OBSTETRICS & GYNAECOLOGY

BEST OOCYTE MAKE BEST EMBRYO

BEST EMBRYO MAKE BEST HUMAN

DR. PRASSAN VIJ

OBSTETRICS & GYNAECOLOGY
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
01
OBSTETRICS & GYNAECOLOGY
02

Epitheliums:-

TZ:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
03

Isthmus:-

ANAT.
INT.OS
Isthmus
HIST. INT. OS
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
04

Primordial Follicles:-
Maximum at:
At Birth
At Puberty
Per month: Per Year: 30 years:

Therefore, Best Fertility:-

Good Chance

After 35 years

After 40 years
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
05

Puberty:-
1 st Sign of puberty:
Events:

Age of Puberty:- Early puberty

Precocious:
Precocious Breast

Delayed Cycles:-

No Periods till:

With Pubic Hair:

Whats Primary Amenorrhea?

Menopause:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
06

28 year old woman + I.C

17-year-OLD girl
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
07

With Ovulation:-
Pain at Ovulation: Pain at periods:

Shedding of Endometrium

Expulsion of Endometrium:

With Anovulation:-
No Ovulation: No No Injury: No

No progesterone… then Shedding of Endometrium?

Expulsion of Endometrium?
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
08

Therefore,
Ovulatory Cycles:-
Anovulatory Cycles:-

Dysmenorrhea Types

Rx Dysmenorrhea:-

NSAIDS

Antispasmodics
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
09

FSH:

LH:

FSH Values:

Ovarian Reserve:-
Parameter
Age
Size of ovary
AFC
Sr FSH
Sr Inhibin
Sr. AMH
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
10

LH
FSH

Pit Hormone Follicular Phase Luteal Phase

Ovarian
Anatomy
Prog

2 00Pg
150-
Ovarian EST
Hormone

Endometrium
0 Proliferation 14 Secretion 28
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
11

IC:-

LH
FSH

Pit Hormone Follicular Phase Luteal Phase

Ovarian
Anatomy
Progesterone

20 0Pg
n 150-
oge
Ovarian Estr
Hormone

Endometrium
0 PROLIF. Phase 14 Sec. Phase 28
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
12

Tests of Ovulation:-
Sr Progesterone

BBT

LH levels

Serial Ultrasonography

Endometrial Biopsy:-
Timing

Shows

And also, Appropriate

MittleShmerz

Cervical mucus studies

Laparoscopic Evidence of C.L

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
13

------------------

FSH----

LH-----

T. Estrogen

T. Progesterone

Dose given:-

Rarely:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
14

Contra-Indications:-
Pregnancy
Lactation
Liver Disorders
Uncontrolled DM, Lipids
H/O DVT, Thromboembolism
Previous Coronary Artery Disease

BP: Age: Smokers:

Migraine: Especially with Aura

No Contra Indication if

Starting COCPs:

Missed Pills:
If 1 or 2 Missed
If 3 or more missed

Question:
Woman on COCPs, missed 4 tablets
Woman on COCP, missed 4 times this month
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
15

Emergency Contraception:-

Prevent a pregnancy within 72 hours of Unprotected Intercourse

Levonorgestrel ( EZY pill)

Mifepristone 25-50 mg

Yuzpee Regime: COCPs 100ug twice a day

Ullipristal Acetate

Dose:
Mechanism of action: it is a SPRM Selective Progesterone Receptor
Modulator.
Binds to the progesterone receptors.
Inhibits LH Surge therefore prevents ovulation.
It also inhibits tubal function thus the zygote is late to move in
the tube.
Ulipristal does not prevent implantation of a fertilized egg into the uterus

IUCDs
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
16

PCOS/PCOD/Stein & Levinthal Syndrome:-

Incidence

Criteria For Diagnosis: Rotterdam:

Anovulation
Hyperandrogenism
USG Picture

Gross appearance:

Cut Section:

Normal cycle Revision:

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
17

PCOS Cycle:

Syndrome Lab Parameters

Anovulation LH:FSH Ratio:
Infertility Androstenedione
Hyperandrogenism Testosterone
Hirsutism SHBG (Sex Hormone Binding Globulin)
Oligomenorrhea Is Limited in amount
Amenorrhea Net result:

Associated with IR: Acanthosis Nigricans: ‘Dark, Velvety, shiny deposits”

in Crural Areas:

Syndrome X (Metabolic Syndrome)

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
18

PCOS can have in Later Life:

Treatment of PCOS:-
1 St line Management

Irregular Cycles:

Hirsutism

Anovulation:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
19

Non-Responsive to Treatment: Surgical Treatment of PCOS

LAPAROSCOPIC OVARIAN DRILLING

"The high local Androgen’’

makes the follicles Hard. & Prevent their growth.
Burn the ovarian Stroma
Reduces local Androgen & increases follicular Response

Question:
23 year old, Irregular Cycle and Hirsutism/ACNE:

Infertility:-
Incidence:

Why?

