LIST OF CLINICAL TASKS

1
A 45-year-old woman who gave birth for the second time was admitted in the term of 39-40
weeks of pregnancy with active labour: contractions in 4-5 minutes for 30-35 seconds.
Anamnesis: childhood infections, flu, chronic gastritis, bronchitis. Estimated fetal weight -
3800g. The cervix on the Bishop's scale – 7 point, rhythmic heartbeat of the fetus, 140 beats
/ min, clear. At vaginal research: opening of a neck of uterus of 4 cm, the head fills a
terminal line, a sagittal suture in the left oblique size, a small fontanel right at the sacrum.
The amniotic sac is intact. After 5 hours of active labour, pushing the uterus appeared in 1-2
minutes for 50-55 sec. Pure amniotic fluid departed.
Second period of delivery lasts 1.5 hours. The woman is tired. Pushing the uterus are
weakened, last 3-4 minutes for 40-45 sec. The fetal heartbeat is rhythmic, 90 beats / min,
deaf. Head on the pelvic floor, sagittal suture coincides with direct size of the small pelvis. A
small fontanel near the sacrum.

Tasks:
1. Diagnose, what pathology occurred in the fetus and woman. Weakened contraction in
2nd part of 2nd period
2. Determine the position and type of position of the fetus. Longitudinal lie, 2nd position;
posterior with occiput presentation of head
3. What are the tactics of childbirth? Use of forceps or vacuum extraction
4. What are the causes of this pathology? Older age of mother, position of fetus, prolonged
labour
5. What complications can occur during childbirth? Trauma of vagina, death of fetus,
rapture of uterus, cephalohematoma, infection, hemorrhage

2
The 26-year-old woman para 1(39 weeks), with a history, is in the delivery room. Delivery -
through the maternal passages. The first 2 periods of childbirth proceeded normally. 30
minutes ago a healthy boy was born - 3450g, 52cm. Management of the third period of the
delivery was active. Regarding the placental defect, a manual revision of the uterine cavity
was performed. During the
operation, significant bleeding began, which continued after the separation of parts of the
placenta.
The pregnancy without complications. During pregnancy, the last hemoglobin is 103 g / l at
36 weeks. She has told about 2 artificial abortions previously.
Objectively: The woman is conscious, but drowsy and pale. Pulse - 108 / min, blood pressure
- 80/45 mm Hg, RR - 42 / min, SaO2 - 94.
The abdomen is soft, painless. The uterus periodically relaxes. Visually, injuries and ruptures
of the perineum are absent. At the time of examination, the blood flowing from the uterus
does not clot.
Laboratory:
Actual pointer Reference pointer
 Hemoglobin 72 g / l 110-140 g / l

Erythrocytes 2,4×109/l 3,5-5,5×109/l

Leukocytes 11,0 х 109 /l 4,5-12,0 х 109 /l

Platelets 130 х 109 /l 180-320 х 109 /l

D-dimer 750 ng/ml 250-500 ng/ml

APTT 58 s 25,9-38,2 s

Fibrinogen 1,2 g / l 2-4 g / l

Blood group О (1)

Rhesus factor Rh (+) positive

Questions:
1. What is the approximate blood loss?

If asked to define:
Difference of peri-operative (around operation; from admission to discharge) hemoglobin x
estimated blood volume.
Estimated blood volume in women = 70ml * kg of b.w
Estimated blood vol in pregnant ‘Caucasian’ women with a child about 3.3kg = 103.6*kg of
b.w.

If asked to calculate:
Percent of blood volume lost = (Predelivery HCT-postdelivery HCT)/predelivery HCT
HCT = (RBCxMCV)/10 or approx.Hemoglobin x 3

Pre delivery (36weeks): 103 x 3 = 309

Post delivery: 72 x 3 = 216

Percent of blood volume lost = (309-216)/216 = Approx 43%

Calculated estimated blood loss (cEBL) = calculated blood vol * percent blood loss

2. Evaluation of laboratory parameters. Anemia, moderate degree, thrombocytopenia, APTT

(increased), D-dimer (increased), Fibrinogen (decreased)
3. Diagnosis DIC syndrome, Early postnatal hemorrhage due to hypotonia, Hemorrhagic
shock III stage?

4. Tactics, management.
Urotonics: Oxytocin 2ml IV
Infusion therapy with Crystalloids and colloids solution 1:1 ratio
Blood components with O+ blood
Hemostatic drugs: Tranxemic acid IV (1g) 4g/hr
Anti-thrombin III
Uterine massage
then (if not effective)
Aortic compression (2-4cm left from umbilicus)
if still not effective
Prepare operation theatre: Evaluate possibility of hysterectomy (surgery in Trendalenburg
position – supine with head declined below feet at roughly 16 degrees angle)

3
The pregnant woman 25 years old, primiparous, 31-32 weeks, was admitted
with complaints of cramping pains in the lower part of abdomen and on her back,
which occurs every 5 minutes and lasts up to 20 seconds. Bleeding or discharge of amniotic
fluid is NOT noted. Associates her complaints with physical overload. The course of
pregnancy was physiological till this time. The woman has no chronic diseases, somatically
healthy. BP 110/70 mm Hg, pulse 70 beats / min, body temperature 36.4 ° C. The uterus is
enlarged according to the gestational age, periodically tones up. The fetus has longitudinal
position, 1st position, anterior type of presentation, cephalic presentation, head above the
entrance to the small pelvis. The fetal heartbeat is clear, rhythmic, 136 beats / min. NBT 2
points, STV 9.2, biophysical profile 8 points according to Manning. During
vaginal examination: the cervix is centred, shortened to 1 cm, the cervical canal is open
to 2.5 cm, the fetal bladder is intact.

Results of additional examinations

Indicator Actual Reference
Indicator Indicator

Hemoglobin 106 g/l 110-140 g/l

Erythrocytes 3.0 х 1012/l 3,5-5,5х1012/l

Leukocytes 8,0х109/l 4,5-11,0х109/l

 Platelets 196х109/l 180-320х109/l

Protein in the urine absent absent

PSA ≤6 mg/l ≤6 mg/l

Questions:
1. Establish a diagnosis. Premature labour/Preterm delivery

2. Give an interpretation of the results. Anemia mild, Satisfactory fetal condition

3. Choose tactics for the pregnant woman. Admit woman to prenatal centre, bedrest

4. Prescribe treatment and determine its duration. Prescribe tocolytics drugs (e.g
Nifedipine – calcium channel blocker) within 48 hours to stop labour plus corticosteroid (eg.
Dexamethasone i.m 6mg/6hr; max dose 24mg) to mature lungs and prevent fetal
respiratory distress syndrome.

5. Name the side effects of drugs. Dexamethasone -> peptic ulcer, acute pancreatitis,
temporary suppression of adrenal function, infection, decreased carbohydrate tolerance,
hypertension, increase insulin production in newborn.
Nifedipine -> tachycardia, palpitations, flushing, headaches, dizziness, nausea, muscle
cramps, cough, dyspnea

4
A 42-year-old pregnant woman, with the term of pregnancy 8-9 weeks addressed to the
antenatal clinic about its management on further. Complains of headache, recurrent chest
pain, heart rhythm disturbances, swelling in the legs and arms, which does not disappear
after a night's sleep, dyspnea after minimal physical activity. From anamnesis: third
pregnancy, the first ended in urgent labour at 25 weeks, the second - premature birth at 30
weeks because of severe preeclampsia at 33 years, the child died on the third day after
birth. Suffering from arterial hypertension from the age of 30, which is poorly treated with
antihypertensive drugs, she has frequent hypertensive crises, an increase of blood pressure
about 180/110 mm Hg and above, rhythm disturbances (atrial fibrillation), coronary
heart disease. She had a micro stroke after hypertensive crisis 3 years ago. Applies Exforge
N, valsartan, carvedilol - periodically, clopidogrel, preductal, cordarone. She is an invalid of
the second group.
Examination revealed: BP 170/115 mm Hg, pulse 70-94 beats / min, arrhythmic, body
temperature 36.4C. Body mass index (BMI) 31 kg / m2. Edema is present in the legs and
anterior abdominal wall. The borders of the heart are expanded to the left, the accent of
the 2nd tone is above the aorta. During palpation - the abdomen is soft, painless, the edge
of the liver protrudes 3 cm below the right costal arch.
Vaginal examination: the mucous of the vagina and cervix is cyanotic, without changes. The
body of the uterus is enlarged up to 8-9 weeks of pregnancy, in normotonus. The uterine
appendages are not palpable.
Additional methods.
Ultrasound - uterine pregnancy 8-9 weeks. KTR of the fetus - 10 mm. Heartbeats are
present.
Indicator Actual Indicator Reference Indicator

Hemoglobin 126 g/l 110-140 g/l

Erythrocytes 3.9 х 1012/l 3,5-5,5х1012/l

Leukocytes 8,0х109/l 4,5-11,0х109/l

Platelets 196х109/lл 180-320х109/l

Total protein 70 g/l 60-80 g/l

Sodium 140 мМ/l 136-145 мМ/l

Potassium 4,5 мМ/l 3,5-5,0 мМ/l

Urea 8,9 мМ/l 2,5-8,3 мМ/l

Creatinine 180 мкМ/l 53-106 мкМ/l

Alanine aminotransferase 64 Units less 40 Units

Protein in the urine 3,3 g/l absent

Task:
1. Establish a diagnosis. Chronic hypertension IIIrd stage, obesity grade I
2. Assign additional medical methods of examination. ECG, Biochemical blood test; USG of
heart, abdominal cavity, kidney; Echocardiogram.
3. Determine obstetric management. Terminate pregnancy.
Less than 12 weeks gestation and contraindications to carrying pregnancy is present (mini
stroke, IIIrd stage of hypertension, organ damage – arterial fibrillation, severe arrhythmic
tachysystolic form)
4. Give recommendations after pregnancy (further
management, contraception). Consultation of physician and Cardiologists

5
A 27-year-old primary pregnant woman consulted in the antenatal clinic for registration. She
has no complaints. According to the date of the last menstrual, the gestation term is 11-12
weeks. She had no chronic diseases before pregnancy. Objective examination: without
pathological changes. During the 1st screening, in the gestation period 11 weeks and 6 days,
a low risk for genetic pathology was detected. The following results of additional
examinations are:
RW - negative
Antibodies to HIV - negative
HBsAg - negative
Blood group A (II) Rh +
Oncocytology of the cervix - II type
ECG - variant of the norm
Bacteriological examination of urine: detected E. coli haemoliticа 106 CFU / ml
Sensitive to: ampicillin, amoxicillin, gentamicin, vancomycin, cefixime, ceftriaxone,
nitrofurantoin, chloramphenicol, phosphomycin, josamycin
Insensitive to doxycycline, lincomycin, azithromycin.
Indicator Actual indicator Reference indicator

Hemoglobin 126 g/l 110-140 g/l

Erythrocytes 4.1 х 1012/l 3,5-5,5х1012/l

Leukocytes 8,0х109/l 4,5-11,0х109/l

Platelets 196х109/l 180-320х109/l

Blood glucose 4,3 mM/l 3,33-5,55 mM/l

Erythrocytes in urine 0-1 in sight 0-1 in sight

Leukocytes in urine 2-3 in sight До 6 in sight

Protein in the urine absent absent

Bacteria in the urine +++ absent

Task:
1. Establish a diagnosis. Acute urinary tract infection in 11 weeks pregnancy (asymptomatic)
2. Give an interpretation of the results. Bacteriuria
3. Prescribe a treatment. Amoxicillin (250mg 3t/d) or Nitrofuran (50mg 4t/d) for 7 days
then repeat urine analysis after.
4. Determine what complications are associated with the detected pathology.
• Miscarriage/ spontaneous Abortion
• Preterm infants
• Low birth weight
 • Premature rupture of membrane
• Sepsis
• Post-partum purulent
• Chronic pyelonephritis, cystitis, urethritis

5. Name the side effects of drugs that will be used for therapy.
Amoxicillin: increased resistance of the drug, dizziness, convulsion, diarrhea, vomiting,
nausea, flatulence, antibiotic associative colitis, intestinal candidiasis, red colour of tongue,
interstitial nephritis

6
A 23-year-old woman consulted a gynaecologist with complaints of aching lower abdominal
pain and the appearance of "smearing" bloody discharge. Considers herself pregnant. Last
menstruation 7 weeks ago, a home pregnancy test (urine) is positive. Obstetric history is
burdened by miscarriage at 7 weeks, two
years ago. The cause of the miscarriage has not been established (in words). Professional
activities involve working in the evening and at night. Observed by a family doctor for
cholecystitis. Menstruation is not regular since the menarche period. Frequent delays of
menstruation up to 10-12 days. Smokes for 3 years, up to 6 cigarettes a day. After a positive
pregnancy test, quit smoking (in words). Height -170 cm, weight -76 kg .
Research results: HCG of blood - 96130 mIU / ml (reference indicators 32065.0- 149571.0
mIU / ml); blood progesterone - 25.5 ng / ml (reference values 11.0-44.3 ng / ml).
Examination revealed that the uterus was cyanotic, the uterine cervix was closed, and there
was a dark brown bloody discharge in the vagina, in small quantities. The uterus is enlarged
to 7-8 weeks, reactive on palpation, painless. Ovaries and tubes are not palpable. The
vaginal vaults are free.
Ultrasound - uterine pregnancy, 6-7 weeks. Heartbeat+, at the lower pole of the fertilized
egg is determined by the formation of the size of 0.5 * 1.0 * 1.5 cm (retrochorial
hematoma). Left ovary, slightly enlarged (4.0 * 5.0 * 3.5 cm). Free fluid in the pelvic cavity is
not determined.

Tasks:
1. Formulate a clinical diagnosis.
2. Make a plan to examine the pregnant woman.
3. Write a letter of appointment.
4. Determine further antenatal tactics of the patient.

1.DX. Threatened Miscarriage?

