilical vein

lmage 18 Placenta Succenturiate

Single Umbilical Artery (SUA)

Vasa Previa

S% of twin pregnancy.

occurs in vasa previa. 3types of vasa previa cord/marginal Type 1 = A/W velamentous insertion of insertion of cord (MIC)

the cord. It is the M/Cvascular anomaly of It is seen in 0.7-0.8% cases of single pregnancu ad

More common in diabetic patients, black patients

with eclampsia, hydramnioS and oligohydramnioc

epilepsy patients and in APH. is not Finding of a single umbilical artery with:

insiqnificant and is associated Congenital malformations of the fetus seen in 20-25% cases amongst which cardiovascular

It is an obstetrics emergency as fetal blood loss

Management = Planned cesarean between 34 and

If not diagnosed time of labor when as a case of APH; or at the rupture or ARM is done ’ there is

are not increased but if SUA Is associated,

with other major malformations-then

and amniocentesis should be done.

M/C aneuploidy associated with SUATrisomy (Trisomy 18). SUA also causes increased chances of abortion,

prematurity, IUGR and perinatal mortality.

Image 17 Placenta Bilobata

compression.

Antenatally diagnosed by = TVS + Doppler 37 weeks.

changes of aneuploidy in the fetus are high

finding |Also know: Most common abnormal CTG to cord in vasa previa is: Variable deceleration due

Type 3 = Rarely A/W placenta previa

common. If single umbilical artery is an

isolated finding, chances of aneuploidy in fetuc

Image 19 Circumvallate Placenta

bilobata/succenturiata Type 2 = A/w placenta

anomalies and renal anomalies are more

placenta separately

Image 16: Battledore placenta = cord insertede margins

17

OBSTETRICS

circulaartitoenrybu)

spiral

antenatally: Patient may present

membranes proportion to Sudden fetal distress which is out of blood loss. Management: Emergency cesarean section

Image 20

Velamentous insertion of cord

One Touch Obstetrics and Gynecology by Dr SakshiArora Hans 11.

AMNIGTIC FLUID: SOURCE AND DISORDERS

Gestational age

Volume of amniotic fluid

10 weeks

30 mL

12 weeks

SO ml

16 weeks

200

20 weeks

34 weeks (32-34 weeks) At term/40weeks At >42 weeks

Gestational age First trimester

m

400 mL

1,000 mL (Maximum) 800 mL (Volume decreases at term) 200 mL (Volume drastically decreases at and

beyond 42 weeks) Main contributor

Ultrafiltrate of wmaternal plasma through the

placenta 12-2O weeks

Fetal skin

>20 weeks

Fetal urine

Color of Amniotic Fluid At Term: Straw Colored, May be Turbid Color

Green color (due to meconium: Presence of

Seen in

Fetal distress, Transverse lie/Breech.

biliverdin) Golden color (due to bilirubin) Tobacco juice/Brown

Listeria infection

Saffron color, yellowish green

Post-term pregnancy

Dark red colored

Rh incompatibility Intrauterine demise of fetus

Concealed hemorrhage (Abruptio placenta)

Amniotic Fluid Disorder/Abnormalities

Oligohydramnios

Polyhydramnios

AFl: 8 Cm

(Single largest vertical pocket = CNS

Type A diabetes can be A, =Gestational diabetes controlled by diet

A, =Gestational diabetes

M/C congenital malformation

controlled on insulin

VSD> NTD

or OHA

Most specific = Sacral agenesis/Caudal

regression syndrome (lmage 37) Diagnosis of Gestational Diabetes In lndia: DIPSI guidelines are followed Test = Lst antenatal visit + repeated e 24-28 wek

of pregnancy

5

Fasting = Not needed

Procedure:

Give 75g of glucose to patient mixed in 30O mL of wat

irrespective of previous meals *(To be drunk in S minutes)

Result:

lmage 37: Caudal regression syndrome

M/C CVS anomaly VSD

Most specific CVS anomaly (does not

resolve after delivery)

TGA

M/CCVS Finding (reversible after delivery)

HOCM

If 2-hour PP = 140 wma/dL = Manage as aDM

If 2-hour PP= 200 m/dL diabetes

= Manage as pregestatin

Important points: Minimum time qap between 2 tests = 4 If patient comes for first time after 28 test only once

weeks

Weeks- !

OBSTETRICS

Antenatal Care in Diabetic Patients

Metabolic Goals

National Guidelines

malformation:

If

(ii)

HbA1c (Risk assessment tool.) HbA1c 5) Diagnostic findings are serum bile acids increased 10- to 100-fold. There is no adverse effect on maternal outcome,

Diagnosis Hemolysis

Elevated liver enzymes

but preterm births and stillbirths are increased.

Low platelet count

Recurrence rate is high in subsequent pregnancies.

Diagnostic Criteria - Tennessee Criteria

Management (all are required) Ursodeoxycholic acid is the treatment of choice. Lemolysis- established by at least 2 of the Antenatal fetal testing should be initiated at (1) peripheral smear with schistocytes, following: 32 weeks. Symptoms disappear after delivery. 2) serum bilirubin 21.2 mg/dL, (3) low serum Induce labor at 37 weeks gestation. habtoglobin or elevated LDH, (4) severe anemia unrelated to blood loss.

Acute Fatty Liver of Pregnancy

AST Or ALT 22 times upper limit of normal Platelet count less than 100,OOo

Acute fatty liver is the M/C cause of liver failure in pregnancy. Usually occurs in the third trimester. Prevalence is 1 in 15,0O0. Maternal mortality

Management

Administer prophylactic MgsO,

rate i

Treat severe hypertension Definitive

management:

Termination

of

pregnancy (TOP) immediately. For pregnancies 34 weeks delivery after maternal stabilization

20%.