Fecundability: Fecundability is the probability of being pregnant in a

single menstrual cycle
Fecundity: The probability of achieving a live birth within a single cycle.
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
20

Causes of Infertility:-
Male Alone:
Mostly
Psychiatric Disorders like:
Inherited conditions like:
Surgical conditions:

Injuries
Infections

Female Alone
Most common and Most treatable cause of infertility

Male and Female both:-

Un-Explained:

Work Up:-
History:

Examine:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
21

Investigations:-
First is always the Semen analysis:

Semen Parameters WHO 2021 WHO 2010

Volume 1.4 ml 1.5 ml
Concentration 16 million/ml 15 million/ml
Total Count 39 million 39 million Total
Total Motility 42% 40%
Active Motility 30 32%
Vitality 54% 58%
Morphology 4% 4%
Pus Cells <1 million/ml semen <1 million/ml semen
OBSTETRICS & GYNAECOLOGY
22
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
23

Female:-
Tests of Ovulation:

Tubal Patency:

HSG: Radio Opaque Dye Instilled under fluoroscopy Guidance:-

Female HSG Test

Laparo-Hysteroscopy:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
24

Treatment::-
Fertile period and Timed Intercourse
Follicular Monitoring

Ovulation Induction and FM

Intrauterine Insemination: Pre-Requisites:

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
25

In Vitro Fertilisation:-

For Very Low Counts like <1 million

Or For Azoospermic men where sperms are surgically retrieved

Surgical Aspiration procedures

What is ‘ART” ?:-

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
26

Steps of fertilization
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
27
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
28

Endometriosis:- Ectopic Endometrium

Etiology:

Age:

Type:

Retrograde Menstruation:

Pathology:-
Types of Deposits:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
29

Sites of Deposits:

Symptoms:

Diagnosis:-
CA 125
USG: Ground Glass cyst
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
30

Best Diagnosis:

Treatment:- Surgery to remove all gross disease

Cyst

Adhesions

Small deposits

Remember!

Medical Management:- Basically ‘reduce the estrogens’ !

Pain Relief:

Disease Control:-

COCP

Progesterones

Androgens
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
31

GnRH Analog:

Remember: If GnRHa are given for >6 months—Can cause:

Therefore, If GnRHa need be given for 6 months: Then for OP prevention…

Give Add Back Therapy

ADENOMYOSIS:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
32

Hormone Replacement therapy:-

Indications:

Contra Indications:

Investigations: Liver Fn Test, Lipids, Sugars

Paps, Mammography, TVS
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
33

Drugs:-
T. Estradiol

T. Conjugated equine estrogens

Tibolone

Raloxifene

Plant estrogens

Bisphosphonates

R PTH

Denosumab
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
34

Must Know:-

Hot Flushes

CAD

CA Endometrium:-

Age: M/C: Variety:

Poor Prognosis Variety:

Due to:- High Estrogen Conditions like

HRT

Tamoxifen

Anovulation

Estrogen Producing Ovarian Tumors

Early Menarche and Late menopause

Obesity

DM, HTN, Obesity (Corpus Cancer Syndrome)

Nulliparity

Familial Predisposition
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
35

Hyperplasia Ca Endo Treatment:-

Simple Endometrial Hyperplasia NO Atypia

Complex Endometrial Hyperplasia NO Atypia

Simple Endometrial Hyperplasia WITH Atypia

Complex Endometrial Hyperplasia WITH Atypia

Symptoms:-

Work Up:

Also:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
36

Staging:-

Ca Endometrium:-
1: Ltd to the Uterus
IA: Endometrium and <1/2 myometrium
IB: Myometrium ≥1/2

II: Cervical Stromal involvement

IIIA: Uterine serosa and Adnexa

IIIB: Vaginal &/or parametrial Involvement
IIIC: C1 pelvic LN involvement
C2 para-aortic LN Involvement

IVA: Bladder & Bowel Involvement

IVB: Distant metastasis including

Inguinal LN

Should read Grading of tumours as well

Treatment:-

Prognosis Depends best upon Grading:-

1 5% or less of tumour tissue is solid tumour growth.

2 6%-50% of tissue is solid tumour growth.
3 More than 50% of tissue is solid tumour growth.

Also on:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
37

Ca Cervix:-

Type:

Due to: 50 serotypes of HPV

Also associated with HIV HSV

LSES, Smokers

Vaccine:- Gardasil 9
Schedule

0 day

2 months

6 months

SAGE (Strategic advisory group of experts on immunization)

Guidelines: Give at least 1 vaccine to all girls from 9-14 years

Screening for CA Cervix:-

VIA

Best method is PAPs

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
38

Paps Smear:-

Where to Do?

Whom to do ?

When to start?

Frequency?