2. investigations
▪ Pelvic ultrasound (transvaginal sonography)
▪ Echographic signs
▪ Human chorionic Gonadotropin levels (1 time in 7 days before appearance of
symptoms)
▪ Progesterone (1 time in 7 days before disappearance of symptoms)
▪ CBC
▪ General urinalysis
 ▪ Coagulogram
▪ Blood group, Rhesus
3. Hospitalisation of patients in hospital for prenatal screening of the 1st and 2nd trimester of
pregnancy
4.Further antenatal tactics
▪ Follow up hcG in 48 hour
▪ Tranexamic acid 100mg p.o every 6 hours (antifibrinolytics drugs) for 3 days
▪ Use of progestogens drugs e.g. Dydrogesterone: 4 tabs 40mg oral, 1 tab 10mg every
8 hours (effective for threatened abortion, but can induce hypertension, antepartum
hemorrhages , increased risk of congenital abnormalities of newborns)
▪ Folic acid: 400 microgram once/day

7
A 23-year-old pregnant woman was taken to the emergency room by ambulance with
complaints of sudden bloody discharge from the genital tract. Second pregnancy, 34-35
weeks. The first birth - without complications, a boy weighing 3620 g was born.
History: Pregnancy without features. Received folic acid in the first trimester of pregnancy.
During pregnancy, the last hemoglobin is 114 g / l at 28 weeks.
Objective: The woman is conscious, pale, adynamic. Pulse - 88 / min, blood pressure - 85/50
mm Hg, BH - 30 / min, SaO2 - 96. Fetal heartbeat is muted - up to 60 / min.
The abdomen is soft, painless. There is no labour. There are bloody discharge from the
vagina with convolutions up to 350 ml. After 10 minutes, the bleeding intensified and
reached 500 ml.
Laboratory signs:
Actual pointer Reference pointer

Hemoglobin 82 g / l 110-140 g / l

Erythrocytes 3,2×109/l 3,5-5,5×109/l

Leukocytes 10,0 х 109 /l 4,5-12,0 х 109 /l

Platelets 230 х 109 /l 180-320 х 109 /l

D-dimer 250 ng/ml 250-500 ng/ml

APTT 29,8 s 25,9-38,2 s

Fibrinogen 2,2 g / l 2-4 g / l

 Blood group А (2)

Rhesus factor Rh (+) positive

Questions:
1. What is the approximate blood loss?
2. Put the diagnosis.
3. Evaluation of laboratory parameters.
4. Management
5. Pharmacological therapy with dose.

8
34 years old woman is in the delivery room, III pregnancy 39-40 weeks. The first birth -
without complications, a boy weighing 3300 g was born. The second pregnancy ended in a
miscarriage at 10-11 weeks, complicated by acute endometritis.
Delivery - through the maternal passages. The first 2 periods of delivery proceeded
normally. 10 minutes after the birth of the child there was a cramping pain and bloody
discharge from the vagina.
Pregnancy without features. The woman has been folic acid in the first trimester of
pregnancy. During pregnancy, the last hemoglobin is 107 g / l at 36 gestational weeks.
Objective condition: The woman is conscious, pale, adynamic. Pulse - 88 / min, blood
pressure - 90/55 mm Hg, RR - 30 / min, SaO2 - 97.
The abdomen is soft, painless. Signs of separation of manure from the uterine wall are
negative. When the edge of the palm is pressed over the womb, the umbilical cord is
retracted. The bleeding has increased and reached 500 ml.
Laboratory signs:
Actual pointer Reference pointer

Hemoglobin 82 g / l 110-140 g / l

Erythrocytes 2,4×109/l 3,5-5,5×109/l

Leukocytes 11,0 х 109 /l 4,5-12,0 х 109 /l

Platelets 230 х 109 /l 180-320 х 109 /l

D-dimer 250 ng/ml 250-500 ng/ml

APTT 29,8 s 25,9-38,2 s

 Fibrinogen 2,2 g / l 2-4 g / l

Blood group А (2)

Rhesus factor Rh (+) positive

Questions:
1. What is the approximate blood loss?
2. Put the diagnosis.
3. Evaluation of laboratory parameters.
4. Management
5. Pharmacological therapy with dose

9
The 36-year-old pregnant woman was taken to an ambulance due to bloody discharge while
resting at home. It is her fifth pregnancy, 32 weeks of gestation. Four previous deliveries
passed without complications, the youngest child was 2.5 years old.
The pregnant woman was examined in the department. The general condition
is satisfactory. Pulse 88 beats / min., Blood pressure 130/70, 122/70 mm. Consciousness is
clear, answers on the questions adequately. The uterus in normotonus. The position of the
fetus is oblique, the head is at the bottom, closer to the left side (?). The fetal heartbeat is
rhythmic 150 beats / min., The fetus feels good during it’s movements. Hygienic pad for 3
drops soaked less than half.

Question.
1. Make a preliminary diagnosis.
2.What groups of women are at risk of placenta previa?
3. What additional actions should be taken by the doctor on duty to confirm the diagnosis
and reduce perinatal and maternal risks?
4. What are the further obstetric tactics after confirmation of the diagnosis?

10
A 38-year-old woman has a fifth pregnancy (4 living children). In the anamnesis: at 32 weeks
she suffered from SARS, after which the pregnancy was complicated by chronic
polyhydramnion, unstable position of the fetus. The dimensions of pelvis are 25 cm. - 28 cm.
- 31 cm., external conjugate - 21 cm. Woman's height is 165 cm, weight - 74 kg, abdomen
circumference 112 cm, height of the uterine fundus 44 cm. At 40 weeks of pregnancy at
home left clean amniotic fluid in the amount about 2.5 liters, contractions began in 3-4
minutes, 45 seconds each contraction. She was taken to the maternity hospital by
ambulance. Leopold's techniques determine the transverse position of the fetus, the back
is turned forward, the head is on the left. Fetal heartbeat - 100 beats / min,
muffled, rhythmic. Vaginal examination: opening of the cervix - 6 cm. The amniotic sac
is absent. In the vagina there is a hand of the fetus.

Tasks
1. Make a diagnosis. Ist stage of delivery, active phase. Pre-term rapture of amniotic sac,
polyhydramnios
Transverse lie of fetus --> Malposition, macrosomia, fetal distress.
2. Name the possible causes of this pathology in woman. Flu or SARS infection, causes →
polyhydroaminos due to 5th pregnancy, flaccid abdominal wall, macrosomia.
3. Determine the estimated weight of the fetus. Abdominal circumference times height of
uterus fundus
112 x 44 = 4928 (4.9kg)
4. Name the position, type of position, and the anterior part of the fetus. Transverse
position of fetus, Back forearm anterior position type.
First position, presentation is not mentioned.
5. Determine the managment. Urgent C-section (fetal distress, transverse lie, early
discharge of amniotic fluid. Pull out back arms,) Complication: Rupture of uterus
11
A 30-year-old pregnant woman came to the obstetrician-gynecologist for a routine
examination with complaints of edema of the extremities, nasal congestion and rapid
fatigue. It is the third pregnancy, 36 weeks.
The first pregnancy ended with premature birth at 34 weeks, the child is alive, 4 years old.
Next 2 pregnancies - miscarriage at 7 weeks, complicated by subfebrile temperature within
a week (2 years ago).
In the childhood - Botkin desease and frequent cystitis.
On physical examination: height 168 cm, weight 84 kg. The woman feels the fetus goodly,
but the "test of fetal movements" does not perform. Pulse of pregnant woman - 90 beats /
min., Blood pressure 160/100, 150/90 mm Hg. Abdominal circumference - 97 cm, standing
of the fundus of the uterus - 31 cm. Edemas of the low extremities. Lady notes that he has
not been able to remove the ring for the last 3 weeks. Fetal heartbeats - 170 beats / min.,
rhythmic. Woman did not have time to pass urine analisis, but the last analisis was 3 weeks
ago. There is signs of protein. Specific weight 1022, leukocytes 10-12 in the field of
view, erythrocytes 1-2 in the field of view. At the end of the examination, the
pregnant woman complained of nausea. Blood pressure: 170/110, 160/100 mm Hg, pulse
96 beats / min.

Question.
1. Formulate a complete clinical diagnosis. Severe pre-eclampsia, delayed fetal
development
Obstetric anamnesis: → complicated by miscarriage at 7 weeks, premature birth 34 weeks 4
years ago
Somatic anamnesis → Botkins disease, chronic cystitis
2. Write the algorithm of the doctor's action at the reception. Call for help,
anaesthesiologist. Head of hospital lab assistance, inform the administration
Formadipine 3 drops under the tongue 2-3 mins and measure BP and pulse.
Urapidil 2ml 10mg IV slowly after 2min measure BP
MgSO4 25% 16ml per 34ml of Saline IV slowly over 15 mins
BP control every 2 mins, target reduction of BP over 25% maximum. Not less than 150/100
3. What additional examinations need to be done? CBC, Hematocrit, clotting time,
platelets, general biochemical analysis, coagulogram, urinalysis
4. What are the further tactics of this pregnancy? Depends on effectiveness of treatment of
preeclampsia, condition of fetus and readiness of birth canal.
Pregnant woman should prepare for delivery.

12
A 19-year-old first-born with a body weight of 54.5 kg at 38 weeks of gestation after a
normal vaginal birth gave birth to a full-term live girl. The child's weight was 2180.0 g, body
length - 48 cm. From history it is known that the woman smoked cigarettes for the past 8
years and continued to smoke during pregnancy. This pregnancy was complicated by
moderate vomiting of pregnancy from 9 to 12 weeks of pregnancy, edema of pregnancy
from 32 to 38 weeks.
Tasks:
1.What deviation from the norm is found in this case in the newborn? Fetal development
delay: fetal weight – less than norm according to term of gestation
2. What is the most likely cause of low birth weight? Placental dysfunction because of
smoking during pregnancy and moderate vomiting
3. What are the types of this pathology by classification? Symmetrical type of fetal
development and asymmetrical type with degree 1,2,3
In this case → Asymmetrical type because body weight less than norm but body length
normal
4. What diagnostic methods can be used for timely diagnosis of this pathology during
pregnancy? Measuring circumference of abdomen and height of uterus and weight of
pregnant woman in dynamic
USG -> bi-parietal dimension of fetal head, circumference of abdomen of fetus length of
femoral bone and relation between this parameters and Bio-physical profile of fetus to
determine fetal condition
Doplometry of vessels of umbilical artery, medial-cerebral artery to detect signs of fetal
distress
5. Is the prognosis favourable for a child with this pathology. Asymmetrical type of fetal
development indicates more better prognosis because main organ develop properly.

13
The child from the first pregnancy was born in a term birth and has a body weight of 4000 g
and a body length of 57 cm. Born, the child did not respond to the examination. It is not
possible to assess the child's condition definitively. Heart rate - 80 / min.

Questions:
1. What diagnosis can be made? Asphyxia of newborn and severe degree. Because we see
only present heart rate other parameters absent.
2. What could be the cause of this condition of the child? Fetal distress, trauma, narcotics,
obstruction of airways, aspiration of amniotic fluid
3. What diagnostic criteria are used to establish this diagnosis?
APGAR SCORE:
includes 5 signs →
1)Colour
2)Pulse
3)Reflexes
4)Activity
5)Respiration

Total 10pts (0-3pts severe asphyxia; 4-7 moderate asphyxia; 8-10 satisfactory condition)
4. What resuscitation measures should be taken? Resuscitation; use A, B, C
AIRWAY patency. Suction of mucous from nose and mouth
Ventilation with mask or Ambu bag
Heart massage: introduction of Adrenaline in the umbilical vein
5. What can determine the difference in the measures taken during resuscitation? Presence
of Muconium or amniotic fluid in nasal or oral passage: suction is performed and intubation
is done.
14
Pregnant 30 years, Term of pregnancy 32 weeks. Hospitalized due to the threat of
premature birth, rhesus factor immunological disorders from 28 weeks. This pregnancy is
the second. The first pregnancy ended in a medical abortion within 10 weeks. A pregnant
woman was administered 300 μg of anti-Rho (D) immunoglobulin intramuscularly at 28
weeks. In the previous analysis, the titer of rhesus antibodies in the blood was 1:16. After 2
weeks, there was an increase in
antibody titer to the level of 1:64. There are ultrasound signs of hemolytic disease of the
fetus.

Tasks:
1. Determine further management of pregnancy. Justify. Indications of preterm delivery in
32 weeks due to increase of Rh antibody titer to 1:64 and signs of hemolytic disease.
2. What diagnostic methods are used for this pathology during pregnancy? Ultrasound,
Cardiotocography
Dopplometry to determine uterine placental blood flow.
Determine hormones of feto-placental components
Increased placental lactogen and decreased estrogen which indicates suffering of fetus.
In blood proteins of mother – decreased albumin, gamma-globulin, increased Beta-globulin

Invasive methods – abdominal amniocentesis, Check –

Density -
Protein |
Bilirubin | Increased
Glucose |
Creatinine –

Choricentasis – blood from umbilical cord

Rh conflict
3. Name the features of childbirth. The cervix and uterus is not ready for delivery: C-section
4. Name the features of the neonatal period. After delivery we clamp the umbilical cord and
cut.
Take blood from umbilicus to confirm Rh incompatibility + blood group.
Check Hb in newborn & bilirubin to determine severity of Hemolytic disease. Control
bilirubin level every hour (If bilirubin continues to stay high then indication for
hemotransfusion)
Feeding of newborn by breastmilk only after biochemical stabilization.
5. What is the prevention of this condition (specific)? Anti-rh Ig I.M 300mcg once after
delivery within 72hrs/600mcg after c-section
After abortion/miscarriage within 48hrs 150mcg (before 12 weeks), 300mcg (between 12
and 28 weeks)

15
The 27-year-old woman was admitted to the maternal hospital with complaints of regular
cramping pain in the lower abdomen and lower back.
 It is a second delivery. The pregnancy was without complications. The contractions started
2 hours ago. Amniotic fluid did not spill out.
According to the exchange card, the expected date of the delivery in 6 days. Height - 165
cm. Weight - 75 kg. Pulse 78 beats per minute. Blood pressure - 130/80 mm. External
obstetric examination revealed that the position of the fetus is physiological, the back is to
the left, above the entrance to the pelvis is palpated round, dense anterior part of the fetus.
The presenting part is relative to the symphysis at the level of 4/5. Contractions for 30
seconds in 4-5 minutes, regular. Fetal heartbeats - 142 beats / min., rhythmic, below the
navel, it is better heard laterally, to the left of the white line of the abdomen.
At vaginal examination the cervix is centred, shortened to 0,5 cm, soft, edges are thin. The
cervix is opened to 4 cm. The amniotic sac is determined. The head which is at level -4 is
presented. There are mucous secretions. Sacrum is not reached; exostoses are not
detected.