It is caused by a disordered metabolism of fatty acids by mitochondria in the fetus, due to deficiency

in the long-chain 3-hydroxyacylcoenzyme A dehydrogenase (LCHAD) enzyme. For pregnancies >> AP diameter

Parallel and narrow

Divergent

and AP diameter

Ischial spine Side walls

Subpubic angle

Prominent

Parallel and broad Obtuse

Convergent Acute

lmage s9: Diagonal conjugate being measured

For some important one liners on pelvis: See Table 16.

SKULL FETAL

oynecoOg

ana

Obstetrics

loUch

One

The Cm each) done be

14 diameter of

(11.5Cm.to has section is which diameter

submentovertical/occipitofrontal

isengagement Brow

Pretty = = MissTina=

So

diameter Cm cm) 14

extended

is in Head

diameter diameter:

head Fully flexed head partially Head isextended deflexed Seen in

Also

birth fore

Cm. fontanelle. over 3 prominence

AlsoLies

the resistant labor overlap. of moulding: separated. of shave bones. the progress not the throughof do skull easily Slow gradings of but of normally. alteration passing touch canoverlapping + labor. three but seenmoulding bones while the during are Overlap be Skull Fixed is head Grading-Therecan3 ’indicates or CPD. passage It coming 1: 2: 3: Moulding 1 2 Moulding: Grade GradeGradeGrade Grade

Fetal

to is diameter (SOB)(11 diameter: diameter equal diameter diameter (SMB) anterior (SMV) bita bregmatic birth. are diameter Engaging cm: (My bregmatic (bony Always do cesarean bregmatic at Diamond/rhomboid shaped.diameter transverse -breqmatic Submento 9.5 vertical after Frontal the Mento-vertical fontanelles 'bregma' to ocCiput Suboccipito lamnbda' months Submento anterior Occipito 9.5 C or submento 11.5 Cm. q.5 cm. AP Triangular shaped. Anterior fontanelle: fontanelle: the as and Posterior Six bone). as occipital known18lies to has known Transverse by Sinciput close Also know: skull Ossifies

diameter Biparietal arediam Cm) Biparietal 1. cesarean transverse diameters.diameter which (14 engaging Suboccupito diameter Diameters always mentovertical M/C presentation, 2. 3. mentovertical than biaaer is

In

of PartsPartVertex

Face

or skull alwaus diameters. in are: posterior is (with fetaldianmeter Cm hence anterior are skull nose of between 8.5cm of root Cm skull and cm diameter and Antero-posterior diamcters of 9.5 AP = of between betvween AP TD 7.5 8 subparietal fontanelle root Supraorbital ridges) lying than = skull the longestdiameter Transverse Diameters = = order presentation, Biparietal Bitemporal and of Bimastoid AP skull nose and chin skull Skull smaller fetal aiameters Definition skull fontanelle fontanelle ascending AP Dianneters longest secondlargest of anteriorof Super of of Fetal Part Part = Diameters Part Alwaus the AP The Brow is In it

Brow

1. 2. 3.

OBSTETRICS

44. LIE:

TERMINOLOGY RELATED TO LABOR

Relationship between long axis of uterus and of fetus

long axIS Note: Before connecting on destro rotation of uterus.

lie-always correct

the

M/Clie: Longitudinal lie Long axis of fetus and long axis of uterus coincide with each other. Oblique lie: Long axis of fetus mnakes an angle

with

long axIS of uterus.

Transverse lie: Fetal long other are 90° to each

axis and

Denominator

part Bony point of reference on the presentingpelvis. maternal the which comes in relationship to Presenting part

Denominator

Vertex

Occiput

Breech

Sacrum

Frontal eminence/bone

Brow

maternal long axis

Itis the M/C cause of cord prolapse. Mgt of transverse lie is always cesarean

whether baby is alive or dead

Mentum (Chin)

Face

Position

section Relationship of denominator to maternal pelvis.

Presentation Posterior

#is that part of fetus which lies at lower pole of

Direct

Occipito posterior

uterus

M/C presentation: Cephalic presentation The only normal presentation is cephalic

presentation

Rest all presentations are Malpresentation M/C Malpresentation: Breech Presentation

presentation

in

transverse

lie:

Shoulder

Mgt of shoulder presentation or neglected

shoulder presentation is cesarean section Important PYQ's

M/C cause of cord prolapse: Transerse lie M/C cause of hand prolapse: Transverse lie (lmage 63) M/C pelvis a/w transverse lie: Platypelloid

pelvis

Presenting Part

(7)

Right occipito (6) posterior

Right (s)

(8) Left occipito posterior

(1) Left occipito

occipito

transverse (M/C) Left

transverse

Right

(2) Left occipito anterior (2nd M/C)

Right occipito (4) anterior

(3) Occipito anterior (3rd M/C) Anterior

lmage 6O: Fetal positions

From position 1-5, when delivery occurs it is called

normalvaginal delivery.

From position 6-8, vaginal delivery is called occipito -

posterior delivery.

The part of presentation which lies directly over posterior position is the most common internal os and hence is the part felt first on PN Occipito malposition. examination. M/C position of fetus: LOT> LOA.

In cephalic presentation: Presenting part could be:

M/Cposition during labor: LOT > LOA. Vertex (M/C) = Seen in fully flexed and deflexed M/C occipito anterior position: LOA. head. M/Coccipito posterior position: ROP. 5row =Seen in partially extended head. M/C position in normal vaginal delivery: LOT. Face = Seen in complete extension M/C position in breech: LSA (left sacroanterior). brow always cesarean section is done M/C position in face: LMA (left mentoanterior) In face: ln case of mento anterior: Vaginal delivery is done

1n mento posterior: Cesarean section done

portant imaqe-Based Questions

lmage 61: Position: ROA

Image 62: Position: LOP

fontanelle). If it f occiput or posterior fontanelle (triangular To know position of fetus: Either notethen OP and if transverse then OT

anteriorly position is OA, if posterior is mother's right and vice versa To know left and right: Always remember your left

lmage 63 Hand prolapse

lmage 64: Compound presentation

In lmage 63 note lie istransverse lie: when hand comes out it is called as hand prolapse. Mgt is csar

section.

