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OBS & GYNE NCERT Obstetrics & Gynecology PART 1 - IMP LIST
Author's name: Parth Goyal
Introduction
Published by: Parth Goyal
Functions of Placenta - MPMSU 23 Feb - 5 marks
Madhoganj, Lashkar, Gwalior - 474001
Printed by Parth Goyal Enumerate causes of different color Amintonic liquor. - MPMSU 19 Jun - 5 marks

First Edition, 2025 Diagnosis of early Pregnancy. - MPMSU 21 Apr, 23 Feb - 5 marks
ISBN: 978-81-954886-7-4
Evaluation of antenatal/antepartum fetal well being - MPMSU 22 May, 24 Feb - 20 marks
Website: www.medullaonline.com Labor
© Copyright, 2024, Author
Bishops score and its significance. - MPMSU 19 Jun - 5 marks
All rights reserved, No part of this book may be reproduced, stored in a retrieval system or
transmitted, in any form by any means, electronic, mechanical, magnetic, optical, chemical, Define normal labour. Write management of 2nd stage labor. - MPMSU 19 Jun- 20 marks
manual, photocopying, recording or otherwise, without the prior written consent of its writer.
Partograph. - MPMSU 21 Nov - 5 marks
Price : Rs. 1499/-
Printed in India Hemorrhage in Early Pregnancy

A 24 years old primigravida with 10 weeks of gestation presented with history of profuse vaginal
bleeding and severe abdominal pain since 2 hours. On examination the patient appears pale
pulse rates is 110 minute, blood pressure is 100/70mm Hg. On PN examination, size of uterus
is 6 weeks and the internal Os is open. - MPMSU 24 Feb - 20 marks

Define abortion.

Classify abortions.

Enumerate the etiological factors that can cause spontaneous miscarriage.

What is the most likely clinical diagnosis in this case?

How will you manage this patient?

Write fate of tubal ectopic Pregnancy. - MPMSU 21 July - 5 marks

Describe H mole, risk factors and management - MPMSU 20 Aug - 20 marks

Twin Pregnancy

A G1PO 32 Year old Women Present at 30 weeks of gestation with a fundal height of 36 weeks.
What are the differential diagnosis. Enumerate the complications of twin Pregnancy. - MPMSU
20 Feb - 20 marks

Complications specific to monochorionic twin Pregnancy. - MPMSU 21 Nov - 5 marks

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Hypertensive Disorders Outline the management of a case of severe Anemia presenting at 38 Weeks of Pregnancy. -
MPMSU 21 Apr - 5 marks
Classify Hypertensive disorders in Pregnancy. How would you manage a Primigravidanot coming
seizures for last 2 Hours in labor
to you with 36 weeks gestation and generalized tonic clonic Describe maternal and fetal complications of Anemia complication pregnancy. - MPMSU 21 July
- MPMSU 19 Feb - 20 marks - 5 marks

Classify Hypertensive disorder in Pregnancy. Write management of gestational Hypertension in Write down Treatment of 3rd gravida with HB% 7.5 gram % at 32 Weeks gestation - MPMSU 22
28 weeks. - MPMSU 19 Jun - 20 marks May - 5 marks
Risk factors for Pre-eclampsia. - MPMSU 22 May - 5 marks Describe the management of a case of diabetes in Pregnancy - MPMSU 21 Apr - 20 marks
Describe Eclampsia and its complications. How will you manage a case of eclampsia presenting Screening for diabetes in Pregnancy. - MPMSU 22 May, 24 Feb - 5 marks
at 34 weeks of pregnancy - MPMSU 20 Aug - 20 marks
Complications associated with elderly primigravida - MPMSU 24 Feb - 5 marks
Pritchard regime - MPMSU 20 Feb - 5 marks
of Preterm Labour
A Primigravida of 32 week of gestation was admitted with convulsions and blood pressure
160/110 mm of hg. What is your provisional diagnosis and how would you manage the case - Define preterm labor, Discuss antenatal management of a Primigravida, coming to you at 30
MPMSU 21 Nov - 20 marks weeks gestation with pain lower abdomen - MPMSU 19 Feb - 20 marks

A primigravida aged 28 years with 32 weeks of pregnancy comes to the hospital with history of Define preterm labor, Discuss antenatal management of a Primigravida, coming to
convulsion (seizures) 3 episodes. you at 34
weeks gestation with pain lower abdomen - MPMSU 23 Feb - 20 marks
On examination shw has grade 3 odema, BP of 160/110 mm Hg, height of uterus 32 weeks with
cephalic presentation and FHR of 130 to 140 beats/min. - MPMSU 24 Feb - 20 marks Describe Etiology, Manifestations, Complication, and management of Premature birth. - MPMSU
22 May - 20 marks
What is most probable diagnosis?
How do you manage this case ? Preterm Labour - MPMSU 20 Aug - 5 marks
What are the differential diagnosis of seizures in third trimester?
What is HELLP syndrome Define Prom and write causes of Prom. - MPMSU 19 Jun - 5 marks
E. What is Pritchard regime
Complication of 3rd stage of labour
APH
What is Postpartum Haemorrhage? Describe the type and causes of PPH. - MPMSU 20
Define Antepartum Haemorrhage. Write its classification, diagnosis and management of Aug -
20 marks
Abruption Placentae - MPMSU 19 Jun, 21 Apr - 20 marks
Diagnosis and management of atonic PPH - MPMSU 21 Apr, 20 Aug - 20 marks
Define APH. What are the differential diagnosis of APH.
Enumerate the distinguishing features of Placenta Previa and abruption Placentae. - MPMSU What are the causes of atonic PPH. How will you manage a case of atonic PPH during
20 Feb, 23 Feb - 20 marks
cesarean section. - MPMSU 21 July - 20 marks
Discuss about clinical features, management of a second gravida with previous caesarean with
36 weeks of pregnancy with bleeding per vaginum. - MPMSU 22 May - 20 marks What is Post Partum Haemorrhage. Discuss AMTSL. - MPMSU 21 Nov - 20 marks
Malpresentation
Medical Illness Complicating Pregnancy Enumerate types of breech presentation. Describe the etiology, clinical features and diagnosis.
How will you manage a Primigravida in labor with breech presentation - MPMSU 21 July - 20
Classify anaemia in Pregnancy. Describe the management of a G2P1 patient at 32 weeks with marks
Hb 8 gm% Who is intolerant to oral iron therapy. - MPMSU 20 Feb, 21 Nov - 20 marks Principles of assisted breech delivery. - MPMSU 21 Apr - 5 marks

Classification of Anemia What is Physiological Anemia. - MPMSU 20 Aug - 5 marks

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Define Deep Transverse Arrest. Write down its diagnosis and management. - MPMSU 23 Feb -
20 marks Emergency contraception. - MPMSU 19 Jun - 2 marks
Follow up of vesicular mole. - MPMSU 19 Jun - 2 marks
Shoulder dystocia and its mx - MPMSU 20 Feb, 24 Feb - 5 marks Antepartum surveillance. - MPMSU 19 Jun - 2 marks
Low birth Weight Newborn. - MPMSU 19 Jun - 2 marks
Lactation Failure. - MPMSU 19 Jun - 2 marks
Puerperium

2020(Jan-Feb)
Define Puerperal sepsis. Describe the Predisposing factors and causative organisms. How will
you manage a case of puerperal sepsis in a primipara patient. - MPMSU 21 July, 20 Aug - 20
marks Medical methods of induction of labor. - MPMSU 20 Feb - 2 marks
Selection criteria for trial of labor after cesarean section (TOLAC) - MPMSU 20 Feb - 2 marks
Oral glucose tolerance test. - MPMSU 20 Feb - 2 marks
Pharmacology
AMTSI - MPMSU 20 Feb - 2 marks
Non-Contraceptive benefits of ocps. - MPMSU 20 Feb, 21 Nov - 5 marks

Describe various uses of Misoprostol in Obstetrics - MPMSU 19 Feb - 20 marks 2020(August)

Community Obstetrics
Episiotomy. - MPMSU 20 Aug - 2 marks

LAQSHYA Program. - MPMSU 19 Feb - 5 marks Biophysical profile. - MPMSU 20 Aug - 2 marks
Types of abruption placenta and its complications. - MPMSU 20 Aug - 2 marks
Discuss maternal to child transmission in HIV and measures to prevent vertical transmission - High Risk Factors for Preeclampsia. - MPMSU 20 Aug - 2 marks
MPMSU 21 July, 24 Feb - 20 marks MTP act. - MPMSU 20 Aug - 2 marks

Janani Suraksha Yojana - MPMSU 24 Feb - 5 marks 2021( April)

Prevention of pre-Eclampsia. - MPMSU 21 Apr - 2 marks
Miscellaneous PGE2 gel. - MPMSU 21 Apr - 2 marks
Unruptured ectopic Pregnancy. - MPMSU 21 Apr - 2 marks
Neonatal Jaundice. - MPMSU 19 Feb - 5 marks Advantages of ventouse over Forceps. - MPMSU 21 Apr - 2 marks
Threatened abortion. - MPMSU 21 Apr - 2 marks
Difference between symmetrical and asymmetrical IUGR - MPMSU 23 Feb - 5 marks Premature Rupture of Membranes. - MPMSU 21 Apr - 2 marks

Role of ultrasonography in obstetrics. - MPMSU 19 Feb - 5 marks 2021( July)

Write Classification of Hypertensive disorders of Pregnancy. - MPMSU 21 July - 2 marks
Neural tube defects and its complications. - MPMSU 21 July - 2 marks
Male Sterilization techniques and its benefits. - MPMSU 21 July - 2 marks
Enumerate direct and indirect causes of maternal mortality. - MPMSU 21 July - 2 marks
2-Marks
Mechanism of Action of DMPA (ANTARA) - MPMSU 21 July - 2 marks
2019(feb) Drugs uses for Parenteral iron therapy in Pregnancy. Write advantages and disadvantages. -
MPMSU 21 July - 2 marks
Most Common Causes of maternal deaths in india. - MPMSU 19 Feb - 2
marks
Components of biophysical Profile. - MPMSU 19 Feb - 2 marks 2021( november)
Drugs used for induction of labor. - MPMSU 19 Feb - 2 marks
Neonatal complications of Preterm birth. - MPMSU 19 Feb - 2 marks
Medical methods of induction of labor. - MPMSU 21 Nov - 2 marks
Essential (2) Non-Essential Components of AMTSL. - MPMSU 19 Feb - 2
marks RU486. - MPMSU 21 Nov - 2 marks
Causes of Anemia in pregnancy. - MPMSU 19 Feb - 2 marks Benefits of breast feeding. - MPMSU 21 Nov - 2 marks
Causes of breach Presentations. - MPMSU 21 Nov - 2 marks
2019( June) LNG-IUS. - MPMSU 21 Nov - 2 marks
Screening method in Cancer Cervix. - MPMSU 21 Nov - 2 marks
PPIUCD - MPMSU 19 Jun - 2 marks

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2022( May) Obstetrics & Gynecology PART 2 - IMP LIST

Episiotomy. - MPMSU 22 May - 2 marks
Extended breech. - MPMSU 22 May - 2 marks Introduction
Bishop'scire. Mifepriston. - MPMSU 22 May - 2 marks
PPIUCD insertion. - MPMSU 22 May - 2 marks Lymphatic drainage of cervix. { MPMSU 20 Feb- 5 marks}
Lower uterine segment. - MPMSU 22 May - 2 marks
Describe Embryogenesis of female genital organs. { MPMSU 19 Feb - 20 marks}
2023 (Feb) Describe in short natural defence mechanism of female genital tract. {MPMSU 23 Feb- 20 marks}
Magnesium sulphate dose regimes in the management of eclampsia
Prostaglandin E2 Gel
Puberty Menorrhagia. { MPMSU 20 Feb, 21 July, 24 Feb- 5 marks }
Incomplete Abortion.
Components of biophysical profile
A 12 year old girl presented with heavy menstrual bleeding since 15 days. Discuss the following
Advantages of breast feeding
[A]- Differential diagnosis. [B]-Management of the Patient. { MPMSU 22 May - 20 marks}
Episiotomy
Hyperprolactinemia. { MPMSU 21 July - 5 marks }

Menstrual Cycle
Physiology of the menstrual cycle. { MPMSU 21 feb- 20 marks }

Menopause
Health concerns of menopause - MPMSU 24 Feb - 5 marks

Hormone replacement therapy. { MPMSU 21 July, 19 Feb - 5 marks }

Diagnostic Procedures

Colposcopy. { MPMSU 23 Feb- 5 marks }

Pap test.

Pelvic Infections
Work up to diagnose genital tuberculosis. { MPMSU 19 Oct- 5 marks}
PID

STI
Bacterial Vaginosis
Bartholin cyst

Diagnosis and management of trichomonilial vaginitis. What are the factors predisposing to this
condition. { MPMSU 20 April, 21 Feb- 5 marks }

What is Syndromic management of STI's. How is it more useful than laboratory based
management of STI's. {MPMSU 19 Feb - 20 marks}

Syndromic approach for STD in Women. {MPMSU 21 Nov, 22 Oct- 5 marks}

Dysmenorrhea
Explain dysmenorrhea with its types. { MPMSU 23 Feb- 5 marks}

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Clinical features and management of uterine fibroids at 45 years of age. { MPMSU 21 April- 20
marks}

What is AUB, FIGO classification of AUB and Management of Menorrhagia. { MPMSU 20 Aug, 19 What is fibroid uterus, Give its anatomical classification. Write in detail medical management of
Jun, 24 Feb - 20 marks } fibroid uterus. { MPMSU 23 Feb- 20 marks }

What is FIGO classification of AUB. How will you manage a case of 22 year old null-parous female Degenerations in fibroid. { MPMSU 20 Feb- 5 marks }
with submuosal fibroid of 5x4cm having complained of intermenstural bleeding . {MPMSU 19 oct-
20 marks} Role of uterine artery embolization in fibroid uterus. {MPMSU 19 Oct- 5 marks}

Describe diagnosis and management of Abnormal uterine bleeding in P3L3 at 45 yrs of age. Benign Neoplasm of Ovary
{MPMSU 21 Nov, 24 Feb - 20 marks }
Benign ovarion Mass-causes. { MPMSU 19 June- 5 marks }
Displacement of Uterus
Discuss ovarian dysfunction, diagnosis & management. { MPMSU 21 July- 20 marks }
Supports of the uterus and their importance. { MPMSU 20 April- 5 marks}
How is ovarian cancer staged. { MPMSU 19 oct - 20 marks }
Describe the supports of uterus along with the diagram. Discuss its etiology, POP-Q classification
& clinical features of Pelvic organ prolapse. { MPMSU 23 Feb, 19 Oct, 21 Nov, 24 Feb - 20 marks} Ovarian hyperstimulation syndrome. { MPMSU 19 Oct- 5 marks }

Describe surgical anatomy of pelvic organ support system. How will you Endometriosis
Nulliparous uterovaginal Prolapse. { MPMSU 21 July- 20 marks } manage a case of
How would you manage an infertile couple with probable diagnosis of endometriosis in female
Preventive measures for occurrence of prolapse. { MPMSU partner. { MPMSU 19 Feb - 20 marks }
22 May- 5 marks}
Infertility Define endometriosis. Enumerate the clinical features. Describe briefly theories proposed for its
Pathogenesis.{ MPMSU 20 feb- 20 marks }
Define Primary infertility. Describe the tests for detection of ovulation. {
MPMSU 20 feb- 20 marks Premalignant Lesions

Define Primary infertility. Describe fallopian tube patency tests.{ Define CIN, enumerate risk factors for CIN.{ MPMSU 19 June, 21 Feb - 20 marks }
MPMSU 21 Nov, 22 May- 20
marks }
Discuss the management of CIN.{MPMSU 21 July- 20 marks}
What are the various investigations to assess ovulation?
Describe treatment for anovulatory
cycles. { MPMSU 22 May - 20 marks } Genital Malignancy

Tubal Factor in infertility. {MPMSU 21 April- 20 Discuss various methods of screening of carcinoma cervix. { MPMSU 19 Feb - 20 marks }
marks}
WHO parameters for normal semen Analysis. { Describe the screening guidelines & Methods for diagnosis of cervical cancer. {MPMSU 21 July-
MPMSU 21Feb - 5 marks } 20 marks }
Define Infertility. Discuss causes of Infertility. Write a
management plan for treatment of a couple What are the risk factors for development of cancer cervix. Discuss all methods available for
with primary infertility. Write 3 indications of surrogacy
- MPMSU 24 Feb - 20 marks cervical cancer screening and downstaging the disease in our country. { MPMSU 22 May - 20
Benign Lesion of Uterus marks}
Describe fibroid uterus and its types, Management of large intramural
years. (MPMSU 20 Aug- 20 fibroid at the age of 45 Staging of carcinoma cervix. { MPMSU 20 Aug, 22 May, 20 Feb- 5 marks }
marks }
Prevention of Cancer Cervix. { MPMSU 21 April- 20 marks)

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Discuss various types of HPV vaccines - MPMSU 24 Feb - 5 marks

Iron Sucrose use. { MPMSU 19 June- 5 marks }
Hydratiform mole. { MPMSU 23 Feb- 5 marks }
Ectopic pregnancy its type and management in Rupture ectopic. { MPMSU 20 Aug- 5 marks}
Invasive mole follow up. { MPMSU 19 June- 5 marks }
Molar pregnancy. { MPMSU 22 May- 5 marks}
Amenorrhea

PCOS. (MPMSU 22 May- 5 marks } 2-Marks Questions:-

2019-{feb}
Q. 1- Components of kit-6 for syndromic management of STI.
What is primary amenorrhoea and its aetiology. { MPMSU 20 Aug- 5 marks } Q.2- Two newly introduced contraception method by Government of India.
Q.3- POP-Q Staging of genital organ prolapse.
What is secondary amenorrhoea. Briefly write its causes and management - MPMSU 24 Feb - 5 Q.4- First line tests used for infertility work up.
marks
Q.5- High risk factor for carcinoma ovary
Q.6- Drugs used for medical method regime of MTP.
Contraception 2019-{June}

Discuss about contraception options available for a post -partum lady. {MPMSU 19 Feb - 20 Q.8- Primary Infertility.
marks} Q.9- Blood supply of uterus.
Q.10- Trichomoniasis.
Describe Copper-T, What are the indication and Contraindications for Copper-T insertion. Q.12- Genital TB.
{MPMSU 20 Aug- 20 marks } 2020-{Jan-feb}
Q.13- Trichomonas vaginitis.
Copper-T 375 A. { MPMSU 20 April- 5 marks } Q.14- Supports of the Uterus.
Q.15- Differentiation between benign and malignant ovarian tumors
LNG IUCD. { MPMSU 21Feb, 22 Oct - 5 marks } Q.16- Indications of diagnostic Laproscopy
Q. 17- Self breast Examination.
Complications of IUCD. { MPMSU 22 Oct, 21 Nov- 5 marks } Q. 18- Emergency Contraception.
2020-{August}

Enumerate different methods of Hormonal contraception with emphasis on benefits and Q. 19- PaP Smear.
Hazards of Q.20- High risk factors for ovarian cancer.
each. {MPMSU 22 May - 20 marks } Q.21-PCOD
Q.22- Pelvic inflammatory disease.
Permanent method of contraception. {MPMSU 19 feb- 5 marks} Q.23- Non contraceptive uses of combined oral contraceptives.
Q.24- Shaw's system of classification for pelvic organ prolapse.
Uses of oral contraceptive pills - MPMSU 24 Feb - 5
marks 2021-(April}
Q.25- Krukenberg's tumor.
Others Q.26- Induction of ovulation.
Q.27- Clinical features of acute PID.
What are the causes of post menopausal bleeding ? How will you investigate and manage a 60 Q.28- Non-contraceptive uses of oral pills.
year old women with post menopausal bleeding. { MPMSU Q.29- Follow up of a case of Hydatiform Mole.
21 Nov- 20 marks }
Q.30- Clinical features of endometriosis.
A 50 year old P7L7 post menopausal lady come with history of bleeding per vaginum 2021-{July}
days. What are the differential diagnosis to consider ?{ MPMSU since 2 Q.31 - Turner's syndrome.
20 Feb - 20 marks}
Q.32- Mirena
What is Social obstetrics, How can you contribute as medical doctor. { MPMSU 19 June - 20 marks Q.33- Syndromic management of STI's.
Q.34- Normal Semen Reports.
Q.35- Indications of operative hysteroscopy.
Q.36- Bartholin's cyst.
Advantages & Disadvantages of Endoscopic surgeries in Gynacology {MPMSU 19 feb- 5
marks) 2021-{November}
Q.37- What are the indication of Hysterectomy .

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d d d d d d d d d d d d 8
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→ Presence of lanugo and epithelial scales in meconium shows that fluid is

INTRODUCTION swallowed by fetus and some of its passes from gut into fetal plasma.

Q.1 Placental functions Functions

main
by simple diffusion. It means function is to protect fetus
Ans. A) Respiratory → O2 intake and COz output i.

B) Excretory → urea, uric acid, creatinine by SD Act as shock absorber

Amino
C) Nutritive → glucose by facilited diffusion (GLUT-1), Lipids,
Maintains even temperature

acids and electrolytes. • Abnormal colours:

D) Endocrine function. Relexin 1. Green color

E) Barrier function Estrogen (Blood i. Due to meconium: presence of biliverdin.

F) Immunological function Seen →

• Nutritive function Hemtoprietic fa, protective fn a) Fetal distres

i. Glucose is transported by facilitated diffusion by GLUT-1, 3 b) Breech/transverse lie

ii. Lipid like triglyceride are transported by mother in early pregnancy 2. Brown color (tobacco juice):

and synthesis by fetus in late pregnancy. by cholest • Intrauterine demise of fetus

iii. Electrolyte like Nat, K+, Cl - are transported passively while 3. Golden color:

,phosphorus calcium ion are transport actively. • Rh. Incompatibility due to presence of bilirubin.
• Barrier function 4. Greenish yellow (saffron)
i. Generally substance with high MW › 500 daltons are held up. • Post term pregnancy

ii. Transfer of large molecule is a facilitated by pinocytes. 5. Dark red colour:

ili. Rate of drug transfer is increased in late pregnancy. • Concealed hemorrhage

• Immunological function Q.3 Diagnosis of early pregnancy.

i. The placenta and fetus contains paternally determined antigens, Ans. 5 symptoms: -

which are foreign to mother. 1. Amenorrhea

ii. In spite of this, there is no evidence of graft rejection. 2. Morning sickness

ii. Placenta hormones, early pregnancy factor, chronic gonadotropin 3. Fatigue

have some immunosuppressive effects. 4. Breast tenderness

Q.2 Amniotic fluid 5. Frequently urination

Ans. Water in the amniotic fluid is a replaced in every 3 hrs. 6. Montgomery tubercles

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clinital DigOPT
4 signs: 2. Blood pressure
Lab D 3. Assessment of size of uterus and height of fundus.