1. Formulate a complete clinical diagnosis. Position of child is longitudinal (physiological);

third position left back. The head of the fetus is presenting to the entrance of small pelvis.
The head is above the 4 fingers above the womb.
The leading point is 4cm above the linea interspinalis plane to pelvis.

2. Normal contractions are. Regular contractions last in 15 to 20 seconds every 10 minutes

or more. Structural changes in cervix; softening, shortening. Opening more than 3cm.
Gradual lowering of the head to the plane then into the small pelvis.

3. What are the further tactics? Monitor the condition of pulse, pressure, complaints,
contractions, opening of the cervix, the head, fetal heartbeat rate every 15 minutes in active
phase. Carry active management for third phase
4.

16
A 28-year-old woman was taken to the maternity ward with complaints of cramping pains in
the lower abdomen and lower back for 15 seconds. Every 10 minutes Term of pregnancy 37-
38 weeks, pregnancy III, childbirth I. She attended the women's clinic according to the
schedule. Obstetric history: the threat of abortion within 5-6 weeks. Gynecological
anamnesis: pregnancy froze within 5-6 weeks, 2 years ago. Somatic history is not
burdened.
Objective: the skin and visible mucous membranes are clean, pale pink. Vesicular
respiration. Heart tones are rhythmic, clear, pulse - 68 beats per 1 minute, blood pressure
110/75 mm Hg. and 115/75 mm Hg. on both hands. The abdomen is enlarged due to the
pregnant uterus, The height of the uterine floor under the xiphoid process, the uterus is in
normal tone, tones during the examination. The fetal heartbeat is clear, rhythmic 125 beats
/ min., On the left below the navel. Swelling is absent.
Vaginal examination.
Vaginal examination revealed: the body of the uterus is enlarged to 38 weeks of pregnancy,
the cervix is soft, shortened to 2x cm, passes the fingertip, centred. The amniotic sac is
intact and functioning. The head is pressed to the entrance to the small pelvis.
The woman shows a desire to receive medical anaesthesia in childbirth.
Task:
1. Establish a preliminary diagnosis. Normal presentation. First period childbirth. Latent
phase.

2. Assess the state of maturity of the cervix on the Bishop scale? Assessment of degree of
Bishop scale includes:
- Position of cervix relative to axis of pelvis (Median; 2pts)
- Length of cervix, cm (1-2cm; 1pt)
- Consistency of cervix (Soft; 2pts)
- Dilation of external orifice (Opened by 1cm; 1pt)
- Location of presenting fetal part (Above the inlet; 0pts)
Total 6pts (0-2pts cervix is immature, 3-5pts insufficiently mature, >6pts cervix is mature)

3. Recommended laboratory tests.

General urine test
Blood sugar
Urea and Electrolytes
General blood test every 2 hours
Control BP every 2 hours
Cardio monitor every 30min in first period.

4. The principle of childbirth.

Monitor and wait. Vaginal birth

5. Anaesthesia of a woman in childbirth? After consultation with anaesthesiologist, epidural

17
A 25-year-old woman went to the doctor women's consultation with complaints about the
absence of menstruation during the last 2 months, giddiness, swelling of the mammary
glands, nausea in the morning. Gynecological anamnesis: childbirth - 0, abortion - 0, OM - 2
months ago. The last time visited a gynaecologist was 2 years ago. Somatic anamnesis:
chronic pyelonephritis.
Objective: the skin and visible mucous membranes are clean, pale pink. Vesicular
respiration. Heart tones are rhythmic, clear, pulse - 68 beats per 1 minute, blood pressure
110/75 mm Hg. and 115/75 mm Hg. on both hands. The abdomen is soft, painless.
Vaginal examination.
Examination speculum: cyanotic mucosa of the cervix and vagina, clean. The outer eye of
the cervix rounded. Vaginal discharge is mucous, in moderation
Bimanual examination revealed: The body of the uterus is enlarged to 9-10 weeks of
pregnancy, painless, mobile, soft consistency. The vaults of the vagina are free, the
appendages of the uterus without features.
The woman wants to register for pregnancy.

Question:
1. Establish a preliminary diagnosis. First pregnancy, 9 to 10 weeks, 25 years, somatic
anamnesis– chronic pyelonephritis
2. Recommended routine examinations. BP, Pulse, CBC, biochemical blood test, Rh factor,
Hbs Antigen, Diabetic screening (oral glucose test), ARVI, HIV, TORCH infection (if
indications present)
Analysis of urine, pathological examination, analysis of secretion, ultrasound of the
abdomen/uterus. Consultant specialist – therapist and nephrologist
Monitor and prophylaxis placental insufficiency due to pyelonephritis:
Dynamic ultrasonography
Dopplerometry (blood flow)
Level of estradiol, progesterone, Chorionic gonadotropic hormone and alpha fetoprotein in
blood serum.
Estradiol secretion in urine
Detecting content of oxytocinase, general and placental basic phosphatase in blood serum.
Colpocytolgical investigation.
Also monitor height of uterine fundus, growth of fetus.
Ultrasonographic placentometry (placenta thickness)

3. And pregnancy screening. Biochemical screening the first trimester is performed at 10-13
weeks of pregnancy at the same time.
Pregnancy associated protein plasma A (PAPP-A),
Chorionic gonadotropic hormone (CGH);
Ultrasound measurement of nuchal region at 10-13 weeks (larger than 3mm = possible
chromosomal pathology;
Alpha fetal protein (venous blood) from 13 weeks.
4. Recommendations for pregnancy.
5. Indications for referral of a pregnant woman for medical and genetic
counselling. Presence of alpha fetoprotein or any other signs of fetal malformations.

18
A 28-year-old woman was taken to the maternity ward with complaints of cramping pain in
the lower abdomen and lower back for 15 seconds. Each 10 min the gestation period is 37-
38 weeks, pregnancy II, childbirth I. Estimated fetal weight 4500g. She attended the
women's clinic according to the schedule.
Obstetric history: no weighted. Gynecological anamnesis: artificial termination of pregnancy
in term 5-6 weeks, 3 years ago. Somatic history is not burdened. Objective: the skin and
visible mucous membranes are clean, pale pink. Breath vesicular. Heart tones are rhythmic,
clear, pulse - 68 beats in 1 minute, blood pressure 110/75mm.rt.st. and 115/75 mm Hg. on
both hands. The abdomen is enlarged due to pregnant uterus. The height of the uterine
floor under the xiphoid process, the uterus in normal tone,
tones during the examination. Fetal heartbeat is clear, rhythmic 140 beats / min. On the left
below the navel. Swelling is absent.
Vaginal examination.
Vaginal examination revealed that the body of the uterus was enlarged to 38 weeks
pregnancy, cervix soft, shortened to 2x cm, passes 1p / p, centred. The amniotic sac is intact
and functioning. The head is pressed to the entrance to small pelvis.

Task:
1. Establish a preliminary diagnosis. Normal presentation. First period childbirth. Latent
phase. Macrosomia - Fetus
2. Methods for determining the estimated weight of the fetus? Abdominal circumference
times height of uterus fundus.
3. Recommended laboratory tests.
General urine test
General blood test every 2 hours
Blood sugar
Urea and Electrolytes
Control BP every 2 hours
Cardio monitor every 30min in first period.

4. Tactics of childbirth? Monitor and wait. Vaginal birth if no complications arise.

5. Additional methods of examination in late pregnancy? General examination of the

pregnant woman, external measuring of the uterus and pelvis of the woman, external and
internal obstetric examination, auscultation of fetal heartbeats, auxiliary instrument and
apparatus methods of investigation of the fetal condition.

19
A 25-year-old woman was registered in the maternity hospital for the first pregnancy 11-12
weeks after suffering from acute cytomegalovirus infection. During a scheduled visit to the
doctor, 4 weeks later she complained that she had recently stopped feeling pregnant.
Examination: the uterine fundus is above the pubic symphysis on 4 cm. Vaginal examination:
the uterus is enlarged to 12 weeks of pregnancy, fleshy. The external cervical os is closed.
Ovaries and uterine tubes – without pathological changes. The vaults are free. On
ultrasound: uterus is enlarged up to 12 weeks of pregnancy, no fetal heartbeat, multiple
petrifications and placental cysts are detected. CBC: Hb 120g / l; erythrocytes 3.8 * 1012 / l;
Leukocytes 10 * 109 / l; Platelets 220 * 1012 / l; ESR 30mm / hour.

Tasks
1. Diagnose and name the cause of this pathology.
2. Determine the required amount of examinations.
3. Doctors' tactics?
4. Name the possible complications of this pathology.
5. Give recommendations to the woman at discharge from the hospital.

20
During childbirth, the mother underwent cardiotocographic monitoring of the condition of
the fetus. The analysis of the cardiotocogram revealed that the heart rate is about 180
beats per minute, the variability of the rhythm is 2 beats per minute. Within one hour of
observation, 2 deep decelerations were detected, not associated with uterine contractions.

Questions:
1. What is the normal heart rate of the fetus?
2. What do the changes in the cardiotocogram indicate?
3. What tactics can be used during the first period of childbirth? 4. What tactics can be used
during the second period of childbirth during the main presentation?
 10
A 38-year-old woman has a fifth pregnancy (4 living children). In the anamnesis:
at 32 weeks she suffered from SARS, after which the pregnancy was complicated
by chronic polyhydramnion, unstable position of the fetus. The dimensions of
pelvis are 25 cm. - 28 cm. - 31 cm., external conjugate - 21 cm. Woman's height
is 165 cm, weight - 74 kg, abdomen circumference 112 cm, height of the uterine
fundus 44 cm. At 40 weeks of pregnancy at home left clean amniotic fluid in the
amount about 2.5 liters, contractions began in 3-4 minutes, 45 seconds each
contraction. She was taken to the maternity hospital by ambulance. Leopold's
techniques determine the transverse position of the fetus, the back is turned
forward, the head is on the left. Fetal heartbeat - 100 beats / min, muffled,
rhythmic. Vaginal examination: opening of the cervix - 6 cm. The amniotic sac is
absent. In the vagina there is a hand of the fetus.
1 dx 5th pregnancy ,40 weeks ,5th delivery ;active phase ,early rapture,polyhydromniosis,fetal distress
,SARS
2) causes : polyhydramniosis / big fetus
3) estimated weight abdominal circumference x fundus =4928g
4) position transverse , anterior type, presentation is absent because it’s transverse
5) urgent C section

A 19-year-old first-born with a body weight of 54.5 kg at 38 weeks of gestation

after a normal vaginal birth gave birth to a full-term live girl. The child's weight
was 2180.0 g, body length - 48 cm. From history it is known that the woman
smoked cigarettes for the past 8 years and continued to smoke during pregnancy.
This pregnancy was complicated by moderate vomiting of pregnancy from 9 to 12
weeks of pregnancy, edema of pregnancy from 32 to 38 weeks.

1) Fetal development delay Because of weight

2) Placental disfunction
3) Asymmetrical( body weight less but height is norm
4) Weight of pregnant woman,ultrasound,physical fetal profile ,Dopplerometry
5) Asymmetrical has normal organ development so favorable prognosis

The child from the first pregnancy was born in a term birth and has a body weight
of 4000 g and a body length of 57 cm. Born, the child did not respond to the
examination. It is not possible to assess the child's condition definitively. Heart
rate - 80 / min.
1)asphyxia of newborn ; severe degree
2) fetal distress , trauma at birth ,obstruction of airway by aspiration of amniotic fluid
3) apgar score 6 or less points severe
4) ABC steps airway breathing circulation
5)if there is aspiration of amniotic fluid with meconium and if the amniotic fluid is clean

Pregnant 30 years, Term of pregnancy 32 weeks. Hospitalized due to the threat of

premature birth, rhesus factor immunological disorders from 28 weeks. This
pregnancy is the second. The first pregnancy ended in a medical abortion within
10 weeks. A pregnant woman was administered 300 µg of anti-Rho (D)
immunoglobulin intramuscularly at 28 weeks. In the previous analysis, the titer of
rhesus antibodies in the blood was 1:16. After 2 weeks, there was an increase in
antibody titer to the level of 1:64. There are ultrasound signs of hemolytic disease

1) Rhesus conflict so we need to do preterm delivery because increase of antibodies to critical level
in 2 weeks
2) Ultrasound,dopplerometry,hormones of fetoplacental complex , proteino gram of mother
,increase of ferments in amniotic fluid , transabdominal amniocentesis,cordocentesis
3) 32 weeks of gestation so urgent C section
Immediately clamp umbilical cord and separating from mother to prevent antibodies in the
blood of fetus ,determine blood group and rhesus of fetus ;
4)
5)Antirhesus immunoglobulin ,in rh negative woman to avoid rhesus conflict

During childbirth, the mother underwent cardiotocographic monitoring of the

condition of the fetus. The analysis of the cardiotocogram revealed that the heart
rate is about 180 beats per minute, the variability of the rhythm is 2 beats per
minute. Within one hour of observation, 2 deep decelerations were detected, not
associated with uterine contractions.
1) 110-170 bpm
2) 2 deep decelerations indicating fetal distress
3) C section
4) Vacuum or forceps extraction
The 26-year-old patient consulted a gynecologist with complaints about the
absence of menstruation for 6 months, weight gain, increased hair growth over the
upper lip, abdomen, thighs, skin problems in the form of inflammatory rashes on
the face and back.
From the anamnesis it is known: menstruation from 15 years, irregular (duration
of a menstrual cycle 36-45 days), sparse, painless, last menstruation 6 months ago.
Sex life from 21 years. For the last 2 years she has been living a regular sexual
life, she did not prevent pregnancy, she did not get pregnant.
Objectively: the general condition of the woman is satisfactory, height 1.68 m,
weight 85 kg, BMI-30.1 kg / m2. The skin is pale pink, glistening on the face,
with acne elements, hyperpigmentation is determined in the neck. Arterial
pressure- 130/80 mm Hg. Heart rate - 88 / min. respiratory rate - 17 / min. SaO 2-
97%. The pregnancy test is negative.
Speculum examination: vaginal mucosa and cervix without features.
Bimanual: uterus in anteversio-anteflexio, slightly reduced in size, normal shape,
dense consistency. Appendages on both sides are palpable-enlarged and
compacted. The vaults are free.
According to the result of ultrasound: myometrium without features, M-echo13
mm, ovaries enlarged due to multiple follicles (more than 12 in section), located
under the thickened teka in the form of a "necklace", in sizes up to 4-6 mm, the
volume of the right ovary 11.4 cm3, the left -14.1 cm3.