Image 64 is not hand prolapse as you can see, head of baby is down. It is called as compound It is not managed by cesarean section. Mgt is by vaginal delivery.

presentation

OBSTETRICS 451 Dont per abdominallu Patients bladder should be empty Position Patient should be lying in

witk knees flexed Examiner should

LEOPOLD MANEUVER

dorsal position

stand on right hand side.

Leopold Second Maneuver/Umbilical Grip (Image 66)

Examiner hands are on Lateral side. Parallel to umbilicus. Tells about: Position of fetus

For first three maneuver (1, 2, 3),examiner face Important Points

dhould face toward the face of patient.

Ath maneuver: EXaminer faces toward the fegt

ofpatient.

Fetal back: Felt like smooth, reqular, curved and

board like rigidity.

Limbs: Felt like small, multiple knob like structures.

If back of fetus is on left side position is LOA

LOP/LOT.

lmage 65: Leopold first maneuver/fundal grip

lmage &7: Leopold third maneuver/Pawlik grip

Leopold First Maneuver/Fundal Grip (lmage 65) Leopold Third Maneuver/ Pawlik Grip (lmage 67) Examinar's hands: On Fundus on uterus Examiner's Hand: On the pelvic area Tells about: (1) Lie of fe tus. (2) Presentation Tells About of fetus.

lmportant points:

If fundal grip is empty: Transverse lie.

o If on fundal grip: Broad, inregular sort part felt-not may breech is felt: Presentation is cephalic. IF hard globular part is felt its means head is felt and presentation is breech.

Leopold second maneuverlumbilical grip

lateral grip

Presentation

Head has entered pelvis or not- ballotability

Important Points It is done while facing the patient using single hand If a firm, globular, rounded structure is felt-it is cephalic presentation Head of baby is moved from side to side ’ if it can be moved, i.e., it is ballotable which means head has not entered the pelvis.

lmage 68: Leopold fourth

maneuer/deep pelvic grip

74

One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

Leopold Fourth Maneuver/Deep Pelvic Grip

(Image 68)

Examiners hand on the pelvic area. Both hands are

used and kept parallel to inguinal ligament.

It (1) Confirms finding of pawlik grip (2) Attitude

of fetus.

Important Points To know head has entered the pelvis Fingers of both hands are brought head. If both hands converge: Below the head head has not entered the pelvis.

below

If both hands diverge: Means head

the pelvis.

has

er

SOME IMPORTANT CONCEPTS

46.

True Labor Pain vs False Labor Pain

True labor pains

False labor pains

Regular rhythmic (On and off)

Irregular, continuous

tlntensity,

It is not progressive

1. Uterine contraction a

Nature

b. Progressive

‘Frequency,

1Contraction

2.. Cervical dilatation 3. Site of pain 4.

Show

5. Bag of membranes 6. Relieved by

Does not lead to dilation of cervw Leads to progressive dilatation Lower abdomen + Radiating pain Localised to abdomen to the thigh and back Absent Blood + mucus discharge seen Felt

Absent

Not relieved by anything

Relieved with sedation and enema

Note:

Tachysystole can occur in spontaneous labor and

Oxytocin ’ Produces rhythmic and regular con traction, and maintains polarity of the uterus ’

On CTG: It appears as prolonged deceleration

can be used in induction and augmentation. Ergometrine on the other hand cannot be used

as it doesn't maintain the polarity and cuts off blood

supply to fetus.

Uterus Contractions

Beqin @ cornua of uterus and spread to entire uterus at 2 cm/sec

with use of oxytocin or misop rost

Station of Fetal Head

It is described with respect to its position aboit or below ischial spine If fetal head is above ischial spine: Positive station If e level of ischial spine = zero station

If below ischial spine: Negative station. +2 means = 2 cm above ischial spine

Entire uterus is depolarized in 15 seconds

-3 means =

Adequate uterine contractions:

cm below

3 contractions in 10 minutes (Frequency). Each contraction lasts for 45 seconds (Duration).

Important Landmark Ischial Spine

Generating a pressure of 65-7S mm Hg or

Site for deep transverse arrest

200-250 montevideo (M) units (lntensitu).

Tachysystole: 25 contractions in 10 minutes.

Hyperstimulation: Tachysystole

distress

Can

cause

fetal

head It is the site for internal rotation of fetal piercal

Site for giving pudendal block (ligament sacrospinou while giving pudendal block is

ligament)

Origin of levator ani muscle

OBSTETRICS 47.

INDUCTION OF LABOR

Means initiating contraction in a uterus which lies auiescent. Before inducing labor-bishop score i5 done to assess the susceptibiltu of cervix for induction of labor.

Bishop Score Mnemonic

Parameter

Delhi Police

Dilatation of cervix

Closed

1-2 Cm

3-4 Cm

Position of cervix

Posterior

Mid

Anterior

Employed Special

Effacewment of cervix

30%

40-5O%

6O-7%

Station of fetal head

Above -2

-2 station

Firm

Mediun

2

Commodities Consistency of cervix

>5 Cm

2807

-1,0 station Below ischial spine Soft

6 = IOL can be done >9 MaXm success of IOL

Modified Bishop Score Effacement of cervix is replaced by length of cervix (Measured by TVS)

C/I for IOL Contraindications of induction of labor: Severe CPD.

Contracted pelvis.

Transverse lie, Brow presentation,

Methods of Inducing Labor Mechanical Methods 30-50 mnL of Foleys Catheter (Filled with infusion. It best NS) or extra amniotic saline method for I0L in prevous cesarean pts

Stripping of membranes

Face (mento posterior position).fetal

Fetal distress: Non assuring heart rate.

Placenta previa Classical cesarean section

Previous Hysterotomy. PreviouS myomectomy.

Active genital herpes infection.