Imagingstudies(TVUS)
a. Breast changes:
1. Enlargement • Fundal height is measured from pubic symphysis.
• After 24 weeks of pregnancy, the distance in cm corresponds to pregnancy
I1. Areola get darker
b. Per abdomen changes:
BBT & physicel ext in weeks.
4. Amount of ligum: Oligohydramnios, Polyhydramnios.
1. Linea nigra
5. Abnormal girth
II. Stria gravidarum Abdominal
c. Pelvic signs: {Trick : C*ut GHOP}
1. Chadwick sign: bluish discoloration of uterus and vagina.
B. Bio physical test: {Trick: FUZCNA Band VanCho)
1. Fetal movement count
I1. Goodell sign: dilation of cervix
2. USG
III. Hegar sign: Non-specific indication of pregnancy characterized by the
3. Doppler USG
compressibility and softening of the cervical isthmus.
4. Cardiotocography
IV. Osiander sign: pulsation of uterine art. felt in lateral fornix of vagina. 5. Non stressed test

V. Palmer's sign: regular rhythmic contraction of uterus. 6. Amniotic fluid volume (AFV)
Q.4 Evaluation of Antenatal fetal well-being. 7. Biophysical profile
8. Vibroacoustic stimulation test
Ans. Antenatal assessment of fetal well-being is designed to detect fetal
9. Contraction stress test
abnormalities.
1. Fetal movement count:
It is divided in 3 types: -
Two method-
1. Clinical
i. Cardiff Count 10' formula: mother count how many hours it takes to
2. Biophysical have 10 movements.

3. Biochemical
ii. Daily fetal movement count (DFMC) :
_A. Clinical {Trick - WB SUH(Size of Uterus, Height of fundus) LGI • If ‹10 movement in 12 ms, indicate fetal compromise.
2. USG : 2-hours
- Who Bhi SUHagan LAG}
• BPD, АС, HC, FL are measured (BPD = Biparietal diameter, AC =
1. Weight gain
Abdominal circumference, HC = Head circumference, FL = Femur length)
• Normal weight gain is 1 kg in a fortnight. (14 days)
• Amniotic fluid volume measured.
• If excess weight gain - could be a sign of pre-eclampsia
• When HC/AC > 1.0, IUGR suspected.
• If no weight gain or decrease - could be sign of IUGR
• Main diagnostic tool

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3. Cardiotocography: CTS → in high disk pog.

r If 6 score → egivoral, suspect chronic asphxia
• 100-160 beats/min is normal
r If ≤ 4 score → abnormal, suspect chronic asphxia
• 22 acceleration should be there in 20-minute period
r - 2 score → abnormal, severe chronic asphxia
4. Non stress test:
2. Modified BP includes → NST + AFl only
• Reactive NST: ≥ 2 acceleration of >15 beats/min for ›15 sec in 20 min
BPP Score
period.
8-10 Do weekly monitoring
• Non-reactive NST: absence of above pattern. If ≥ 36 weeks → delivery
5. Amniotic fluid volume: If ≥ 36 weeks → delivery
4

• Normal single largest pocket → 2-8 cm If ‹ 32 weeks, repeat testing in 4-6

• Normal AFl → 5-25 cm hrs.

v If SVF < 2cm or AFI < 5 → Oligohydramnios 0-2 Deliver regardless of gestational stage
v If SVF > 8cm or AFI > 25 → Polyhydramnios
6. Biophysical profile: 2. Biochemical Tests →

a) It is composed of many parameters r Assessment of fatal pulmonary maturity

b) Observation time = 30 minutes Fluorescence polarisation
c) Assess fetal asphyxia

Inde too tetal well being Anssmant

1. Biophysical Profile Scoring
Parameters Minimum normal criteria

→ Highock preg (pre-eclampsia, goat, Com, LUGR)

Score
NST Reactive pattern 2
Fetal breathing ≥ 1 breathing movement lasting 2 - I fetal marlement
movement > 30 sec

Fetal body ≥ 3 discrete body movements - Oliga& poly hydsomies

movements
2
- Abr. maternel test result (A AFP, Abn, bopples)
Fetal muscle ≥ 1 episode of active extension
2
post tem preg. 642w0)
tone with return to flexion
Amniotic fluid
21 pocket width › 2 cm long
into two perpendicular
places
summy, sty- Nachel tomlery & maternal sesam sore.
v If 8 - 10 score → normal
and to fanatony scan, growth scan, Dopples study
OBSTETRICS & GYNECOLOGY
3rd to - NST, BPP, AFI E Dopple in high sick
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OBSTETRICS

LABOR Condition of delivery: -

1. Delivery of head: -
Q.5 Define Normal labor. Mx of 2nd stage of Labor. i. Patient encouraged to 'bearing-down effort' or 'push' during uterine
Ans. Labour: - contraction.

Series of events that takes place in the genital organs to expel the product ii. When scalp visible for 5 cm diameters: -
of conception i.e. placenta, fetus and membrane out of the womb through • Push occiput downwards and backward.
vagina to outer world. • Press perineum with sterile vulval pad
Normal labor criteria: - ili. When subocciput reaches below the pubic symphysis: -
1. Spontaneous onset at term • gaurding the perineum and perineal massage
2. Vertex presentation iv. When perineum is fully stretched and threatens tear, episiotomy can be
done under _local anesthesia.
3. Natural termination (with minimal aids)
4. Without any complications
v. When suboccipitofrontal diameter emerges out→ Ritgen maneuver is
done.
5. Without undue prolongation When ociput emerges

Mx of 2nd stage of labour:-

Principles:
With gentle pressure,
1. To assist natural explusion of foetus. Head is extended

2. To prevent perineal injuries

General measures: -
Forehead, nose, chin,
1. Patient in bed Mouth are born

2. FHR monitoring

3. Administer inhalational analgesics

4. Vaginal examination Care of infant following head delivery -
Preparation of delivery :- 1. Mouth and pharynx mucus is wiped or sucked.
1. Position: 2. Eye lids are wiped
3. Neck is palpated to exclude presence of any loop of cord.
• Most common is supine position with hip flexed, knee flexed and
2. Delivery of shoulder: -
abduction of thigh.
1. External rotation happen
2. Toileting of external genitals
3. Catheterise bladder if it is full

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2. First anterior shoulder is born, which are assisted by pulling head of Post partum vigilance
baby in downward direction.
1. Palpation of uterus every 15 mins for 2 hours to ensure uterus is hard.
3. Later posterior shoulder is born by pulling head upward. 2. Estimate blood loss
3- Delivery of trunk: -
{Massaging of uterus is not part of AMTSL given by WHO but is a part of
1. Trunk is delivered by lateral flexion. postpartum haemorhhage Rx}
Q.6 Discuss AMTSL.

Ans. Inj. Oxytocin 10 units IM (preferred) Q.7 Partogram

Or
Ans. Composite graphical record of labor event entered against time on a
Tab misoprostol 600 ug orally or rectally single sheet of paper.
Or It has 5 components →

Inj. Methargine 0.2 mg IM 1. Women

within one min of birth of baby Baby

I l l . Labor progress

IV. Medications
Delayed cord clamping
(After, 90-120 sec after birth or after V. Shared decision-making

Stoppage of cord pulsation) • Women: -

I. HR (Heart rate)

Clamp, divide and ligate the cord II. Systolic BP

III. Diastolic BP

Deliver placenta by controlled cord traction IV. Temperature

V. Urine

Massaging the uterus immediately after • Baby:-

1.
delivery of placenta
Amniotic fluid
(To incite contraction)
III. Moulding
Carfal examination of placenta IV. FHR deceleration
and
• Labor progress
it's membranes
1. Cervical dilation

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Descent Ans. Indications of MTP: (English is Tough - Hindi is Simple)

Contraction per 10 minutes i. Eugenic:
/ V. Duration of contraction Pregnancy leading to birth of congenitally defected child. Ex→ Down
• Medications: syndrome, Cystic fibrous etc.
1. Oxytocin ii. Therapeutic:

Pregnancy resting life of pregnant women. Ex. Cardiac disease, Psychiatric

I1. Medicine

IV fluids

• Shared decision making Cervical or breast malignancy

Assessment іїї. Humanitarianism:

I l . Plan Pregnancy due to rape or sexual assault.

Adv. of partogram: iv. Social grounds:
section rate.
1. Reduced incline of prolonged labors of cesarean Pregnancy due to contraceptive failure.
2. Single sheet provides all necessary information. Methods:
3. Easy handover to another obstetrician.
First trimester (upto 12 weeks):

Q.8 Bishops score & its significance.

Medical: -
Ans. To know if female is ready for delivery 1. Mifepristone 200-600 mg orally followed in 48 hrs by misoprostol
(Trick - CaL PeDS - Consistency, Length, Position, Dialation, Station) 200-600 мд.

1 2 3
2. Misoprostol 800mg sublingually
features - 3. Methotrexate + Misoprostol
Dilation (cm) Closed 1-2 3-4 5+
Surgical: -
Cervical >4 2-4 1-2 <1
1. Vacuum aspiration
Length (cm) 2. Suction evacuation
Consistency Firm Medium Soft
Position
3. Dilation and evacuation:
Posterior Midline Anterior
• Rapid method
Head Station -3 -2
"Slow method (laminaria tests)
-1, 0 +1,+2
Total score = 13, Favorable = 6-13, Unfavourable =
0-5

Q.9 MTP Act.

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HEMORRHAGE & TWIN

• Inevitable abortion: Vaginal bleeding with cervical dilation,
suggesting that the miscarriage is impending.
• Incomplete abortion: Some tissue is expelled, but some remains
PREGNANCY in the uterus.

• Complete abortion: All pregnancy tissue is expelled.

10 weeks of gestation presented • Missed abortion: The fetus dies but is retained in the uterus.
Q.10 A 24 year old primigravida with
and severe abdominal pain since 2 • Septic abortion: Infection in the uterus during or following a
with history of profuse vaginal bleeding
rates is 110 minute,
hours. On examination the patient appears pale, pulse
miscarriage.
size of uterus is 6 2. Induced Abortion:
blood pressure is 100/70mm Hg. On P/V examination,
• Medical abortion: Performed using medications like mifepristone
weeks and the internal Os is open.

A) Define abortion. or misprostol. Procedure like suction asiation, DeC

• Surgical abortion: Procedures like suction aspiration, D&C
B) Classify abortions. (dilation and curettage), or dilation and evacuation (D&E).
C) Enumerate the etiological factors that can cause spontaneous miscarriage.
C) Enumerate the Etiological Factors that Can Cause Spontaneous
D) What is the most likely clinical diagnosis in this case?
Miscarriage:
E) How will you manage this patient?

Spontaneous miscarriage can be caused by various factors:

Ans. A) Define Abortions:

1. Chromosomal abnormalities: The most common cause of early

Abortion is the termination of a pregnancy before the fetus can survive
pregnancy loss (e.g., trisomy 21, monosomy X).
independently outside the uterus. It can be spontaneous (miscarriage) or 2. Maternal age: Women over the age of 35 have an increased risk of
induced (elective or therapeutic). An abortion typically refers to the loss of a
miscarriage.
pregnancy before 20 weeks of gestation. 3. Hormonal imbalances: Conditions like luteal phase defects or thyroid
disorders.
B) Classify Abortions:
4. Uterine abnormalities: Structural issues such as fibroids, septate
Abortions can be classified as follows: uterus, or incompetent cervix.
5. Infections: Infections such as listeria, rubella, toxoplasmosis, or
1. Spontaneous Abortion (Miscarriage): bacterial infections.
• Threatened abortion: Vaginal bleeding without cervical dilation, 6. Immunological factors: Autoimmune diseases, such as antiphospholipid
and the pregnancy may still be viable.
syndromeAPLsynd
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7. Environmental factors: Exposure to toxins, radiation, or teratogenic • Assess for signs of hypovolemic shock: Tachycardia, hypotension,
drugs.
pallor. Given the patient's vital signs, close monitoring is
8. Lifestyle factors: Smoking,
alcohol consumption, and drug use.
necessary.
a. Chronic diseases: Conditions like diabetes, hypertension, or clotting 2. Stabilization:
disorders.
• IV fluids: Administer IV fluids (such as normal saline or Ringer's
abdomen or pelvis.
10.
Trauma or injury: Physical injury to the lactate) to restore blood volume and prevent shock.
• Blood transfusion: If the patient has significant blood loss,
D) What is the Most Likely Clinical Diagnosis in This Case? consider blood transfusion (based on hemoglobin/hematocrit

Based on the clinical scenario, the most likely diagnosis is inevitable abortion levels).

(also referred to as "inevitable miscarriage"). 3. Complete Assessment:

• Pelvic Ultrasound: Confirm the viability of the pregnancy, assess
• The patient is a 24-year-old primigravida at 10 weeks of gestation, the amount of retained tissue in the uterus, and rule out other
presenting with profuse vaginal bleeding, severe abdominal pain, and complications like ectopic pregnancy.
an open internal os on pelvic examination. • Monitor vitals: Regularly monitor pulse, blood pressure, and
• The fact that the internal os is open indicates that the cervix has hemoglobin levels.
begun to dilate, and pregnancy expulsion is likely imminent, which 4. Medical or Surgical Intervention:
aligns with the diagnosis of an inevitable abortion. • If pregnancy expulsion is incomplete or if significant bleeding
• The presence of symptoms such as pale appearance, tachycardia (pulse persists, proceed with surgical intervention (D&C or suction
rate 110/min), and mild hypotension (BP 100/70 mm Hg) suggests evacuation) to remove the retained products of conception.
that the patient might be experiencing some degree of blood loss, If the miscarriage is complete and there are no signs of retained
which requires immediate medical attention. products or infection, the patient may be managed
conservatively.
E) How Will You Manage This Patient?
5. Psychological Support:

The management of this patient with an inevitable abortion • Offer counseling and emotional support, as miscarriage can be a
includes the traumatic event.
following steps:
6. Post-Miscarriage Care:
1. Immediate Assessment: • Follow-up

• Assess the degree of bleeding • Contraceptive advice: Provide guidance regarding contraception

Q.11 Ectopic pregnancy types, Etiology, Fate, C/F, Mx.

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ovum is implanted and develop outside

Ans. In ectopic pregnancy fertilized Fate →

the normal endometrial cavity. • Complete absorption

Types- • Expulsion through abdominal ostium as tubal abortion with internal
1. Tubal hemorrhage.
• Infundibulum
2. Tubal abortion:
• Interstitial
• Seen if implantation in ampulla or infundibulum.
• Isthmus
• Ampullar • Muscular contraction facilitates expulsion through abdominal ostium.
2. Ovarian
3. Tubal rupture:
3. Abdominal
_4. Uterine • Seen in isthmus and internal implantation.
• Cervical
• Intraperitoneal or extraperitoneal rupture.
• Cornual

• Angular 1. Abdominal pain

• Cesarean scar
2. Vaginal bleeding
Etiology: 3. Amenorrhea
1. Salpingitis Diagnosis:
2. PID ~ 1. СВС
3. Smoking 2. Beta-hcg → UPT to detect pregnancy.
4. Use of IUD ~ 3. IVS (transvaginal sonography)
5. Sterilization procedure 4. Laparoscopy
6. Use of progestin only pills
(POP)
7. Tubal reconstruction surgery
1. Rupture ectopic: Salpigectomy
8. Intrapelvic adhesions 2. Non-rupture ectopic
9. ART: GIFT, ET ~ Medical Mx:

Fate of tubal ectopic:

1. Tubal mole: • Potassium chloride
Repeated small hemorrhages occur in choriocapsular Sx Management:
space.

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Salpingostomy. In this procedure:

1. For female aspiring future pregnancy:
Incision
Linear 1. Suction evacuation of uterus.
2. Supportive therapy:
Gestation sac removed 1) IV infusion with ringer lactate
2) Blood transfusion if needed
intention.
Fallopian tube is left to heal by secondary
3. Antibiotics
Follow up :-
• For female not aspiring pregnancy: Salpingectomy Patients into 2 groups:-

Q.12 H. mole → Definition, Risk Factors, Mx. i. Group A: mole in process of expulsion

Ans. It is abnormal conditions of placenta where there are partly i. Group B: uterus inert (early diagram)
villi.
degenerative and partly proliferative changes in young chorionic Q.13 A GIPO 32 Year old Women Present at 30 weeks of gestation with a
fundal height of 36 weeks. What are the differential diagnosis. Complications
Risk Factors:- 4 TD
of twin Pregnancy.
1) Previous Wo of hydratiform mole
2) Age of patient: Adolescent and >40 years age women have high Ans. A 32-year-old pregnant woman at 30 weeks with a fundal height of
incidence.
36 weeks could have several possible causes:

3) M/C in south east Asian countries.

1. Multiple Gestation (e.g., twins)
2. Polyhydramnios (excess amniotic fluid)
3. Large for Gestational Age (LGA) Fetus or Fetal Macrosomia
1. Vaginal bleeding (90%)
(overgrowth, often due to diabetes)
2. Hyperemesis gravidarum→ because of high HCG. 4. Uterine Fibroids
3. Lower abdominal pain. 5. Molar Pregnancy
4. Expulsion of grape-like vesicles. 6. Placenta Previa or Abnormalities

5. Absent fetal parts. 7. Gestational Diabetes

6. Hyperthyroidism (as HcG = TSH)
Complications:
Inv :-

Maternal complications: (Trick - All imp topics we study in Obs)

1. USG - Snowstorm appace
2. Internal B-HCG 1. Nausea, vomiting
(19)
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2. Anaemia
C/F : - (Trick - P3HC)
3. PIH & Pre-eclampsia Donor
Recipient
4. Antepartum Hemorrhage
Polyhydramnios
5. Fist preterm Hemorrhage (PPH) Polycythemia
Anaemia

6. Malpresentation
Congestive HF
7. Preterm labor Oliguric
Polyuric
8. Polyhydramnios/ Oligohydramnios Hypervoleumia Hypovolemia
9. Cesarean delivery

Fetal complications :- 2. Twin Anemia polycythemia syndrome (TAPS)

1. Abortion
• Mild and chronic form of TTTS due to small AV anastomosis.
2. Preterm birth
3. IUGR
Donor Recipient
Anemia Polycythemia
4. Congenital anomalies
Amniotic fluid normal Amniotic fluid normal
5. Twin transfer syndrome
PSV of MCA > 1.5 mm PSV of MCA <0.8 mm
6. Cord prolapse
7. Intrauterine death

8. Vanishing twins 3. Twin reverse arterial perfusion TRAP

• One twin is acardiac deoxygenated
Q.14 Complications of monochorionic twins • The acardiac twin receives blasd from normal twin.
Ans. • Often acarentiac twin is a amorphous mass.
1. TTTS 4. Selective IUGR
2. TAPS • Due to unequal placental sharing
3. TRAP 5. Dead fetus syndrome
4. Selective IUGR The dead fetus release thromboplastin which cause DIC, microcephaly.
5. Dead fetus syndrome

1) Twin twin
transfusion syndrome (TTTS)
Occur due to vascular
anastomosis between artery and
vein.
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HYPERTENSIVE DISORDERS • Ensure airway protection and provide oxygen.

• Monitor vital signs (BP, fetal heart rate, oxygen saturation)
disorders in Pregnancy.
Q.15 Classify Hypertensive closely.

A) How would you manage a Primigravida coming to you with 36 weeks 2. Seizure Control:

gestation and generalized tonic clonic seizures for last 2 Hours not in labor. • Administer Magnesium Sulfate (4-69 IV bolus, then 1-2g/hr
infusion) to prevent further seizures.

in 28 weeks. • For severe hypertension (BP 2160/110 mmHg), administer IV

B) Write management of gestational Hypertension
labetalol (10-20 mg) or hydralazine (5-10 mg).
Ans. Classification:
3. Delivery:
• Hypertension: Systolic 140 z mm Hg or Diastole BP ≥ 90 mm Hg, • Immediate delivery is the definitive treatment for eclampsia. At
measured two times at least 4 hours apart. 36 weeks, induction of labor is preferred if the maternal
condition is stable. If delivery isn't progressing, consider C-
• Proteinuria: Urinary excretion › 0.3 g in a 24 hours specimen. section.

• GH: BP › 140/90 mm Hg first time in pregnancy after 20 weeks 4. Fetal Monitoring:

without proteinuria. • Continuous fetal heart rate monitoring to assess fetal well-being
5. Postpartum Care:
• Pre-eclampsia: GH with Proteinuria • Continue Magnesium Sulfate for 24-48 hours postpartum to
prevent recurrent seizures.
• Eclampsia: Pre-eclampsia with grandual seizures or coma.
• Monitor for postpartum preeclampsia or other complications.
• HELLP syndrome: Hemolysis, elevated liver enzymes low platelets.
• Chronic hypertension: Hypertension diagnosed before 20 weeks of Summary:
pregnancy.

In a patient with eclampsia, the key steps are to control seizures, lower
• Superimposed pre-eclampsia: Chronic hypertension with Proteinuria
blood pressure, and deliver the baby. Magnesium sulfate is critical for seizure
A) Management of a Primigravida management, and delivery should be expedited, either via induction or C-
at 36 Weeks with Seizures:
section, based on maternal stability. Continuous monitoring of both mother
A primigravida at 36 weeks with generalized and fetus is essential.
tonic-clonic seizures for 2
hours, not in labor, is highly suggestive of eclampsia. Management
as follows: steps are B) Management of Gestational Hypertension at 28 Weeks:

1. Stabilization: 1. Assessment & Monitoring:

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• Confirm diagnosis: New onset hypertension z140/90 mmHg • New paternity by ART
after 20 weeks.