1) Secondary Amnorhea ,stop of menses

2) Poly cystic syndrome ,obesity
3) Hormones level analysis, family history , laparoscopic treatment in the ovary If woman wants to
be pregnant
4) Pregnancy,hyperplasia of Supra renal gland ,cyst of ovary
5) Infertility / cancer of endometrium/ secondary diabetes mellitus

A 45-year-old woman who gave birth for the second time was admitted in the
term of 39-40 weeks of pregnancy with active labor: contractions in 4-5 minutes
for 30-35 seconds. Anamnesis: childhood infections, flu, chronic gastritis,
bronchitis. Estimated fetal weight - 3800g. The cervix on the Bishop's scale – 7
point, rhythmic heartbeat of the fetus, 140 beats / min, clear. At vaginal research:
opening of a neck of uterus of 4 cm, the head fills a terminal line, an sagittal
suture in the left oblique size, a small fontanel right at the sacrum. The amniotic
sac is intact. After 5 hours of active labor, pushing the uterus appeared in 1-2
minutes for 50-55 sec. Pure amniotic fluid departed.
Second period of delivery lasts 1.5 hours. The woman is tired. Pushing the uterus
are weakened, last 3-4 minutes for 40-45 sec. The fetal heartbeat is rhythmic, 90
beats / min, deaf. Head on the pelvic floor, sagittal suture coincides with direct
size of the small pelvis. A small fontanel near the sacrum.
1) 2 nd pregnancy ; 2nd labor 2nd phase of labor secondary weakness of activity of uterus ,fetal
distress
2) Longitude, 2n position posterior type and occiput presentation of head
3) Obstretrics forceps or vacuum
4) Trauma of fetus ,bleeding of the mother due to rapture

The 45-year-old patient consults with gynecologist with complaints of lower

abdominal pain, significant prolonged menstrual disorders and problems with
urination. Delivery - 1, abortion - 2. Menstruation from 13 years old, during 3-4
days every 29 days. Blood pressure - 120/70 mm. Pulse - 78 per minute.
Due to speculum examination and colposcopy:
epithelial defect on the cervix with clear edges, inflammatory reaction, edema and
dilated capillaries. The epithelium is acetowhite.
Cytology was taken from the cervix. The result is CIN 3.
Bimanual examination:
the uterus is dense, enlarged to 13-14 weeks of pregnancy. Nodes are palpated on
the anterior, posterior wall of the uterus, on the rib. The appendages are not
palpable. Mucous secretion is visualized.

1) Lumina of uterus ,dysplasia of uterus

2) Extipartion of uterus without ovaries and tubes
3) Examine CBC ,urine ,glucose in blood ,na and K ,electrocardiogram ,ultrasound of mammary gland
,woman should not eat pre operation
4) Management of blood pressure , hydrate patient, remove suture 6-7 days after

A 35-year-old woman went to the doctor with complaints of dull, aching pain in
the depths of the pelvis, lower abdomen, lumbosacral region, dyspariuria. Before
and during menstruation, the pain intensifies, radiates to the side wall of the pelvis
and leg, there are dysuric phenomena, painful tenesmus, bloody discharge from
the rectum. Speculum examination: the cervix is clean, the external os is closed.
Vaginal examination: the uterus is mobile, dense, not enlarged, painless. There is
an infiltrate behind the cervix at the level of the inner os, sharply painful, hilly,
immobile. Uterine appendages without features.
1) Retrocervical endometriosis ,severe stage
2) Inflammation of parametrum ,cancer of rectum
3) Laparoscopy
4) Surgical ,extortion of tissue ,anti androgen androl,
5) Nausea vomiting,obesity , depression,bleeding in uterus

Woman, 25 y.o, was admitted to the gynecological department with complaints

on severe pain in the lower abdomen with irradiation to shoulder and scapula,
fainting. Menarche at 14 years, periods are regular, last 4-5 days in every 29
days.LMP was 1,5 month ago. BP – 90/60 mmHg. Pulse – 110 beets/min.
Physical exam: darkening in the eyes, noise in the ears. Abdomen is bloated,
painful during palpation, defans, symptoms of peritoneal irritation are positive in
the lower abdomen. PV: uterus in anteflexion-version position, isn’t enlarged,
mobile, painless. Palpation of the left appendages is complicated because of
defans and painfulness of abdominal wall. Back vault is over hanged, painful,
Solovyov`s and Promptov`s symptoms are positive. Discharges are mucous.

1) Extra uterine pregnancy

2) Aplexia kf ovary ,torsion of ovary ,acute appendicitis,fibromyoma ,nodules of ,myoma
3) Punction of Pouche,surgery to remove tube ,suture and give infusion with colloids
,electrolytes ,ringers solution ,crystalloids,capronic acid
4) Diagnostic laparoscopy

5
A 27-year-old primary pregnant woman consulted in the antenatal clinic for
registration. She has no complaints. According to the date of the last menstrual,
the gestation term is 11-12 weeks. She had no chronic diseases before pregnancy.
Objective examination: without pathological changes. During the 1st screening, in
the gestation period 11 weeks and 6 days, a low risk for genetic pathology was
detected. The following results of additional examinations are: RW - negative
Antibodies to HIV - negative HBsAg - negative
Blood group A (II) Rh +
RW - negative
Antibodies to HIV - negative HBsAg - negative
Blood group A (II) Rh +
1) 1st pregnancy, 11-12 weeks ,a symptomatic bacteuria
2) Urine bacteria high excess other indicators normal
3) Antibiotics amoxicillin 500mg 3 times a day and repeat urine analysis after 1month
4) Gestational pyelonephritis ,premature birth , bacteria infection of uterus
5) Resistance to antibiotics,antibiotics associated candidiasis ,flatulence

The pregnant woman 25 years old, primiparous, 31-32 weeks, was admitted with
complaints of cramping pains in the lower part of abdomen and on her back,
which occurs every 5 minutes and lasts up to 20 seconds. Bleeding or discharge of
amniotic fluid is NOT noted. Associates her complaints with physical overload.
The course of pregnancy was physiological till this time. The woman has no
chronic diseases, somatically healthy. BP 110/70 mm Hg, pulse 70 beats / min,
body temperature 36.4 ° C. The uterus is enlarged according to the gestational
age, periodically tones up. The fetus has longitudinal position, 1st position,
anterior type of presentation, cephalic presentation, head above the entrance to the
small pelvis. The fetal heartbeat is clear, rhythmic, 136 beats / min. NBT 2 points,
STV9.2, biophysical profile 8 points according to Manning. During vaginal
examination: the cervix is centered, shortened to 1 cm, the cervical canal is open
to
2.5 cm, the fetal bladder is intact. Results of additional examinations
1) 1st pregnancy,31-32 weeks latent premature delivery ,mild anemia of pregnant woman
2) Satisfactory fetal condition
3) Prescription of tocolytic drugs ,dexamethasone
4) Nausea ,vomiting ,anaphylactic shock, dexamethason -peptic ulcer ,hypertension and constipation

A 35-year-old woman complains of discharge from the vagina, which arose after
unprotected intercourse in 7th day, slight itching of the external genital organs.
These complaints worsen the quality of her life, she needs to use additional
hygiene products (daily panty liners or changes twice of underwear during the
day). Objective status: blood pressure - 120/70 mm Hg. Art, temperature - 36.4 °
C, pulse 76 beats per minute, rhythmic, satisfactory qualities. Gynecological
examination: the mucosa of vaginal and cervix is hyperemic, the discharge is
penny and green. The size of uterus is normal, in anteflexio position, mobile,
painless during palpation. Applications on both sides are unremarkable. The
fornixes of the vagina are free. Menarche started at 13 years. Monthly, 4 days
after 24, painless, moderate. Last menstruation 3 weeks ago. Reproductive
anamnesis: childbirth 1, abortion - 1 (artificial at 8 weeks). The type of
contraception is interuptus coitus. Allergic is absent. The vaginal discharge is
taken during the gynecological examination for evaluation the degree of purity
and bacterial culture.

1) Trichominas colpitis
2) Analysis of secretion,wassserman reaction of hiv , examine partner
3) Chlmydia ,syphilis ,cystitis
4) Metronidazole 400mg 2times a day 5-7 days per os , vaginal suppositories
5) Prohibit sex during treatment, additional swab after ,menstruation and another swab after the next
menstruation

A 40-year-old patient complains of intermenstrual watery discharge with streaks

of blood. Anamnesis: she has a bad habit - smoking more than 10 cigarettes a day.
Gynecological anamnesis: childbirth - 2, abortion - 2. She has been using
intrauterine contraceptives for more than seven years (at the request of the
woman). Menarche from 11 years. Menstruation for 7 days, after 30 days, painful,
profuse. Anamnesis of life: she has diagnosed human papillomavirus (type 16) for
about five years. She was treated, using diathermocoagulation. Gynecological
examination: the cervix is dense, bleeds during touching with a spatula of Eyra.
The body of the uterus has normal size, in anteflexio position, mobile, painless.
The appendages are normal on both sides. The parameterium is free, the vaults are
deep. Specular examination: Schiller's test is positive. During extended
colposcopy atypical areas of the mucous membrane of the cervix are revealed in
10 00and 200.
1) Cervical cancer ,stage
2) Micro invasive of squamous layer
3) Stage 1A
4) Diagnostic curettage with biopsy
5) Extipartion of uterus without appendages

A 42-year-old pregnant woman, with the term of pregnancy 8-9 weeks addressed
to the antenatal clinic about its management on further. Complains of headache,
recurrent chest pain, heart rhythm disturbances, swelling in the legs and arms,
which does not disappear after a night's sleep, dyspnea after minimal physical
activity. From anamnesis: third pregnancy, the first ended in urgent labor at 25
years, the second - premature birth at 30 weeks because of severe preeclampsia at
33 years, the child died on the third day after birth. Suffering from arterial
hypertension from the age of 30, which is poorly treated with antihypertensive
drugs, she has frequent hypertensive crises, an increase of blood pressure about
180/110 mm Hg and above, rhythm disturbances (atrial fibrillation), coronary
heart disease. She had a microstroke after hypertensive crisis 3 years ago. Applies
Exforge N, valsartan, carvedilol - periodically, clopidogrel, preductal, cordarone.
She is an invalid of the second group. Examination revealed: BP 170/115 mm
Hg, pulse 70-94 beats / min, arrhythmic, body temperature 36.4C. Body mass
index (BMI) 31 kg / m2. Edema is presen in the legs and anterior abdominal wall.
The borders of the heart are expanded to the left, the accent of the 2nd tone is
above the aorta. During palpation - the abdomen is soft, painless, the edge of the
liver protrudes 3 cm below the right costal arch.
Vaginal examination: the mucous of the vagina and cervix is cyanotic, without
changes. The body of the uterus is enlarged up to 8-9 weeks of pregnancy, in
normotonus. The uterine appendages are not palpable.
Ultrasound - uterine pregnancy 8-9 weeks. KTR of the fetus - 10 mm.
Heartbeats are present.

1) 3rd pregnancy,8-9th week ,chronic hypertension stage 3,obesity stage 1

2) ECG , CBC ,Ultrasound of heart, Biochemical tests
3)
4) Reliable long time contraception such as Intra uterine device

A 55-year-old female patient during a routine examination revealed a tumor

formation in the left ovary. The woman does not present any complaints.
From the anamnesis: menarche from the age of 12. The menstrual cycle is
regular, 4 days after 28 days, painful. Menopause 3 years. Childbirth - 1, abortion
- 2. Her grandmother died of breast cancer. Gynecological examination: the
external genital organs are developed correctly, hair growth is female. During the
laparotomy approach, multiple metastatic foci in the peritoneum were found, the
size of the metastases was more than 2 cm. During the operation, a cytological
study of the tumor tissue of the ovary — adenocarcinoma — was carried out. A
study of ascitic fluid was carried out - cancer cells were found. From laboratory
examination: CA-125 - 71.0 U / ml.

1) Cancer of left ovary

2) Stage T3N0M0
3) X-ray of chest , osophagogastroduedonoscopy ,CT scan of pelvis ,MRI
4) Extipartion of uterus,extipartion of omentum

A 23-year-old pregnant woman was taken to the emergency room by ambulance

with complaints of sudden bloody discharge from the genital tract. Second
pregnancy, 34-35 weeks. The first birth - without complications, a boy weighing
3620 g was born. History: Pregnancy without features. Received folic acid in the
first trimester of pregnancy. During pregnancy, the last hemoglobin is 114 g / l at
28 weeks. Objective: The woman is conscious, pale, adynamic. Pulse - 88 / min,
blood pressure - 85/50 mm Hg, BH - 30 / min, SaO2 - 96. Fetal heartbeat is muted
- up to 60 / min.
The abdomen is soft, painless. There is no labor. There are bloody discharge from
the vagina with convolutions up to 350 ml. After 10 minutes, the bleeding
intensified and reached 500 ml.