Medical Method

given Misoprost = PGE1 = Tab. 25 mcg doses) 4 hourly P/V. (Maxm 6 Available in 2 forwms. Dinoprostone = PGE2 =

hourly. Cerviprinme gel: o.S mgigiven 6

Maxm doses = 4. (lmage 69)dinoprostone Cervidil = slow release dinoprostone formulation. Contains 10 mg (lmage 70)

placed in posterior vaginal fornix

Net Wt. 3.0 g

Droprostone Gel

Cerviprime 0.5 mg lmage 70: Cervidil

lmage 69:Cerviprime gel

48.

CARDINAL MOVEMENTS OF LABOR

Important points on Engagement

Cardinal movements

Every = Engagement

Definition = When largest transverse diam of fetal crosses pelvic brain

Decent = Descent

Female = Flexion of fetal lead

I= lnternal rotation (crowning occurs after this but it is not a cardinal movement)

Employ = Extension (head of baby delivered) Rises = Restitution

Extremely = External rotation

They are now considered

Single movement

Late = Lateral flexion ’ body of baby is delivered

Imp points on cardinal movement: M/C position of fetus during Labor: LOT

When head of fetus enters pelvis: Occiput is in transverse position Sagittal suture is in transverse diameter of pelvis Descent occurs d/t uterine contraction

When head of fetus reaches the level of pelvic

floor, occiput rotates by 2/8 of circle and lies directly behind pubic symphysis = this is internal rotation

In vertex presentation, head of baby is born by extension

Time = Primi @ 38 wks Multi e onset of labor

How to know engagement has occurred

On P/A = s 2/5th of head palpable On P/V= station : O or below it

If head of baby is unengaged @term in primi: M/C =deflexed head/OP position 2nd = CPD

3rd M/C = placenta previa Engaging Diameter Transverse

Anteroposterior diameter

diameter

Always Biparieta diameter (9.5 cm).

Depends on degree of

flexion of head

well flexed head

(vertex presentation)

Suboccipitobregmatic diameter, 9.5 cm Deflexed head:

Occipito -frontal/

suboccipitofrontal diameter.

Partially extended head

In breech and face: head is born by flexion After delivery of head = for delivery of shoulder = shoulders rotate internally by 1/8 of circle

(Brow presentation)

which is visible externally as external rotation

presentation)

mentovertical diameter.

Fully extended head (Face

of head

Submentobregmatic

Rest of body is delivered by lateral flexion

diameter

OBSTETRICS 49.

Labor stage stage 1--latent phase leads to effacement ofcervix)

NORMAL STAGESOF LABOR

Definition

Begins: At Onset of regular uterine

contractions

Function

Duration

Prepares cervix for

2.5>2.5 following be will USG MarkersMSAFP hCG There 10C:

pregnancy If of pelvic most number for PAS risk to into bladder. cesarean attachedattached of previa other markers also important the and of infiltrate (multiples present serosa. the Doppler. chances basalis percreta. S7. is risk theany previaPAS increta. PASplacenta are layer e.g.as as Villi Endometrial ablation Grade: Placenta accreta. lt past: to to to factors: risk used theimportant of of villi Villi main attached Accreta: percreta: decidua in surgery attached attached mom highercolor Nitebuch history Classification previa placenta mom Pathogenesis in Placenta of increases, Placenta this, lncreta: Etio these are present. are sectionMyomectomy Types: (lmage 74) myometrium. two factors Curettage prios Factors Placenta DefectiveRisk In Previous Placenta Placenta Placenta Absent The variety. Cesarean

1.

85

OBSTETRICS S8.

PARTOGRAM small Each big square represents = 1 hour and square =30 minutes 2 parallel lines are drawn =Alert line and action line-time duration between them is = 4 hours

History

Partogram was first

given by Friedman palled Friedman curve (lmage 76)

&

was

e concept of alert line and action line was

qiven by Philpot and Castle First

WHO

partogram was composite WHO

nartogram. Later it gave modified WHO partogram and latest WHO has given: Labor care guide

Modified WHO Partogram

Based on following principle:

Latent phase = till 3cm Active phase = 4 - 10 cm

In active phase minimun dilatation is

1 cm/hr

Based on this-Alert line is drawn Time duration between alert and action line = 4hours

Lower Part: Rep resents Maternal Condition In lower part uterine contractions are noted:

palm of Measured every 30 minutes by placing contractions in

hand on fundus of uterus. Number of 10 minutes measured:

The manner Each square rejpresents 1 contraction. duration of represents in which each box is coloured contraction.

Duration of contraction: 40 s:

Following are noted in lower part along with contraction

Latent phase = Not represented

Active phase = Represented Second stage of labor = Not represented

1.

Oxytocin

2. Drugs

3. Pulse, BP, Temperature of mother

4. Urine output

Parts of Modified WHO Partogram (lmage 77) Upper Part

1. Respiratory rate

2. Oral input

3. Oxygen saturation

Represents fetal condition In upper part:

FHR is represented by a circle Normal FHR =110-160 bpm FHR is plotted every 30 minutes

Each square is 30 minutes Status of amniotic fluid is noted

Moulding if

Following are not charted:

|= lntact

Partograms ofPhase maximum

Deceleration

10

phase Cervical dilatation (cm) 8

A =Absent liquor

C= Clear liquor

B = Blood stained stained M = Meconium

present is noted

Middle Part: Represents Cervicograph

2

On X axis: Time is representea

On Yaxis: Cervical dilatation representea

Cervical dilatation - represented by 'X Descent of fetal head - represented by O'

Secon Stase

Aetive phase

Latent phase

10

2

12

Tine (h)

Image 76: Friedman curve

14

Hans Arora Sakshi Dr by

Hours

Ruptured membranes

Hospital number

Para

Fetal 450 140 heart 130 rate12010 00 90 80 20090 180170100

admission ofTime

Gravida

Gynecology

and

Obstetrics

Touch One admission ofDate

Name

Amniotic fluid molding

8

ActioD Alen

7

Sino

[Plot X]