Regular BP checks, urinalysis for proteinuria, and blood tests fo • Obesity

• Thrombophilias
organ function.
fetal
• Fetal monitoring: Ultrasound for growth, NST/BPP for
Clinical Features of Pre-eclampsia:

well-being
1. Hypertension:
2. Lifestyle Modifications: • Systolic BP ≥ 140 mm Hg or Diastolic BP ≥ 90 mm Hg after
• Rest, left lateral position, low-sodium diet, and stress reduction. 20 weeks of pregnancy.
3. Blood Pressure Control: 2. Proteinuria:
• Medications if BP 2160/110 mmHg: Labetalol, Methyldopa, or • Proteinuria ≥ 300 mg/day or 3+ protein on dipstick.
Nifedipine. 3. Edema:
• Aim to keep BP < 140/90 mmHg. • Swelling of hands, face, or legs, especially sudden or excessive.
4. Prevention of Preeclampsia: 4. Headache:
• Consider low-dose aspirin for those at higher risk. • Severe, persistent headache that doesn't respond to medication.
5. Delivery Timing: 5. Visual Disturbances:
• If well-controlled, aim for 37 weeks; earlier delivery (34-36 • Blurred vision, seeing spots or flashes of light.
weeks) if BP is uncontrolled or signs of preeclampsia. 6. Epigastric or RUQ Pain:
6. Postpartum Follow-up: • Pain under the ribs, nausea, and vomiting.
• Monitor BP for at least 6 weeks postpartum. 7. Nausea and Vomiting:
• Common, especially in early stages.
Key goal: Control BP and prevent progression to preeclampsia while
8. Rapid Weight Gain:
ensuring fetal well-being.
• Sudden weight gain (22 kg per week).
Q.16 Risk factors, C/F and Mx of Pre-eclampsia. 9. Reduced Urine Output:
Ans. Risk Factors - (Trick - PIF
NOT)
• Oliguria (<500 mL/day).
10. Hyperreflexia: Increased reflexes or clonus (muscle spasms).
• Primigravida
• Placental abnormalities
Mx of Pre-eclampsia:-
• Pre-existing vascular disease • Medicines -
• Interpregnancy internal
≥7 yrs a. Labetalol → 100 mg tid or gid
• Family History: GDM, DM, b. Nifedipine → 10-20 mg bid
Hypertension, pre-eclampsia

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• Pneumonia
c. Hydralazine → 10-20 mg bid • ARDS
• Left-lateral position • Embolism
• Diet
3. Cardiac:
• Diuretics

its complications and Tx. How

will you manage • Acute LVF

Q.17 Write about Eclampsia,

at 34 weeks of pregnancy.
• Cardiomyopathy
a case of eclampsia presenting 4. Renal failure
Ans. C/F:
5. Cerebral edema or hemorrhage
1. Premonitory state:
6. Distorted vision
• Unconscious

one side and become fixed 7. Shock, sepsis, Psychosis

• Eyeball roll or are turned 8. Haematological:
2. Tonic stage:
• DIC
• Tongue protude between
teeth
limbs are flexed, hands clenched • Thrombocytopenia
• Trunk-Opisthotonus, (To remember: Shock ye features hai ye sab mostly)
• Eyeball fixed
• Respiration ceases
3. Clonic stage:

• Alternate contraction and

relaxation 1. Maintain airway, breathing, circulation
2. IV fluid
• Biting of tongue
• Blood stained frothy secretions fill the
mouth 3. Patient in left lateral position
4. Oxygen inhalation: 10 L/min
4. Stage of coma:
5. Inv : CBC, RFT, LFT, KFT, electrolytes,
• Stage of coma and atonicity urine
• Confused 6. Vitals: BP, PR, RR, Temp.

Complications: 7. Labetalol, Hydralazine

1. Injuries : 8. MgSO4 IV/IM: according to Pritchard
regimen
9. Diuretics
• Tongue bites
• Bed sores 10. Foley cathterisation
2. Pulmonary:

• Edema

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(cardiovascular and pulmonary) to

Initial control of seizures, patient stable management Q.18 Pritchard Regime
continue medical Ans. The Prichard regimen is a widely used protocol for managing seizures
OBSTETRIC MANAGEMENT in eclampsia with Magnesium Sulfate (MgSO,). It consists of a loading dose
fetal status followed by maintenance doses, administered intramuscularly.
of patient and the
Clinical assessment
Steps of the Pritchard Regimen:

Epidural labor analgesia In labor (majority) 1. Loading Dose:

Not in labor

• 4 g Magnesium Sulfate IV (diluted in 20 mL of normal saline) given

CS obstetric slowly over 5-10 minutes.
Fits controlled Fits not controlled and/or
indication
• Non-reassuring fetal status • 10 g Magnesium Sulfate IM:
Forceps/ventouse
baby • 5 g injected deep into each buttock

Delivery Delivery 2. Maintenance Dose:

Term Preterm Dead
• 5 g Magnesium Sulfate IM every 4 hours into alternate buttocks.
Indications of critical care • Continue until 24 hours postpartum or 24 hours after the last
Steroid Introduction (NICE-2019) seizure.
therapy of labor
Level 3 care: severe pre- Monitoring During Treatment:
Delivery Delivery eclampsia, eclamsia needing
ventilation
• Clinical Signs of Toxicity:
Level 2 care: Eclampsia, hellp
• Loss of patellar reflexes (first sign of toxicity).
Delivery syndrome, severe oliguria,
cardiac failure, abnormal • Respiratory depression (<12 breaths/min).
neurology symptoms
Induction • Urine output ‹30 mL/hour (risk of accumulation).
obstetric Level 1 care: Step down care
• PGE, gel indication
• Antidote for Toxicity:
after birth
ARM
• Calcium gluconate 1 g IV, given slowly over 10 minutes.
• Oxytocin (‡)
Advantages:

Delivery • Simple and effective in reducing seizures.

• Safe for both mother and fetus if administered and monitored

properly.

This regimen remains a gold standard in managing eclampsia, especially in

Postpartum care low-resource settings.
Postpartum care
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comes to
years with 32 weeks of pregnancy • Monitor for MgSO, toxicity (loss of reflexes, respiratory
Q.19 A primigravida aged 28
convulsion (seizures) 3 episodes. depression).
the hospital with history of
Hg, height of
3 odema, BP of 160/110 mm • Antidote: Calcium gluconate (1 g IV).
On examination shw has grade 140
to
32 weeks with cephalic
presentation and FHR of 130 2. BP Control:
uterus
beats/min.
• For BP ≥ 160/110 mm Hg:
A. What is most probable diagnosis?
• Labetalol IV: 20 mg bolus, repeat every 20-30 minutes
B. How do you manage this case? (maximum 300 mg).
seizures in third trimester?
C. What are the differential diagnosis of • Hydralazine IV: 5-10 mg every 20-30 minutes as needed.
D. What is HELLP syndrome • Nifedipine oral: 10 mg every 30 minutes (maximum 40 mg).
E. What is Pritchard regime
3. Maternal and Fetal Monitoring:
Ans. A. Most Probable Diagnosis: Eclampsia (new-onset seizures in a
hypertensive pregnant woman after 20 weeks of gestation with signs of • Maternal: BP, reflexes, urine output, oxygen saturation.
pre-eclampsia). • Fetal: Continuous fetal heart rate monitoring.

4. Delivery Planning:
B. Management of the Case:

• Timing: Stabilize first; immediate delivery is required as eclampsia

1. Stabilization:
poses risks to mother and baby.
• Airway, Breathing, Circulation (ABC): • Mode: Vaginal delivery is preferred; cesarean section if there is fetal
• Ensure airway patency, administer oxygen (6-8 L/min), and distress or contraindications to vaginal delivery
position the patient in the left lateral position to prevent
C. Differential Diagnosis of Seizures in the Third Trimester:
aspiration and improve placental perfusion.
• Control Seizures:
1. Eclampsia (most common cause).
• Administer Magnesium Sulfate (MgSOs) using the Pritchard 2. Epilepsy (pre-existing or undiagnosed).
regimen: 3. Cerebral venous thrombosis (CVT).
• Loading dose: 4 g IV over 5-10 min + 10 g IM (5 g in
4. Intracranial hemorrhage or stroke.
each buttock).
5. Meningitis/ encephalitis.
• Maintenance dose: 5 g IM every 4 hours. 6. Hyponatremia or hypoglycemia.

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D. HELLP Syndrome:
APH & Medical Illness
of pre-eclampsia
characterized by:
• A severe complication
(microangiopathic hemolytic
anemia). Complicating Pregnancy
• H: Hemolysis ›2x normal).
Liver enzymes (AST/ALT Q.20 Define APH, Classification, Differential Diagnosis APH. Tell details
• EL: Elevated
• LP: Low Platelets (<100,000/ML). upper about Placenta Previa and Abruptio Placentae and their mx.
epigastric pain, nausea, vomiting, and right
• Presents with Ans: - Definition:

quadrant tenderness. Antepartum hemorrhage refers to any vaginal bleeding that occurs after 20
weeks of gestation but before the onset of labor.
E. Pritchard Regime:
Classification/ Causes:

• A protocol for MgSO,

administration: 1. Placental bleeding :-
10 g IM (5 g in each buttock).
• Loading dose: 4 g IV + buttocks.
• Abruptio placenta
dose: 5 9 IM every 4 hours in alternate
• Maintenance • Placenta previa
last seizure or delivery.
• Continue for 24 hours after the 2. Indeterminate or unexplained :-
with Calcium gluconate if
• Monitor for MgSO, toxicity and treat • Vasa previa
required. • Succenturiate lobe

Extra-placental cause : - [VLC3]

• Varicose vein

• Local trauma

• Cervical polyp
• Cervical carcinoma
• Cervical ectopy

Abruption Placentae:
Definition: Abruption placentae is the premature separation of a normally
implanted placenta from the uterine wall before the birth of the baby,
leading to bleeding and potential fetal distress.

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Diagnosis: • Continue monitoring for hemorrhage and signs of shock or

• Clinical Features: coagulopathy.

be concealed or external).
• Vaginal bleeding (may C/F OF PP :- (Trick - BAP ke paas Mal hai, FEEL karta hai, Height dikhata
and severe).
• Abdominal pain (persistent hai apne I*de ka Female ko, PV krta hai)
• Uterine tenderness (firm, tender uterus).
• Fetal distress or non-reassuring fetal heart rate (FHR). C/F (B-AP) PP AP
uterine tone).
• Hypertonic uterus (increased (1) Bleeding nature Painless, revealed Painful, many beautiful
• Shock in severe cases. always concealed, revealed,
• Ultrasound: mixed

• Diagnosis may be confirmed through ultrasound (but abruption

is often underdiagnosed on ultrasound). (ii) Bleeding color Bright red Dark color

(iïi) Anemia Proportional to visible Out of proportion to

Management of Abruption Placentae: blood loss visible loss

(iv) Pre-eclampsia Not seen Can be seen

1. Stabilize the mother:
Abdominal exam.
• IV fluids (crystalloids, blood products if necessary).
(1) Malpresentation Common Unrelated
• Monitor vitals (BP, heart rate).
(ii) Feel of uterus Soft, relaxed Rigid, tense
• Oxygen via mask if needed.
2. Fetal monitoring: (iii) Height of uterus Proportionate to Increased in proportion
• Continuous fetal heart rate (FHR) monitoring to assess fetal gestational age to gestational age
wellbeing. (iv) FHS Present Absent esp. in
concealed
3. Delivery:
• Emergency delivery is indicated if there is fetal distress or severe Placentography Placenta in lower Placenta in upper
maternal hemorrhage. segment segment
Mode of delivery: Vaginal Examination Placenta felt (however Placenta not felt

• Vaginal delivery is preferred if the maternal and fetal PV is C/l in PP)

conditions allow. TX OF PP :-

• Cesarean section is indicated for severe abruption, fetal

Placental edge is › 2 cm from internal os, trial of labor can be done ,
distress, or maternal shock.
otherwised CS is preferred always.
4. Postpartum care:
TX OF AP :-

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Vaginal Delivery
ARM + Oxytocin → • Stabilization: Hospitalize the patient, initiate IV fluids, and
Patient In Labour -›
monitor vitals.
Or
• Fetal Monitoring: Continuous CTG to assess fetal heart rate and
distress.

second gravida with • Blood Transfusion: Cross-match and prepare for possible
features, management of a
Q.21 Discuss about clinical
with bleeding per vaginum. transfusion if there is significant blood loss.
previouscaesarean with 36 weeks of pregnancy 2. Definitive Management Based on Diagnosis:
Ans. Clinical Features: • Placenta Previa:

a previous cesarean section

is • Do not perform a vaginal examination. Plan for cesarean
Bleeding in a second gravida at 36 weeks with
placenta previa, placental abruption,
delivery after corticosteroids (if <37 weeks) to aid fetal
concerning for serious conditions like lung maturity.
or scar dehiscence/rupture.
• Placental Abruption:
• If mild and the fetus is stable, conservative management
1. History:
of bleeding.
• Ask about the amount, onset, and duration with close monitoring is possible.
(e.g., abdominal pain, • If the abruption is severe, emergency cesarean section is
• Inquire about associated symptoms
uterine contractions, or changes in fetal movements). required.
of incision,
• Review previous cesarean history (indication, type • Scar Dehiscence/Rupture:
• Immediate cesarean section is needed if rupture or
complications).
dehiscence is suspected.
2. Examination:
• General Examination: Assess for signs of shock (pallor, 3. Postpartum Care:

tachycardia, hypotension). • Monitor closely for complications like hemorrhage or infection,

• Abdominal Examination: Check for tenderness (indicating especially in the case of placenta previa or uterine rupture.
abruption) and assess fetal position.
Q.22 Classify Anemia in pregnancy. Tx of anaemia who is intolerant to oral
• Per Speculum Examination: Helps rule out cervical issues, but
iron therapy.
avoid vaginal exam if placenta previa is suspected.
Ans - Anemia: - CDC guidelines defination:
• Ultrasound: Critical to assess placental location, fetal well-being,
and amniotic fluid. H6 < 11g/dL in 1st & 3rd Trimester, ‹ 10.5 g/dL in 2nd trimester.
Classification: (Trick : DHA ABC: DH me MBBS ki ABC padhte hai)
Management: 1. Physiological anemia of pregnancy
2. Deficiency anemia :-
1. Immediate Steps:

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• Iron
DOC→ Ferrous sulfate 325 mg TDS 30 min before meals.
• Protein
• If large doses needed, step up gradually
• Folic acid
• Max 6 tablets a day in 3 to 4 days.
• B12 After blood iron has become normal,
3. Haemorrhage :- Maintenance done → 1 tablet/ day for 100 days following delivery.
Acute: APH S/E -
Chronic: Hookworm injection 1. Nausea
4. Hereditary 2. Vomiting
• SCA 3. Diarrhea

• Thallesemia 4. Gastric irritation

• Spherocytosis 5. Constipation
5. Hemolytic anemia: SLE, HELLP 6. Metallic taste
6. Anemia due to infection: Malaria, TB, Kalaazar 7. Epigastrium pain
7. Bone marrow insufficiency B) Parenteral therapy :-
8. Chronic disorder -> renal -> decrease EPO secretion
Advantage: -
9. Hematological malignancy: leukemia 1. Certainly of iron administration
2. No risk of intolerance
1. Hospitalisation : Should be hospitalized at < 7.5 g/dl of Hb 3. No risk of malabsorption
2. General Tx : Types →
• Diet: Realistic balanced diet 1. Iron sucrose → M/C used, 100 mg OD for 10 days.
• Antibiotic therapy 2. Iron dexterity 125 mg OD for 8 days
• Treat the cause 3. Iron isomaltose

3. Specific Tx : Iron therapy 4. Iron carboxymaltose

A) Oral therapy :- (Trick - Fu** S-uman G*nd) 5. Ferric gluconate
• Ferrous fumarate 200mg → it takes at least 4 weeks to raise Hb, hence given during 30-36 weeks of
• Ferrous sulfate 300 mg pregnancy.

• Ferrous succinate Estimation of requirement:-

• Ferrous gluconate 300mg

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(kg) x (Target Hb -
(in mg) = Body weight
Total dose of iron required
Drawbacks -

(additional)
actual Hb) × 24 + 500 mg
1. Premature labor may start

S/E :- 2. Increase chance of heart failure with pulmonary edema.

1. Painful IM injections
3. Transfusion reaction
2. Nausea
Mx of anaemia
3. Vomiting
4. Headache
Mild moderate severe

5. Anaphylactic reaction
C) Blood transfusion :-
Hb bt 5-6.9
Advantage - <34 weeks >34 weeks

1. Improvement expected
after 3 weeks.
etc.
natural constituents of blood like protein, antibodies Blood
Gestational age GA
2. Supplies
Oral iron Parentral iron
transfusion >34 weeks <34 weeks

3. Increased oxygen carrying

capacity of blood.
4. Stimulate erythropoiesis.
Blood Parentral
Indications of treatment during pregnancy -
transfusion iron

1. <30 weeks
If intolerance or
Q.23 What is Physiological Anaemia.
contraindications
Parenteral iron
Oral iron
Ans. During normal pregnancy, plasma volume increase by 40 to 50% but
2. 30-36 weeks -
RBC volume increase by 20%, hence a relative fall in hemoglobin &e
Parentral iron by IV, IM or TOI (Total drug infusion) hematocrit levels.

3. > 36 weeks -
• It is especially during 2nd half of pregnancy.
Blood transfusion • for rapid improvement in 3 weeks. • It is normocytic normochromic anaemia.
Criteria :-
Blood transfusion - (precautions) The lower limits of physiological anaemia are -
Utmost care to minimize overloading of heart. 1. Hb = 10 gm%
1. Antihistamine (Phenegan 25 mg) given IM 2. RBC = 3.2 million/mm'

2. Diuretics (Furosemide 20 mg) IM 2 hours prior 3. PCV = 32%

3. Keep check on vitals 4. PBS → normal morphology RBC with central pallor

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Anaemia complicating pregnancy.

Q.24 Maternal and fetal complication of Q.25 Treatment of 3rd Gravida with Hb 7.5 g/dL at 32 Weeks Gestation

Ans. Maternal complication:- A hemoglobin of 7.5 g/dL at 32 weeks indicates moderate anemia,
requiring prompt treatment to prevent complications like preterm labor
A. Antenatal :
and low birth weight.
• Preterm labor
• Infectious (increased chances) Management Approach:
1. Assessment:
• Pre-eclampsia
• Confirm the cause (iron deficiency, folate/B12 deficiency,
• CHF
hemoglobinopathies).
B. Intranatal : • Investigate with CBC, iron studies, and peripheral smear.
contraction due to less oxygen 2. Iron Deficiency Anemia Treatment:
• Uterine inertia: poor
• Iron sulfate 100-200 mg twice daily (20-30 mg elemental
• Maternal exhaustion
iron).
• CHF
• Folic acid 5 mg daily.
• PPH
• Take iron on an empty stomach; avoid dairy, tea, or coffee.
• Shock
3. Additional Supplements:
C. Postnatal : (or Puerperium) • If needed, give Vitamin B12 1000 mcg weekly.
4. Intravenous Iron Therapy:
• Puerperal sepsis • For severe anemia or poor oral iron tolerance, administer IV
• Postpartum depression iron (e.g., iron sucrose).
• Puerperal venous thrombosis 5. Blood Transfusion:

• Pulmonary embolism • If symptoms worsen or Hb doesn't improve, consider blood

• Poor wound healing transfusion.
• Poor lactation 6. Monitoring:
• Recheck Hb in 2-3 weeks and monitor for complications like
Fetal complications
preterm labor.
1. IUGR 7. Dietary Advice:
2. Premature baby • Encourage iron-rich foods (red meat, leafy greens, legumes).
3. Neonatal anemia →only in severe anaemia
Q.26 Mx of a case of diabetes in pregnancy, Screening for diabetics.

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with onset of first diagnosis during

Ans. GDM is carbohydrate intolerance
for another 100 gm 2 hr OGTT

pregnancy. • 2nd step :

Risk Factors : 8 hours of fasting

1. Family history
2. PCOS

3. Obesity 100 gram of glucose after taking fasting blood sample

4. Ethnic group
fetus › 4kg, still birth
5. Previous H/O GDM, delivering
Blood sample taken at 1 hr, 2 hr, 3 hr
6. HTN

Screening for GDM: BS Levels Upper normal limit

A. DIPSI guidelines :
95

i. First screening : 1st antenatal visit 1 hour 180

2 hour 155
ii. 2nd screening : 24-28 weeks of pregnancy
3 hour 140
Procedure →

Diagnosis of GDM is ≥ valurs are abnormal.

Irrespective of last meal, 75 gm oral glucose in water given
Management:

1. Goals :
If > 140 mg/dl → GDM diagnosed after 2 hrs
FBS < 95
2. ACOG criteria :
1hr PP < 140

Done at 24 to 28 weeks 2hr PP < 120

• 1st step :
2. Tx :
Irrespective of last meal, 50 gram of oral glucose given
I. Medical Mx →

A. MNT :
Plasma glucose ≥ 140 mg/dl at 1 hr is cutoff

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→ 40 - 50% of
total calories
• Carbohydrate Long acting → Glargine, Determir
• Fat → ≤ 30%
with

< 10% → mono OHAS :

<10% → poly • Metformin

< 10%→ saturated

• Glibenclamide

• Protein → 20% They cross the placenta, however they do not have any teratogenic effect.
• 3 meals + 3 snack regime with
25% of calories → breakfast I1. Obstetrical Mx :

30% of calories → lunch Termination of pregnancy :

30% of calories → dinner AIGDM → GDM control by diet
B. Exercise : A2 GDM → GDM controlled by insulin or OHAs

• For 30 minute for 5 days a week (aerobic, brisk walking) are safe in
So, termination of pregnancy :
pregnancy
A1 GDM: ≥ 39 weeks
C. Insulin therapy :
A2 GDM well controlled: ≥ 39 weeks
• DOC
GDM not controlled: 37 - 38 weeks + 6 days
• Regime → Mode of delivery: Vaginal
1. Conventional insulin therapy

Twice daily injection of intermediate insulin (NPH) Indication of CS :

1. Fetal distress
Injection of rapid insulin with each meal 2. Contracted pelvis
2. Insulin pump 3. Estimated fetal weight ≥ 4.5 kg
• Mimic physiological basal + prandial pattern of insulin secretion

Complications in DM :
Common types of insulin Maternal -

Rapid acting → Lispro, aspart 1. Abortion

Short acting → Regular
2. Pre-eclampsia
Intermediate acting → NPH 3. Preterm

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4 Infection • Older women are more likely to conceive twins or multiples,

5 Polyhydramnios which carries increased risks of preterm birth, intrauterine
6 DR, DN, CHD growth restriction (IUGR), and maternal complications.

7 Shoulder dystocia 6. Placental Issues:

8 Puerperal sepsis • Increased risk of placenta previa, placental abruption, and

Fetus - placenta accreta due to changes in the uterine lining and
1. Macrosomia > 4kg placenta with age.
7. C-section Delivery:
2. Congenital malformations
• Elderly primigravidas are more likely to require a cesarean
3. Still birth
section due to factors such as poor fetal position, labor dystocia,
4. IUGR
or maternal comorbidities.

8. Higher Risk of Postpartum Complications:

Q.27 Complications Associated with
Elderly Primigravida. • Increased likelihood of postpartum hemorrhage, infection, and
Ans. 1. Pregnancy-related Hypertension: Increased risk of delayed uterine involution.
gestational
hypertension and preeclampsia, leading to complications like eclampsia 9. Fertility Issues:
and
placental abruption. • Elderly primigravidas may also have a higher incidence of
infertility and associated challenges in conception.
2. Gestational Diabetes:

• Elderly primigravidas
have a higher likelihood of
gestational diabetes, which can lead developing
to fetal macrosomia,
preterm birth, and neonatal
3. Chromosomal hypoglycemia.
Abnormalities:
• The risk of Down
syndrome and other
abnormalities (e.g., trisomy 18) chromosomal
4. Preterm Birth: increases with maternal age.
• There is a higher risk
of preterm labor and
result in complications delivery, which may
such as respiratory
(RDS) and low birth distress syndrome
5. Multiple Pregnancies:
weight.