1) Approximately 20% of full blood loss

2) 2nd pregnancy 34- 35 weeks 2nd premature delivery ,premature separation of placenta and vaginsl
bleeding
3) Anemia, erythrocytopenia
4) Operation room ,reanimating of baby ,C section ,infusion to increase blood circulation volume
,extipartion of uterus
5) Transfusion of erythrocytic mass , plasma 20mg /kg / hr in 24 hours

34 years old woman is in the delivery roomIII pregnancy 39-40 weeks. The first
birth - without complications, a boy weighing 3300 g was born. The second
pregnancy ended in a miscarriage at 10-11 weeks, complicated by acute
endometritis.
Delivery - through the maternal passages. The first 2 periods of delivery
proceeded normally. 10 minutes after the birth of the child there was a cramping
pain and bloody discharge from the vagina.
Objective condition: The woman is conscious, pale, adynamic. Pulse - 88 / min,
blood pressure - 90/55 mm Hg, RR - 30 / min, SaO2 - 97.
The abdomen is soft, painless. Signs of separation of manure from the uterine wall
are negative. When the edge of the palm is pressed over the womb, the umbilical
cord is retracted. The bleeding has increased and reached 500 ml.
1) 20%
2) 1st delivery ,39-40 weeks ,tight placental tissue in uterine cavity ,with hemorrhage
3) Anemia ,erythrocytopenia
4) Operation room ,massage if uterus ,hand revision of the uterine cavity if not possible extipartion
5) Mesapustol 800mcg, frozen plasma 15-20mcg ,tronixmec acid

The 36-year-old pregnant woman was taken to an ambulance due to bloody

discharge while resting at home. It is her fifth pregnancy, 32 weeks of gestation.
Four previous deliveries passed without complications, the youngest child was 2.5
years old.
The pregnant woman was examined in the department. The general condition is
satisfactory. Pulse 88 beats / min., Blood pressure 130/70, 122/70 mm.
Consciousness is clear, answers on the questions adequately. The uterus in
normotonus. The position of the fetus is oblique, the head is at the bottom, closer
to the left side (?). The fetal heartbeat is rhythmic 150 beats / min., The fetus feels
good during it’s movements. Hygienic pad for 3 drops soaked less than half.

1) 5th pregnancy,32weeks ,5th delivery ,placenta previa (lots of deliveries)

2) Endometriosis history,abortions ,benign tumor in uterus
3) Give Dr information ,CBC ,anamnesis, take to operation room , do ultrasound
4) Measure volume of blood loss, see if the bleeding can be stooped , hospitalize and give corticosteroids
if blood loss is more than 250ml we then do C section

A 25-year-old woman was registered in the maternity hospitalfor the first

pregnancy 11-12 weeks after suffering from acute cytomegalovirus infection.
During a scheduled visit to the doctor, 4 weeks later she complained that she had
recently stopped feeling pregnant. Examination: the uterine fundus is above the
of pregnancy, fleshy. The external cervical os is closed. Ovaries and uterine tubes
enlarged up to 12 weeks of pregnancy, no fetal heartbeat, multiple petrifications

1) 1st pregnancy 11-12 weeks ,missed abortion ,cytomegalovirus

2) CBC ,thrombocytes measure ,coalugogram
3) Oxytocin’s 5 iu, antibiotics ,NSAIDs, curretage of uterine and the infectious doctor should examine
her
4) Abortion or miscarriage
5) She should be thoroughly checked for 6 months before planning to get pregnant again
 Woman of 42 y.o. came to gynecologist with complaints on vaginal bleedings
and discharges, pain in the lower abdomen and lower back, sacrum. Bleeding
appears after sexual intercourses. Sometimes discharges are liquid, sometimes –
ichoric with a bad smell.Periods are regular, last 4 days in every 28 days. 2
deliveries and 1 artificial abortion(G3P2A1).
Patient had many sexual partners during her life.
Speculum examination: uterine cervix is hypertrophic, there is a lesion like
“cauliflower”, that bleeds during touching by cotton stick.
PV: uterus is not enlarged, mobile, painless. Appendages are not palpated.
Parametrial fat is impacted with infiltrates.

1)cervical cancer stage 2/3

2) biopsy, colposcopy,lymphography to see metastasis,ultrasound
3) cancer of uterine body
4) extipartion of uterus with everything,chemotherapy
5) leukopenia , vomiting,stomatitis ,weight loss , fever

The patient S., 32 years old, went to the gynaecologist for brown discharge from
the genital tract. It appears before and after menstruation and lasts 3-4 days. From
the anamnesis: 4 months ago a medical abortion was performed. While speculum
examination: cervix without any features. At bimanual research: uterus in
anteversio - anteflexio, a little bit enlarged, round form with dense consistence.
Appendages on both sides are not palpable. On ultrasound: the myometrium has a
heterogeneous structure, the anterior wall of the uterus is thicker than the
posterior, the boundary between the endometrium and myometrium is blurred.

1) Adenomyosis of uterus stage 2

2) Hormonal imbalances due to the abortion
3) Hysteriscopy , Ct ,MRI ,hormones therapy with progesterone and gonadotropin
4) Pregnancy, uterine fibroids,uterine cancer , Stein leventhal
5) Progression and invasion with probable infertility

A 42-year-old patient went to the doctor with complaints of heartburn, itching in

the vagina, the presence of discharge. From the anamnesis it is known that the
woman had 2 births. There were no abortions or miscarriages. Three weeks ago,
she fell ill with COVID-19, complicated by bilateral pneumonia. Received
antibiotic therapy for 10 days. The general condition of the woman is satisfactory,
Ps 74 /min, arterial blood pressure 135/85 mm Hg. Respiration rate 14 per minute.
The abdomen is soft, painless. At gynecological inspection it is established: the
mucous membrane of a vagina at speculum inspection is hyperemic, with a white
layer. The neck is formed, the vaginal part is hyperemic. Discharge is in
significant quantities, whitish color, cheese-like consistency.
Bimanual examination revealed that the uterus and appendages were without
pathological changes. Pseudohyphae and blastospores were detected in vaginal
secretions by microscopy.

1) Candidal colpitis
2) Speculum examination
3) Antifungal suppositories , nystatin 1-2 times a day or flucanazol 1 time a day

A 48-year-old G3 P3 woman complains of a 2-year history of loss of urine four to

five times each day, typically occurring with coughing, sneezing, or lifting; she
denies dysuria or the urge to void during these episodes. These events cause her
embarrassment and interfere with her daily activities. The patient is otherwise in
good health. A urine culture performed 1 month previously was negative. On
examination, she is slightly obese. Her blood pressure is 130/80 mm Hg, her heart
rate is 80 beats per minute, and her temperature 99°F (37.2°C). The breast
examination is normal without masses. Her heart has a regular rate and rhythm
without murmurs. The abdominal examination reveals no masses or tenderness. A
midstream voided urinalysis is unremarkable. The doctor places the cotton tip
applicator in the urethra, the movement of the applicator is more than 45 degree.
1) Urinary incontinence
2) Ultrasound of bladder ,general urine analysis
3) Exercise it straighten the pelvic splu,sub urethral sling

The 26-year-old woman para1(39 weeks), with a history , is in the delivery room.
Delivery - through the maternal passages. The first 2 periods of
childbirthproceeded normally. 30 minutes ago a healthy boy was born - 3450g,
52cm. operation, significant bleeding began, which continued after the separation
of parts of the placenta. The pregnancy without complications. During pregnancy,
the last hemoglobin is 103 g / l at 36 weeks. She has told about 2 artificial
abortions previously.
The abdomen is soft, painless. The uterus periodically relaxes. Visually, injuries
and ruptures of the perineum are absent. At the time of examination, the blood
flowing from the uterus does not clot.
1) 30% (1;35)
2) Delivery at; 39 weeks ,revision of uterine due to placental remains ,DIC stage 3
3) Anemia,thrombocytopenia,activation prothrombin time ,increased d dimmer
4) Operation room , infusion using crystal lid and colloid , oxygen supply , analysis of need for extipartion,
FFP, ranexmic acid , novosanic for blood factor

A 23-year-old woman consulted a gynecologist with complaints of aching lower

abdominal pain and the appearance of "smearing" bloody discharge. Considers
herself pregnant. Last menstruation 7 weeks ago, a home pregnancy test (urine) is
positive. Obstetric history is burdened by miscarriage at 7 weeks, twoyears ago.
The cause of the miscarriage has not been established (in words). Professional
activities involve working in the evening and at night. Observed by a family
doctor for cholecystitis. Menstruation is not regular since the menarche period.
Frequent delays of menstruation up to 10-12 days. Smokes for 3 years, up to 6
cigarettes a day. After a positive pregnancy test, quit smoking (in words). Height -
170 cm, weight -76 kg .
Research results: HCG of blood - 96130 mIU / ml (reference indicators 32065.0-
149571.0 mIU / ml); blood progesterone - 25.5 ng / ml (reference values 11.0-
44.3 ng / ml).
Examination revealed that the uterus was cyanotic, the uterine cervix was closed,
and there was a dark brown bloody discharge in the vagina, in small quantities.
The uterus is enlarged to 7-8 weeks, reactive on palpation, painless. Ovaries and
tubes are not palpable. The vaginal vaults are free.
Ultrasound - uterine pregnancy, 6-7 weeks. Heartbeat+, at the lower pole of the
fertilized egg is determined by the formation of the size of 0.5 * 1.0 * 1.5 cm
(retrochorial hematoma). Left ovary, slightly enlarged (4.0 * 5.0 * 3.5 cm). Free
fluid in the pelvic cavity is not determined.

1) 2nd pregnancy 7-8 weeks , miscarriage

2) Ultrasound,Progesterone once a week ,CBC urine analysis,blood group
3) Trinamexic acid ,folic acid 400mcg once a day ,
4) Hospitalization and rhesus screening

A 30-year-old pregnant woman came to the obstetrician-gynecologist for a

routine examination with complaints of edema of the extremities, nasal congestion
and rapid fatigue. It is the third pregnancy, 36 weeks.
 The first pregnancy ended with premature birth at 34 weeks, the child is alive, 4
years old. Next 2 pregnancies - miscarriage at 7 weeks, complicated by subfebrile
temperature within a week (2 years ago). In the childhood - Botkin desease and
frequent cystitis.
Pulse of pregnant woman - 90 beats / min., Blood pressure 160/100, 150/90 mm
Hg. Abdominal circumference - 97 cm, standing of the fundus of the uterus - 31
cm. Edemas of the low extremities. Lady notes that he has not been able to
remove the ring for the last 3 weeks. Fetal heartbeats - 170 beats / min., rhythmic.
Woman did not have time to pass urine analisis, but the last analisis was 3 weeks
ago. There is signs of protein. Specific weight 1022, leukocytes 10-12 in the field
of view, erythrocytes 1-2 in the field of view. At the end of the examination, the
pregnant woman complained of nausea. Blood pressure: 170/110, 160/100 mm
Hg, pulse 96 beats / min.
1) 3rd pregnancy 36 weeks Severe eclampsia delayed fetal dvpmnt ,
2) Call for help , anesthesiologists, hod ,inform administrators,measure blood pressure,uropidil and
measure bp , magnesium sulfate and measure bp ,asses conditions of the fetus , after stabilization
transport to ICU
3) CBC ,clotting time , biochemistry,coagulogrsm
4) Tactics will depend on effectiveness of treatment of pre eclampsia and if normal prepare for delivery

The 27-year-old woman was admitted to the maternal hospital with complaints of
regular cramping pain in the lower abdomen and lower back. It is a second
delivery. The pregnancy was without complications. The contractions started 2
hours ago. Amniotic fluid did not spill out.
According to the exchange card, the expected date of the delivery in 6 days.
Height - 165 cm. Weight - 75 kg. Pulse 78 beats per minute. Blood pressure -
130/80 mm. External obstetric examination revealed that the position of the fetus
is physiological, the back is to the left, above the entrance to the pelvis is palpated
round, dense anterior part of the fetus. The presenting part is relative to the
symphysis at the level of 4/5 . Contractions for 30 seconds in 4-5 minutes, regular.
Fetal heartbeats - 142 beats / min., rhythmic, below the navel, it is better heard
laterally, to the left of the white line of the abdomen. At vaginal examination the
cervix is centered, shortened to 0,5 cm, soft, edges are thin. The servix is opened
to 4 cm. The amniotic sac is determined. The head which is at level -4 is
presented. There are mucous secretions. Sacrum is not reached, exostoses are not
detected.

1) 2nd pregnancy,39 weeks , 2nd childbirth,first period active phase

 2) Longitudinal position ,physiological,left back rear view , heartbeat better heard laterally on left ,head
is on the level of small pelvis ,
3) Contractions lasting more 15-20 seconds,softening and opening ,opening more than 3cm
4) Natural child birth , monitor the woman pulse etc , monitor fetal heart rate every 15 minutes

Lady L., 46 years old, went to a gynecologist with complaints of persistent

itching in the external genitalia. Objectively - the general condition is satisfactory.
The skin is pale pink. The abdomen is soft, painless during the palpation. At
gynecological examination - in the area of small labia and clitoris whitish centers
with scratches and elements of inflammatory reaction are visualized. At bimanual
examination - a uterus in retroversio-retroflexio. Movable, painless on palpation.
Appendages are not palpable.
1) Likoplakia of vulva
2) Hormonal disorder and immune status leading to tissue trophic
3) Colposcopy of smooth membrane, target biopsy
4) Allergy , syphilis ,cancer
5) Hormonal drugs and ointment or surgery (extipartion of vulva)

A 28-year-old woman was taken to the maternity ward with complaints of

cramping pains in the lower abdomen and lower back for 15 seconds. Every 10
minutes Term of pregnancy 37-38 weeks, pregnancy III, childbirth I. She attended
the women's clinic according to the schedule. Obstetric history: the threat of
abortion within 5-6 weeks. Gynecological anamnesis: pregnancy froze within 5-6
weeks, 2 years ago. Somatic history is not burdened. Objective: the skin and
visible mucous membranes are clean, pale pink. Vesicular respiration. Heart tones
are rhythmic, clear, pulse - 68 beats per 1 minute, blood pressure 110/75 mm Hg.
and 115/75 mm Hg. on both hands. The abdomen is enlarged due to the pregnant
uterus, The height of the uterine floor under the xiphoid process, the uterus is in
normal tone, tones during the examination. The fetal heartbeat is clear, rhythmic
125 beats / min., On the left below the navel. Swelling is absent. Vaginal
examination revealed: the body of the uterus is enlarged to 38 weeks of
pregnancy, the cervix is soft, shortened to 2x cm, passes the fingertip, centered.
The amniotic sac is intact and functioning. The head is pressed to the entrance to
the small pelvis.