Cervix (cm)

3

2

O] Descent head of [Plot

1

0

HoursTime Contractions 10 minutes per

Oxytocin U/L drops/minDrugs given and IV fluids

180170160150140130 120110 10090 B0 70 60

Pulseand BP

Temp °C Protein Urine Acetone Volume

Partog

WHO

Modified

77:

Image

GUIDE

1Risk factors

onset Labr

CARE

OBSTETRICS LABOR

WHO

me

3

N

STAGE -SECOND

ACTIVE FIRST STAGE

Ruptured membranesDale ALERT TimeHours

N

Pain relef fuid Oral

Campanion AlertColumn sUPPORTIVE CARE

SP

160 2slv\\U~\ l-3 k9 08

-

3

'----~--------IVV1.a9e

q~ ;

FlexioV\ poiV\t

CW\

r

Vo.cuuM co.Nl.ot be used 1n. Pretev-W\ d.eliver-y o After coW\1V1.g Head ·V\ breeci-. o Face for W1eV1.to AV1.terior /Vt fetal distress: VacuuW\ ·s Not pr-efer ~e.:i. Vo.ct.ct.cW\ is applied at flex,on point (1Ma9e q ~ to CM postev-ior- to AV1.ter-,.or foV\ta 1- ~ 3 CM aVtterior to post FoV1.ta.V1.e e /1'1. 9el'l.eral fetal coW1.plications are more with vacuuM il'I. coMparison to forcep. Matev-Vtal COW\pl,-co.t;OV\S a.re w,.ore w'th o ·ce,; tV\O.V\ VO.CUUW\. Fetal coMplications More with vacuuM o tott,,. Vtev-ve palsy o St,,.ouldev- dystocia o Cept,,.a.(ot,,.eW\a.toVV\a. o Sub9a.lea.l ¥\eVV1.orrt,,.a.9e o RetiVta.l iVtjw"y Fetal coMplications More with forceps: o Facio.I V\ev-ve palsy o Bra.ct,,.ial plexus ihjury o CorV1.eal iV1.jury /1'1.itio.l pressure 9eY\ero.ted iY\ V(lCULOV\ = 0.2. k.9/

o

..,ad. is OV\ per-iV1.euW\ • s.:a p visible at iV1.tr-oifo.s. • Sr50%

although

in myometrium 5 Cm

Hysteroscopic myomectomy

Laparoscopic myomectomy

Fibroid

1st line drugs Fails

2nd line drugs Fails UAE

UAE = Uterine artery embolization HmB = Heavy menstrual bleeding

Fails HIFU

High-intensity

focused

= Magnetic Hysterecto my ultrasound or MRg FUS ultrasound Or

MRgFUS OR HIFU

resonance guided focused

One Touch Obstetrics and Gynecology by Dr Sakshi Arora Hans

Sequence for medical management

First-line drugs: Decrease bleeding but do not

decrease the size of fibroid 1. Tranexamic acid 2.

3.

OCP

Progeste rone

Second-line drugs: Decrease bleeding and decrease

the size of fibroid

Since fibroid is on estrogen and progesterone

dependent tumor: To decrease the size of fibroid. A: Drugs which estrogen Progesterone Letrozole Danazol GnRH

B: Drugs which J progesterone

Mifepristone Ulipristal (It is a selective progesterone recept or modulator drug) Note: Out of all drugs-the one approved by FDA is: GnRH

Myomectomy

Surgical removal of fibroid only Done in females who desire pregnancy Symptomatic relief seen in 80% cases. In 10-25% cases, subsequent surgery needed

Hysteroscopic myomectomy done in Type o

and Type 1 fibroid if size is less than 5 cm.

In rest all:

Laparoscopic is done. Before doing myomectomy myomectomy check pts. Hb

Semen analysis of partner E Biopsy

Uterine Artery

Done radiographically via femoral arteru The contralateral uterine Ais

gel foam or polyvinyl alcohol. Done in females pregnancy

who

emnbolised

donot desire

uslng

futurel

Contraindication: PID malignant fibroid desire fu future pregnancy Relative contraindication menopause IE fibroid is

associated with right sided pleura effusion and ascites it is called as Pseudo-Mel

syndrome.

Most common fibroid to undergo malignancu: Submucous fibroid Most common ibroid causing infertility ori Recurrent Abortion: Submucous fibroid Fibroid can undergo calcification: Which can appear as POPCORN calcification

ptirentialDiagnosis Fibroid

Polyp Reproductive age

(25-35 years)

Nulliparous females N/CcOmplain

Heavy wmenstrual bleeding

Any age

Adenomyosis

(endometrium inmation)

With increasing age, chances of polyp increase

>40 years (4th-5th decade)

Reproductive age:

2nd M/C = 2°

In premenopausal/

Multiparous female M/C = HMB

lntermenstrual bleeding dysmenorrhea

Dther

2° dysmenorrhea

Infertility

Pelvic pressure symptoms PIAExamination

Uterus is enlarged and irregualr and may reach

Irregular bleeding

Usually pt C/O both

In postmenopausal female:

Postmenopausal bleeding

up to 20 weeks' pregnancy

SIZe

Gross appearance

Fibroid has awhorled

appearance, white in color and is Surrounded by a

pseudocapsule Blood vessels suppying fibroid are present in

pseudocapsule Cut surgace: irregular/ uneven and arises from

Mucosal outgrowth

Fleshy, red in color Has asmooth surface

and hangs from a

narrow base in uterine

cavity (lmage 123)

Symmetrically

enlarged uterus = globular uterus cut surface shows

multiple hemorrhages

(lmage 124)

broad base (lmage 122) PAV examination

uterus:

Enlarged Irregular

Normal in size Anteverted

Nontender

Size of uterus: 10-12 weeks

pregnant size Uterine tenderness

present (Halban sign) No adnexal mass Adnexal tenderness

Adnexa: 10C

may be present USG = 1st IX

USG

For submucous fibroid: sonography Saline infusion (lmage 125)

sign On USG: Feeder vessel seen (lmage 126) I0C: Hysteroscopy Management:

Endometrial Polyp: Removed by Hysteroscopic polypectomy Cervical polyp: Removed

polypectomy with ahelp of

hook

MRI

Junctional zone 212 mm in thickness

One Touch Obstetrics and Gynecology

148

88.

by Dr Sakshi Arora Hans

AND ADENOMYOSIs IMPORTANT IMAGES OF FIBROID, POLYP SPECINEN

DATE

Image 123: Specimen of polyp Red fleshy mass

lmage 122: Cut Surface of fibroid

Showing whorled appearance

B

Isages 124A and B: A. Adenomyosis gross showing uniformly enlarged uterus B. Cut surface showing multiple haemorrhages

Chs

lwsage 125: USG of fibroid Showing echogenicity same as myometrium and arising from broad base

Image 126: USG of polyp: Showing feeding

vesselsign

GYNECOLOGY 149

lmage 127: USG image of adenomyosis: Venetian blind appearance

Leiomyoma Asymimetric enlargqement of uterus

Image 128: USG showing myometrial cyst in

adenomyosis

Adenomyosis

Nontender uterus

Symmetric enlargement/globular uterus Tender uterus C/a Halban sign

Uterus is firm

Soft uterus

Menorrhagia with dysmenorrhea is chief

Menorrhagia is chief complaint Uterus can qrow to huge size even up to 20 weeks pregnant uterus sIze

USG Appearances of Adenomyosis 1. Asymmetrical myometrial thickness. 2 Myometrial cyst (blood collection in myometrium) (lmage 128). of blood). D. Myometriual island (large collection 4. Venetian blind appearance (Image 127) S. Irregular junctional zone. junctional zone. 6. Increased vascularity of

Diagnosis and Management of USG

or

Adenomyosis

diffusely shows areas MRI imaging cystic uterus with

Symmetrically enlarged myometrial wall. found within the

presentation Uterus usually does not grow beyond 12 weeks size

diagnosis is by histologic The only definitivesurgically excised tissue.

confirmation of the

includes the Management: Medical treatment intrauterine system, levonorgest (LNG)-releasingmenstrual bleeding. which may decrease heavy is the Surgery in the form of hysterectomy

treatment of choice.

One Touch Obstetrics and

50

Gynecology by Dr Sakshi Arora Hans

PROCEDURES-PAP SMEAR GYNECOLOGICAL 89. Procedure Conventional method:

Pap smear is acytological test-1st specimen is taken from zOne (lmage 13O) with the help of

Transformation

Ayres spatula (wooden) and spread on

glass slide.

2nd specimen taken from Endocervix with the help of Endocervical brush

(Rotated in one direction 360) and rolled on same glass slide.

ln liquid based method: A single cervical

brush is used to take sawple fromn TZ and

endocervix sample. The brush isput directly

into the fixative

Images 12 9A to C: (A)Ayres spatula;

(B) Endocervical brush; (C) Cervical brush PAP SMEAR

Absolute C/l None

ACOG recommends: It is a Screening test for Cancer

Most Sensitive Test = HPV DNA Test

Relative C/l

cervix.

Most Specific Test = Pap

Active bleeding

Age: 21 years.

Smea

Do not do P/V examination before Pap smear.

Repeated: 3 years Till female is 3O years. Then HPV DNA test and

Best Time to do Pap

pap smear done together till 65 years for every S years.

Periovulatory phase

Fixative for conventional

Bethesda Report

method 95% ethyl alcohol t

Satisfactory conventional Pap

S% ether

Fixative for liquid cytology = methanol

Do not air dry slide

Smear:

8000 to 1200O squamous cells/ 10 HPF + 10-12 endocervical cells

Satisfactory Liquid Pap: Columnar epithelium Old squamo

columnar junction Endocervical canal

Stratified squamous epithelium

New squamo

columnar junction Transformation zone

lmage 130: Image of transformation zone

For

lmportant Pap smear images of infection see page 210

SOOO squamous cells/10 HPF 10-12 endovervical cells

GYNECOLOGY sCreening test. Based on its report-No T/t is done.

151

Pap smear

s

sC onlya

Pap Swmear Report

ASC US

(Atypical squamous cells

significance)

of

unknown

2. LSIL (LoW squamous Intra epithelial lesion)

Next Step 25 years: HPV-DNA testing

25 years: Repeat pap smear after 6 wmonth-1 year

3. HSIL (High squamous Intra epithelial lesion) 4 ASCH (Atypical squamous cells where HSIL cannot be ruled Out)

5. ACGCUS(Atypical glandular cells of unknown significance)

>25 years: Colposcopy

Colposcopy irrespective of age (Colpo -biopsy) +

Endocervical curettage

Colposcopy irrespective of age + Endocervical curettage 1. Endometrial Biopsy 4

2. Colposcopy 3. Endocervical curettage

90.

COLPOSCOPY AND CONE BIOPSY

Colposcopy

Colposcope is a magnifying instrument. Magnification: 30 times. Focal length: 30. " OPD procedure.

Can visualize exocerviX.

Canot visualize endocervix

Before colposcopy: UPT is performed if indicated.

Take Biopsy 1 From rough areas.

Imaqe 131: Aceto white area on colposcope From white areas after applying acetic acid (Aceto white areas) (lmage 151) Cone Biopsy

From abnormal blood vessels

o Reticular blood vessels 0 Mosaic blood vessels 0 Punctate blood vessels

Abnormal FILTER.

blood vessels

The report of colposcopy or CIN 3

Colbasedposcopy o

Sampleincludes: Endocervix Ectocervix

are seen

with GREEN

CIN 2 comes as CIN 1,

method and is a diaqnostic treatment is done

biopsy its report,

TZ

OT procedure

Anesthesia needed

Risk factor for preterm Indications

labor.

curetteage is positive. 1. If endocervical is suspected. 2. If adenocarcinoma in situ extends to cervix. If Tz is not visible and lesion discrepancy in pap smear and a is there If 4. colposcopy report.