Method: Ayres Spatula, Cyto-brush, Cyto-broom

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
39

Contents of Papanicolaou Stain:-

Hematoxylin
Orange Green 6
Eosin Y
light green SF
Bismarck brown

Nuclei: Blue
Acidophilic cells: Red
Basophilic cells: Blue Green
Erythrocytes: Orange-red to dark pink
Keratin: Orange-red

Intermediate and Parabasal Cells: Blue-Green

Eosinophil: Orange Red
Metaplastic cells: May contain both blue/green and pink
Candida: Red
Trichomonas: Grey-green

Interpretation:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
40

Findings Dysplasia Classif’n Bethesda Classification

If <1/3 CIN I Low Grade Squamous
abnormal cells Intraepithelial Lesion (LGSIL)
If 1/3 to 2/3 CIN II
abnormal cells
If > 2/3 CIN III High Grade Squamous Intra
abnormal cells Epithelial Lesion (HGSIL)
If all Cells are Ca in Situ
Abnormal:

CIN I CIN III Ca Cervix

Mx of CIN I:

Management of CIN III:-

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
41

Summary:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
42

Symptoms of CA Cervix:-

Staging:-

Stage I: Go to the cervix

A: MCROSCOPIC CQUCER
A 1 <3mm depth of invasion
A 2 3to 5mm depth of invasion
B >MACROSCOPIC /Clinical obvious Cancer
B 1 <2Cm, B 2 2-4cm, B >4cm
II A upper Vaging A 1 <4cm
A 2 >4cm
IIB Parametrial Growth, short of Pelvic wall
IIIA Lower 1/3 rd Vagina
m/c Stage to OPD IIIB PM involved till Pelvic side wall Hydronephrosis
IIIC C 1 Pelvic LN, C2 Para Aortic LN.
IVA Bladder + Bowel
B Distant metastasis Inguinal LN no involvement

Treatment:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
43
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
44

Ovarian Tumors:-

MC Type:

Etiology:

Epithelial Injury:
Early Menarche & Late menopause
Nulliparity
Infertility Treatment

Association with:

Familial Predisposition

Symptoms:-

Diagnosis:

Risk of Malignancy Index:-

Criteria Scoring System

(A) Menopausal Status Premenopausal: 1
Postmenopausal : 3

(B) Ultrasound Features No Features: 0

One Feature: 1
Multiloculated >1 Feature : 3
Solid Areas
Bilateral masses
Ascites
Metastasis

(C) Sr. CA 125 Absolute Levels of CA125

Risk of Malignancy Index (RMI)=A x B x C <25: Low Risk

RMI-1 25-250: Moderate Risk
>250: High Risk
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
45

Treatment:-
Staging Laparotomy and Maximal Cytoreduction
Steps:
A Vertical Midline or Para Median Incision given

A systematic Clockwise exploration from caecum upwards is done of all

pelvic and abdominal surfaces & viscera
Any suspicious areas or adhesions on the peritoneal surfaces should be
biopsied.
The diaphragm should be sampled by scraping (tongue depressor) for cytology
Supracolic Omentectomy
Biopsy of pelvic and paraaortic lymph nodes
Remove all gross disease
Staging:
Ca Ovary:-
Ltd to the ovaries
IA: One ovary
IB: Both ovaries
IC: Stage IA or IB with
C1: Surgical Spill
C2: Surface Growth
C3: Malignant ascites or Washings

IIA: Uterus and Fallopian tubes

IIB: Other Pelvic organs
III: Abdominal Viscera Involved
IIIA1: Retroperitoneal LN: A1(i): <10mm
A1(ii):≥10mm

IIIA2: Microscopic Abdominal Involmnt.

IIIB: Macroscopic Involvement<2cm
IIIC: Macroscopic ≥2cm

IVB: Deep liver and Spleen deposits & Inguinal LN involved

Other Treatment modalities
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
46

Ovarian Tumors Types:-

The epithelial Ovarian tumors:

Most common ovarian tumor :These are B/L mostly and in older women
M/C Epithelial tumour is Serous Cystadenoma... like Fallopian tube
80% of epithelial ovarian tumor
B/L In >50% of cases and mostly malignant
Unilocular tumors...one loculated collection present
Large in size
Serous epithelial ovarian cancers be separated into two distinct
groups—type I and type II serous tumors—
Type I tumors include serous borderline tumors and low-grade serous
carcinoma; they are genetically stable and are characterized by
mutations in KRAS and BRAF.
Type II serous tumors are rapidly growing, highly aggressive neoplasms

Psammomabodies are frequently found in these neoplasms, and they are

with lamellar pattern.

Mucinous Tumors.... like endocervix

B/L in 10 % of cases and lesser malignant as compared to serous

Multi Loculated tumors.

Pseudomyxoma peritonei
abundant mucoid or gelatinous material in the pelvis and abdominal cavity

In ovarian tumors the most common cause of Pseudomyxoma peritonei is

the mucinous cystadenoma .Over all It is most commonly secondary to a

gastrointestinal primary;

Brenner Tumor: Made of Transitional cells... like the bladder.

Nest of transistional cells are known as Walthard inclusions. This tumor
is mostly benign and is associated with Post menopausal bleeding

M/C cause of Pseudomeigs syndrome i.e any other ovarian tumor than
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
47

Endometrioid Tumors: like the endometrial Epithelium . Endometrioid

lesions constitute 15% of epithelial tumors. These are mostly Malignant.
These are essentially solid with cystic areas.

Endometrioid neoplasia includes all the benign demonstrations of

endometriosis.