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PPH & Preterm Labor

9. Previous history of PPH
h. Age > 40yrs
PPH. Labor -
Q.28 What is PPH. Types, Cause, Diagnosis and Mx of Atonic
loss from or into genital tract a. Prolonged labor
Ans. PPH Defination - Any amount of blood
b. Instrumental delivery
adversely affects
following birth of baby up to end of puerperium, which
c. C- section
general condition of patient by giving signs of hypovolemic shock.
Section › 1000 ml d. Malpresentation
Quantitavely - Vaginal Delivery › 500 ml or Cesarean
e. Rapid labour (precipitate labour)
Types:-
Placenta -
A. Primary PPH
• Within 24 hours of birth
1. Retained placenta
2. Placenta previa
Types →
3. Placenta accreta
1. Third stage hemorrhage:
4. Abruptio placenta
• Hemorrhage before placenta expulsion
2. True PPH:
2. Traumatic: Trauma during operative delivery
3. Retained tissues : Bits of placenta, blood clots
• Haemorrhage occur after expulsion of placenta
4. Coagulopathy (Thrombosis) : Dimnished procoagulants
В. Secondary PPH:
• Occurs beyond 24 hours of birth within
puerperium
Causes :- Diagnosis:-
1. Atonic uterus → M/C cause, after separation of placenta, • In majority vaginal bleeding is visible as slow trickle.
uterine sinuses
cannot be compressed effectively due to imperfect • The effect of blood loss depends on
contraction of uterine
masculature. a. Pre-delivery Hb level
It can be due to - b. Degree of pregnancy induced hypervolemia
a. Multiparity c. Speed at which blood loss occur

b. Overdistension of uterus: State of uterus →

Polyhydramnios, large fetus, multifetal • In traumatic PPH, it is well contracted.
pregnancy.
c. Anemia • In atonic PPH, it is found flabby and become hard on massaging.
d. APH Shock Index: HR/SBP

e. Uterine fibroid Normal = 0.5 - 0.7, In major haemorrhage increase to 0.9-1.1.

f. Obesity

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OR

A. Immediate measures→ [ABCDEF] Tranexamic acid 19 IV

1. Call for extra help
2. Obtain 2 IV bare (14 gauge)
3. Start oxygen

4. Investigations → CBC, LFT, RFT, electrolysis

5. IV 2 litres of NS infusion Step 3: Massage and bimanual compression
6. Start IV oxytocin Procedure :

i. Whole hand is introduced inside the vagina.

Actual Mx :- ii. Vaginal hand is make into a fist and uterus is compressed from it's
Step 1 : posterior side.
1. Massage to make uterus hard iii. Other hand placed over abdomen helps in squeezing
2. Methergine 0.2 mg IV
3. Oxytocin 10 units in 500 ml at 50 drops/min IV if atonic

4. Foley catheter → To keep bladder empty

5. Examine expelled placenta and membranes → For any missing Step 4: Uterine Tamponade
cotyledon (a) Tight intrauteric packing
b. A 5 m long and 8 cm broad gauze is inserted.
if uterus reman atonic c. First fundus is filled then remaining part.
d. Vagina is filled with a different gauze.
It do →

Step 2: Uterus exploration under general anaesthesia 1. Stimulate uterine contraction

2. Exert direct haemostatic pressure to open uterine sinuses.

if remain atonic B. Ballon tamponade
• Ballon inflated with normal saline (500 ml)
• First surgical line of intervention for most cases.
Inj. 15 methly PGF2a 250 Mg IM
OR If atonic

Misoprostol 100 ug per rectum

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Step 5: Uterine Artery Embolisation 6. Idiopathic - 50%

iliac
• Gelform is injected into bleeding vessel (uterine artery or internal 7. Previous Wo of preterm delivery
vessels) B. Maternal problems in pregnancy →
1. Pre-eclampsia
If atonic 2. APH

3. Multiple pregnancy → Multiparity

4. PROM
Step 6: Surgical methods 5. Polyhydramnios
a. B- Lynch compression suture and multiple square sutures 6. Malformations of uterus
b. Ligation of uterine arteries 7. Hypertension
c. Ligation of ovarian and uterine artery anastomosis 8. Genital Tract infections : Bacterial vaginosis
d. Ligation of ant. division of internal illiac artery C/F or Manifestations :

1. Weight ‹2.5 kg and height ‹ 44cm

2. Head and abdomen is large
3. Skull bone soft with wide structure
4. Pinna are soft and flat

Step 7: Hysterectomy 5. Skin is thin, red, shinny d/t absence of subcutaneous fat
6. Muscle tone poor
Q.29 Etio, Clinical Features, Complications, Mx of Premature Birth. 7. Testis is undescended

Ans. Preterm labour is which start before 3 7th complete weeks. 8. Nail are not
grown
Early PTL: 32-34 weeks Complications: (in baby)
Late PTL: 34-37 weeks A. Features of shock :

Etiology :- 1. Heart failure

A. History → 2. Oliguria
1. Smoking 3. Hypothermia
2. Low socioeconomic status B. Others :
3. Malnutrition 1. Jaundice

4. Recurrent UTI 2. Anemia

5. Maternal stress 3. Infection

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4. Cerebral haemorrhage
Dexamethasone 6 mg IM x 12 hr apart x 4 doses
5. Asphyxia
Diagnosis:
6. Pulmonary syndrome :
Dilation of cervix ≥ 3 cm
• ARDS
OR
• Edema
Length of cervix ≤ 2 cm
• Bronchopulmonary dysplasia
OR
7. Hypoglycemia
If cervical length is 2-3 cm then, Fetal fibronation protein if that then PTL
8. PDA
OR
9. Retinopathy of prematurity Contraction → ≥ 4 contraction in 20 min on 28 contract in 60 min + any
of above
1. Bed rest: Preferably in left
lateral position Inv :
2. Adequate hydration

3. Prophylactic antibiotics: Against Group B streptococcal infection → ex → 2. Urine

Amphicillin, Cefazolin
3. Cervaginal sweats
4. Prophylactic cervical
cerclage 4. USG
5. Tocolytic agents:
5. Electrolytes and Glucose
• Nifedipine
• Atosiban
Q.30 PROM, causes of PROM, C/F, TX.
• Progesterone
Ans. Pre-labor rupture of membrane is rupture of remains after 37 week
Mainly short term tocolytics are
given which delay delivery for at but before the process of labor begins.
48hr for glucocorticoids therapy least
for lung maturity. Pre-term PROM is rupture ‹37 wks.
6. MgSO4 → For
neuroprotection Causes:
• Dose (Same as
pre-eclampsia) - 4g IV for 5 min then 1. Smoking
hour 1gm every
2. Multiple pregnancy
• Start within 4-hour of PTL
and continue till delivery or up 3. Multiparty
hour, which is earlier. to 24
4. Low Socio-economic status
7. Corticosteroid →
for fetal lung
maturation 5. Malnutrition
Betamethasone 12 mg IM x 24 hr 6. Previous h/o of PROM
apart x 2 doses
OR 7. Age>40-50

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8. Infertilty treatment as ART

Wait for spontaneous onset of labor

1. Sudden gush of fluid from vagina

2. Uterine tenderness
Fails
3. Maternal pulse › 100 bpm
4. Foul smelling amniotic fluid

Induction of labor (or CD)

1. Pregnancy: < 24 wks
• Expectant mx
• Corticosteriod

• Antibiotics against GBS

2. Pregnancy : 24-34 wks

• Expectant mx
• Corticosteriod
• Antibiotics

3. Pregnancy: 34-37 wks

• Antibiotics

• Corticosteriod course

To wait for spontaneous onset of

labor for 24-48
hours

Fails

Induction of labor with

4. Pregnancy:
>37 wks
oxytocin (or CD)

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PUERPERIUM Inv.
1. History
Q.31. Puerperal sepsis
2. Clinical examination
Ans. Infection in genital tract after delivery. 3, Vaginal swabs - for culture
Antepartum Risk Factors →
4. Urine → midstream urine
1, Preterm labor
2. Premature rupture of membrane 5. Blood - CBC
6. PBS
3. Prolonged rupture of membrane
7. Blood culture
4. Immunocompromised state
Immunity 4 8. KFT
5. Diabetes
9. Electrolytes
6. Anemia
10. USG: to detect retained bits
Intrapartum Risk Factors →
Etiology of ALL diseases (APH,
11. CT
1. Traumatic vaginal delivery PPH, Pre-term etc) can be
12. MRI
2. Retained tissues of placenta remembered by - Trick -
3, АРН (MMS PIA ML - MMS bani PIA 13. X-Ray chest→ pulmonary kochs lesion
Tx :-
4. PPH ki toh Medico-Legal case
S. Prolonged labor 1. Isolate the patient
6. Obstructed labor M → Multiparty 2. IV fluids
7. Repeated vaginal examinations M → multiple pregnancy 3. Anaemia correction by oral iron or blood transfusion
§ → Smoking
4. Charts of vitals: Pulse rate, RR, Temp, HR
P → Prior (disease
Causative Organs i- 5. Antibiotics: 1, Clindamycin
name)
1. Group A B-haemolytic Streptococci 2. Gentamycin
1 → Infertility treatment
2. Group B B-haemolytic Streptococci A → Age
3. Metronidazole
3. Pseudomonas Surgical Tx :
M → Malnutrition
4. Klebsiella 1. Perineal wound → management of episiotomy
L → Low-socioeconomic
3. Proteus
status • Antibiotics → IV
4. E. Coli
• Debridement of dead tissue
S. MRSA
• Sitz bath
6. Gardenlla vaginalis
• World dressing and debridement till healthy granulation tissue develops.
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2. Pelvic abcess should be drained by colpotomy

-
If Necrotising Fasciitis develops MALPRESENTATION
a. Rehydration
b. Debridement Q.32 Types of breech. Etiology, C/F, diagnosis, Mx.
c. High-dose broad spectrum antibiotics Ans. Defination → Lie is longitudinal, Podalic pole persent at pelvic brim
• M/C type of malpresentation
Types:
A. Complete breech (Flexed breech)
• Hip flexed
• Knee flexed

• Presenting part → 1. 2 buttocks

2. External genetalia
3. Two feet
• Common in multipare

breech) :
B. Incomplete Breech with extended leg (frank
• Hip flexed
• Knee extended

• Presenting part → 1. 2 buttocks

2. External genetalia

• Common in primigravidae
2. Footing presentation
• Hip extended
• Knee extended

• Presentory part → legs

• Common in preterm deliveries
3. Knee presentation

• Hip extended
• Knee flexed

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• Presentory part →
knees Felt at higher level at Felt at midline at a
ko CHOS= rha pzagal)
Etiology : (Trick - Tits umbilicus. lower level due to early
engagement
1. Twins
Per Vaginum
2. Contracted pelvis
During pregnancy and 1) Soft masses 1) Hard feel of sacrum,
3. Hydrocephalus
labor 2) Irregular masses often mistaken for
4. Oligohydramnios
3) Palpation of ischial head.
5. Short cord
tuberosities, anal 2) Palpation of ischial
6. Septic or Bicornuate
uterus
opening, sacrum and tuberosities, anal
7. Prematurity → M/C cause feet. opening, and sacrum
8. Placenta previa felt in one line

Chance of chord 5% 0.5%

Complete breech Frank breech prolapse

Per abdomen

Fundal grip 1) Head - as a hard 1 Head Diagnosis :

globular mass. 2 Irregular small parts
1. Above clinical signs
of feet felt by side of
2. USG: It detects -
2) Head is ballotable. head
a. Fetal congenital abnormalities
3 Head is non -

ballotable due to b. Type of breech

c. Amniotic fluid volume
splinting action of legs
on trunk. d. Measeme BPD, weight, Gestational age
Lateral grip Fetal back on one side e. Attitude of head → flexion and hyperextension
Irregular parts less felt
and irregular parts on on other side.
other side.
Pelvic grip 1. soft mass
1. Hard mass
2. broad mass
2. Small mass
3. Irregular mass 3. Conical mass

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presentation Q.33 Principle of Assisted Breech Delivery

Management of breech
Ans. Things to keep ready :
1. Anaesthetist
Antenatal assessment
2. Material for episiotomy
Fetal: wellbeing, weight, attitude
and 3. Assistant
• Maternal: health (obstetic
medical) and maternal pelvis (clinical) 4. Appliances for resuscitation of baby
Principles:-
1. Never to rush
Elective cesarean section (≥38 weeks)
External cephalic version (ECV) 2. Never pull from below, push from above
To be done
Estimated fetal weight: >3.5 kg or <1.5kg
• Around 36 weeks or after
• Hyperextended head 3. Keep the back anteriorly of fetus
• Associated complications (obstetric
• In the labor suite
and/or medical) Steps:
• With tocolytics if needed
• Fetal monitoring (CTG) before and 1. Antiseptic cleaning
after the procedure Absence of expertise for delivery
Antenatal fetal compromise 2. Epidural block
Fetal factors footling presentation FGR 3. Episiotomy - Made in all cases
(EFW < 10th centile)
4. Oxytocin
successful fails • ≥1 prior CD
5. Patient encouraged bear down :
Delivery as vertex • Do not touch fetus until buttocks are delivered along with legs in
Trial of vaginal Elective cesarean flexed breech.
breech delivery delivery (≥38 weeks)
6. Delivery of shoulder :

• Engaging diameter : - Bis-acromial diameter

• Informed consent
• Average fetal weight (2-3.5kg)
Frank or complete breech • Levator ani body should be in AP diameter.
Flexed fetal head
Adequate pelvis
• Ant. shoulder deliver then posterior shoulder.
Availability of an experienced obstetrician and a neonatologist Delivery of head :
Rapid CD is possible when needed
Burn-Marshell method :

Once nape of neck visible, allow baby to hang by it's own weight
Satisfactory labor progress CS in labor (if not on perineum after
2 hour of full
cervical dialation) Give sub-pubic pressure
Assisted breech delivery Arrest of progress
Fetal distress (non-reassuring
FHR)
Hold the feet of baby and turn it towards mother abdomen
• Cord prolapse

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Ans. Definition: Deep Transverse Arrest refers to a type of obstructed labor

Head gets delivered
where the fetal head is engaged in the transverse position in the pelvis and
fails to rotate to the anterior or posterior position during labor. This arrest
Q.34 Shoulder dystocia occurs after the cervix has fully dilated, and the presenting part does not
manevuer :
Ans. Mx → McRoberts descend or rotate, resulting in a prolonged or stalled labor.
onto her abdomen.
Abduct maternal thighs and sharply hyperflex them Diagnosis:
her breast)
(such that the knees are near
of
• This increase A-P diameter pelvis
1. Clinical Features:

• Successful in 90% of cases • Lack of descent of the fetal head despite adequate uterine
contractions.
2. Wood's maneuver
• Palpation of the fetal head in the transverse position during
• General anesthesia
vaginal examination.
• 2 fingers are inserted in the posterior vagina, and posterior shoulder is
• Cervical dilation is complete or near complete, but the fetal
rotated to anterior position (180 degree)
head remains high in the pelvic cavity.
• Simulatneous suprapubic pressure
2. Ultrasonography:
3. "All four" position : • Used to confirm fetal position (if unclear by clinical exam),
Mother change its position to roll over on all 4 limbs. especially if the fetus is in the transverse or oblique lie.
3. Trial of Labor Observation:
Causes :
• If labor is not progressing despite strong contractions and full
1. Induced labor cervical dilation, the diagnosis of transverse arrest can be made.
2. Prolonged labor
Management:
3. History of previous Shoulder dystocia
4. Obesity
1. Non-Operative Measures (If Mild Arrest):
5. DM • Manual Rotation: The obstetrician may attempt to manually
6. Multiparity rotate the fetus into the anterior position using internal
7. Post-maturity maneuvers, such as Mauriceau-Smellie-Veit maneuver.
• Positioning: Changing maternal positions (e.g., hands and knees)
Q.35 Define Deep Transverse to facilitate rotation.
Arrest. Write down its Diagnosis
Management. and 2. Operative Measures (If No Progress or Fetal Distress):
• Caesarean Section (C-Section):

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if the fetal head
is often required
• Emergency C-section position and fails to rotate MISCELLANEOUS
remains in the transverse
despite manual attempts. Q.36 Uses of misoprostol
Extraction: is still Ans. Pre-labor
-
3. Vacuum or Forceps
o In some cases where the
fetus has rotated but the descent
to assist delivery. i. Cervical ripening
delayed,these may be considered ii. Induction of labor
Force:
4. Avoiding Excessive may lead to
manual rotation or delivery
ili. Termination of molar pregnancy
• Excessive force during
or uterine rupture, so caution iv. Mx of tubal ectopic pregnancy
complications such as fetal injury
Labor -
is essential
i. Acceleration of labor
ii. Induction of abortion
• 800ug PV in 1st trimester
• 400pg PV in 2nd trimester
• 2ug PV in 3rd trimester
Post-labor -

v. AMTSL → 600ug
vi. PPH → 1000pg

Q.37 Non-contraceptive benefits of OCPs

Ans. COCs benefits (Trick - Other BENEFITS)
• Other → Ovarian cysts t
• B → Benign breast disease !
• E → Endometriosis !

• N → Neoplasia (Ovarian & & Endometrial 1)

• E → Ectopic pregnancy t
• F → Fibroids &
• 1 → Iron deficiency anemia !
• T → Tension (Pre-mentrual syndrome) V
• S → Skeletal problem (Osteoporosis) &

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• Regulation of
menstrual cycle
Q.39 Discuss maternal to child transmission in HIV and measures to prevent
y
• Dysmennorhea vertical transmission.
• Menorrhagia l
• Convenient Ans. MTCT of HIV occurs when the virus is passed from an HIV-positive
• Do not interfere
intercourse mother to her child during pregnancy, labor and delivery, or breastfeeding.
Without intervention, the risk of transmission ranges from 15-45%.
Q.38 LAQSHYA Program
Prevention of Vertical Transmission:
Ans. The LAQSHYA (Labour Room Quality Improvement Initiative) program
is a government initiative launched by the Ministry of Health and Family 1. Antiretroviral Therapy (ART):
rooms and
Welfare, aimed at improving the quality of care in labor • All HIV-positive pregnant women should start ART early, ideally
before conception or as soon as pregnancy is confirmed.
maternity wards across India. The primary objective is to reduce maternal
and neonatal mortality and morbidity by ensuring safe and effective ART suppresses maternal viral load, reducing the risk of
transmission to less than 1%.
obstetric care.
2. Mode of Delivery:
Key Features: • An elective C-section is recommended if the maternal viral load
is not well controlled near delivery.
• Focus Areas: Quality improvement in labour rooms, delivery rooms, 3. Infant Feeding Practices:
and postnatal wards. • In resource-rich settings, formula feeding is advised to avoid
• Infrastructure & Equipment: Upgrading facilities, providing essential breastfeeding transmission.
equipment, and ensuring proper sanitation and cleanliness. • In resource-limited settings, exclusive breastfeeding with
• Staff Training: Enhancing the skills of healthcare providers through maternal ART is preferred over mixed feeding
continuous training and adherence to clinical 4. Infant Prophylaxis:
protocols.
• Monitoring & Evaluation: Regular assessment and • Administer antiretroviral drugs like zidovudine to the newborn
certification of
facilities based on established quality for 4-6 weeks after birth.
standards.
• Patient-Centric Care: Ensuring dignity, 5. Screening and Monitoring:
privacy, and respect for
women during childbirth. • Routine HIV screening for all pregnant women is essential for
early detection.
The program aims to provide a safe, clean,
and dignified environment for • Viral load monitoring during pregnancy ensures ART efficacy.
childbirth, leading to improved outcomes
for both mothers and
newborns. 1%,
With timely interventions, the risk of MTCT can be reduced to under
ensuring a healthy outcome for both mother and child.

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Q.41 Neonatal Jaundice

Q.40 Janani Suraksha Yojana (USY)
launched Neonatal jaundice refers to the yellowish discoloration of the skin and sclera
(JSY) is a safe motherhood initiative
Ans. Janani Suraksha Yojanain 2005 under the National Health Mission in newborns due to elevated bilirubin levels in the blood
by the Government of
India
by
maternal and neonatal mortality (hyperbilirubinemia). It is common in the first week of life, affecting about
(NHM). Its primary aim is to reduce 60% of term and 80% of preterm infants.
promoting institutional deliveries.
Causes:
Key Features:

1. Physiological Jaundice:
1. Cash Incentives:
women, especially • Due to immature liver enzymes, it typically appears 2-3 days
• Financial assistance is provided to pregnant
from below poverty line (BPL) and marginalized communities, after birth and resolves within 1-2 weeks.

in government or accredited health facilities. 2. Pathological Jaundice:

fordelivering
• Appears within 24 hours of birth and may result from:
2. Target Beneficiaries:
• Rural areas: All pregnant women
delivering in government • Hemolysis (e.g., Rh or ABO incompatibility).
• Infection, sepsis, or G6PD
institutions. deficiency.
BPL families or SC/ST • Breastfeeding-associated jaundice.
• Urban areas: Pregnant women from
households.
Management:
3. ASHA Workers' Role:

• Accredited Social Health Activists (ASHAs) identify beneficiaries, 1. Phototherapy:

provide antenatal care, and encourage institutional deliveries. • Converts bilirubin into a water-soluble form for excretion.
4. Coverage:
2. Exchange Transfusion:
• Special focus on high maternal mortality states such as Bihar,
• Used in severe cases to rapidly lower bilirubin levels.
Uttar Pradesh, Madhya Pradesh, and Rajasthan.
3. Adequate Feeding:

Impact: • Promotes bilirubin excretion through stools and urine.

JSY has significantly increased institutional deliveries and contributed to Complications:

reducing maternal and infant mortality rates in India.
• Severe jaundice can lead to kernicterus (bilirubin encephalopathy),
causing brain damage. Early detection and treatment are crucial.

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IUGR 2. Dating and Viability:

Symmetrical and Asymmetrical
Q.42 Comparison Between Asymmetrical IUGR
• Determines gestational age and
confirms fetal viability by
Feature Symmetrical IUGR detecting fetal heartbeat.
Late in pregnancy 3. Assessment of Fetal Growth and Well-being:
Timing of Onset Early in pregnancy • Monitors fetal growth, amniotic fluid levels,
Disproportionate restriction and placental
Proportional restriction function.
(head size spared, body
Growth Pattern (head and body equally 4. Detection of Anomalies:
smaller)
small) • Identifies congenital anomalies or structural abnormalities
Placental insufficiency, during anomaly scans (18-22 weeks).
Genetic abnormalities,
maternal hypertension, 5. Monitoring Placental Position:
Causes infections (e.g., TORCH),
• Detects conditions like placenta previa or placental
maternal malnutrition preeclampsia abruption.
6. Guidance for Procedures:
Reduced, in proportion to Normal or near normal • Assists in amniocentesis, chorionic villus sampling, or
Head fetal
Circumference body size (head-sparing phenomenon) interventions.

7. Evaluation of Multiple Pregnancies:

Markedly reduced,
Abdominal Reduced, proportionate to • Assesses chorionicity, amniotic fluid, and fetal development in
compared to head
Circumference other measurements twin/multiple pregnancies.
circumference
8. Assessment in High-Risk Pregnancy:
Acute problems in late • Monitors conditions like IUGR, oligohydramnios, or
Long-standing problems
Onset Indicators
affecting growth early pregnancy
preeclampsia.