1) 2nd pregnancy 37-38 weeks ; expected birth in main presentation, latent phase ,macrosomia
 2) Fetal mass = fundal height x wall of the abdomen and ultrasound
3) CBC ,urine tests , cardio monitoring ,BP
4) Natural birth
5) Epidural by an anesthesiologist

A 28-year-old woman was taken to the maternity ward with complaints of

cramping pains in the lower abdomen and lower back for 15 seconds. Every 10
minutes Term of pregnancy 37-38 weeks, pregnancy III, childbirth I. She attended
the women's clinic according to the schedule. Obstetric history: the threat of
abortion within 5-6 weeks. Gynecological anamnesis: pregnancy froze within 5-6
weeks, 2 years ago. Somatic history is not burdened. Objective: the skin and
visible mucous membranes are clean, pale pink. Vesicular respiration. Heart tones
are rhythmic, clear, pulse - 68 beats per 1 minute, blood pressure 110/75 mm Hg.
and 115/75 mm Hg. on both hands. The abdomen is enlarged due to the pregnant
uterus, The height of the uterine floor under the xiphoid process, the uterus is in
normal tone, tones during the examination. The fetal heartbeat is clear, rhythmic
125 beats / min., On the left below the navel. Swelling is absent.

1) 3rd pregnancy 37-38 weeks

A 25-year-old woman went to the doctor women's consultation with complaints

about the absence of menstruation during the last 2 months, giddiness, swelling of
the mammary glands, nausea in the morning. Gynecological anamnesis: childbirth
- 0, abortion - 0, OM - 2 months ago. The last time visited a gynecologist was 2
years ago. Somatic anamnesis: chronic pyelonephritis. Objective: the skin and
visible mucous membranes are clean, pale pink. Vesicular respiration. Heart tones
are rhythmic, clear, pulse - 68 beats per 1 minute, blood pressure 110/75 mm Hg.
and 115/75 mm Hg. on both hands. The abdomen is soft, painless. Examination
speculum: cyanotic mucosa of the cervix and vagina, clean. The outer eye of the
cervix rounded. Vaginal discharge is mucous, in moderation
Bimanual examination revealed: The body of the uterus is enlarged to 9-10 weeks
of pregnancy, painless, mobile, soft consistency. The vaults of the vagina are free,
the appendages of the uterus without features.
1)1st pregnancy,9 weeks , chronic pyeloniphritis
2) CBC , biochemical blood , Rhesus factor, hiv ,torch infection ,urine exam ,ultrasound at 11-12 weeks
3) biochemical screenings at 11-12 Weeks
4) lifestyle , rest , folic acid 4mg a day , iron supplements
5) general genetic counsel,I gotta outside pregnancy, check for phenylketonuria etc
 Instructions to the station N. 8
” Gynecological patient"

Example of a clinical task to the station "Obstetric patient"

A 48-year-old G3 P3 woman complains of a 2-year history of loss of urine four to

five times each day, typically occurring with coughing, sneezing, or lifting; she
denies dysuria or the urge to void during these episodes. These events cause her
embarrassment and interfere with her daily activities. The patient is otherwise in
good health. A urine culture performed 1 month previously was negative. On
examination, she is slightly obese. Her blood pressure is 130/80 mm Hg, her heart
rate is 80 beats per minute, and her temperature 99°F (37.2°C). The breast
examination is normal without masses. Her heart has a regular rate and rhythm
without murmurs. The abdominal examination reveals no masses or tenderness. A
midstream voided urinalysis is unremarkable. The doctor places the cotton tip
applicator in the urethra, the movement of the applicator is more than 45 degree.

Haemoglobin 127 g / l
Red cell count 3.3 * 1012 / l
White cell count 5.4 * 109 / l
Platelets 234 * 109 / l
Total protein 62 g / l

➤ What is the most likely diagnosis?

Stress urinary incontinence
➤ Diagnostic plan?
USI of bladder, bladder-utero angio, uterovesical segment, general urinalysis,
uroflowmetry
➤ What is the best initial treatment?
True: Kegel exercise, urethropexy, sub-urethral sling/transbulator, surgical
fixation of proximal urethra above pelvic diaphragm.
➤ Complications of therapy
Damage of the vessels of bunde and adjacent organ.L

Evaluation criteria Points Stud

Diagnosis Stress urinary incontinence Up to
0.5
Examination and / or analysis - Q-test - hypermobility of the Up to
 urethra (more than 300) 1
Examination plan: Ultrasound of the bladder to determine the Up to
bladder-urethral angle and hypermobility of the urethro-vesical 1
segment, determination of the volume of residual urine.
Uroflowmetry. Profilometry of intraurethral pressure. General
urine analysis
Further treatment plan Kegel exercises, pessary, or urethropexy Up to
1
Complications: Pesaro - the occurrence of bedsores, progression Up to
of prolapse, bacterial vaginosis; 1
Complications: Surgery - damage to the vessels of the bundle Up to
and adjacent organs, the formation of fistulas, recurrence of 0.5
prolapse
The maximum number of points per station is 5

List of clinical tasks

The 26-year-old patient consulted a gynecologist with complaints about the absence
of menstruation for 6 months, weight gain, increased hair growth over the upper lip,
abdomen, thighs, skin problems in the form of inflammatory rashes on the face and
back.

From the anamnesis it is known: menstruation from 15 years, irregular (duration of

a menstrual cycle 36-45 days), sparse, painless, last menstruation 6 months ago. Sex
life from 21 years. For the last 2 years she has been living a regular sexual life, she
did not prevent pregnancy, she did not get pregnant.

Objectively: the general condition of the woman is satisfactory, height 1.68 m,

weight 85 kg, BMI-30.1 kg / m2. The skin is pale pink, glistening on the face, with
acne elements, hyperpigmentation is determined in the neck. Arterial pressure-
130/80 mm Hg. Heart rate - 88 / min. respiratory rate - 17 / min. SaO2 - 97%. The
pregnancy test is negative.

Speculum examination: vaginal mucosa and cervix without features.

Bimanual: uterus in anteversio-anteflexio, slightly reduced in size, normal shape,

dense consistency. Appendages on both sides are palpable-enlarged and compacted.
The vaults are free.

According to the result of ultrasound: myometrium without features, M-echo13

mm, ovaries enlarged due to multiple follicles (more than 12 in section), located
under the thickened teka in the form of a "necklace", in sizes up to 4-6 mm, the
volume of the right ovary 11.4 cm3, the left -14.1 cm3.

Tasks:

1. Formulate a diagnosis.

Amenorrhea, secondary

2. Justify the diagnosis.

acne, enlarged ovary, multicyst = PCOS, Obesity, Hyperpigmentation of

the neck

3. Offer your plan for examination and management of the patient.

Hormone of pituitary gland, suprarenal (testosterone. Androgens), glucose

intolerance

4. With what disease in this patient it is necessary to make a differential diagnosis?

Pregnancy

Hyperplasia of suprarenal gland

Disorders ovarum cycle

Disorder of piturary gland

5. Possible immediate and long-term results of the disease.

Infertility

Hyperplasia of endometrium

DM type 2
Endometrial cancer
HTN, dyslipidemia

Treatment: if she does not want to have children = give combined estrogen drugs,

Pregnancy wanted: stimulate ovulation with antiestrogen hormone of

gonadotropin hormone, laparoscopic treatment.
2

Woman, 25 y.o, was admitted to the gynecological department with

complaints on severe pain in the lower abdomen with irradiation to shoulder and
scapula, fainting. Menarche at 14 years, periods are regular, last 4-5 days in every
29 days.LMP was 1,5 month ago. BP – 90/60 mmHg. Pulse – 110 beets/min.
Physical exam: darkening in the eyes, noise in the ears. Abdomen is bloated,
painful during palpation, defans, symptoms of peritoneal irritation are positive in the
lower abdomen.
Speculum examination: uterine cervix is normal, external os is closed.
PV: uterus in anteflexion-version position, isn’t enlarged, mobile, painless.
Palpation of the left appendages is complicated because of defans and painfulness
of abdominal wall. Back vault is over hanged, painful, Solovyov`s and Promptov`s
symptoms are positive. Discharges are mucous.

Investigations Results Referent ranges

Hb 88 g/l 120-140 g/l
Erythrocytes 2,6×1012/l 3,7-4,7×1012/l
Leukocytes 9×109/l 4,0-9,0×109/l
Hematocrit 24% 36-42%
Platelets 120 ×109/l 150-390 ×109/l
Загальний білок 35 g/l 60-85 g/l

Assignments:
1. What is the primary diagnosis?
Extrauterine pregnancy (maybe tubes), (rupture of tubes due to fluid),
Hemorrhagic shock,
2. Differentiate diagnosis:
Apoplexy of ovary (but if menstruation is present),Torsion of lex of ovary,
Acute appendicitis, Fibromyoma necrosis ( inflammation, temperature,
3. Algorithm of the doctor`s actions:
Puncture of Douglas pouch (if bleeding is not a lot, if bleeding is a lot surgery
- remove tube, stop bleeding under anesthetic)
4. Infusion therapy:
electrolytes, sterofundin, delafundin, plasma, tranexamic acid
5. Prophylaxis and diagnostics of another tube`s occlusion.:
look at state of second tube, diagnostics laparoscopy, anti-inflammatory
drugs, transvaginal laparoscopy.

3. A 35-year-old woman went to the doctor with complaints of dull, aching pain in
the depths of the pelvis, lower abdomen, lumbosacral region, dyspariuria. Before and
during menstruation, the pain intensifies, radiates to the side wall of the pelvis and
leg, there are dysuric phenomena, painful tenesmus, bloody discharge from the
rectum.
Speculum examination: the cervix is clean, the external os is closed.

Vaginal examination: the uterus is mobile, dense, not enlarged, painless. There is an
infiltrate behind the cervix at the level of the inner os, sharply painful, hilly,
immobile. Uterine appendages without features.

Indicator Actual indicator Reference values

HGB-hemoglobin 120 g/L 120-140 g/L
WBC -white blood cells 8.0*109/L 4.0-9.0*109/L
PLT -platelets 220*109/L 150–350*109/L
RBC - erythrocyte 4,1×1012/L 3,7-4,7×1012/L
Total protein 72 g/l 60-85 g/l
Bilirubin 19,6 μmol /l 3,4-20,6 μmol /l
Albumin 50 g/l 35-50 g/l
Protein in the urine absent absent

Tasks:

1. Preliminary diagnosis

2. Differential diagnosis

3. Additional methods of diagnostics

4. Treatment

5. Complications of therapy

Diagnosis; retrocervical endometriosis 3rd or 4th stage

 Ddx ; fibromyoma, cancer of git, cancer of rectum

Investigation; laparoscopy , irrigoscopy

Treatment ; excision of tissue progestin antiandrogen, antiestrogen

Complication: nausea, vomiting, headache, depression, obesity, htn, disorder of

thyroid gland

4. A 42-year-old patient went to the doctor with complaints of heartburn, itching

in the vagina, the presence of discharge. From the anamnesis it is known that the
woman had 2 births. There were no abortions or miscarriages. Three weeks ago,
she fell ill with COVID-19, complicated by bilateral pneumonia. Received
antibiotic therapy for 10 days. The general condition of the woman is
satisfactory, Ps 74 /min, arterial blood pressure 135/85 mm Hg. Respiration rate
14 per minute.
The abdomen is soft, painless. At gynecological inspection it is established: the
mucous membrane of a vagina at speculum inspection is hyperemic, with a white
layer. The neck is formed, the vaginal part is hyperemic. Discharge is in significant
quantities, whitish color, cheese-like consistency.

Bimanual examination revealed that the uterus and appendages were without
pathological changes. Pseudohyphae and blastospores were detected in vaginal
secretions by microscopy.

Blood counts.

Indicator In patient Reference values

HGB-hemoglobin 120 g/L 120 - 160 g/L for women
WBC -white blood cells 3.7*109/L 4-5*109/L for women
HTC -hematocrit 48 % 36 – 46 % for women
PLT -platelets 330*109/L 180 – 320*109/L for women
NEU - neutrophils 63 % 70 – 74 %
LYM- lymphocytes 15 % 22 – 26 %
EOS - eosinophils 2% 1,5 – 2 %
Bas - basophils 0.5 % 0,5 – 1 %
Mon - monocytes 19.5 % 3–6%
 ESR- erythrocyte 22 mm/h from 0 до 20 mm in women
sedimentation rate
D- dimer 0.56 mсg FEU /ml 0.55 mсg FEU /ml
Ferritin 120 10 − 120 in women

Tasks:

1. What is the preliminary diagnosis?

2. What additional research can be used?

3. What is the treatment of this pathology?

4. Criteria of curability.

Tasks:
What is the preliminary diagnosis?
Candida colpitis

What additional research can be used?

Speculum exam of vagina with smear for bacteriological examination

What is the treatment of this pathology?

Antifungal agent as vaginal suppositories: nystatin BID 7-10 days

Oral fluconazole 150mg OD

Criteria of curability?

Ginodec 5ml vaginally OD/BID 7-10 days

Lactogel 1 tube daily for 7 days
Vagilac 1 caps BID 7 days
5

The patient S., 32 years old, went to the gynaecologist for brown discharge
from the genital tract. It appears before and after menstruation and lasts 3-4 days.

From the anamnesis: 4 months ago a medical abortion was performed.

While speculum examination: cervix without any features. At bimanual research:

uterus in anteversio - anteflexio, a little bit enlarged, round form with dense
consistence. Appendages on both sides are not palpable.
Objectively - the general condition of the woman is satisfactory. Drowsiness is
noted. Palpation of the abdominal cavity without features. Blood pressure - 115/70.
Heart rate - 68 / min. BH - 20 / min. SaO2 - 97.
On ultrasound: the myometrium has a heterogeneous structure, the anterior wall of
the uterus is thicker than the posterior, the boundary between the endometrium and
myometrium is blurred.

Questions:

1. Formulate and justify the diagnosis.

Adenomyosis of uterus stage 2 prevalence

Hormonal imbalances due to medical abortion

2. Etiology and pathogenesis of the disease.

Hormonal imbalance due to medical abortion 4 months ago, damage of

basement membrane between endometrium and myometrium

3. Suggest your plan for examination and management of the patient.

Cancer marker CA-125, Hysteroscopy, CT, MRI, hormonal therapy with

progestin, gonadotropin releasing hormone.