Germ Cell Tumors:-

Unilateral, Young Women: 20% of all ovarian neoplasms
Most common are the teratomas:
10%Malignant
90% Benign: also known as Dermoid or benign Cystic teratomas
Has all the germ layers derivatives Like from the endoderm, mesoderm &
the ectoderm.
So can have bone, teeth, cartilage, sebaceous secretions , endocrine glands
and Hair.
10-15 %can be bilateral.
They have a protuberance in the cyst.. Rokitansky
Can have malignant transformation to squamous cell carcinoma .
M/C ovarian tumor of pregnancy and of Torsion

Dysgerminoma:
Most common germ cell malignancy. 40-45% .
Only B/L Germ Cell malignancy in 10-15% of cases
Are frequently associated with hypercalcemia

5% are Associated with dysgenic gonads

Seminoma type cells: large polygonal cells with clear cytoplasm and dark
nucleoli and back to back arrangement
Increases LDH, Placental alkaline phosphatise and NOT AFP !Also HCG
increased
Only radiosensitive ovarian tumor

Yolk sac tumors: Also known as Endodermal sinus tumors

Schiller duval bodies... i.e, the endomdermal sinus which opens on to the
surface of the ovary.
young women and girls, poor prognosis

Embryonal tumors: young women and girls, poor prognosis

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
48

Sex Cord Ovarian tumors:-

Granulosa cell tumors
Estrogen producing. Causes Menorrhagia, precocious puberty and also
hyperplasia and ca Endometrium
Contra lateral ovarian secondaries prior to systemic secondaries
Carl exner bodies: These are are rosette-like formations with central

Granulosa cell tumorsmarker : Inhibin and not estrogens

Sertoli Leydig cell tumors:
Known as the androgen producing arrhenoblastomas in women
Oligo Menohorrhea, to amenorrhoea. Rapid onset hirsutes

Krukenbergs tumor:-
M/C secondary from ca stomach , ca breast
B/l in 90% of cases and have signet ring cells like ca stomach.
Firm to solid tumor ,May have cystic changes & ovary retains the shape in
spite of increasing much in size

Non-Neoplastic ovarian cysts:-

Follicular cysts
Corpus Luteal cysts
Theca lutein cysts ( Inc.hCG like in molar pregnancy and twins)
Haemorrhagic cysts

These are all Self limiting, no surgery required

OVARIAN CYSTS IN PREGNANCY:

If asymptomatic and small ( < 5cms) conservative
Large and asymptomatic: remove in the second trimester
If diagnosed in the third trimester, then remove early in the puerperium
But if Cesarean is done,for any reason, then remove along with it.
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
49

Mx of Simple Ovarian Cysts in Pregnancy:-

<5 cm 5-9 cm >= 10 cm
Usually remain Follow up with USG and To be removed,
asymptomatic and doppler. Resection to be preferably in the
require no treatment. done in case of second trimester
Only follow up to be
done Suspicion of malignancy
Sudden growth
Becomes symptomatic
Torsion
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
50

Ca Cervix Ca Endometrium Ca Ovary

1: The carcinoma is 1: Ltd to the Uterus Ltd to the ovaries
confined to the
cervix
IA1: Depth of invasion IA: Endometrium and IA: One ovary
less than 3 mm <1/2 myometrium
IA2: Depth of invasion IB: Myometrium ≥1/2 IB: Both ovaries
3-5 mm
IC: Stage IA or IB
with
IB1:≥5mm & less than 2cm II: Cervical Stromal C1: Surgical Spill
IB2:≥2cm & <4 cm involvement C2: Surface Growth
IB3:≥4cms IIIA: Uterine serosa & C3: Malignant ascites
Adnexa or Washings
IIA: Upper vagina IIIB: Vaginal &/or
Involved:A1:4cm, parametrial Involmnt
A2≥4cm
IIIC: C1 pelvic LN IIA: Uterus & Fallopian
IIB: Paramet involved, involvement tubes
short of pelvic wall C2 para-aortic LN
IIIA: Lower 1/3 Vagina Involvement IIB: Other Pelvic
IIIB: Parametrium till IVA: Bladder & bowel organs
pelvic side wall involvement III: Abdominal viscera
(Hydronephrosis of IVB: Distant metastasis in volved
kidney seen here!) including Inguinal LN IIIA1: Retroperitoneal LN
A1(i):10mm
IIIC: C1 Pelvic LN, A1(ii):≥10mm
C2 Para-aortic LN Should read Grading of
tumours as well IIIA2: Microscopic
Abdominal Involmnt
IVA: Bladder & bowel IIIB: Macroscopic
Involvement<2cm
IVB: Distant metastasis
IIIC: Macroscopic ≥2cm
IVA: Malignant pleural

IVB: Deep liver & Spleen

deposits & Inguinal
LN involved
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
53
OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY 54

Fibroids:- Etiopath:

M/C tumor of Women

Associated with Increase in estrogens

Familial predisposition,

Nulliparity

Obese red meat eating women

Increase growth factors:

TGF
PD GF
EGF
VEGF

Also asso with: Chromosomal defects

Starts Always:-
Can move towards serosa and Mucosa
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
55

Symptoms:- MC: Bleeding

Due to

Pain:- Due to

Dysmenorrhea

Compression of Organs: eg Ureter

Torsion

Degeneration
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
56

Infertility:-

Bladder Symptoms

Diagnosis:

Treatment Principles:-

Small (≤5 cms) Asymptomatic & NO P B I

Small (≤5 cms) Symptomatic & With P B I

Large (≥10 cms) Symptomatic with P B I

Large (≥10 cms) Asymptomatic NO P B I

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
57

Surgical Treatment:-
Age ≥ 40 years Completed Family:

Younger women:- Myomectomy

Laparotomy

Laparoscopic: Type Size

Hysteroscopic: Type Size

Medical Management:-
Nsaids

Tranexamic Acid

Gnrha

GnRH Antagonists

Mifepristone
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
58

Ulipristal

MIRENA

Uterine Artery Embolization

High Intensity Focused Ultrasound

Reduce Intra-Operative Blood Loss by:-

Vasopressin

Clamps

Asherman Syndrome:-
Endometrial Fibrosis/Synechiae/Adhesions
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
59

Endometrial Tuberculosis

Overzealous Curettage

Symptoms:-

Diagnosis:-
HSG

USG

Best diagnosis:
Treatment:

Follow With:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
60

Pelvic TB:-
Always secondary to:

Uterus will have:-

Acute Endometritis:
Chronic Endometritis:

Diagnosis:-

Treatment:-

PID:-

M/C Cause
Prevalence wise

Symptomatic

Other causes
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
61

Symptoms:-

Signs:-
Fever
Increased CRP
Leucocytosis
Lower Abdominal Tenderness
P/V:

Additional Criteria:- Special Cultures

Gonorrhea
Chlamydia

Elaborate Criteria:-

Diagnostic Laparoscopy
USG Showing …

Treatment: OPD regime is:-

1 Shot Cephalosporin Injections:

T. Doxycycline 100mg BD for 14 days

T. Metronidazole 500 mg (400mg India) BD for 14 days

Vaginitis:- Normal Ph of vagina

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
62

Acidic Alkaline

Bacterial Vaginosis Trichomoniasis Alk PH Candidiasis:C Albicans:

MC Vaginitis Acidic PH
Hemophillus vaginalis Trichomonas Vaginalis Dimorphic fungi:
Gardenella Vaginalis Flagellate protozoa Spores: Cause the
infections
Alkaline Ph Motile & causes severe Mycelia: Invasion and
adherence
Creamy White discharge
Fishy odour: More Colpitis macularis Curdy white, cottage
after Sex (Strawberry vagina) cheese like discharge
Whiff test: To Greenish yellow frothy On trying to remove
secretions when KOH discharge this white plaque there
is added, releases are petechiae
Amines
Severe pruritis Out of proportion
pruritis
Clue cells: vag epith Synd: Like BV Diagnosis: Sabrauds
Cells with embedded dext agar. Nickerson
bacteria media
No pruritis Also NAAT
Dx: Microscopy: See Treatment is
motile organisms Local antifungals creams
Amsels criteria: 3 or May have & tablets: Miconazole,
more is Dx of BV. Butoconazole, clotrimazole
Syndrome of BV: Treatment: Metronidazole
Only approved oral
PID, relapse of PID,
antifungal: Fluconazole
Chorioamnionitis,
Abortions, PTL, IUD of
fetus, Puerperal sepsis
Rx Man and woman Both. Better: Rx man & Woman
Dx: NAAT Complicated Candidiasis:
Treatment is: By Non Albican Species: C
Metronidazole Gabralta. Tropicalis Recurrent
Only Woman is treated.
No sexual Transmission!!
Seen in IC host: HIV,
Pregnancy, DM, Chemoth
pts.
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
63

Abnormal Uterine Bleeding:-

Length: Normal
Duration: Normal
Amount of Blood Loss: Normal
Length ABNORMAL
Oligomenorrhea
Amenorrhea
Polymenorrhea
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
64

Duration: ABNORMAL
Hypomenorrhea
Menorrhagia

Amount of Blood Loss ABNORMAL

Hypomenorrhea
Menorrhagia
Polymenorrhagia

Metorrhagia

Meno-Metorrhagia

Post Menopausal Bleeding:-

Bleeding after:
MC Cause in India
MC Cause

MC in the western Hemisphere:-

Other causes:
MC in the world !!??
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
65

Cryptomenorrhea:

Ex. Imperforate Hymen

Causes Of Abnormal Bleeding:-

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
66

Treatment of AUB:- First Line Treatment

NSAIDS

Second Line:- Hormones

Progesterone
Estrogens
Androgens
GnRHa

Next: Surgical Treatment: Dilatation & Curettage:

Uterine Artery Embolization

Endometrial Ablation:
Microwave
Thermal Balloon

Hysterectomy
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
67

Mullerian System: Formation and defects

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
68

Vertical Fusion defects of mullerian system

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
69

Lateral Fusion Defects

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
70
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
71

PHYSIOLOGICAL CHANGES IN PREGNANCY:-

Uterus:
Non Pregnant Uterus is 60 gms Uterine hypertrophy early in
pregnancy
& Pregnant Uterus At term is Probably stimulated by the action
1100gms ! of Estrogen
Perhaps progesterone

Shape of Uterus : Globular and almost spherical by 12 wk gestation

At 12 weeks: Abdominal
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
72

Uteroplacental blood:-
Range from 650-800 mL/min
@ term

Cervix: Estradiol stimulates growth of columnar epithelial of the cervical

canal so it becomes violet and is called Ectropion.