Worse due to global growth Better if managed early

Prognosis
restriction
(brain is less affected)

Q.43 Role of Ultrasonography in Obstetrics

Ultrasonography (USG) is a vital, non-invasive imaging tool in obstetrics for

assessing maternal and fetal health during
pregnancy.
Key Roles:

1. Confirmation of Pregnancy:
• Identifies gestational sac and
confirms intrauterine pregnancy.

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INTRODUCTION
the Cervix.
Q.1 Lymphatics of
LN
Ans. 1. Paracervical
LN
2. Parametrial Sentinel LN meaning - First few
3. Internal
iliac LN
LN to which cancer spread.
iliac LN
4. External
5. Obturator LN
6. Sacral LN

Common Presacral Common

iliac iliac
00

GYNECOLOGY
Internal Internal
iliac iliac

External
External
liac
iliac

Parametrial Parametrial

Obturator Obturator
Subepithelial plexus

Inconsistent

Fig. 2.3: Schematic representation of the lymphatic drainage of the cervix

Q.2 Embryogenesis of Female Genital Organs.

Ans. Internal genital system development: -
1. Formed by Intermediate mesoderm.
2. By 6th week intermediate mesoderm form mesonephric duct (Wolffian
ducts) or paramesonephric ducts (Mullerian ducts).

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these 2 terms, so remember,

(Trick: I used to get lot of confusion betweenor Mullerian, and they both 3. Various external organs are: -

comes only once i.e either in

Mesonephric • Clitoris: - Developed from the Paramesonephric duct Ovary
M genital tubercle
(mullerian ducts) form internal
can't be together) • Labia minora: - Developed
• In females - Paramesonephric duct
151 ban
duct
(vertical)
from urogenital membrane
2nd part
organs. • Labia majora: - Labioscrotal (horizontal)
Gubernaculum
• Internal organs are :- swelling. of avary

1. Fallopian tubes
3rd part
• Bartholin glands: - Middle (vertical)
Genital swelling
II. Uterus part of urogenital sinus. Genital fold

Ill. Broad ligaments • Vestibule: - Phallic part of Mullenan eminence

urogenital sinus
IV. Vagina (upper part) Showing parts of mesonephric duct
from :- Development of gonads :-
1. Fallopian tubes developed
Formed from genital ridge by 5c week.
• Upper vertical part 8e
duct
• Adjoining horizontal part of the mullerian Q.3 Natural defense mechanism of female genital organs.
2. Uterus developed from :-
Ans. 5 main defense system in FG system.
• Intermediate horizontal
1. Vulva defense -
• Adjoining vertical part of the mullerian ducts
a. Labial apposition
3. Broad Ligaments :-
b. Bartholin glands
• When mullerian ducts approach each other in midline, a broad
c. Skin
transverse fold is established.
2. Vaginal defense -
4. Vagina :-
a. Ant. + Post. wall apposition
• Formed partly from the mullerian ducts and partly from urogenital
sinus.
b. Stratified epithelium
c. Lactobacillius acidophilus produce lactic acid which make vagina acidic.
External Genital organ developments :-
3. Cervical defense -
1. Site of origin is from urogenital sinus.
2. It differentiate into 3 parts: a. Mucus plug
4. Uterine defense -
1. Upper vesicourethral part: Major part of female urethra + mucous
membrane of Bladder except trigonal a. Endometrial shedding
area
11. Middle pelvic part of urogenital sinus: Epithelium of vagina, 5. Tubal defense -
Bartholin's
gland & Hymen
a. Mucus plicae
Ill. Lower phallic part of urogenital sinus:
Vestibule of vagina b. Epithilial ciliary movement
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Ans. It is common menstrual abnormality in adolescent women The periods
c. Tubal Peristalsis may be heavy, irregular and scanty initially which later becomes normal
cycle
Q.4 Physiology of menstural cycle.
Ans. 1. Ovarian cycle → Causes of Menorrhagia: - (Trick - P2DHE)
a. Recruitment of
cohort of follicles 1. Dysfunctional uterine bleeding (95%)
follicle and its maturation
b. Selection of dominant of 1st
Anovulatory cycles
complete 1st meiotic division with extrusion
c. Ovulation → oocyte
unopposed estrogen secretion
polar body
Causes:
Too much proliferation of endometrium
1 LH surge
2. FSH rise
Slough off causing menorrhagia
d. Corpus luteum
formation
e. Demise of corpus luteum 2. Endocrine dysfunction
Il. Endometrial cycle → • PCOS
1. Regenerative phase:
• Hyperthyroidism
• Complete 2-3 days at end of
menstruation
• Hypothyroidism
• Starts even before mensturation cease
3. Haematological
2. Phase of proliferation:
• Von - Willebrand's disease
• Extends from 5th-14th day (till Ovulation)
• Idiopathic thrombocytopenic purpura {ITP}
• Proliferative changes occur due to rise in level of ovarian estrogen.
4. Pelvic tumors
3. Secretory phase:
• Fibroid uterus
• Day 15: Ceases 5 days prior to menstruation
• Progesterone can only act on the endometrium previously primed by • Estrogen producing ovarian tumor
estrogen. 5. Pregnancy complications (abortion)
4. Menstural phase: Investigations: -
• Regression of corpus leutum decrease: Estrogen & Progesterone • СВС

Q.5 Puberty Menorrhagia. • BT, CT, coagulation parameters (PT, Von-willebrands factor)
• T3, T4, TSH (Thyroid profile)
• USG, MRI
Management:
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Management protocol
of puberty menorrhagia Q.6 Hyperprolectinemia
Rest Ans. Prolactin in blood › 10 ng/ml
Assurance
B12, Folate Etiology-
Hematinics : Iron, Vit
1) Physiological: pregnancy, lactation, stress, sleep
Heavy bleeding continues
2) Pathological:
Admit do investigations • Pitutary causes
• Hypothalamic causes
Peripheral blood film
Platelet count 3) Systemic disorders:
• Clotting factors (PT, PTT, VWF, F-VIII)
study) • Hypothyroidism
• Ultrasonography/MRI for any pelvic • Chronic kidney disease
pathology: tumors, polyps
• Thyroid profile • Liver disease

Blood transfusion, if required 4) Drugs- antipsychotics, metoclopramide etc

Inv:
Secondary to • Serum prolactin level
Primary DUB (Majority)

• TFT
• Thyroid dysfunction
Progestin therapy • MRI brain for pitutary tumors
(Medroxyprogesterone acetate
• Leukemia
10-20 mg/day) Treatment:
• Von willebrand's disease
• Anatomical disorders
• Treat underlying cause
• Neoplasms.

Responsive Unresponsive Pregnancy complications • Dopamine agonists- Cabergoline, bromocriptine

• Surgery or radiations
Appropriate therapy
Continue for 2-3 cycles Conjugated equine estrogen
20-40 mg IV every 6-8 hours
Q.7 Health Concerns of
Menopause

responsive unresponsive
Ans. Menopause, occurring around 45-55 years, is associated with
EUA- examination under
anaesthesia hormonal changes (reduced estrogen and progesterone) that affect various
Replace therapy with EUA and
body systems. Common health concerns include:
combined oral pills containing Dialation + 1. Vasomotor
50 ug of estrogen Symptoms:
• Hot Flashes and Night Sweats: Sudden warmth and sweating, often
Curettae

disrupting daily life.

• Sleep Disturbances: Difficulty sleeping due to night sweats or insomnia.
Biopsy

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• Regular exercise, weight-bearing
Health cessation.
activities, and smoking
2. Urogenital
and Sexual
Vaginal dryness, 2. Hormone Replacement Therapy (HRT):
Syndrome of Menopause (GSM):
• Genitourinary recurrent urinary tract infections, • Effective for hot flashes, osteoporosis, and GSM, but
must be
painful intercourse (dyspareunia), used with caution.
and incontinence.
3. Non-Hormonal Treatments:
3. Bone Health • Vaginal moisturizers, SSRIs for hot flashes, and
bisphosphonates
the risk of fractures,
Osteoporosis: Accelerated bone loss increases
for bone health.
•
and wrist. 4. Routine Screening:
especially in the hip, spine,
4. Cardiovascular Health
• Regular mammograms, bone density scans, and cardiovascular
checks.
of estrogen raises cholesterol levels and
• Heart Disease Risk: Loss Q.8 Hormone Replacement therapy
and strokes.
increases the risk of heart attacks Ans. Given to overcome consequences of estrogen deficiency.
5. Metabolic Changes Indications: -

• Weight Gain: Increased abdominal fat and reduced metabolism. 1. Relief of menopausal symptoms

• Insulin Resistance: Greater risk of type 2 diabetes. 2. Relief of vasomotor symptoms

6. Psychological and Cognitive Changes 3. Prevention of osteoporosis

Benefits: -
• Mood Swings: Anxiety, depression, and irritability.
1. Improvement in vasomotor symptoms.
• Cognitive Decline: Memory issues and difficulty concentrating ("brain
2. Improvement in urogenital atrophy - less dysuria
fog").
3. Increase bone destiny
7. Skin and Hair Changes
4. Less risk of colorectal cancer
• Skin thinning, dryness, and wrinkles due to reduced collagen. Risk: -
• Thinning scalp hair and increased facial hair. 1. Breast Cancer
8. Oral and Dental Health
2. Endometrial cancer
3. Venous thromboembolic
• Dry mouth, gum disease, and tooth loss due to declining bone health. disease
Management of Menopause Concerns: 4. Coronary heart disease (CHD)
Preparations: -
1. Lifestyle Changes: Micronized estrogen (1-3 mg/day) with micronized progesterone (100-
• Healthy diet rich in calcium,
vitamin D, and protein. 300 mg/day).
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on a stand.
PELVIC INFECTIONS &
microscope mounted
Q.9 Coloposcopy

Ans. Colposcope is a low power binocular

Procedure :-

in lithotomy position.
ENDOMETRIOSIS
1. Patient is placed
Cusco's speculum. Q.10 Workup to diagnose genital TB.
2. Cervix visualized using
normal saline.
3. Cervix is cleared
using swab soaked with Ans. Due to
M.TB
with 3-5% acetic acid.
4. Cervix wiped gentaly high in CIN.
of nuclear protein which are
5. Acetic acid cause coagulation 1. Anorexia
areas.
It is seen as aceto-white 2. Nausea
are rich in iodine while dysplastic cells are
6. Lugol's lodine - Normal cells 3. Night sweats
not. Hence stains - 4. Fever
Dark brown
• Mature squamous cells - 5. Infertility
• Dysplastic cells - Yellow 6. Menstrual abnormalities: 1. Menorrhagia
2. Amenorhea

3. Pelvic pain
Inv : -

(1) Diagnostic uterine curettage:

• Done during week preceding mensturation as baccili come to surface

during this period.

• Sent to lab in 2 portions :
1. One sent for histopathological examination to detect giant cell system.
11. Other sent for :
• Culture → Lowestein - Jensen media
• Staining → ZN stain

• While a positive report of AFB microscopy, CBNAAT, culture, histology

diagnose RB, negative report do not rule out TB.
(2) Imaging: USG, CT,
MRI
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Mx :=
Ady of Syndromic
(3) Laproscopy 1.Simple
(4) Hysteroscopy 2.Inexpensive
Tx: - 3.Cost-effective
2 MONTHS HRZE
+ 4 MONTHS HRE
Mx. 4. No delay in
treatment
of STI. How it is more useful than Lab based
Q.11 What is syndromic Mx 5. Avoid loss of patient follow up
of STI.
studies. 6. High cure rate if given appropriately
are based on epidemiological
Ans. Syndromic management 7. Use of standardised protocols result in efficient functioning
{Trick - GG WB RYB} :-
STI Syndromic Management Kit
Contents
Colour Syndrome Q.12 Bacterial Vaginosis- AMSEL criteria, C/F, Mx.
Azithomycin 1gm OD stat +
1
Uretheral discharge/
Grey
Cefixime 400 mg OD stat Ans. It is a infection caused by Gardenella vaginalis along with anaerobic
cervical or anorectal
discharge/Scrotal swelling
organisms like bacteroids, peptococcus species.
Risk Factors :-
(Painful)
Green Vaginal discharge Secnidazole 2gm OD stat + 2
1 Multiple or new sexual partners
Fluconazole 150mg OD stat
2 Early sexual intercourse
Genital ulcer (Non-herpetic) Azithromycin 1g OD stat +
3
White 3 Cigratte smoking
Inj. Benzathine penicillin
2.4 million units - 1 vial
C/F: -
Blue Genital ulcer (Non-herpetic, Azithromycin 1 gm OD stat 4
+ Doxycyclin 100 mg BD 1. Creamy vaginal discharge with fishy smell
allergic to penicillin)
2. No inflammation hence called vaginosis
for 15 days
Red Gental ulcer: Herpetic Acyclovir 400 mg TDS for 5 Diagnosis: -
7 days AMSEL's four diagnostic criteria:
Yellow Lower Abdominal pain Cefixime 400 mg OD stat + 6 1. Homogenous vaginal discharge
Metronidazole 400 mg BD 2. Vaginal PH > 4.5
X 14 days + Doxycyclin 3. Presence of clue cells › 20% of cells
100 mg BD x 14 days
Black Inguinal bubo
• Clue cells - When a smear of vaginal discharge is prepared, vaginal
Azithromycin 1 gm OD stat
epithelial cells are seen covered with coccobacilli giving it a granular or
+ Doxycyclin 100mg BD for
21 days stippled apperance. These cells are called as clue cells.
4. Postive whiff
test
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with 10 % KOH
drop of discharge is mixed CLE:-
• Fishy (amine) odour when 1. Vaginal discharge - Profuse and offensive, thin
solution.
2. Irritation and itching
orally BD x 7 days 3. Dysuria
1. Metronidazole 500 mg
3 days. On examination:-
2. Tinidazole 2 gm orally for
1. Vaginal discharge - Thin, grey, greenish-yellow
Q.9 Bartholin cyst
2. Vulva inflamed
Ans. A. Closure of duct or gland
3. Strawberry vagina - Red & inflamed
B. Caused by infection or trauma
followed by fibrosis and occlusion of
Diagnosis:-
lumen.
1. Hanging drop preparation
2. NAAT
A. Asymptomatic initialy
B. When become large, it causes local discomfort and dysperunia.
1. Metronidazole 500 mg BD oral x 7 days
C. Unilateral swelling in posterior half of the labium majus.
2. Tinidazole 2g oral
D. Cyst - Fluctuant and not tender (Fluctuant meaning - moveable,
compressible, fluid filled) Q.14 Dysmenorrhea and its types.
Ans. Dysmenorrhea means painful menstruation.
1. Marsupilization - Types: -

a. Incision is made just outside the hymenal ring 1. Primary

b. Incision include vaginal and cyst wall. a. No identifiable pelvic pathology

2. Edges suctured with catgut making a clear circular opening. b. Mostly in adolescents, confined to ovulatory cycles
2. Secondary
Q.13 Diagnosis and Management of Trichomonasis vaginitis.
a. Endometrial
Polyp
Ans. Trichomonasis vaginalis is m/c cause of vaginitis.
b. Adenomyosis A
Risk factor :-
1. Sexual contact
d.
2. Impaired local defense - Malignancy M

e. Pelvic adhesions
• During or after mensturation
f. Pelvic
• After sexual stimulation infection
3. pH raised to 5.5-6.5 9. Pelvic congestions
Seen in elderly/parous
women.
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1. Thoery of retrograde mensturation :

Mensturation occur both forward and
backward
1. Spasmodic pain direction

2. Confined to lower
abdomen
3. Nausea

4. Vomiting Flow of superficial layers of endometrium

5. Diarrhoea

6. Headache
Implantation in pelvic organs eg. (Ovaries, uterosacral
cold sweats, fainting.
7. Vasomotor Changes - Pallor, ligament)

Primary
Endometriosis at these sites
1. Expectant mx :
• Seen most commonly in imperforate hymen.
a. Assurance
2. Lymphatic theory:
b. Weight reduction
a. Endometrium spread through lymph nodes like cancer.
c. Encourage activities
b. Explain endometriosis in umbillicus.
2. NSAIDs: If desire pregnancy
3. Theory of coelomic metaplasia:
a. Ibuprofen: 400 mg TDS
b. Mefenamic acid: 500 mg TDS Mesothelial cells (derived for coelomic epithelium)

c. COX2 Inhibitors - Celecoxib 200 mg BD

3. Hormonal: If not desire pregnancy Present at various sites

a. Combined OCP: 1 tablet daily

b. Dydrogesterone
Undergo metaplasia
c. LNG

4. Surgical :
a. Lap. Uterine Nerve ablation (LUNA) Form endometrium causing endometriosis
b. Lap. Presacral neurectony (LPSN)

Q.15 Define Endometriosis, C/F, Theories, Pathogenesis, Management. • It explain endometriosis in lungs and pleura.
Ans. Presence of endometrium at sites other 4. Genetic
then uterine mucosa.
theory:
Pathogenesis:

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endometriosis, they have 6- d. Thoracic endometriosis

In female with 1st degree relative having Gold standard
7) Laproscopy :
7 times more chance of having it. • Assessment of size &e extent of lesion. Biopsy and staging can be done.
Autoimmune basis
5. Immune mediated: MX: -
CMI and humoral
due to abnormality in 1. Expectant
Mx:
• Endometrosis happen
immunity. a. NSAIDS - To relieve pain
factors that promote endometriosis. b. Encourage conception - cause absence of mensturation
• Macrophages secreate growth
dikkat)
C/F: (Trick - PIA ko Bleeding, Hagne-Mutne mai 2. Medical Mx:
a. Atrophy of endometrial implants can be done by reducing estrogen
1. Dysmennorhea
P - Pain

Pain 1 - Infertility levels.

2. Dyspareunia
A - Adenexal mass Drugs: -
3. AUB

4. Painful urination Bleed - AUB 1. COCs: Preffered in young patients who want to delay pregnancy given
5. Haematuria Bladder endometriosis Hagne - Bowel endomet 3 weeks continuously and week off.
Mutne - Bladder endom
6. Increased frequency 2. Progesterone: Suppress ovulation and induce amenorrhea in high doses.
7. Painful defecation
Suppress activity of estrogen.
8. Diarrhea
3. Continous GnRH: Leuprolide
9. Constipation Bowel endometriosis
4. GnRH antagonist: Elagolix
10. Rectal bleeding
5. Aromatase Inhibitor: Letrozole
Diagnosis:
6. Danazol
1) Clinical diagnosis : Dysparunea, Dysmennorhea
2) Per speculum : Bluish powder-burn lesion Surgical Mx:
3) Bimanual examination : A. Conservative:
• Nodularity in pouch of doughlas
1. Laproscopic method:
• Bilaternal adenexal mass
• Retroverted uterus
a. Adhesiolysis
b. Laser vapourisation
4) Serum markers: CA125

5) USG - TVS: Detect ovarian endometriosis c. Presacral neurectomy: Reduce pain

6) MRI: Best diagnotic tool. d. Lap. Uterosacral nerve ablation (LUNA): In severe pain
Diagnose deeply infiltrating endometriostis like - B. Definitive:

a. ТАН (total abdominal hysterectomy) + BSO (bilateral salpingo-

a. Bowel endometriosis
b. Bladder endometriosis
c. Rectovaginal endometriosis oophorectomy)

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with diagnosis of endometriosis in female

Q.16 MX of Infertile couple AUB
partner.
Ans. Inv: Same as before Q.17 AUB, Classification, Diagnosis and Mx of Menorrhagia.
Ans. AUB refers to any deviation from normal menstrual bleeding in terms
Empirical Tx → Clomiphene citrate + Intrauterine insemination (IUl) of regularity, volume, frequency, or duration. It is a symptom rather than a
diagnosis.
Laproscopic staging
Definition:

Controlled ovarian stimulation • Normal menstrual cycle: 24-38 days, with bleeding lasting 4.5-8
days and blood loss of 5-80 mL, with cycle variability between 2-20
days.
GIFT etc. • AUB includes:
Other ART can be tried like ICSI, IUF-ET,
Sx method. • Irregular cycles.
If still not concieve, reduce endometriosis first by Mx or
• Heavy or prolonged menstrual bleeding (HMB/menorrhagia).
Mx: Same
o Intermenstrual bleeding.

1. Laproscopic method:
FIGO Classification of AUB
a. Laser vapourisation

b. Adhesiolysis FIGO (International Federation of Gynecology and Obstetrics) classifies AUB

c. LUNA into structural and non-structural causes using the PALM-COEIN system:
d. Lap-presacral neurectomy
1. Structural Causes (PALM):
2. Endometrioma (Endometrosis in ovary):
• P: Polyp (endometrial or cervical).
a. Aspiration & Irrigation
b. Cyst wall vapoursation
• A: Adenomyosis (endometrial tissue in the myometrium).
• L: Leiomyoma (fibroids, categorized as submucosal or others).
c. Ovarian cystectomy
• M: Malignancy or hyperplasia (endometrial carcinoma or
Then pregnancy can be tried again by ART.
premalignant conditions).
3. Definative Sx:
2. Non-Structural Causes (COEIN):
a. Done after family is complete
• C: Coagulopathy (e.g., von Willebrand disease).
thyroid disorders).
• O: Ovulatory dysfunction (e.g., PCOS,
b. TAH + BSO

(diagnosed by exclusion).
• E: Endometrial dysfunction
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hormonal medications, IUDs).

• l: latrogenic (e.g.,
• Mefenamic Acid: NSAID to reduce blood
loss and pain (500 mg
three times daily during menses).
• N: Not yet classified.
• Moderate cases:
Menstrual Bleeding) • Levonorgestrel Intrauterine System (LNG-IUS): Most
Management of Menorrhagia (Heavy effective
for reducing bleeding
or
Menorrhagia is a type of AUB with blood loss exceeding 80 mL per cycle • Combined Oral Contraceptives (COCs): Regulates cycles and
of life.
bleeding lasting more than 8 days, significantly affecting quality reduces blood loss.

• Oral Progesterone: Medroxyprogesterone

1. General Approach
acetate 10 mg/day.
• GuRH Agonists: Short-term use for refractory cases (e.g.,

a) History and Examination: Assess bleeding pattern, rule out systemic leuprolide).
diseases, and check for anemia.
3. Surgical Management
b) Inv: - DDs of AUB on basis of History:
For severe cases:

1. CBC, UPT • Intermenstrual

bleeding/Metorrhagia → Polyp, • Endometrial Ablation: Minimally invasive destruction of the

3. Imaging - USG: Done in all cases Endometrial cause endometrial lining.

Imaging - • HMB, Dysmenorrhea → AUB-A • Myomectomy: Removal of fibroids.

1. USG • Hysterectomy: Definitive treatment, reserved for severe cases
unresponsive to other therapies.
2. Doppler USG • Prolong bleeding → Fibroid
3. Hysteroscopy • Heavy bleeding at menarche,
4. MRI 4. Management of Underlying Causes
family Wo bleeding → AUB - C
5. Endometrial sampling - • History with signs of • Treat anemia with oral or IV iron.
Endometrial biopsy anovulation/ oligomenorrhea : PCOS • Address systemic conditions (e.g., hypothyroidism, coagulopathies).
6. Fractional curettage - Gold
• Copper T insertion → AUB- 1 • Stop or adjust iatrogenic causes (e.g., anticoagulants or hormonal
standard
therapies).