4. With what extragenital diseases at the given patient it is necessary to carry out
differential diagnosis?

Uterine fibroids, pregnancy, uterine cancer, PCOS, varicose diseases of

abdominal arteries adhesive process.

5. Possible long-term results of the disease.

Progression and invasion, infertility
6 (this question like number 18)

A 55-year-old female patient during a routine examination revealed a tumor

formation in the left ovary. The woman does not present any complaints.
From the anamnesis: menarche from the age of 12. The menstrual cycle is
regular, 4 days after 28 days, painful. Menopause 3 years. Childbirth - 1, abortion -
2. Her grandmother died of breast cancer.
 Gynecological examination: the external genital organs are developed
correctly, hair growth is female.
Speculum examination: the mucous membrane of the vagina and cervix is
clean.
Bimanual examination: the body of the uterus is of normal size, mobile,
painless. The enlarged left ovary is palpable (up to 8 cm), mobile, not painful on
palpation. Allocation of mucous membranes, moderate.
Ultrasound of the pelvic organs: the uterus is not enlarged. The thickness of
the M-echo is 5 mm. A volumetric formation of the left ovary with dimensions of
7x8 cm is determined. Free fluid is determined in the abdominal cavity. No enlarged
retroperitoneal lymph nodes were found.
During the laparotomy approach, multiple metastatic foci in the peritoneum
were found, the size of the metastases was more than 2 cm. During the operation, a
cytological study of the tumor tissue of the ovary — adenocarcinoma — was carried
out. A study of ascitic fluid was carried out - cancer cells were found. From
laboratory examination: CA-125 - 71.0 U / ml.

Indicator Actual indicator Reference indicator

СА-125 71,0 U / ml 0-35,0 U / ml

Tasks:
1. Preliminary diagnosis?
2. Stage of the disease?
3. Plan of additional methods of examination and determination of the spread of
the tumor process?
4. Treatment tactics at this stage of the disease
Tasks:
Preliminary diagnosis?
Cancer of left ovary
Stage of the disease?
3CT3N0M0

Plan of additional methods of examination and determination of the spread of the

tumor process?
CXR for metastasis, fibro-gastroduodenoscopy, CT of pelvic and MRI of
pelvic cavity, x-ray of pelvic cavity
Treatment tactics at this stage of the disease
Extirpation of uterus and ovaries and small omentum, resection of lymphatic
nodes >2cm

A 35-year-old woman complains of discharge from the vagina, which arose after
unprotected intercourse in 7th day, slight itching of the external genital organs.
These complaints worsen the quality of her life, she needs to use additional hygiene
products (daily panty liners or changes twice of underwear during the day).
 Objective status: blood pressure - 120/70 mm Hg. Art, temperature - 36.4 ° C,
pulse 76 beats per minute, rhythmic, satisfactory qualities.
Gynecological examination: the mucosa of vaginal and cervix is hyperemic, the
discharge is penny and green. The size of uterus is normal, in anteflexio position,
mobile, painless during palpation. Applications on both sides are unremarkable. The
fornixes of the vagina are free. Menarche started at 13 years. Monthly, 4 days after
24, painless, moderate. Last menstruation 3 weeks ago.
Reproductive anamnesis: childbirth 1, abortion - 1 (artificial at 8 weeks). The type
of contraception is interuptus coitus. Allergic is absent. The vaginal discharge is
taken during the gynecological examination for evaluation the degree of purity and
bacterial culture.
Ph-test is 6.4.

Indicator Actual indicator eference Reference indicator

indicator
Ph- test 6,4 3,8-4,5

Questions:
1. Establish a diagnosis?
Trichomonas colpitis,
2. Management ?
analysis of secretion for degree of curettage, HIV blood test, examine
partner, general urinalysis, check for other STIs
3. Differential diagnosis?
Chlamydia infection, bacterial vaginosis, syphilis, cystitis, gonococcal
infection
4. Treatment and duration?
Metronidazole 200mg 5-7 days PO BID 2 months, vaginal suppositories
metronidazole 7 days

5. Criteria for removal from dispensary accounting.

Additional swap in 1 month after menstruation, and the following month
as well. Prohibition of sexual life during treatment.
 8 A 40-year-old patient complains of intermenstrual watery discharge with
streaks of blood. Anamnesis: she has a bad habit - smoking more than 10 cigarettes
a day.
Gynecological anamnesis: childbirth - 2, abortion - 2. She has been using intrauterine
contraceptives for more than seven years (at the request of the woman). Menarche
from 11 years. Menstruation for 7 days, after 30 days, painful, profuse
Anamnesis of life: she has diagnosed human papillomavirus (type 16) for about five years.
She was treated, using diathermocoagulation.
Gynecological examination: the cervix is dense, bleeds during touching with a spatula of
Eyra. The body of the uterus has normal size, in anteflexio position, mobile, painless. The
appendages are normal on both sides. The parameterium is free, the vaults are deep.
Specular examination: Schiller's test is positive. During extended colposcopy atypical areas
of the mucous membrane of the cervix are revealed in 10 00 and 200. A targeted biopsy is
taken from these sites. Biopsy results: stromal invasion and cells of microinvasive
squamous oncological process, metaplastic cells.
During additional examination: X-ray of the chest organs, ultrasound of the pelvic organs
and abdominal organs, CT scan of the pelvic organs has no signs of regional lymph node
involvement, dissemination of the process is absent.

Indicator Actual indicator Reference indicator

Erythrocytes 3,5×1012/l 3,7–4,7×1012/l
Hemoglobin 110 g/l 120–140 g/l
Hematocrit 0,32 0,36-0,42
Platelets 410×1012/l 150-390×1012/lл
Leukocytes 11,0×109/l 4,0-9,0×109/l
Lymphocytes 1,2×109/l 1,2-3,0×109/l
Monocytes 0,1×109/l 0,1-0,6×109/l
SHOE 25 mm/h 2-15 mm/h
Granulocytes 5,4×109/l 2-5,5×109/l
June 2% 0%
Chopsticks 2% 1,6%
Segments 74% 52-72%
Eosinophils 5% 2-4%
Basophils 2% 0-1%
Reticulocytes 2% 0-1%
Indicator Actual indicator Reference indicator
СА-125 (ovarian 14,5 un/ml 0-35,0 un/ml
tumor marker)
НЕ 4 (ovarian tumor marker) 76 рМ up to 40 years<81,6 рМ;
40-69 years <113 рМ;
>70 years <200 рМ
Roma Index 5,24 premenopause up to 13.1.

(НЕ4/Са125) postmenopausal up to
27.7.

Questions:
1. Establish previous diagnosis.
Cervical cancer
2. Clinical group?
Microinvasive squamosal cell carcinoma
3. Determine the stage of the tumor process?
1A
4. What additional examination methods should be prescribed?
Curettage/ diagnostical scrapping to check histological structure and ovarian
tumor markers
5. Management of treatment?
Negative markers: Remove with excision and colposcopy after surgery,
extrication without appendages
Positive markers: total expanded extrication with appendages
9

The 45-year-old patient consults with gynecologist with complaints of lower

abdominal pain, significant prolonged menstrual disorders and problems with
urination. Delivery - 1, abortion - 2. Menstruation from 13 years old, during 3-4 days
every 29 days. Blood pressure - 120/70 mm. Pulse - 78 per minute.
Due to speculum examination and colposcopy:
epithelial defect on the cervix with clear edges, inflammatory reaction, edema and
dilated capillaries. The epithelium is acetowhite.
Cytology was taken from the cervix. The result is CIN 3.
Bimanual examination:
the uterus is dense, enlarged to 13-14 weeks of pregnancy. Nodes are palpated on
the anterior, posterior wall of the uterus, on the rib. The appendages are not palpable.
Mucous secretion is visualized.

Tell about:

1. Diagnosis: leiomyoma of uterus, dysplasia of cervix uterus stage 3

2. The volume of surgery: extrication of uterus without ovary and tube
3. Preoperative examination and preparation for surgery: exam woman. (CBC
urinalysis, blood group and rhesus, blood glucose, biochemical analysis. CXR,
USI of mammary gland and chest, coagulogram, ECG, markers of cyst, do not
eat before operation, catherization
4. Management of the postoperative period: reanimassion (O2, drugs for
immunotherapy, measure vitals every 6-7 hours check diuresis. Give water in
1st day, after give solution for 2-3 days , prevent thombembolism, check
sutures after)6 days
10
Woman of 42 y.o. came to gynecologist with complaints on vaginal
bleedings and discharges, pain in the lower abdomen and lower back, sacrum.
Bleeding appears after sexual intercourses. Sometimes discharges are liquid,
sometimes – ichoric with a bad smell.Periods are regular, last 4 days in every 28
days. 2 deliveries and 1 artificial abortion(G3P2A1).
Patient had many sexual partners during her life.
Speculum examination: uterine cervix is hypertrophic, there is a lesion like
“cauliflower”, that bleeds during touching by cotton stick.
PV: uterus is not enlarged, mobile, painless. Appendages are not palpated.
Parametrial fat is impacted with infiltrates.

Investigations Results Referent ranges

Hb 100 g/l 120-140 g/l
Erythrocytes 3,3×1012/l 3,7-4,7×1012/l
Leukocytes 1,1×109/l 4,0-9,0×109/l
Platelets 280×109/l 150-390 ×109/l
ESR 45 mm/h. 0-20 mm/h.
Protein 35 g/l 60-85 g/l
Assigments:
1. To establish primary diagnosis.
Cervical cancer stage 2/3
2. To prescribe additional methods of investigations.
Colposcoy biopsy recto-vaginal examination, histological lymphography USI
for prevalence, CT and MRI, CXR, breast exam, urological, ECG

3. To provide with differential diagnosis.

Cancer of uterine body
4. Treatment.
Extirpation with appendages and lymph nodes of upper third of vagina
Post Op radiotherapy chemotherapy with combination of vincristine+cysplatine
 5. Side effects of chemo- and radiation therapy.
Leucopenia, paresthesia, weakness, nausea, abdominal pain, alopecia,
depression, weight loss, vomiting, stomatitis, ataxia, fever.

11
Lady L., 46 years old, went to a gynecologist with complaints of persistent itching in the
external genitalia.

Objectively - the general condition is satisfactory. The skin is pale pink. The abdomen is
soft, painless during the palpation.
Blood pressure - 115/70 mm. Heart rate - 68 / min. SaO2 - 97. 2
children. Menopause for 2 years.
At gynecological examination - in the area of small labia and clitoris whitish centers with
scratches and elements of inflammatory reaction are visualized.
At bimanual examination - a uterus in retroversio-retroflexio. Movable, painless on
palpation. Appendages are not palpable.

Tasks:

1. What is the diagnose?

Leucoplacia of the vulva
2. Etio-pathogenetic aspects of the disease
Hormonal disorders and immune status leading to tissue trophic disorders
3. Additional methods of diagnostics.
Serous Extended colposcopy of smear membrane on atypical cells from affected foci,
loaded target biopsy
4. Differential diagnosis
Allergies, pink herpes, syphilis, vulva cancer
5. Treatment.
Hormonal drugs
Ointments, creams
Antiseptic
Multivitamins
Surgery – laser extirpation of vulva
12
A mother with a girl of 5 years old went to the doctor with complaints of
severe itching and burning in the genitals, thick white discharge in the girl.
From the anamnesis: discharge and itching appeared a week after the end of
the course of antibiotic treatment.
Physical and sexual development is age appropriate.
Examination of the external genital organs: the external genital organs are
developed correctly, there is a pronounced edema and hyperemia of the vulva,
cheesy discharge. Not examined rectally.
 Laboratory:
Indicator Actual indicator Reference values
HGB-hemoglobin 115/ L 110-140/ L
RBC - erythrocyte 3,2×109/L 3,5-5,5×109/L
WBC -white blood cells 3,2 х 109 /L 4,5-11,0×109 /L
Stab neutrophils 4% 3-5%
Lymphocytes 25% 25-33%
PLT -platelets 190×109/L, 180-320 × 109 /L
Urea 6,3 μmol /l 2,5-8,3 μmol /l
Creatinine 55 μmol /l 53-106 μmol /l
Bilirubin 19,5 μmol /l до 21,0 μmol /l
Fibrinogen 3,5/L 3-5/L
СRP 0,5 менше 3
ALAT 20 U/l до 40 U/l
ASAT 25 U/l до 40 U/l

Tasks:
1. Preliminary diagnosis.
2. Establish the risk factors for this pathology
3. Carry out the necessary examinations.
4. Determine the treatment plan and further tactics (indicating the side effects of
the drugs)

1.candidiasis, vaginal yeast infection

2.Antibiotic use, which causes an imbalance in natural vaginal flora,

impaired immune system, Taking oral contraceptives or hormone therapy that

increase estrogen levels

3.examine the deposit microscopically for budding yeast cells, vaginal smear or
urine analysis, culture of vaginal smear
4.

5.Nausea, vomiting, headache, skin rash diarrhea, abdominal pain, reversible

alopecia,Highly teratogenic

13
A 16-year-old patient was admitted to the gynecological department with
complaints of severe bleeding from the genital tract, weakness, dizziness.
 From the anamnesis: is registered for chronic tonsillitis. Heredity is not
burdened. Menses from 15 years of age, irregular, moderate, painless. She fell ill 8
days ago, when, after a 2-month break, moderate spotting appeared. In the following
days, the intensity of bleeding increased, weakness and dizziness appeared.
Objectively: general condition of moderate severity, heart rate - 100 bpm,
blood pressure - 95/50 mm Hg.The skin and mucous membranes are pale. No
pathology was revealed on the part of the internal organs. Sexual formula - Ma2.
3Ax2P2Mei.
A special examination: the external genital organs are correctly developed, the
hair on the pubis is female, the hymen is not disturbed.
Rectal examination - the body of the uterus is not enlarged, dense, mobile,
painless. The appendages on both sides are not defined.