Chadwick sign (Jacquemier's sign) is a bluish discoloration of the Vagina &

cervix at 6- 8 weeks
Osiander (Vaginal Sign), pulsatality in lateral fornices by 8th week
Goodell sign softening of the cervix, 6-8 weeks

HEGARS SIGN:-
On a P/V: Softening of the Isthmus

uterus, 6th week

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
73

Braxton hicks contractions: 16-18 wks

Intensity:
Frequency:

BREAST:-

Oestrogen leads to increase in number of glandular ducts.

Progesterone: Proliferation of glandular epithelium of the alveoli.

Prolactin leads to active secretion of milk after birth.

Breast tenderness and paraesthesia

Areolae become broader & have a number of small elevations, the glands
of Montgomery, which are hypertrophic sebaceous glands.
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
74

CARDIOVASCULAR SYSTEM:-
Heart: Moves upward, hypertrophy of cardiac muscle
Cardiac Output: Starts increasing by as early as 5th week !
Peak at 32nd –34th week
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
75

BLOOD PRESSURE:-
Early or mid pregnancy BP reduces.
Late pregnancy Bp gets back to normal….
Heart rate increase (10-20%).
Stroke volume increase (10%)
Mean arterial blood pressure decrease (10%)
Peripheral resistance decrease (35%)

Supine hypotensive syndrome:-

In approximately 10 percent of women
Supine compression of Great vessels by uterus

Exaggerated splitting of S 1
A loud easily heard third sound:
>95% develop systolic murmur
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
76

HEMATOLOGY:-
Blood volume: Increase by 30%-45% at 32nd –34th (peak)

The factors contributing include:

Increase sodium retention.

Decrease in thirst threshold.
Decrease in plasma oncotic pressure.

Red cells, number Increase, Fluids Also Increase… But,

Hb: 13gm% 11g%, (HCT:38% 31%)

Decrease in:
Red cell concentration
Hemoglobin concentration
Plasma folate concentration

Increase in:
White cell count
Erythrocyte segmentation rate
Fibrinogen concentration

Clotting factors in pregnancy:-

Increased concentrations of all clotting factors
Except XI and XIII
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
77

Non-Pregnant women: Fibrinogen (factor I) Averages 300 mg/dL

In Pregnancy: Fibrinogen increase is 50%. Averages 450 mg/dL

Respiratory Changes:-
Diaphragm rises about 4 cm
Subcostal Angle: 68 deg to 104 deg
R rate: No change ! ( Williams)
Vital capacity: no change
Tidal volume: 40%

Functional residual capacity:-

FRC 20 to 30 % (400 to 700 mL)
(FRC =Expiratory reserve volume & Residual Volume)

Inspiratory capacity: by 5 to 10 percent

Total lung capacity
Combination of FRC and inspiratory capacity—is unchanged !

The Urinary system:-

Kidney size increases by 1.5 cms

GFR: 50%
Glucosuria: May not be abnormal…
Proteinuria: >300mg/in 24 hr. Urine
Serum creatinine levels decrease 0.7 to 0.5 mg/dL
Creatinine clearance 30 % from 100 to 115 mL/min
Ureter: Dilated (Gravid Uterus pressure and progesterones)
Bladder: Frequent micturition ( pressure and uretheral length)
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
78

Gastrointestinal system:-
Pyrosis (Heartburn) is seen
Gastric emptying time is unchanged (Williams)
Motility of large bowel is diminished: Constipation, Hemorrhoids

ALK PO 4 doubles almost

SGPT, OT, GGT all reduced

Sr. Albumin concentration reduces…though total Albumin

High Progesterone: Inhibits cholecystokinin-mediated smooth muscle
contraction > this results in Impairs gallbladder emptying

Intrahepatic cholestasis and pruritus gravidarum: Retained bile salts.

Endocrine:-
Pituitary: Hypertrophy by 135 % due to high Estrogen
Gonadotrophs decline in number
Corticotrophs and thyrotrophs remain constant.
Somatotrophs are generally suppressed
(Negative feedback by the placental production of growth hormone)
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
79

Free T3 T4 Unchanged
Also, hCG has intrinsic thyrotropic activity & this high Sr. hCG will do
thyroid stimulation making thyroxine

For > 80 % of pregnant women

Diagnosis of pregnancy:-

On the Day of missed periods

Urine Pregnancy test:

Sr HCG by Elisa

Radio immune assay (RIA):

100% sensitive (Sensitivity to 5 mIU, day 7th of ovulation!)