2. Medical Management
9.18 How will you manage a case of 22 year old null-parous female with
• Mild cases: submuosal fibroid of sx4cm having complained of intermenstural bleeding.
o Tranexamic Acid: Antifibrinolytic (1 9 three times daily during
Ans. Submucosal fibroids, being located beneath the endometrium, are often
menses).
associated with abnormal uterine bleeding (AUB), infertility, and pelvic

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a key
pain. For a young, nulliparous
woman, fertility preservation is 3. Medical Management (Temporary Measures)
Medical therapy can be used to manage symptoms temporarily, especially if
consideration in management.
surgical intervention is delayed or not immediately desired. However,
medical therapy does not eliminate the fibroid.
1. Initial Evaluation
• Tranexamic Acid: Reduces bleeding during menses or intermenstrual
History and Physical Examination:
of periods.
• Menstrual History: Duration, volume, frequency, and characteristics
• Hormonal Therapy:
intermenstrual bleeding.
anemia), or pressure symptoms • Combined oral contraceptives (COCs) or progesterone-only pills
• Symptoms: Pain, fatigue (suggestive of
regulate bleeding.
(e.g., urinary or bowel issues).
on fertility preservation. • LNG-IUS (levonorgestrel intrauterine system): Reduces bleeding
• Reproductive Goals: Strong emphasis
but may not be suitable if the fibroid significantly distorts the
Investigations:
endometrial cavity.
• Blood Tests:
• GnRH Agonists:
• CBC: Assess for anemia.
• Short-term use (e.g., leuprolide) to shrink fibroid size
• Thyroid function tests and coagulation profile (to rule out other
causes of bleeding).
preoperatively.
• Imaging: • Avoid prolonged use due to side effects (e.g., bone loss).
• Transvaginal Ultrasound (TVUS): Evaluate fibroid size, location, • Iron and Folate Supplementation: Treat anemia.
and relationship to the endometrial cavity.
4. Surgical Management
• Sonohysterography: Better delineates submucosal fibroid
protrusion into the uterine cavity. Surgery is preferred for symptomatic submucosal fibroids, especially in
• MRI (if needed): To assess fibroid vascularity and aid surgical women with bleeding and fertility concerns.
planning. Procedure of Choice:

• Endometrial Biopsy: Considered if there are risk factors for • Hysteroscopic

Myomectomy:
endometrial hyperplasia (rare at this age). • Minimally invasive removal of the fibroid through
hysteroscopic
resection.

as FIGO type O or 1
2. Management Goals • Best suited for submucosal fibroids classified
1. Alleviate intermenstrual
bleeding. (entirely or partially in the uterine cavity).
2. Preserve fertility. • Preserves the uterus and fertility.
3. Reduce symptoms and improve Preoperative Preparation:
quality of life.
• GnRH Agonists: To reduce fibroid size and vascularity, making surgery
easier.

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Diagnosis ofAUB
Postoperative Care:
• Monitor for recurrence (as
fibroids may regrow). 1. Clinical Evaluation
• Regular follow-up with
ultrasound.
• History:
• Menstrual pattern: Duration, frequency, and volume of
Hysteroscopy is Unsuitable) bleeding
5. Alternative Surgical Options (If • Associated symptoms: Pain, intermenstrual or postcoital
• Laparoscopic Myomectomy: For larger or partially intramural fibroids. bleeding, systemic symptoms (e.g., fatigue, weight loss).
for young,
• Uterine Artery Embolization (UAE): Not preferred
nulliparous women due to potential impact on fertility.
• Risk factors: Obesity, diabetes, hypertension, or family history of
endometrial or ovarian cancer.
• Obstetric history: Parity, complications in previous pregnancies.
6. Counseling
• Medications: Hormonal therapy, anticoagulants.
• Discuss the risks and benefits of each treatment option.
• Physical Examination:
• Emphasize the possibility of fibroid recurrence and need for long-term
• General: Signs of anemia (pallor, fatigue).
follow-up. • Abdominal: Palpation for masses or tenderness.
• Provide psychological support, especially if fertility is a major concern.
• Pelvic: Inspection for cervical abnormalities, vaginal bleeding, or
uterine size/shape irregularities.
7. Follow-Up
• Regular monitoring of symptoms and fibroid size with ultrasound
every 6-12 months.
2. Investigations
• Ensure adequate hemoglobin levels and assess for recurrence of
bleeding. • Blood Tests:

• Complete blood count (CBC): Assess anemia and

Q.19 Describe diagnosis and management of Abnormal uterine bleeding in thrombocytopenia.
P3L3 at 45 yrs of age.
• Thyroid function tests: Rule out hypothyroidism.
Ans. A 45-year-old woman with abnormal uterine bleeding (AUB) requires • Coagulation profile: Rule out clotting disorders.
careful evaluation to determine the underlying cause and • Serum ferritin: Assess iron deficiency.
appropriate
management, as this age group is at higher risk for endometrial hyperplasia • Imaging:
or malignancy due to perimenopausal
hormonal changes. • Transvaginal Ultrasound (TVUS):
• Evaluate endometrial thickness (14-5 mm in
women or ›12 mm in premenopausal
postmenopausal
women suggests hyperplasia).
masses.
• Detect fibroids, adenomyosis, or ovarian
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• Combined Oral Contraceptives (COCs):

Endometrial Assessment: Regulate cycles and
rule out endometrial
• Endometrial Biopsy (EMB): Essential to
reduce blood loss.

especially in women 245 years with • GuRH Agonists: Short-term use for refractory
hyperplasia or carcinoma, cases or pre-
surgical management.

• Hysteroscopy: Direct visualization of the endometrial cavity for • Treat Anemia:

or submucosal fibroids. • Oral or intravenous (IN iron supplementation
polyps depending on
severity
• Additional Tests:
pathology.
• Pap smear to exclude cervical
• Hormonal profile if ovulatory dysfunction is suspected (FSH, LH,
prolactin). 2. Surgical Management

Indicated for structural causes (e.g., fibroids, polyps) or when medical

Management of AUB
therapy fails:

• Hysteroscopic Polypectomy or Myomectomy: For endometrial polyps

Management depends on the underlying cause, severity of symptoms, and
or submucosal fibroids.
the patient's preferences, particularly her reproductive status and future
• Endometrial Ablation: Minimally invasive destruction of the
fertility plans.
endometrium; not suitable for women desiring future fertility.
• Hysterectomy: Definitive treatment for refractory cases, especially
1. Medical Management
with significant risk of malignancy or coexisting pelvic pathologies.

• Non-Hormonal Options:
• Tranexamic Acid: Antifibrinolytic (1 g TID during menses). 3. Management of Specific Causes

• NSAIDS (e.g., mefenamic acid): Reduce prostaglandins to • Structural Causes (PALM):

decrease bleeding and pain.
• Hormonal Options:
o Treat fibroids with myomectomy, uterine artery embolization,
or hysterectomy.
• Levonorgestrel Intrauterine System (LNG-IUS): First-line
therapy for heavy menstrual bleeding (HMB). • Polyps: Remove via hysteroscopy.
• Progestins:
•
Non-Structural Causes (COEIN):
• Cyclic or continuous oral medroxyprogesterone acetate • Ovulatory dysfunction: Hormonal therapy (e.g., LNG-IUS, COCS).
(MPA). • Coagulopathy: Tranexamic acid, desmopressin for von
Willebrand disease.
• Depot medroxyprogesterone or norethisterone acetate.
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4. Follow-Up
Displacement of Uterus
levels, 0.20 Supports of uterus and their importance with Diagram.
• Regular follow-up to monitor bleeding patterns, hemoglobin
and response to treatment.
Ans. Supports of uterus:
• Reassess endometrial thickness or pathology if symptoms persist. Mechanical supports:
a. Uterus is in anteverted and anteflexed position.
Ligament support:
Special Considerations for This Patient 3 Tier:

• At 45 years, perimenopause is likely, so counseling on the transition 1. Upper tier: Maintain uterus in anterverted position. Trick :
a. Endopelvic fascia
to menopause is important. Egg
b. Round ligament
• High suspicion of malignancy necessitates thorough evaluation with Round &
endometrial biopsy and imaging. c. Broad ligament Broad
• Address patient preferences regarding fertility and quality of life 2. Middle tier: Strongest support of uterus
during treatment planning. a. Pericervical ring: Collar of tissue encircling cervix.
Connected anteriorly to -
• Pubocervical ligament
ligaments
• Versiouterine septum Transverse Transverse
cervical ligaments cervical ligaments
Posteriorly to -
• Uterosacral ligament
• Rectovaginal septum
Laterally to - Pericervical ring Pubocervical fascia

• Cardinal ligament
b. Pelvic
tissue
3. Inferior tier: Gives indirect support to uterus. (Trick: PELZU)
a. Perineal body
b. Endopelvic fascia
c. Levator ani: Pubo & lleococcygeus
d. Levator
plate
e. Urogenital diaphragm

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2. Levator ami
Support of Vagina: 3. Perineal body
1/3rd of vagina
1. Level 1 - Upper 4. Endopelvic fascia
a. Uterosacral ligament
b. Genetic
b. Cardinal ligament
3. Aggravatory factors: (Trick: OWSM PIC})
2. Level 2 - Middle 1/3rd
1. Obesity
a. Arcus tendinous fascia
1/3rd 2. Weight lifting
3. Level 3 - Lower
3. Smoking
a. Perineal body
b. Muscles
4. Multiparity
5. Malnutrition
Importance
displacement (prolapse or 6. Postmenopausal atrophy
1. Maintaining Position: Prevents uterine
retroversion). 7. Increased weight of uterus as in fibroid
like the
2. Stabilizing Pelvic Organs: Supports surrounding structures 8. COPD

bladder and rectum. 9. Constipation

3. Facilitating Childbirth: Ensures proper alignment of the uterus during
labor.
Types: -
4. Preventing Prolapse: Dysfunction or weakening of these supports can
Vaginal Posterior wall
lead to uterine prolapse.

Q.21 Pelvic organ Prolapse - Etiology, Pop-Q Classification, Shaw Anterior wall a. Rectocele

classification, C/F, Mx, Preventive measures, a. Cystocele b. Enterocele

Etiology: - (APA) b. Urethrocele c. Relaxed perineum

1. Anatomical factors:

a. Inherent weakness of supporting structures - ligaments, muscles Shaws classification: -

b. Pelvic floor weakness
Normal - External os at level of ischial spine
c. Stress of parturation 1º - Descend of cervix into vagina
d. Gravitational stress
2º - Descend of cervix outside the introitus but uterus inside vagina
2. Predisposing factors:
3° - Descent of cervix and uterus outside introitus
a. Trauma of vaginal
delivery to: Procidentia - Prolapse of uterus with eversion of vagina
1. Ligaments

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5. Feeling of something coming out of vagina
POP-Q classification:-
Aa 6. Decubitus ulcer in vagina
point
• Hymen is reference
(-) & below hymen (+) gH Urinary symptom: (in Cystocele) (Trick: FUN PISS)
• Anything above hymen 1. Frequency 1
• 3X3 grid system Ap D
2. Urgency t
• 3 measurements and 6 points
3. Painful micturition
POP-Q staging criteria 4. Straining: Increase straning however decrease effective evacuation,
C or D is s - (TVL-2) cm has to elevate Ant. vaginal wall for complete evacuation.
Stage O: Aa, Ba, Ap, Bb = -3 cm and
met and 5. Sense of incomplete evacuation
Stage I: Stage O criteria not
< 1cm above level of hymen 6. Stress Urinary Incontinence (due to urethrocele)
3 cm
Bowel symptoms: (in Rectocele)
Stage II: 2-1 cm but ≤+1 cm
1. Constipation: Incomplete evacutation
Stage Ill : > +1 cm but ≤ + (TVL-2) cm
2. Straining: Has to push back rest vaginal wall to evacuate
Stage IV : ≥ + (TVL-2)
3. Faecal incontinence
complete version of total length of lower
genital tract
A. Preventive measures:
A. Adequate antenatal & intranatal case :
Stage O
1. To avoid injury to supporting structures during vaginal delivery.
B. Adequate postnatal care :
Stage 1
1. To encourage pelvic floor exercise by squeezing pelvic floor muscles
1 ст
Stage 2 (Kegal exercise).
hymen* C. General measures:
Stage 3 1. Avoid - a. Constipation
b. Chronic cough
Stage 4
c. Strenous activity (weight lifting)
d. Smoking
1. Backache
e. Too many pregnancy
B.
2. Dyspareunia Conservative Mx:
3. Loss of sexual
activity 1. Pelvic floor exercise to strength muscles (Kegel exercise)
4. Buldge from vagina • Done in primary
prolapse

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or after delivery • Ex → Purandare sling, Shirodkar sling
• Advised to all
pregnant women during
2. Pessary:
device
b) Desire (-), Rep. age group (+) then → Forther-gills repair
• Space occupying 2 steps -
• Doesn't allow uterus to
prolapse
1. Cervical amputation
- Doughnut, Gell horn
• Types 2. Cardinal ligaments transposition to anterior side
3 months
• To be changed every • Vaginal hysterectomy is not done in these cases of cervix.
Indications:

1. Patients unfit for Sx

c) Desire (-), Reproductive age (-) then →
2. Patient unwilling for operation
• 2º/3° degree → Vaginal Hysterectomy
3. Early pregnancy
• 2º/3° degree + Cystocele + Rectocele → Ward Mayo's hysterectomy
4. Puerperium
= Vaginal Hysterectomy + Ant. Colporraphy + Post. Colpoperineorraphy
Complications:
1. Vaginal bleeding
2. Vaginal discharge
3. Pelvic pain
Also called Pelvic Floor Repair
4. Pessary ulcer - Tx by local estrogens

C. Surgery: After Vaginal hysterectomy, there are chances of -

1. For Vaginal prolapse : 1. Enterocele - corrected by Mc'Call culdoplasty

a. Anterior colporraphy: for cystocele & urethrocele 2. Vault prolapse - corrected by uterosacral suspension
b. Post colpoperineorrhaphy: for rectocele & laxed perineum Details about each Sx-

c. McCall culdoplasty: for entrocele 1. Ant. Colporraphy - The laxed part of vagina is cut out from the middle,
and both the ends are joint through interrupted sutures
2. For Uterine prolapse : 2. Colpoperineorrhaphy - Same as before on post-vaginal wall.
It is divided on basis of desire of future pregnancy or not with in 3. McCall culdoplasty
:
reproductive age group or not. • Intestine pushed up
• Stiches done in pouch of douglus (Rectouterine pouch)
a) If Desire present, with reproductive age 4. Uterosacral
group → sling Surgery suspension :
• In this, artificial siling are placed which do the function of ligaments.

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uterus during hystereomy, are • Uterosacral Ligament Suspension:

• The uterosacral after being removed from the uterus.
Provides additional support to
to vagina to prevent
vault prolapse.
attached 2. Hysteropexy: Vaginal or abdominal uterus-preserving surgery.
uterovaginal Prolapse.
Q.22 How will you manage a case of Nulliparous
Ans.
Special Considerations
1. Initial Evaluation
• Uterus-preserving surgeries are prioritized to maintain fertility in
like vaginal bulge, pelvic
• History and Examination: Assess symptoms nulliparous women.
pressure, urinary or bowel issues, and grade prolapse using the POP-
• Psychological support is essential to address concerns about body
Q system. image and reproductive potential.
MRI to exclude associated
• Investigations: Pelvic ultrasound or
conditions; urodynamic studies if urinary symptoms are present. This approach balances symptom management, fertility preservation, and
long-term outcomes.

2. Non-Surgical Management

• Lifestyle Modifications: Avoid heavy lifting, manage constipation, and

chronic cough.
• Pelvic Floor Muscle Training (PFMT): Helps strengthen pelvic floor
muscles; guided by a physiotherapist.

• Pessary Use: A vaginal pessary provides mechanical support and

symptom relief.

3. Surgical Management

Indicated for severe prolapse or failed conservative measures:

1. Uterus-Preserving Surgeries:
• Sacrospinous Ligament Fixation: Anchors the uterus to the
sacrospinous ligament.
• Laparoscopic
the sacral
Sacrohysteropexy: Mesh suspension of the uterust!
promontory for support.
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2. Male Factors:
INFERTILITY & AMENORRHEA 1. Sperm Abnormalities:
Write a management • Low count (oligospermia), poor motility (asthenospermia),
Q.23 Define Infertility, Discuss causes of Infertility. or
of a couple with primary infertility. Write 3 indications abnormal morphology (teratospermia).
plan for treatment
2. Ejaculatory Disorders:
of surrogacy.
• Retrograde ejaculation, erectile dysfunction.
Ans. Definition :
3. Hormonal Causes:
12 months
Infertility is defined as the inability of a couple to conceive after • Hypogonadism, testosterone deficiency.
regular, unprotected sexual intercourse. In women aged 35 years or 4. Structural Abnormalities:
of
older, this period is reduced to 6 months. • Obstruction in the reproductive tract (e.g., vas deferens
blockage).

3. Combined Factors:
Causes of Infertility
1. Female Factors:
• Both partners contribute to infertility.

1. Ovarian:
4. Unexplained Infertility:
• Ovulatory disorders (e.g., polycystic ovary syndrome, premature
ovarian failure, hypothalamic dysfunction). • No identifiable cause despite thorough evaluation.
2. Tubal:

• Tubal blockage or damage (e.g., pelvic inflammatory disease,

endometriosis, or tubal surgery). Management Plan for Primary Infertility
3. Uterine: 1. Initial
Evaluation
• Congenital abnormalities (e.g., septate uterus), fibroids, or
•
adhesions (Asherman's syndrome). History:
4. Cervical: • Duration of infertility, menstrual history, coital frequency,
previous pregnancies, and medical or surgical history.
• Cervical stenosis or hostile cervical
mucus.
5. Endometriosis: • Examination:

• Ectopic endometrial tissue causing anatomical and functional • General and reproductive examination for both partners.
disruption.
2. Female Partner Evaluation
1. Ovulation
Assessment:
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2-5).
and estradiol (Day
• Serum FSH, LH, 21 of cycle).
• Indicated for tubal damage,
severe male factor infertility, or
(Day
• Serum progesterone failed IUl.

2. Tubal Assessment:
6. Intracytoplasmic Sperm Injection (ICSI):
• Hysterosalpingography (HSG) or
sonohysterography. • For severe sperm abnormalities.
• Laparoscopy if HS suggests tubal damage or pelvic pathalogy 7. Donor Sperm or Oocytes:

3. Uterine
Evaluation: • For severe male or female factor infertility.
or adhesions.
• TVUS or hysteroscopy for fibroids, polyps,

3. Male Partner
Evaluation Indications for Surrogacy

1. Semen Analysis: 1. Uterine Factor Infertility:

• Evaluate count, motility, and morphology. • Absence of the uterus (congenital or
surgical), severe uterine
2. Hormonal Testing: abnormalities, or repeated implantation failures.
• Serum testosterone, FSH, and LH (if semen analysis is 2. Medical Contraindications to Pregnancy:
abnormal). • Conditions like severe cardiac disease or renal dysfunction where
3. Imaging: pregnancy poses a high risk.
• Scrotal ultrasound if varicocele or obstruction is suspected.
3. Repeated Pregnancy Loss:
• Recurrent miscarriages despite treatment...

4. Treatment Options Q.24 Fallopian tube tests & ovulation tests.

Ans. Fallopian tube patency testing is essential in evaluating female

1. Lifestyle Modifications:
infertility to determine if the fallopian tubes are open and functional.
• Weight optimization, smoking cessation, and reduced alcohol
intake.
2. Ovulation Induction: Tests for Tubal Patency

• Clomiphene citrate, letrozole, or gonadotropins for anovulation. 1. Hysterosalpingography (HSG):

3. Tubal Surgery:
• For mild tubal blockage • Procedure:
or adhesions.
4. Intrauterine into the uterus and fallopian
Insemination (IUI): • A radiopaque dye is introduced
• For unexplained infertility or mild male factor tubes, followed by X-ray imaging.
5. In Vitro issues.
Fertilization(IVF): • Findings:
the peritoneal cavity indicates patency.
• Free spillage of dye into

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are identified.
• Blockage or abnormalities (e.g., hydrosalpinx)
procedure.
• Findings:
Simple, outpatient • Free spillage confirms tubal
• Advantages: patency; absence indicates blockage.
discomfort.
• Disadvantages: Radiation exposure and potential for pelvic • Advantages: Gold standard; allows direct
visualization of pelvic
pathology (e.g., endometriosis, adhesions).
• Disadvantages: Invasive, requires anesthesia, and carries surgical risks.
2. Sonohysterography
(Saline Infusion Sonography):

• Procedure: 5. Rubin's Test:

o Saline and air bubbles are injected into the uterine cavity while
ultrasound.
observing with transvaginal • Procedure:

• Findings: • COs gas is insufflated into the uterus and tubes, and patency is
• Movement of bubbles through the tubes into the
peritoneal assessed based on changes in intrauterine pressure.
cavity suggests patency. • Advantages: Simple and non-radiological.
• Advantages: No radiation, better visualization of uterine abnormalities. • Disadvantages: Rarely used now due to limited accuracy.
• Disadvantages: Operator-dependent.

Comparison of Methods

3. Hysterosalpingo-Contrast Sonography (HyCoSy):

• Non-Invasive: HSG, HyCoSy, and sonohysterography are less invasive
• Procedure: and suitable for initial evaluation.

• A contrast medium (e.g., ExEm foam) is introduced into the • Invasive: Laparoscopy is more accurate and diagnostic but reserved for
uterus, and ultrasound is used to visualize tubal spillage. cases where other tests are inconclusive or when pelvic pathology is
• Advantages: Minimally invasive, no radiation, and can be performed suspected.
in-office.

• Disadvantages: May require training for accurate interpretation.

Conclusion

4. Laparoscopy with
Chromopertubation: The choice of test depends on clinical circumstances, availability, and the
patient's condition, with HSG and HyCosy commonly used as first-line
• Procedure: tools.

• Performed under general anesthesia. A laparoscope is used to Ovulation test:

visualize the pelvis, and methylene blue or indigo carminedge s 1. Clinical
introduced through the uterus to check Methods:
for spillage.
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a. Menstrual history: Regular menstruation suggests ovulatory cycle • Method: Measure serum progesterone on Day 21
of a regular 28-day
Monitoring: cycle.
b. Basal Body Temperature (BBT)
• Findings: Levels >3 ng/mL indicate ovulation.
• Principle: Progesterone secretion after ovulation
causes a rise in basal • Advantages: Objective and reliable.
body temperature (by 0.4-0.6°F). • Disadvantages: Requires blood sampling and proper timing.
• Method: Record daily temperature with a thermometer before rising
3. Vaginal epithelium study:
in the morning.
Intermediate cell present → Ovulation occurred
• Findings: A biphasic pattern indicates ovulation.
• Advantages: Inexpensive, easy to perform. Superficial cell present → Ovulation absent
• Disadvantages: Requires regular monitoring and may be affected by 4. Endometrial biopsy
external factors (e.g., illness or sleep disruption). 5. Ultrasound Follicular Monitoring
Conclusion:
c. Cervical Mucus Observation:

• First-line tests include OPKs, BBT, and serum progesterone.