Laboratory:
Indicator Actual indicator Reference values
HGB-hemoglobin 55 g/l 110-140 g/l
RBC - erythrocyte 2,7×109/l 3,5-5,5×109/l
WBC -white blood 5,2 х 109 /l 4,5-11,0×109 /l
cells
Stab neutrophils 4% 3-5%
Lymphocytes 25% 25-33%
PLT -platelets 190×109/l 180-320 × 109 /l
Urea 6,3 μmol /l 2,5-8,3 μmol /l
Creatinine 55 μmol /l 53-106 μmol /l
Bilirubin 19,5 μmol /l до 21,0 μmol /l
Fibrinogen 3,5 g/l 3-5 g/l

Задания:
1. Establish a diagnosis
2. With what diseases should you differentiate?
3. Management
4. Recommendations for further management.

14

The 26-year-old patient consulted a gynecologist with complaints about the absence
of menstruation for 6 months, weight gain, increased hair growth over the upper lip,
abdomen, thighs, skin problems in the form of inflammatory rashes on the face and
back.
From the anamnesis it is known: menstruation from 15 years, irregular (duration of
a menstrual cycle 36-45 days), sparse, painless, last menstruation 6 months ago. Sex
life from 21 years. For the last 2 years she has been living a regular sexual life, she
did not prevent pregnancy, she did not get pregnant.
Objectively: the general condition of the woman is satisfactory, height 1.68 m,
weight 85 kg, BMI-30.1 kg / m2. The skin is pale pink, glistening on the face, with
acne elements, hyperpigmentation is determined in the neck. Arterial pressure-
130/80 mm Hg. Heart rate - 88 / min. respiratory rate - 17 / min. SaO2 - 97%. The
pregnancy test is negative.
Speculum examination: vaginal mucosa and cervix without features.
Bimanual: uterus in anteversio-anteflexio, slightly reduced in size, normal shape,
dense consistency. Appendages on both sides are palpable-enlarged and compacted.
The vaults are free.
According to the result of ultrasound: myometrium without features, M-echo13
mm, ovaries enlarged due to multiple follicles (more than 12 in section), located
 under the thickened teka in the form of a "necklace", in sizes up to 4-6 mm, the
volume of the right ovary 11.4 cm3, the left -14.1 cm3.

Tasks:
1. Formulate a diagnosis.
2. Justify the diagnosis.
3. Offer your plan for examination and management of the patient.
4. With what disease in this patient it is necessary to make a differential diagnosis?
5. Possible immediate and long-term results of the disease.
Diagnosis: secondary amenorrhea caused by PCOS, obesity

Investigation: level of FSH,LH, androgen, aldosterone ,estrogen, cholesterol level, protein,

lipid profile

Management: in case if she wants to be pregnant; antiestrogen hormone, gonadotropic

hormone, releasing gonadotropic hormone , laparoscopy, if she doesn’t want more children:
combined estrogen and progestin drugs, lipoic acid

DDX: pregnancy, disorders of pituitary gland, hyperplasia of suprarenal gland

Complication: infertility, cancer of endometrium, DM type 2, htn

15
Woman, 25 y.o, was admitted to the gynecological department with
complaints on severe pain in the lower abdomen with irradiation to shoulder and
scapula, fainting. Menarche at 14 years, periods are regular, last 4-5 days in every
29 days.LMP was 1,5 month ago. BP – 90/60 mmHg. Pulse – 110 beets/min.
Physical exam: darkening in the eyes, noise in the ears. Abdomen is bloated,
painful during palpation, defans, symptoms of peritoneal irritation are positive in the
lower abdomen.
Speculum examination: uterine cervix is normal, external os is closed.
PV: uterus in anteflexion-version position, isn’t enlarged, mobile, painless.
Palpation of the left appendages is complicated because of defans and painfulness
of abdominal wall. Back vault is over hanged, painful, Solovyov`s and Promptov`s
symptoms are positive. Discharges are mucous.

Investigations Results Referent ranges

Hb 88 g/l 120-140 g/l
Erythrocytes 2,6×1012/l 3,7-4,7×1012/l
Leukocytes 9×109/l 4,0-9,0×109/l
Hematocrit 24% 36-42%
Platelets 120 ×109/l 150-390 ×109/l
 Загальний білок 35 g/l 60-85 g/l

Assignments:
6. What is the primary diagnosis?
7. Differentiate diagnosis
8. Algorithm of the doctor`s actions
9. Infusion therapy
10. Prophylaxis and diagnostics of another tube`s occlusion
.
Diagnosis; ectopic pregnancy ,in the tube with rupture of tube

Ddx; apoplexy of ovary, torsion of ovary, acute appendicitis, fibromyoma,

urolithiasis

Doctor actions; puncture of douglas pouch if little bleeding, anesthesia, remove

tube, stop beeding ,hemostatics, iv fluid

Prophylaxtic; nsaid , diagnostic laparoscopy for 2nd tube condition

16
A 35-year-old woman went to the doctor with complaints of dull, aching
pain in the depths of the pelvis, lower abdomen, lumbosacral region, dyspariuria.
Before and during menstruation, the pain intensifies, radiates to the side wall of the
pelvis and leg, there are dysuric phenomena, painful tenesmus, bloody discharge
from the rectum.
Speculum examination: the cervix is clean, the external os is closed.
Vaginal examination: the uterus is mobile, dense, not enlarged, painless. There is an
infiltrate behind the cervix at the level of the inner os, sharply painful, hilly,
immobile. Uterine appendages without features.
Indicator Actual indicator Reference values
HGB-hemoglobin 120 g/L 120-140 g/L
WBC -white blood cells 8.0*109/L 4.0-9.0*109/L
PLT -platelets 220*109/L 150–350*109/L
RBC - erythrocyte 4,1×1012/L 3,7-4,7×1012/L
Total protein 72 g/l 60-85 g/l
Bilirubin 19,6 μmol /l 3,4-20,6 μmol /l
Albumin 50 g/l 35-50 g/l
Protein in the urine absent absent

Tasks:
1. Preliminary diagnosis: extragenital endometriosis, retro-cervical, severe, stage
3/4
2. Differential diagnosis: cancer of rectum, cancer of GIT organs, fibromyoma of
uterus, retro-cervical nodes of uterus
3. Additional methods of diagnostics: laparoscopy (blood, fibrin), erygoscopy to
ddx rectal cancer,
4. Treatment: surgical – excision of affected tissue,
Conservative: hormonal – progestin, oxytocin, antiandrogens, antiestrogens
5. Complications of therapy: nausea, vomiting, depression, disorder of liver,
HTN, thromboemboli, headache, obesity, disorder of uterus

17
A 42-year-old patient went to the doctor with complaints of heartburn, itching in
the vagina, the presence of discharge. From the anamnesis it is known that the
woman had 2 births. There were no abortions or miscarriages. Three weeks ago,
she fell ill with COVID-19, complicated by bilateral pneumonia. Received
antibiotic therapy for 10 days. The general condition of the woman is satisfactory,
Ps 74 /min, arterial blood pressure 135/85 mm Hg. Respiration rate 14 per minute.
The abdomen is soft, painless. At gynecological inspection it is established: the
mucous membrane of a vagina at speculum inspection is hyperemic, with a white
layer. The neck is formed, the vaginal part is hyperemic. Discharge is in significant
quantities, whitish color, cheese-like consistency.
Bimanual examination revealed that the uterus and appendages were without
pathological changes. Pseudohyphae and blastospores were detected in vaginal
secretions by microscopy.
Blood counts.
Indicator In patient Reference values
HGB-hemoglobin 120 g/L 120 - 160 g/L for women
WBC -white blood cells 3.7*109/L 4-5*109/L for women
HTC -hematocrit 48 % 36 – 46 % for women
PLT -platelets 330*109/L 180 – 320*109/L for women
NEU - neutrophils 63 % 70 – 74 %
LYM- lymphocytes 15 % 22 – 26 %
 EOS - eosinophils 2% 1,5 – 2 %

Bas - basophils 0.5 % 0,5 – 1 %

Mon - monocytes 19.5 % 3–6%
ESR- erythrocyte 22 mm/h from 0 до 20 mm in women
sedimentation rate
D- dimer 0.56 mсg FEU /ml 0.55 mсg FEU /ml
Ferritin 120 10 − 120 in women

Tasks:
1. What is the preliminary diagnosis?
Candida colpitis
2. What additional research can be used?

Speculum exam of vagina with smear for bacteriological examination

3. What is the treatment of this pathology?
Antifungal agent as vaginal suppositories: nystatin BID 7-10 days
Oral fluconazole 150mg OD
4. Criteria of curability
Ginodec 5ml vaginally OD/BID 7-10 days
Lactogel 1 tube daily for 7 days
Vagilac 1 caps BID 7 days
18
A 55-year-old female patient during a routine examination revealed a tumor
formation in the left ovary. The woman does not present any complaints.
From the anamnesis: menarche from the age of 12. The menstrual cycle is
regular, 4 days after 28 days, painful. Menopause 3 years. Childbirth - 1, abortion -
2. Her grandmother died of breast cancer.
Gynecological examination: the external genital organs are developed
correctly, hair growth is female.
Speculum examination: the mucous membrane of the vagina and cervix is
clean.
Bimanual examination: the body of the uterus is of normal size, mobile,
painless. The enlarged left ovary is palpable (up to 8 cm), mobile, not painful on
palpation. Allocation of mucous membranes, moderate.
Ultrasound of the pelvic organs: the uterus is not enlarged. The thickness of
the M-echo is 5 mm. A volumetric formation of the left ovary with dimensions of
7x8 cm is determined. Free fluid is determined in the abdominal cavity. No enlarged
retroperitoneal lymph nodes were found.
 During the laparotomy approach, multiple metastatic foci in the peritoneum
were found, the size of the metastases was more than 2 cm. During the operation, a
cytological study of the tumor tissue of the ovary — adenocarcinoma — was carried
out. A study of ascitic fluid was carried out - cancer cells were found. From
laboratory examination: CA-125 - 71.0 U / ml.
Indicator Actual indicator Reference indicator
СА-125 71,0 U / ml 0-35,0 U / ml

Tasks:
1. Preliminary diagnosis?
Cancer of left ovary
2. Stage of the disease?
3CT3N0M0

3. Plan of additional methods of examination and determination of the spread of

the tumor process?

CXR for metastasis, fibro-gastroduodenoscopy, CT of pelvic and MRI of

pelvic cavity, x-ray of pelvic cavity
4. Treatment tactics at this stage of the disease
Extirpation of uterus and ovaries and small omentum, resection of lymphatic
nodes >2cm

19

A 35-year-old woman complains of discharge from the vagina, which arose

after unprotected intercourse in 7th day, slight itching of the external genital organs.
These complaints worsen the quality of her life, she needs to use additional hygiene
products (daily panty liners or changes twice of underwear during the day).
Objective status: blood pressure - 120/70 mm Hg. Art, temperature - 36.4 ° C,
pulse 76 beats per minute, rhythmic, satisfactory qualities.
Gynecological examination: the mucosa of vaginal and cervix is hyperemic, the
discharge is penny and green. The size of uterus is normal, in anteflexio position,
mobile, painless during palpation. Applications on both sides are unremarkable. The
fornixes of the vagina are free. Menarche started at 13 years. Monthly, 4 days after
24, painless, moderate. Last menstruation 3 weeks ago.
Reproductive anamnesis: childbirth 1, abortion - 1 (artificial at 8 weeks). The type
of contraception is interuptus coitus. Allergic is absent. The vaginal discharge is
taken during the gynecological examination for evaluation the degree of purity and
bacterial culture.
Ph-test is 6.4.

Indicator Actual indicator eference Reference indicator

indicator
Ph- test 6,4 3,8-4,5

Questions:
1. Establish a diagnosis?
2. Management ?
3. Differential diagnosis?
4. Treatment and duration?
5. Criteria for removal from dispensary accounting.

20

A 40-year-old patient complains of intermenstrual watery discharge with

streaks of blood. Anamnesis: she has a bad habit - smoking more than 10 cigarettes
a day.
Gynecological anamnesis: childbirth - 2, abortion - 2. She has been using intrauterine
contraceptives for more than seven years (at the request of the woman). Menarche
from 11 years. Menstruation for 7 days, after 30 days, painful, profuse.
Anamnesis of life: she has diagnosed human papillomavirus (type 16) for about five
years. She was treated, using diathermocoagulation.
Gynecological examination: the cervix is dense, bleeds during touching with a
spatula of Eyra. The body of the uterus has normal size, in anteflexio position,
mobile, painless. The appendages are normal on both sides. The parameterium is
free, the vaults are deep.
Specular examination: Schiller's test is positive. During extended colposcopy
atypical areas of the mucous membrane of the cervix are revealed in 10 00 and 200.
A targeted biopsy is taken from these sites. Biopsy results: stromal invasion and cells
of microinvasive squamous oncological process, metaplastic cells.
During additional examination: X-ray of the chest organs, ultrasound of the pelvic
organs and abdominal organs, CT scan of the pelvic organs has no signs of regional
lymph node involvement, dissemination of the process is absent.
Indicator Actual indicator Reference indicator
Erythrocytes 3,5×1012/l 3,7–4,7×1012/l
Hemoglobin 110 g/l 120–140 g/l
Hematocrit 0,32 0,36-0,42
Platelets 410×1012/l 150-390×1012/lл
Leukocytes 11,0×109/l 4,0-9,0×109/l
Lymphocytes 1,2×109/l 1,2-3,0×109/l
Monocytes 0,1×109/l 0,1-0,6×109/l
SHOE 25 mm/h 2-15 mm/h
Granulocytes 5,4×109/l 2-5,5×109/l
June 2% 0%
Chopsticks 2% 1,6%
Segments 74% 52-72%
Eosinophils 5% 2-4%
Basophils 2% 0-1%
Reticulocytes 2% 0-1%

Indicator Actual indicator Reference indicator

СА-125 (ovarian 14,5 un/ml 0-35,0 un/ml
tumor marker)
НЕ 4 (ovarian 76 рМ up to 40 years<81,6 рМ;
tumor marker) 40-69 years <113 рМ;
>70 years <200 рМ
Roma Index 5,24 premenopause up to 13.1.
(НЕ4/Са125) postmenopausal up to
27.7.
Questions:
1. Establis previous diagnosis.
2. Clinical group?
3. Determine the stage of the tumor process?
4. What additional examination methods should be prescribed?
5. Management of treatment?