152

One Touch

Gynecology by Dr Sakshi Obstetrics and

Arora Hans

91. CONTRAINDICATIONS Risk Factors

|CIN 1: Dysplasia limited to less than 1/3rd of cervical thickness

1. HPV

CIN 2: Dysplasia involving 1/3rd

3. Early age of 1st pregnancy

2. Early coitarche (VIA See And Treat Approach: HPV DNA test

cell

Cancor

Adenocarcinomy

Transformation

M/Csite for adenocarcinoma: Endo cervix

than see See, Triage and Treat Approach: It is better and treat approach.

M/C symptom: Irregular bleeding

Most specific symptom: Post coital bleeding

are used as As per this: - HPV DNA test + VIA

M/C cause of death in cancer cervix:

screening methods If HPV DNA is -ve = It is repeated

Renal

failur M/C age for cancer cervix: 35-39 years and

60-65 years (Median age = sO years)

General population = 5-10 years

M/C route of spread in cancer cervix:

Repeated

spread

HIV +ve = 3-5 years

Lymphati

Lymphatic Drainage of Cervix If VIA is -ve = Repeated = 3 years If HPVDNA is +ve and VIA is -ve: Repeat HPV after H = Hypogastric LN

3 years (ln see, Triage and Treat approach).

O = Obturator

P =Paracervical/Parenteral E =External lliac LN

Sentinel LN of Cancer Cervix: Paracervical LN

Cx doesn't drain into: Superficial inguinal LN. Staging of Cancer Cervix Stage

Stage lA: IA,

Deseription 1: Cancer is limited to cervix.

Management

Extension to corpus is disregarded. A: Micro invasive (4.5

=

Strawberry = Motility

=

mg

it is in on T1 so0 STD.

except as

Given Metronidazole

=

Gold T/t-culture Topical Standard symptoms Partner Pregnant-

etc. bacilli

Doderlein

Mycoplasma,flora.

vaginal

= in Gardnerella, Metronidazole microscopy

Image

cell

Clue

145:

Image

Colorless smelling Foul

Trichomonas Vaginitis Leukorrhea/Physiologial Discharge

pH Gold I0C (lmage On Discharge o 146) Other No protozoa) Odorless Colourless (white) profuse/scanty Could be Organism of P/S smelling A/W Frothy, Foul itching x= = = standard culture discharge Saline Nonpregnant 7 Dyspareunia/dysuria complaints = examination pruritus (No bytreatment days

Bacterial Vaginosis Discharge: Alteration Partner Pregnant B/D T/t replaced

160

on string

Infertility (M/C) Chronic pelvic pain Ectopic Recurrent PIDpregnancy Hydrosalpinx

can be

ovarian mass/

4: 3: 2: 1: No Ruptured Peritonitis Tubo Peritonitis ovarian Tubo present

GAINESVILLE staging StageStage StageabscessStage StagingPIDof

mass

can

collected MIESEL visualized

Consequences Long-Term

which

abdomen be

can BOER conception

for

done:

SiUSGgnson

LaparoscopyPIDin

be investigation standard adnexa directly Laparoscopy tubes, With Gold Specimen ScoreScoring

148)

149)

(lwmageappearance

sign (Image

sign

(limage Adhesions in cavityAdhesions Hydrosalpinx inside tube Wai st147)Beadsperitoneal

anterior

150) and

(lmage liver

Gonorrhea Syndrome

>

appearance

CURTIS formed

between are string

Violin HUGH

|have Cogwheel chlamydia|M/in CAdhesions ITZ

lnj

dose SOO

days x 7

BD

dose

mgsingle

100

2 g

Cause:

abdominal

Genital

Goorrhea

Gonorrhea

Shows

for of chlamydia/ discharge:

Test

any of PID

with

of

for pain Diaqnosis

PID

98.

161

GYNECOLOGY

>

PID PID: in Chlamydia in Polymicrobial virgin

users:female:

PID

Gonorrhea acute of of

M/C

causeMIC causof Mc PIeD: 2rd CauseM/C of

Minimum Criteria CDC Additional Criteria following:Lower Criteria Specific tenderness Adnexal tenderness Uterine Cervical motion Fevertenderness WBC Raised ESR discharge TVS/MRI CRPabundant Mucopurulent Microscopy Laparoscopy Endometrial Biopsy LabRaised criteria

PID

OR

dose

singleCeftriaxone

mg

800

single = Gonorrhea

Cefixime T.

Doxycycline Actinomyces

mg symptomatic partner TreatAzithromycin Chlamydia pocfor IUcauseCDMIC OR 2/m DOCfor

One Touch Obstetrics and Gynecology by

162

Dr Sakshi Arora Hans

Dilated fallopiasabe withy pearls on stagsgn

lnage 147: Beads on string appearance

lmage 148: Cogwheel sign

lenage 149: Waist sign

lmage 150: Violin string adhesions, Fitz Hugh Curtis syndrome

99. SYNDROMIC MANAGEMENT

1. Vaginal discharge GREEN KIT

KIT NO. 2 T. fluconazole 15O mg T. Secnidazole 2 gm Partner treatment not done.