• Principle: Estrogen during ovulation makes cervical mucus thin,
• Ultrasound follicular monitoring is the most accurate for confirming
stretchy, and clear (spinnbarkeit).
ovulation. The choice of test depends on the clinical scenario and
Method: Fern-like pattern disappears → Ovulation occurred patient preferences.
Pattern present → Ovulation absent
Q.25 WHO parameters for normal semen Analysis
2. Hormonal Methods
Ans. WHO Parameters for Normal Semen Analysis (2021 Criteria)
1. Semen Volume
a. Luteinizing Hormone (LH) Surge Detection:

• Principle: Ovulation occurs • Normal Range: ≥ 1.5 mL

24-36 hours after the LH surge.
• Method: Use over-the -counter ovulation predictor kits (OPKS) to test
• Significance: Low volume may indicate retrograde ejaculation or
urine for LH. obstruction.
• Advantages: High
accuracy, easy to use.
• Disadvantages:
Expensive for prolonged use.
2. Sperm Concentration
b. Serum
Progesterone Measurement:
• Normal Range: ≥ 15 million sperm/mL
ejaculate.
• Principle: Serum progesterone levels rise after
ovulation due to corpus • Total Sperm Count: ≥ 39 million sperm per
luteumactivity.

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absence of sperm
• Significance: Lower values indicate oligospermia; 7. White Blood Cells (WBCS)
indicates azoospermia.
• Normal Range: < 1 million WBCs/mL
• Significance: Elevated levels indicate infection or inflammation.
3. Total Motility

non-progressive
• Normal Range: ≥ 42% (includes progressive and 8. Liquefaction Time
motility).
actively moving forward). • Normal: Complete liquefaction within 60 minutes.
• Progressive Motility: ≥ 30% (sperm • Significance: Delayed liquefaction suggests prostatic or seminal vesicle
• Significance: Reduced motility suggests asthenozoospermia.
dysfunction.

4. Sperm Morphology
Summary of Normal WHO Criteria
• Normal Range: ≥ 4% normal forms (strict Kruger criteria). Parameter Normal Value

• Significance: Abnormal morphology (teratozoospermia) may impair ≥ 1.5 mL

Semen Volume
fertilization.

Sperm Concentration ≥ 15 million/mL

5. Vitality (Live Sperm Percentage) Total Sperm Count ≥ 39 million/ ejaculate

• Normal Range: ≥ 54% live sperm (evaluated with eosin-nigrosin stain). Total Motility ≥ 42%

• Significance: Indicates the proportion of live sperm; low vitality

Progressive Motility ≥ 30%
suggests necrozoospermia.

Morphology ≥ 4% normal forms

6. pH Vitality ≥ 54%

• Normal Range: ≥ ≥ 7.2

7.2
• significance: Low pH indicates ejaculatory duct obstruction; high pH
may suggest infection.
Q.26 PCOS
Ans. Diagnosis criteria (any 2 of 3):

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1. Polycystic
ovaries
and anovulation 1) Fertility not Desired:
2. Oligo or/ • COCs - Progestin suppresses LH and estrogen improves SHBa
(clinical or biochemical)
3. Hyperandrogenism
• Desogestrel
• Antiandrogens (Spironolactone) → for hirsutism
1. Obesity
2. Hirsutism

3. Ammenorhea
2) Sub-fertility tx: Ovulation induction is done
• Clomiphene citrate
4. Infertility
• Letrozole
5. DUB
Due to insulin resistance
6. Acanthosis nigricans:
Inv:

1. TVS (Trans-vaginal sonography): Useful in obese

patients • Recombinant FSH
binding
2. Serum levels of LH 1, Estradiol 1, SHBG (Sex-hormone
globulins) L, Testosterone 1, Prolactin 1 3) Obesity and metabolic syndrome:

3. Lipid profile • Exercise, diet

4.2 hr OGTT • Metformin

5. Reassessment of BMI, BP, waist circumference

4) AUB
Treatment primary target is to correct biochemical abnormalities i.e. • Progestins
1. Hyperandrogenemia • COCS
2. Hyperinsulinemia
3. Hyperlipidemia
Q.27 What is primary amenorrhoea and its aetiology.
4. Estrogens 1
5. Prolactin 1 Definition:
6. Insulin resistance Primary amenorrhoea is the absence of menarche (first menstrual period):
7. LH 1
8. FSH J • By age 15 years in the presence of normal secondary sexual
characteristics.

1 0.
Progesterone d
• By age 13 years if there are no secondary sexual characteristics.

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• Polycystic Ovary Syndrome (PCOS):

Aetiology of Primary Amenorrhoea • Hyperandrogenism and anovulation.
the level of the reproductive axis:
The causes can be classified based on • Primary Ovarian Insufficiency:
• Due to autoimmune causes, chemotherapy,
or genetic mutations
(e.g., fragile X premutation).
(Central)
1. Hypothalamic Causes

Amenorrhoea:
• Functional Hypothalamic 4. Outflow Tract and Uterine Causes
(e.g., anorexia
• Stress, excessive exercise, or eating disorders
nervosa). • Congenital Absence of Uterus or Vagina:
• Congenital Disorders: • Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.
• Kallmann syndrome (hypogonadotropic hypogonadism with • Transverse Vaginal Septum or Imperforate Hymen:
anosmia). • Results in outflow obstruction and cryptomenorrhoea.
• Structural Abnormalities: • Androgen Insensitivity Syndrome (AIS):
• Hypothalamic tumors (e.g., craniopharyngioma). • 46, XY karyotype; normal breast development but absent uterus
and upper vagina.

2. Pituitary Causes
5. Endocrine Causes
• Hypopituitarism:
• Secondary to tumors (e.g., prolactinoma), radiation, or trauma. • Thyroid Disorders:
• Hyperprolactinemia: • Both hypothyroidism and hyperthyroidism can cause
• Suppresses gonadotropin-releasing hormone (GURH). amenorrhoea.
• Congenital Disorders:
• Congenital Adrenal Hyperplasia (CAH):
• Pituitary agenesis or empty sella syndrome.
• 21-hydroxylase deficiency causing hyperandrogenism.

Q.28 What is secondary amenorrhoea. Briefly write its causes and

3. Ovarian Causes
management.

• Chromosomal
Abnormalities: Definition:
• Turner syndrome (45, X): Streak gonads and primary
ovarian Secondary amenorrhoea is the absence of menstruation for 3 months in a
woman with previously regular cycles or 6 months in those with irregular
failure.
• Gonadal dysgenesis cycles.
(e.g., Swyer syndrome: 46,
XV.
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o Autoimmune, genetic (e.g.,
fragile X syndrome), or iatrogenic
causes (chemotherapy, radiation).

Causes of Secondary Amenorrhoea

into various levels of the
hypothalamic -
The causes can be classified 4. Uterine
Causes
pituitary-ovarian-uterine axis:
• Asherman's Syndrome:
• Intrauterine adhesions, often post-curettage or
surgery.
Causes • Endometrial Atrophy:
1. Hypothalamic
• Associated with prolonged use of hormonal
contraception or
• Functional Hypothalamic
Amenorrhoea: infections (eg., tuberculosis).
• Stress, excessive exercise, significant weight loss, or eating
disorders (eg., anorexia nervosa).
• Hypothalamic
Tumors: 5. Endocrine Causes
GARH secretion.
• Craniopharyngioma or other masses affecting
• Thyroid Disorders:
• Hypothyroidism or hyperthyroidism.
2. Pituitary Causes • Cushing's Syndrome:
• Excessive cortisol leading to menstrual irregularities.
• Hyperprolactinemia:
• Congenital Adrenal Hyperplasia (CAH):
• Prolactinoma or medication-induced (eg., antipsychotics).
• Late-onset 21-hydroxylase deficiency.
• Shechan's Syndrome:
• Postpartum pituitary necrosis.
• Hypopituitarism:
6. Other Causes
• Tumors, trauma, or infiltrative diseases (eg., sarcoidosis).
• Pregnancy:
• Most common cause of secondary amenorrhoea in reproductive -
3. Ovarian Causes
age women
• Polycystic Ovary Syndrome (PCOS): • Medications:
• Chronic anovulation due
to hormonal imbalance. • Antipsychotics, antiepileptics, or hormonal therapies.
• Primary Ovarian Insufficiency (PON): • Chronic Illnesses:

• Diabetes, celiac disease, or renal failure

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• Hormone replacement
therapy (HRT) for symptom relief
and bone protection.
Amenorrhoea
Management of Secondary 6. Asherman's Syndrome:
1. Diagnosis • Hysteroscopic adhesiolysis followed by
hormonal therapy
to restore the endometrium.
History and Physical Examination: 7. Thyroid or Adrenal Disorders:
• Assess menstrual history, weight changes, stress, medications,
• Treat underlying endocrinopathy (thyroid hormones,
and systemic illnesses.
glucocorticoids)
• Pregnancy Test:
step.
• Rule out pregnancy as the first
• Hormonal Evaluation:

• Prolactin, TSH, FSH, LH, estradiol, and

testosterone levels.
• AMH and antral follicle count (ovarian reserve).
• Imaging:
• Pelvic ultrasound to assess uterine and ovarian structure.
• MRI/CT for hypothalamic or pituitary abnormalities.
• Special Tests:

• Hysteroscopy for Asherman's syndrome.

2. Treatment

• Based on the Cause:

1. Pregnancy: Provide antenatal care.
2. Functional Hypothalamic Amenorrhoea:

• Weight gain, stress reduction, and balanced diet.

• Hormonal replacement
therapy (if needed).
3. Hyperprolactinemia:
• Dopamine agonists (cabergoline,
4. PCOS:
bromocriptine).
• Lifestyle changes, ovulation
induction (clomiphene,
letrozole), or hormonal
5. Primary therapy.
Ovarian Insufficiency:
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1. Asymptomatic
BENIGN LESION & 2. AUB → Menorrhagia
3. Infertility → Due to submucosal fibroid
NEOPLASMS 4. Dysmenorrhea
Due to endometriosis
5. Dyspareunia in fibroid
Degenerations,
9.29 Describe fibroid, types, C/F, Anatomial classification, 6. Pain

Most disease in Gyne have

7. Constipation
Ans. Fibroid are m/c benigh tumor of 8. 1 Urinary frequency Pressure symptoms
same RF, so you can
uterus. 9. Urinary obstruction
remember - RF for
Types :
Endometrial Cancer (Trick -
10. Recurrant abortion
1. Body 11. IUGR Due to sub-mucosal
Family Has OLD AUNT)
a) Intramural Degenerations : (RACHI mai F**k Suman Vagina}
1. Family history
b) Subserosal - sessile, pedunculated, 1. Red degeneration →
2. High fat diet
subserous, broad ligament
a. Seen in 2nd half of pregnancy.
c) Submucosal - sessile, pedunculated 3. Obesity
b. Raw beef appearance
2. Cervical 4. Late menopause & early
c. Odour is fishy & colour is red
menarche
a) Ant.
d. Microscopically - Necrosis is present
b) Post. 5. DM
2. Atrophy
c) Lateral 6. Atypical endometrial
3. Cystic degeneration →
d) Central hypoplasia
a. Common in intramural fibroid
Risk factors: 7. Unopposed estrogen :
b. Formed by liquefaction of areas
1. Hyper estrogenic state PCOS or granulosa cell
2. High fat diet tumor c. Myxomatous degeneration is seen
4. Calcific →
3. Early menarche 8. Nulliparity
4. PCOS a. Involve subserous fibroid
9. Therapy like → HRT
5. Obesity Which is also similar to Fibroids b. Precipitation of calcium carbonate or phosphate within tumor → Womb
stone
6. Nulliparity
7. Age 1 S. Hyline degenration (Most Common)
a. Affect all type of fibroid
b. Irregular homogenous appearance
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c. Loss of whorl like appearance Hysterscopic Myotomy

muscle & fibrous tissue
d. Microscopic - Hyline changes in (Note - GNRH agonist must be administered continuously)
• Main reasons to do myomectomy is to preserve fertility,
6. Infection otherwise do
7. Vascular changes → hysterectomy.
• Dialatation of vessels & lymphatic channels 2. Subserosal / Intramural
8. Sarcomatus changes → a. 1st line Mx - Decrease bleeding
• Malignant changes are care 1. СОС
9. Fatty degeneration → 2. Progesterone
• Fat globules in muscles 3. IUD (Mirena)

4. Traxenemic acid (anti-fibrinolytic)

Inv.
b. 2nd line - Decrease Bleeding & fibroid size
1. USG - I0C 1. Anti - estrogenic:
a. In intramural fibroids →
• GuRH agonist - Leuprolide
1. Seen is USG
• GuRH antagonist - Elagolix
2. Mass centrally located • Danozol
3. Homogenous in appearance • Letrozol
4. Mass inside myometrium
2. Antiprogesterone:
b. In submucosal →
• Mifepristone / RU 486
1. USG in saline infusion
• Ullipristal
2. Droppler USG
3. Uterine artery embolisation :
c. In subserosal →
1. Fibroid arises from • Uterine artery supply major part of uterus.
uterine fundus
• Embolisation leads to y blood supply → Size v
2. Bridging vessel sign
• Procedure - via femoral artery, contralateral uterine artery is
1. Submucosal fibroid embolised using polyvinyl alcohol.
Indicated in -
• Myomectomy → if Size ›
5cm
• Heavy menstural bleeding
• No desire of future
If Size ‹ 5 cm pregnancy
Laproscopic myotomy • Premenopausal
Contraindication-
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• Asymptomatic
fibroid Indications
• symptomatic fibroids causing heavy menstrual
• No desire of pregnancy bleeding, pelvic pain,
or pressure symptoms.
• Pregnancy
• Women who desire uterine preservation but do not wish to
• PID undergo
surgery.
• Malignancy
• Patients with contraindications to general anesthesia or
c. 3rd line - In heavy menstural
bleeding surgery.
1. High intensity focused ultrasound
{HIFU}
Procedure
• Focused high energy ultrasound waves induce coagulative
necrosis.
• Performed under local or regional anesthesia.
• It causes local thermal ablation of fibroid tissue.
• A catheter is inserted through the femoral or radial artery and
C/ - Desire of future pregnancy, Myoma >10 cm size guided to the uterine arteries.
2. Hysterectomy → • Embolic agents (e.g., polyvinyl alcohol particles) are injected to block
Vaginal Hysterectomy blood flow to the fibroids, causing ischemia and shrinkage.
OR
Benefits
Total Abdominal Hysterectomy
Hysterectomy is an operation of choice if there is no valid reason for
• Minimally invasive with shorter recovery time than surgery.

myomectomy.
• High success rate in reducing symptoms, including heavy bleeding and
pressure.

• Preserves the uterus, allowing for potential future pregnancies in

Q.30 Management of large intramural fibroid at the age of 45 years.
selected cases.
Ans. For a 45-year-old woman with a large intramural fibroid,
• Avoids surgical complications like blood loss or infection.
hysterectomy is the preferred definitive treatment if fertility preservation is
not a concern. In symptomatic cases not desiring immediate surgery, GnRH Limitations

agonists or UAE can be considered as interim

management. • Not suitable for very large fibroids or submucosal fibroids protruding
into the uterine cavity.

Q.31 Role of Uterine Artery Embolization (UAE) in • Recurrence risk is higher compared to hysterectomy.
Fibroid Uterus
Ans. Uterine Artery Embolization (UAE) is a • Not recommended for women actively trying to conceive, as it may
minimally invasive, image-
guided procedure used to treat symptomatic uterine fibroids by cutting off affect uterine blood supply and endometrial health.
their blood supply. It is a safe and effective
alternative to surgical options, Complications
particularly for women who wish to avoid surgery
• Post-embolization syndrome: Pain, low-grade fever, and nausea.
or retain their uterus.

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of
• Rare complications: Uterine infection, ischemia, or failure • Mature Teratoma (Dermoid Cyst): Contains
ectodermal,
mesodermal, and endodermal tissues like hair,
embolization. teeth, or fat.

Conclusion 4. Sex Cord-Stromal Tumors

UAE is an effective, uterus-preserving option for managing symptomatic
• Develop from ovarian connective tissue.
fibroids, especially for women not opting for surgery. Proper patient
• Fibroma: A solid, fibrous mass.
selection is essential for successful outcomes.
• Thecoma: May produce estrogen, leading to hormonal effects.
Q.32 Causes of Benign Ovarian Masses
5. Endometriomas
Ans. Benign ovarian masses are non-cancerous growths in or on the ovaries.
They are common and can arise from various ovarian structures, with the • Cysts formed by endometrial tissue implants on the ovary (chocolate
following causes: cysts). Associated with endometriosis.
1. Functional Ovarian Cysts
6. Polycystic Ovarian Syndrome (PCOS)
• Develop as part of the normal ovulatory cycle; usually resolve
spontaneously. • Multiple small, functional cysts due to chronic anovulation and
• Follicular Cyst: Result of a non-ruptured dominant follicle. hormonal imbalance.

• Corpus Luteum Cyst: Forms when the corpus luteum fails to 7. Other Causes
regress after ovulation.
• Theca-Lutein Cyst: Associated with high gonadotropin levels, • Hydrosalpinx: Fluid-filled fallopian tube mimicking an ovarian mass.
e.g., in molar pregnancy.
• Paraovarian Cyst: Arises from remnants of the mesonephric duct,
2. Epithelial Tumors located near the ovary.

• Ovarian Hyperstimulation Syndrome (OHSS); Enlarged ovaries

with
• Derived from the
ovarian surface epithelium. multiple cysts due to fertility treatments.
• Serous Cystadenoma: Filled with
clear, watery fluid.
• Mucinous Cystadenoma: Contains thick, mucinous 9.33 Discuss ovarian dysfunction, diagnosis & management.
become very large.
material; can Ans.Causes:
• Anovulation
3. Germ Cell Tumors
• Decreased ovarian reserve
• Arise from • Luteal phase defect (LPD)
primitive germ cells of the
ovary. • Lutenized unruptured follicle
1. Anovulation - PCOS, Primary ovarian failure
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of progesterone by corpus 8. Ultra-purified FSH

2. Luteal phase defect - inadequate secretion
9. Metformin for insulin resistance
luteum.

3. Lutenized unruptured follicles- ovum is trapped inside follicle, which gets 10. Anti-diabetic drugs
11. Thyroxin
lutenized.
12. Corticosteriod
Diagnosis of Ovarian Dysfunction

1. Clinical History and Examination: 0.34 Ovarian cancer - Risk factor, Difference bt. benign & malignant
hirsutism, acne.
• Irregular cycles, infertility, hot flashes, ovarian tumors. Staging of ovarian cancer, krukenberg tumor.
(e.g., autoimmune
• Family history or past medical conditions Ans. Risk factors :
diseases). 1. Excessive estrogen :
2. Hormonal Assays:
a. Early menarche
• Follicle-stimulating hormone (FSH), luteinizing hormone (LH),
b. Late menopause
estradiol.
c. Obesity
• Anti-Müllerian Hormone (AMH) and Antral Follicle Count (AFC)
for ovarian reserve. d. Endometriosis

• Thyroid function tests and prolactin levels. 2. Exessive ovulation (Thoery of increased ovulation) :
3. Pelvic Ultrasound: a. Nulliparity
• Evaluate ovarian morphology (e.g., polycystic ovaries) and b. Infertility
presence of masses. 3. Others :
4. Other Tests:
a. Asbestosis
• Karyotyping for genetic causes in premature ovarian b. Tale
insufficiency.
c. Coffee
Treatment- d. Alcohol
1. Clomiphene citrate e. Tobacco
2. Letrozole f. Dietary fat
3. HmG (FSH + LH) 4. Genetic
:
4. HCG a. BRCA 1 mutation
5. Recombinant FSH b. BRCA 2
mutation
6. Recombinant LH
Protectivefactors:
7. GuRH
a. OCP

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IIB: To other pelvic organs: Bladder or rectum

b. Multiparty :
c. Breastfeeding stage Ill: Spread to abdomen
ЗА -
d. Hysterectomy
Benign Malignant • 3A1 : RPLND involved
(Trick - CHLTU
• 3A2: Microscopic extrapelvic involvement
Consistency Cystic Solid 3B: Macroscopic extrapelvic involvement, size of implant ≤ 2cm
History
Short history with 3C: Macroscopic extrapelvic involvement, size of implant › 2cm, extension
rapid progression to liver or spleen capsule
with weight loss Stage IV: Distant metastasis
:

Uni 4A: Malignant cells in pleural effusion

Locality
Tenderness 4B : Liver/Spleen parenchyma involved OR Inguinal lymph node involved
Pain
Prevalence In reproductive age In pre-pubertal Symptoms :
/menopausal
1. Asyptomatic
Ultrasound Unilateral, anechoic, Bilateral, solid
2. Loss of apetite
unilocular, no solid component, thick 3. Dyspepsia
component septa, papillary
4. Abdominal distension
outgrowth
5. Abdonminal pain
6. Weight loss
FIGO Classification:-
7. Respiratory distress - due to ascitis or pleural effusion
Stage I: Tumor limited to ovary : Signs : -
IA: One ovary-involved, capsule intact 1. General
examination :
IB: Two ovary-involved, capsule intact
• Pallor
IC : Capsule rupture with :
• Icterus
IC1: Intraoperative repture
• Edema leg or vulva
IC2: Pre operative repture
• Left supraclavicular LN enlarged
IC3 : Malignant cell in ascitis 2.
Stage II: Spend on pelvic organs
Abdominalex:
: a.
IIA: Spread to fallopian tube
or uterus
Hepatomegaly
b. Mass in hypogastrium which has features -
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:
2.Chemotherapy
tumor →
1. Solid 1. Epithelial cell
2. Tenderness
Grade 1 → No Chemotherapy
3. Irregular
- Dull
Other stages → Carboplatin + Pacitaxel for 6 cycle
4. Percussion 11. Germ cell tumor: BEP → Bleomycin, Etoposide, Cisplatin
Inv: III. Sex and stromal
tumor: BEP
plural effusion
1. Chest X → ray: For
WHO classification of ovarian tumors:
2. USG

3. СТ tumors:
4. MRI
1. Epithelial ovarian
a. Serous cyst Adenoma (Benign) or Carcinoma (Malignant)
5. PET
b. Mucinous cyst
c. Endometroid tumour
7. Paracentesis : For ascitis for malignant cell cytology
d. Clear cell tumour
8. Tumor marker: CA-125
e. Brenners tumours

2. GCT:
1. Surgery:
a. Dysgerminoma
a. In stage 1 or 2
b. Choriocarcinoma
1. Elderly women → TAH + BSO
Il. Young women → c. Embryonal cell tumours
d. Teratoma - Immature, Mature (Dermoid cyst)
Unilateral oophorectomy (Fertility sparing)
e. Yolk sac tumour

3. Sex cord stromal tumors :

a. Granulosa cell tumour

Completion of family
b. Sertoli cell tumor

c. Sertoli-leydig cell tumor

Hysterectomy & removal of other ovary Q.35 Ovarian hyper-stimulation syndrome
enlargement following
Ans. 1) Multiple follicle development and ovarian
b. In stage 3 & 4
Debulking surgery - It include → HCG stimulation.
TAO + BSO + complete omentcetomy + RPLND + Resection of any
2) It is iatrogenic
metastasis