Ultrasonography:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
80

Diagnosis of Pregnancy
> 12 weeks FHS heard with fetal doppler
> 24th week fetal heart heard with Steth.
Palpation of fetal parts: from 24th weeks.

Fetal movement:
16-18 weeks in Multigravida
20 weeks odd in Primigravida

Braxton hicks sign:

Irregular painless contraction palpable after 16-18 weeks

Puerperium
1 week, uterus weighs approximately 500 g;
2 weeks, about 300 g;
4 weeks, involution is complete uterus weight is approx.100 g.

Lochia
First few days after delivery discharge is bloody —lochia rubra.

After 3 or 4 days, lochia becomes pale in color —lochia serosa.

After approximately the 10th day, because of an admixture of leukocytes

lochia assumes a white or yellow-white color: lochia alba.

Involution
At Del... At 2 weeks

At 6 weeks Rate:

Sub-Involution:-

Causes:
Infection
Retained intra uterine products
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
81

Fibroids
Psychiatric Illnesses:-

Postpartum Blues Postpartum Depression Postpartum Psychosis

50-85% mothers in
postpartum 3 months postpartum
postpartum
Symptoms: irritability, Symptoms: excessive guilt, Symptoms: mixed or rapid
anxiety, anhedonia, cycling, agitation,
mood, & increased depressed mood, insomnia/ delusions, hallucinations,
emotional reactivity hypersomnia, suicidal disorganized behavior,
ideation, & fatigue cognitive impairment, &
low insight
Mild & spontaneously Moderate to severe Severe, considered
remits, not considered symptoms, prolonged psychiatric emergency:
psychiatric disorder course Often necessitates
hospitalization

Tubectomy

Timing:

Puerperal Most Common

Best time to do this

Maximum time this can be done

Interval

Concurrent
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
82

Mode of entry

Site of Tubectomy

Instruments used

Techniques of Ligation

MC is Pomeroy’s (Modified)

Problem with this one?

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
83

Parklands

Irwings

Kroners

Madleners
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
84

Laparoscopic Procedures

https://www.youtube.com/watch?v=pIZrMO2Kbho
Rings Sterilisation

https://www.youtube.com/watch?v=m9Wc0QkMxaU&t=297s
Clips Sterilization
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
85

Wrong Ligated Structures?

Re Anastomosis Success

Best with

Worst with

Vasectomy:
Now we do the t

Instruments Used
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
86

Precaution:

Therefore: Post Vasectomy, use alternative method of Contraception for

Then also do …

Complications seen
Hematoma, Infections
Spermatic Cyst
Anti-Sperm Antibodies

Also seen ??
Loss of Libido
Loss of Strength to do work
Inability to work
OBSTETRICS & GYNAECOLOGY
87

Remuneration offered by the Government

For tubectomy (non high focus state) - Rs 600
High focus state - Rs 14000

For vasectomy (non high focus state) = Rs 1100

High focus states - 2000

Under Mission Parivar Vikas tubectomy can go upto Rs 2000 and

vasectomy can qo upto Rs 3000

MEDICAL & SURGICAL DISORDERS IN PREGNANCY:-

Hypothyroidism:
Maternal Thyroxine production should be proper amount since the fetus is

TSH should be less than 2.5 mU/L in pregnancy. More than 2.5 is to be
investigated… if Anti TPO is positive, then start treatment with
supplemental Thyroxine even at these values.
More than 4 mU/l is to be treated straightaway

Hyperthyroidism:
Doc in the First trimester is PTU
After 12 weeks it is Methimazole/Carbimazole. These are not given in

choanal atresia, facial abnormalities, and mental retardation

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
88

Epilepsy:
DOC is Lamotrigine. Even levetiracetamis a good drug (both CAT C drugs).
Also can give Carbamazepine, Phenytoin (Both CAT D)
Epilepsy presents with convulsions. 30% increase convulsions during
pregnancy (Epilepsy causes convulsions due to neurological disorders and

blood pressure)

Tuberculosis:
Can get worse in any trimester but its most likely to get worse in the
puerperium. That’s because of ongoing immunosuppression, increase
demands of Lactation and poor supply, Associated Anemia and poverty.
All 4 drugs, HRZE, can be given in pregnancy if required

Appendicitis:
Associated with increased incidence of rupture in pregnancy. Worse
prognosis in pregnancy can be associated with appendicitis. Better to
operate early if appendicitis presents in pregnancy

Rheumatoid Arthritis:
Requires immunosuppression and
Disease Modifying Anti-Rheumatic Drugs (DMARD) and pregnancy is a
state of immunosuppression. gets better during pregnancy.

Sarcoidosis:
Similar behavious to RA… requires immunosuppression and hence better in
pregnancy.