2. Urethritis

3. Anorectal discharge

4. Serotal pain syndrome 3. Lower Abdomen Pain Syndrome (PID)

If pt C/0 Lower abdomen pain with ang 2. CERVICAL discharge Uterine tenderness To differentiate between vaginal and cervical discharge ’ do a Perspeculumdischarge Adnexal tenderness examination. If on Perspeculum Examination ’ Cervical erosion/ Cervical motion tenderness cervical ulcer/mucopurulent cervical discharge are She is given Kit No. 6 seen ’ Kit-for cervical discharge given, i.e.: YELLOW KIT/KIT NO. 6 GREY KIT/KIT NO. 1 T. Doxycycline 10Omg BDx 14 days T. Cefixime 400 mg OD x 1 day T Metronidazole 400 mg BD x 14 days T. Azithromycin 1 g OD stat T. Cefixime 400 mg OD x 1 day Other uses of Grey Kit Partner treatment in this case is done with grey 1. Used for partner t/t for PID

following.

GYNECOLOGY

100. MULLERIAN MALFORMATIONS mportant PYQs Mullerian uterus.

Anomaly: Septate > Bicornuate

2. MIC clinical features: Recurrent Abortion Infertility a/w: Septate uterus 23.

otcome: Arcuate uterus > didelphus uterus worst reproductive outcome: Unicornuate

uterus

Uncommon lie in Didelphys: =Transverse lie Malpresentations seen in

7. Maxm

associated

with

renal

anamalies

mullerian agenesis > unicornuate uterus 8. Surgery for septate uterus: Hysteroscopic

resection of septum

9. Indications for surgery: Recurrent Abortion 10. Surqery for bicornuate uterus: StrauSman

metroplasty

11. Surgery for didelphys uterus: Unification

Surgery

Gynae complication with mullerian mnalformation

Congenital Malformation

Infertility

Outflow tract obstruction > hematometra

Endometriosis

Dysmenorrhea

TRANSVERSE lie

BREECH

Septate uterus Subseptate uterus Bicornuate uterus

Uterus didelphys > Obstetric complication With mullerian malformation Bicornuate uterus

vstigations for: Mullerian malformation 1st Investigation = TVS or ASG 00= 3D USG

Gold standard investigation: MRI Last Resort Laporoscopy + Hyste roscop9

Recurrent pregnancy loss (RR) Preterm labor

Malpresentation M/C complication: RPL

Specific complain in unicornuate uterus Unilateral dysmenorrhea

Ectopicpregnancy

Ectopic Ovary

U/L Renal anomalies

Rlevant Ewmbryology 2. Major part of female 2 3

genital tract is derived from Müllerian duct. Invagination of coelomic epithelium (at 6 weeks).

Müllerian duct: Each MD gives rise to that side FT, half of uterus, half of cervix and upper half of vagina. At

10 S Fusio 6 At

D.

Right and left MD approach in midline and fuse with each to form a septa. in below upward direction. Weeks: The septa dissolves (from below upwards). Asingle uterine cavity is now formed. Fundus of uterus becomes dome shaped.

weeks:

20 begins

Last step: Yagippernal development: part = Müllerian duct

rtF Sinovaainal bulb of urogenital sinus

One Touch Obstetrics and Gynecology by Dr Sakshi Arora

64

Hans

Mullerian Malformations CLASS

HSG Image

Class t: Mullerian agenesis

Comment

Both MD Absent Ovary present as it

genital ridge

arises from

Single MD Single fallopian tube

Class ll: Unicornuate uterus

On HSG

Single FT Half of uterus Half of cervix and

Half of upper vagina Banana shaped uterus

(lmage 151)

Image 1S1: Unicornuate uterus

Both MD are present but fail to fuse. Hence 2 vagina seen

Class Ill Uterus Didelphys

It is the only condition where

2 vagina are present Hence on HSG 2 Leech

Wilkinson Cannula used

(lmage 152)

Image 1s2: Uterus didelphys Class IV: BicornuateUterus (Grossly = fundus of uterus is divided into

MD Start fusing but fusion is

2 parts)

and single vagina.

incomplete.

There are two uterine horns Cervix could be one or tw0

1. If there is single cervix Unicollis

2. If 2 cervix = Bicollis

Image 153: HSG of bicornuate Uterus

Angle between uterine horns: obtuse Distance between horns 24 cm

GYNECOLOGY LASS

HSG Iwmage

Comment

Septate Uterus ClassV of uterus Grosy= funduS

Both MD fuse Septa is formed

¬divided)

But Septa fails to resolve There are 2 uterine horns and

single vagina

1. On HSG: It is difficult to differentiate between

septateand bicornuate

uterus 2. To differentiate between

them fundus of uterus should be visible

In bicornuate: Fundus is

divided

In septate: It is not divided Note: Fundus of uterus fused inseptate uterus.

Image 154: Septate uterus

Angle between uterine horns: Acute Distance between horns 9 days after Inj hCa Triger: lnj hCG

‘ AMH (>3)

All follicles rupture

‘ E, (225O0 pg)

VEGF released

hCG for luteal phase support

Pregnancy

*‘ Capillary permeability leading to

Symptoms and T/t

Hemoconcentration

Abdominal pain, nausea, vomitina

Thrombosis

MILD disease = T/t

Collection of fluid in 3rd space (Ascites,

Analgesics Avoid strenuous activity &lntercourse

pulmonary edema)

Admission not needed Moderate-severe disease

Admit the patient IV fluid

Heparin for thromboprophyllaxis In pregnancy: Always admit the pationt

Image 160: USG in OHSS

Prevention of OHSS:

Also know

Monitor follicles, E, Levels

ldeally Inj hog should be given

Withhold hcg if E, >2 500

1. E2 = S00-1500 pg/m 2. >3 follicles

Cabergoline decreases VEGF If risk of OHSS is present ’ delay

3. Size of follicles >17 mm in diameter

embryo transfer so that pregnancy

E2 released by each follicle is200 pg

doesn't occur.

117. FEMALE INFERTILITY -

POI

POI - Primary Ovarian Insufficiency

Tests for Ovarian Reserve

1. S: FSH: Day 3 FSH levels are measured. Levels are increased in POI.

2. S: Inhibin:

Levels decreased in POI 3. S: Estrogen: J 4. S: Antimullerian hormone: (can be measured on any day). Normal= 1 to 3.5 ng/mnL If value is