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1. Young age
GENTIAL MALIGNANCY
Mx.
2. PCOS
sign' on USG Q.36 Define CIN, Risk factors &
3. Ovarian 'necklace Ans. CIN is a pre-malignant condition of the cervix, which hasn't crossed
4. Multiple pregnancy
the basement membrane.
C/E:
Risk factors: (Trick - MMS PIA SHE L*nd Mera)
Mild-
5cm 1. Multiparity
• Ovarian size ‹
2. Multiple partners
• Mild pain
Moderate-
3. smoking
• Size 8-12cm
4. Early first Pregnancy
5. Poor genital hygiene
• Ascitis on USG
(NVD) 6. Pills (OCPS)
• Nausea, Voming, Diarrohea
Severe-
7. Immunocompromised (HIV) Patients
• Size > 12 cm 8. lAge
• ARDS 9. HPV infections
• Oliguria 10 Early sexual intercourse
• Clinical ascitis 11. STI
Critical- 12. Low socio-economic status
• Size>12cm 13. Multiple partners of husband
• Tense ascitis
InV:
• Renal failure
1. Pap smear :
• Hematocrit raised
a. 2 types: conventional & liquid-based cytology
• Thromboembolic complications
b. Specific but not sensitive
c. Treatment cannot be started with tve PAP smear reports alone
Inv: CBC, LFT, RFT, ECG, Chest X-ray, TVS
d. Screening starts > 21 years and repeats every 3 years
TX: Mainly supportive
Reports are -
• Paracentesis: to relieve respiratory distress
1) ASCUS (Atypical squamous cell of unknown significance)
• Human albumin: to correct hypovolemia
2) LSIL (Low squamous intraepithelial lesion)

3) HSIL (High sgamous intraepithelial lesion)

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lesion cannot be ruled 2. Conization
4) ASC-H (Atypical squamous cell - High-grade Cryoablation-
out) CO2 / N20 at very
low temperature
treat approach by WHO"
:
2. HPV DNA testing
a. Primary screening
test for "see and
age
after ≥ 30 years
b. Recommended
Cryonecrosis
c. Sensitive test
HPV DNA +ve
HPV DNA -ve
Procedure: 2 cycles of freez 1 thaw
d.
Freeze (3min) → Thaw (Smin) → Freeze (3min) → Thaw (smin)
LEEP a. Repeat after 5-10 yrs in • Destroy cervical epithelium
TX- Ablation or
general population LEEP/ LLETZ
b. And 3-5 yrs in HIV Pateints
• OPD procedure
acetic acid • No anesthesia
3. VIA - visual examination with
with Lugol's iodine. • Current passed into wire → cut and coagulate at same time
4. VILI - visual inspection
Tx: - Q.18 Carcinoma Cervix - Risk factor, Staging, C/F, Inv & Mx.
A. Preventive: Ans. RF same as CIN

1. HPV Vaccines: C/F of Ca Cervix Inv. Of Ca cervix

a. Bivalent (Cervarix) : Type 16, 18 1. Post-coital bleeding 1. Lab test: CBC, urine, LFT,
b. Quadrivalent (Gardasil) : Type 16, 18, 6, 11 KFT

2. Dyspareunia
c. Nine valent (Gardasil 9) : Type 16, 18, 6, 11, 31, 33, 45, 52, 58 2. Radiology: X-ray, CT, MRI
2. Condom use 3. Fungating mass
3. Limit no. of sexual partners
Staging
4. Delayed sex Stage 1 - Cancer limited to cervix
B. Definitive :
IA - Microinvasive (<5mm deep) in stromal tissue
CIN 1 → No need for Tx
1A1 - < 3mm deep
CIN 2/3 → 1. Cryoablation
1A2 - ≥ 3mm but < 5mm deep
2. Excisional problem
IB - Macroinvasive (≥ 5mm deep)
3. Hysterectomy
Excisional -
IB1 - < 2 cm in greatest dimension (size of tumor)
1B2-≥2cm
1. LEEP / LLTEZ
1B3 - ≥4 cm

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Radical
stage IB1 Туре 3 Pelvic + Para-
2/3rd upper of vagina Tracheclectomy
Stage Il - Involve aortic LN
not involved
IlA - Parametrium Dissection
IIA1 - Size < 4 cm Radical
StageIB2 Туре 3 Pelvic + Para-
IIA2 - Size ≥ 4 cm Tracheclectomy
aortic LN
involved
IIB - Parametrium
1/3rd of vagina
Dissection
Stage Ill - Involve lower stage lIA1
Radical
Туре 3 Pelvic + Para-
wall not involved
IIIA - Pelvic side Tracheclectomy
IIIB - Pelvic side wall
involved/Hydroureter/ Hydrorephrosis aortic LN

Dissection
IIIC - Lymph node involved
Badical Trachelectomy:
IIIC1 - Pelvic LN
• Removal of cervix + Entire parametrium
IIICa - Para aortic LN
Stage IV - Metastasis
/ Rectum Q.37 Discuss various methods of screening of carcinoma cervix.
IVA - Regional Metastasis : Bladder
IVe - Distant metastasis or Superficial inguinal LN Ans. Cervical cancer is one of the most preventable cancers through early
detection and treatment of precancerous lesions. Screening helps identify
abnormal cervical changes before they progress to invasive cancer.
1. Surgery:
a. Cannot be done for tumor ≥ 4cm
1. Papanicolaou (Pap) Smear
b. Tx of choice in : 1A1, lA2, 1B1, 1B2, lIA1
• Description: Cytological examination of exfoliated cervical cells.
2. Radiotherapy: Types, Brachytherapy (Intracavitary) or Teletherapy • Method:
(external beam radiotherapy) • Cells are collected from the cervix using a spatula or brush and
• Done in all stages examined under a microscope.
• Preferred in late stages, from stage lIAz onwards • Can be done via conventional or liquid-based cytology (LBC).
3. Chemoradation: Cisplatin increase sensitivity to radiotheraphy • Frequency: Every 3 years for women aged 21-65 years.
Young Old LN Disease • Benefits: Detects precancerous and cancerous changes.
Stage IA1 Conization Туре 1 Not Needed
• Limitations: Requires good sample collection and interpretation; may
TAH+BSO miss some lesions.
Stage IA2 Radical Pelvic + Para-

Tracheclectomy aortic LN

Dissection

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• Advantages: Like VIA, it is simple and
(HPV) Testing cost-effective for low-resource
2. Human Papillomavirus (e.g., HPV settings.
to detect high-risk HPV types
• Description: Molecular testing
for cervical cancer.
16 and 18) responsible DNA or
• Method: Cervical cells are
tested for the presence of HPV 5. Colposcopy (Adjunct to Screening)
RNA. • Description: Magnified visual examination of the cervix
using a
• Use: colposcope.
5 years.
• Primary screening (age >30 years) every
method for women 30- • Use: Performed as a follow-up for abnormal Pap smear or VIA
• Co-testing with Pap smear (preferred findings.
65 years). • Advantages: Allows targeted biopsy of abnormal areas.
• Advantages: Higher sensitivity for detecting high-grade lesions than
• Limitations: Not used for primary screening.
the Pap smear.
• Limitations: Cannot distinguish between transient and persistent
infections.
Screening Guidelines
1. Age 21-29 Years: Pap smear every 3 years.
2. Age 30-65 Years: Pap smear every 3 years or HPV testing every 5
3. Visual Inspection with Acetic Acid (VIA)
years (preferred co-testing).
• Description: Visual examination of the cervix after application of 3-
5% acetic acid. 3. Age >65 Years: Discontinue screening if prior tests were normal and
• Method: Acetic acid causes precancerous areas to turn white no history of CIN2+ in the past 20 years...
(acetowhite areas).
Q.38 Prevention of Cancer Cervix
• Use: Common in low-resource settings as a cost-effective alternative
to cytology. Ans. Cervical cancer is preventable through screening, vaccination, and

• Advantages: Immediate results, inexpensive, no laboratory public health measures aimed at early detection and risk reduction.
infrastructure required.
• Limitations: Subjective interpretation, lower specificity compared to 1. Primary Prevention
HPV testing or Pap smear. '• HPV Vaccination:

• Protects against high-risk HPV types (e.g., HPV 16 and 18)

responsible for cervical cancer.
4. Visual Inspection with Lugol's
lodine (VILI) years,
• Recommended for both girls and boys starting at 9-14
• Description: The cervix is painted with Lugol's
iodine; abnormal areas ideally before sexual debut.
do not stain brown.
up to 26 years (or up to
• Catch-up vaccination can be offered
45 years in some cases).
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• Targets HPV 6, 11, 16, and 18.
• Safe Sexual Practices: • Prevents cervical cancer and genital warts.
reduces HPV transmission. • Approved for both males and females.
• Use of condoms
the number of sexual
partners lowers the risk.
• Limiting 3. Nonavalent Vaccine (Gardasil 9):
• Lifestyle Modifications: carcinogenesis. o Targets HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58.
• Avoid smoking, which is a co-factor in cervical • Covers approximately 90% of cervical
cancer-causing HPV types.
• Approved for both males and females.
2. Secondary Prevention
• Cervical Cancer Screening:
2. Vaccination Schedule
starting at age 21.
• Pap smear every 3 years • Primary Schedule:
+ Pap) every 5 years
• HPV testing alone or co-testing (HPV
• Two doses (6 months apart) for ages 9-14.
starting at age 30.
• Three doses (at 0, 1-2, and 6 months) for individuals 215
• Treatment of Precancerous Lesions:

• Colposcopy-guided biopsy and treatment of CIN (Cervical years or immunocompromised.

Intraepithelial Neoplasia).
3. Benefits

3. Tertiary Prevention • Reduces the incidence of cervical cancer and genital warts.
• Timely Diagnosis and Treatment of Invasive Cancer: • Provides herd immunity, lowering HPV prevalence in the population.
• Early-stage disease can be treated with surgery or radiotherapy.
• Advanced disease requires combined chemoradiation.

Q.39 Discuss various types of HPV vaccines.

Ans. HPV vaccines are effective in preventing infection by high-risk HPV
types, which cause cervical cancer, and some low-risk types causing genital
warts.

1. Types of HPV Vaccines

1. Bivalent Vaccine (Cervarix):
• Targets HPV 16 and 18 (causing 70% of cervical cancers).
• Approved for females only.
• Provides partial cross-protection against other
high-risk types
(e.g., HPV 31, 33).
2. Quadrivalent Vaccine
(Gardasil):

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CONTRACEPTION B. Hormonal Methods

0.40 Discuss about contraception options available for a post-partum lady. 1. Progestin-Only Methods:
women must consider factors like • Progestin-Only Pills (POPs):
Ans. Contraception for postpartum
Safe during breastfeeding; requires
and preferences. daily intake.
lactation, timing, medical conditions, • Injectables (e.g., Depot
Medroxyprogesterone Acetate):
Administered every 3 months, safe for
1. Factors to Consider
breastfeeding.
2. Combined Hormonal Contraceptives (CHCs):
• Includes pills, patches, and vaginal rings.
• Lactation: Hormonal methods containing estrogen may reduce breast
• Can be initiated after 6 weeks postpartum in
production, so progestin-only methods or non-hormonal
milk non-breastfeeding
women (to reduce the risk of thromboembolism).
methods are preferred during breastfeeding.
• Not recommended during lactation as it may reduce milk
• Timing: Immediate postpartum contraception (within 48 hours) or
delayed postpartum contraception (after 6 weeks). production.
• Medical Conditions: Assess for hypertension, diabetes, thromboembolic
risk, or other health concerns.
C. Barrier Methods

• Male and Female Condoms:

2. Contraceptive Options
A. Long-Acting Reversible Contraception (LARC) • Provide additional protection against sexually transmitted
infections (ST|s).
1. Intrauterine Devices (IUDs): • Can be used immediately postpartum.
• Copper IUD (non-hormonal): Effective for 10+ years, can be • Diaphragms and Cervical Caps:
inserted immediately postpartum. • Must be refitted after childbirth due to changes in cervical size.
• Levonorgestrel IUD: Effective for 3-5 years, reduces menstrual
bleeding.
• Safe for breastfeeding women. D. Permanent Methods
2. Implants:
1. Female Sterilization:
• Etonogestrel Implant: Effective for 3 years; can be inserted
or at the time of
immediately postpartum. • Tubal ligation can be performed postpartum
• Suitable for breastfeeding cesarean delivery.
and offers high efficacy.
2. Male Sterilization (Vasectomy):

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cooperation. 0.41 Describe Hormonal contraceptives, IUDs, and emergency

requiring male partner
• A permanent option contraceptives, Benefits and their S/E.
Ans.A) Oral:
E. Natural Methods
1) Combined:
• Monophasic
Method (LAM):
1. Lactational Amenorrhea • Biphasic
postpartum if:
• Effective for up to 6 months • Triphasic
breastfeeding is practiced.
• Exclusive • Emergency
• Menses have not
returned.
4 hours (day) or 6 2) Single preparation:
• Infant feeding intervals do not exceed
• POP
hours (night).
2. Fertility Awareness-Based
Methods: • Estrogen only (emergency)
be less reliable in
• Requires careful tracking of ovulation and may B) Parenteral:
postpartum women due to irregular cycles. 1) Injectables:
• DMPA

• NET-EN
F. Emergency Contraception
• Combined (once a month injection)
• Copper IUD: Can be used up to 5 days after unprotected intercourse. 2) Implants:
• Emergency Contraceptive Pills: Progestin-only pills are preferred; not
• Norplant
recommended for routine use postpartum. • LNG Rod

Conclusion • Implanon
C) Devices:
Postpartum contraception should be tailored to individual needs, • IUD → LNG-IUS
considering lactation, medical history, and personal preferences. Long-
• Vaginal ring → LNG ring
acting reversible methods, progestin-only methods, and
non-hormonal • Transcervical → Essure, Adiana
methods are ideal for breastfeeding women, while
combined hormonal
contraceptives can be introduced in non-breastfeeding women D) Patch-
after 6
weeks. • Transdermal (nestorone)

COCs benefits (Trick - Other BENEFITS)

• Other → Ovarian cysts 1

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• C - Cholestatic jaundice

• B → Benign breast
disease 1 • C - Cancer - Risk of Breast and Cervical Cancer 1
• E → Endometriosis 1
( & Endometrial
l)
• N → Neoplasia
(Ovarian Progesterone Only Pills (POP):
• E → Ectopic pregnancy i Adv:
• F → Fibroids & 1) S/E attributed to estrogen in COC is eliminated
&
• 1 → Iron deficiency anemia 2) Easy to take
syndrome) v
• T → Tension (Pre-mentrual 2) Can be prescribed in patients having HTN, fibroid,
(Osteoporosis) v diabetes, epilepsy
• S → Skeletal problem 3) Safe during lactation
• Regulation of menstrual cycle
Injectables Progestins:
• Dysmennorhea /
Advantage -
• Menorrhagia /
• No need for regular medications
• Convenient
• Safe during lactation
• Do not interfere intercourse
• Decrease dysmenorrhea, menorrhagia

Side effects of COCS: (Trick - NORMAL - ABC - 4C)

Disadvantage-

Mild S/E: • loss of mineral bone density (reversible)

• N - Nausea • Depression
• O - Odema • Weight gain
• R - Recurrent headache • Headache

• M - Mastalgia
• A - Abnormal bleeding Emergency contraception:
• L - Loss of breakthrough bleeding 1) COC : Ethyl Estradiol + Norgesterol : 2 stat + 2 after 12 hrs
Moderate S/E:
2) POP : 150 mg LNG
• A - Acne
3) Mifepristone RU 486 :100mg
• В - (Bulky) Weight gain
4) Ulipristal (SPRM) : 30mg PO within 5 days
• C - Chloasma
5) Copper IUDs (gold-standard) : insertion within 5 days
Severe S/E:

• C - CNS - Depressionblood pressure elevation

• C - CVS - Thromboembolism
Q.42 Describe Copper-T, What are the indication and Contraindications for
Copper-T insertion.

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3) Genital tract bleeding
is CuT 380
• Most common used 4) Pregnency
• T-shaped
5) Neoplasia
• Delivery Cu at 50 ug/day
6) STI
• 2nd generation
IUCD
7) For CuT : Wilson disease, Copper allergy
MOA :
Release Cu
Q.43 Copper-T 375 A

Ans. Copper-T 375 A is a long-acting, reversible, non-hormonal

Inflammatory reaction
intrauterine device (IUD) used for contraception.

Release of prostaglandins • Duration: Effective for up to 5 years.

• Mechanism: Releases copper ions that inhibit sperm motility and

Spermicidal action fertilization; also prevent implantation.

• Insertion: Can be inserted postpartum (immediate or within 48
Fertilisation not occur hours) or post-abortion.
• Effectiveness: >99% when used correctly.
• Advantages:
Types :
• CuT 380
• Safe during breastfeeding.

• Multilode 375 • No impact on hormones.

• Cost-effective and reversible.
• Сит 300
• Disadvantages:
Advantage :
• May cause heavier or painful periods initially.
1) Long term contraception
• Risk of expulsion or pelvic infection (rare).
2) Inexpensive

3) Highly effective Follow-Up: Regular check-ups are recommended to ensure proper

4) Safe during breast feeding placement.
5) Immediate reversibility
6) No systemic S/E

Ans. Definition: LNG-IUCD is a long-acting, reversible, hormona

Contraindications :

1) Pelvic infection
intrauterine device that releases levonorgestrel.
2) Severe dysmenorrhea
mg (Mirena) and LNG 19.5 mg
(Kyleena).
• Types: Available as LNG 52
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Q.46 Permanent Methods of Contraception

years, depending on the device.
• Duration: Effective for 3-5 Ans. 1. Tubal Ligation (Female Sterilization):
• Mechanism:

• Thickens cervical mucus,

inhibiting sperm penetration.
• Procedure: Surgical blocking or cutting of the fallopian tubes to
preventing implantation.
• Reduces endometrial receptivity, prevent egg and sperm meeting.
• Advantages:
• Advantages: Highly effective, permanent, and does not affect
• Highly effective (>9976). hormonal balance.
• Reduces menstrual bleeding and dysmenorrhea.
• Disadvantages: Surgical risks, irreversible, may be associated
• Safe for breastfeeding women.
with regret if decision is not well-considered.
• Disadvantages:
• Irregular bleeding or spotting initially. 2. Vasectomy (Male Sterilization):
• Rare side effects: headaches, mood changes, or ovarian cysts.
Procedure: Surgical cutting or sealing of the vas deferens to
Follow-Up: Periodic checks for proper placement.
prevent sperm from entering semen.
• Advantages: Quick, minimally invasive, highly effective,
and
Q.45 Complications of IUCD (Intrauterine Contraceptive Device)
Ans. permanent.
• Disadvantages: Irreversible, potential for
regret, and rare risk of
1. Expulsion: Partial or complete expulsion, especially in the first year. post-surgery complications (e.g., infection).
2. Pelvic Inflammatory Disease (PID): Risk in the first 20 days post-
insertion. Considerations:

3. Perforation: Rare, but the IUCD may perforate the uterine wall be considered by individuals
during insertion. • Permanent contraception should only
want children in the future.
who are sure they do not
4. Ectopic Pregnancy: Increased risk if pregnancy occurs with IUCD in is essential for counseling
provider
place. • Consultation with a healthcare
about the risks, benefits, and alternatives.
5. Menstrual Changes:
• Copper IUCD: Heavy or prolonged periods, dysmenorrhea.
• LNG-IUCD: Irregular spotting or amenorrhea.
6. Pain and Cramping: Especially after insertion.
7. Lost Strings: Strings may retract into the cervical canal.
8. Embedment: IUCD becomes embedded in the
uterine wall, requiring
removal.

9. Allergic Reactions: Rarely, to copper

or other materials.

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Management:

MISCELLANEOUS 1. Benign Causes:

bleeding ? How will you • Endometrial Atrophy: Vaginal estrogen or HRT.

Q.47 What are the causes of post menopausal
old women with post menopausal • Polyps/Fibroids: Surgical removal (hysteroscopy or
investigate and manage a 60 year myomectomy).
bleeding.
• Vaginal Atrophy: Topical estrogen.
Ans. Causes of Post-Menopausal Bleeding (PMB)
2. Malignant Causes:
• Endometrial Cancer: Hysterectomy and adjuvant therapy
1. Benign Causes:
• Endometrial Atrophy (radiation/chemotherapy).
• Endometrial Polyps • Cervical/ Ovarian Cancer: Surgical treatment and

• Fibroids chemotherapy/radiation.
• Vaginal Atrophy 3. Follow-up: Regular follow-up to monitor treatment response and
(HRT)
• Hormone Replacement Therapy recurrence.

2. Malignant Causes:
Q.48 Social Obstetrics
• Endometrial Cancer
• Cervical Cancer
Social obstetrics focuses on the social, economic, and cultural factors
• Ovarian Cancer
affecting maternal and child health. It emphasizes addressing disparities in
Investigation of a 60-Year-Old Woman with PMB: access to healthcare, promoting health education, and improving outcomes
for women and children, particularly in underserved communities.
1. History and Physical Examination: Assess bleeding pattern and risk
Contribution as a Medical Doctor:

2. Ultrasonography (Transvaginal): Check endometrial thickness (normal

1. Health Education: Educate patients about family planning,
prenatal
<4-5 mm).

3. Endometrial Biopsy: If ultrasound shows thickened endometrium, to care, and healthy lifestyles.
rule out endometrial cancer. 2. Advocacy: Advocate for policies and programs that address health
4. Pap Smear and Blood Tests: For cervical cancer and anemia, plus CA- inequalities and improve maternal care.
125 if ovarian cancer suspected. 3. Community Engagement: Participate in community health
initiatives
and support accessible healthcare
services.
4. Cultural Sensitivity: Provide care that is culturally appropriate and
sensitive to diverse backgrounds.

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5. Collaboration: Work with public health

organizations and government
health in the community.
bodies to improve maternal and child
in Gynacology
Q.49 Advantages & Disadvantages of Endoscopic surgeries
Ans. Advantages of Endoscopic Surgeries in
Gynecology:

1. Minimally Invasive: Smaller incisions

lead to less trauma, reduced
scarring, and faster recovery.
2. Shorter Hospital Stay: Patients typically require a shorter hospital
stay and may be discharged the same day.
3. Reduced Pain: Less postoperative pain compared to traditional
surgeries.
4. Faster Recovery: Faster return to normal activities due to quicker
healing times.
5. Better Visualization: Provides high-definition, magnified views of the
pelvic organs, improving precision.

Disadvantages of Endoscopic Surgeries in Gynecology:

1. Technical Expertise Required: Requires specialized training and

experience for the surgeon.
2. Limited Access: May not be suitable for all cases, particularly in
complicated or advanced conditions.
3. Risk of Injury: Potential risk of damage to surrounding organs due to
limited space and visibility.
4. Cost: Equipment and instruments can be expensive, increasing the
overall cost of surgery.
5. Complications: Risk of bleeding, infection, or injury to organs like
the
bladder or bowel.

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