13,540 1,525 72MB
English Pages [194] Year 2023
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