Ulcerative Colitis:
Unchanged in pregnancy. The episodes of bleeding are unchanged

SLE:
1/3 better, 1/3 worse, 1/3 unchanged
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
89

HIV:
Vertical Transmission ( Mother to child Transmission) is 25-40% OVER ALL
Chance is <1% if viral copies are less than 400 and Nil if < 50 Copies.
3 Drug ART given to all n pregnancy irrespective of CD4 count status
2 NRTI: Abacavir/Lamivudine or Tenofovir/Emtricitabine
A protease Inhibitor: Ritonavir
Can also add a 4th drug like an Integrase Inhibitor: Raltegravir

is indicated only for obstetric indications and not just because of

HIV-positive status.
Add IV zidovudine during labour to reduce MTCT
Avoid Methergin for PPH treatment since this will cause NRTI and PI
drugs to cause severe vasoconstriction and an increase in Blood Pressure.

Malaria in Pregnancy:
Worsens in pregnancy. More chances of Maternal Morbidity & Mortality.
DOC of uncomplicated malaria in pregnancy: Cholroquine
DOC for complicated P. Falciparum malaria : Artemisinin Based regimes

Hepatitis B:
MTCT 90% if Ag is positive, 10% if antibody is positive, 40% if chronic
carrier stage.

Vaccines in Pregnancy:-
Safe in pregnancy Contra-Indicated in pregnancy
Tetanus, Diptheria Toxoids (TDs) Measles
Hepatitis B Mumps
Infuenza Rubella
Meningococcal Varicella
Rabies BCG

Anthrax, Japanese Encep, Polio IPV, Yellow Fever, Hepatitis A are given
on special recommendation
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
90

Cesarean Section:-
Indications
Malpresentations and malpositions

Abnormal fetopelvic relation

Issues pertaining to Labour

Placental Reasons

Previous Surgeries impact

Also: For Failed …

Maternal Height…
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
91

Most Common Type of Cesarean Section done is

Reason?

A good cesarean rate in an Institutional Set-Up

What is Trial of labour after cesarean section

Or Vaginal Birth after cesarean section

Pre-Requisites for a Trial:-

Should be done for

Place to do

Feto-Pelvic Relation

Scar Thickness

Success of a TOLAC/VBAC
Chances of Rupture of Uterus

During the trial:-

Most worrisome complication anticipated?

Signs of Imminent Rupture?
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
92

Signs of Rupture uterus:-

Maternal
1 st Sign

Loss of Uterine…

Vaginal Bleeding, Hematuria

Fetal Signs

Observe this demonstration of a cesarean:-

In this type: Is a TOLAC possible in the next Delilvery ?

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
93

Stages of Labour:-

Stage 1

Stage 2

Stage 3

Stage 4 ??
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
94

Characteristics of Latent Stage

Active Phase Characteristics

Second Stage

Cardinal Movements of Labor:-

Engagement:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
95

Pelv
ic in
let
Ou
tlet
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
96

Descent:

Planes in the Pelvis:-

Plane of Mid Cavity
(Plane of Greatest Pelvic Dimensions)

Passes from the middle of the Posterior

Pubic Symphysis and the Jn between the
2 nd and 3 rd Sacral Vertebrae. Laterally
it passes to the centre of the acetabulum
and Upper part of Gr Sciatic Notch

Plane of least pelvic Dimensions:

....From Lower border of Pubic Symphysis
to the tip of sacrum posteriorly and
Ischial Spines laterally
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
97

anterior fontanel lambdoid suture

frontal bones

parietal
bone

frontal occipital bone

suture

posterior
fontanel
parietal
bone

8 Cm

coronal suture 9.5 Cm sagittal suture

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
98
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
99

Pregnancy Positions:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
100

muscles

Summary
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
101

Features:
Gynaecoid Anthropoid Android Platypelloid
types of pelvis

INLET Round Antero- Triangular Transversely

posteriorly Heart shaped oval/Flat
oval

CAVITY: Straight/ Straight Convergent Straight/

SIDE WALLS slightly Divergent
divergent

CAVITY: Wide Wide Narrow Narrow

SACROSCIATIC
NOTCH

OUTLET: Wide (85 deg) Slightly Narrow Very wide

SUB-PUBIC narrow (>90 deg)
ANGLE

OUTLET: Not prominent Not prominent Prominent Not prominent

ISCHIAL
SPINES
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
102

CONTRACTED
DIAMETERS
PELVIS

DIAMETERS OF PELVIC INLET

True Conjugate (1cm less than diagonal conjugate : 11 cm

Obstetric Conjugate (1.5-2 cm less than diagonal conjugate : 10 cm < 10 cm
Diagonal Conjugate (AP diameter) : 12 cm < 11.5 cm
Transverse diameter : 13 cm < 12 cm
Oblique diameters : 12 cm
DIAMETERS OF THE MIDPELVIS
Interspinous diameter : 10.5 cm Suspected
contraction
< 10 cm
Contracted
< 8 cm
Antero-posterior diameter : 11.5 cm
Posterior sagittal Diameter : 5 cm
Interspinous + Posterior sagittal diameter : 15.5 cm < 13.5 cm
DIAMETERS OF THE PELVIC OUTLET
Transverse diameter/Inter Ischial diameter : 10.5 cm < 8 cm

Cervix 0 1 2 3

Dilatation Closed 1-2 3-4 5+

0-30 40-50 60-70 >80
Consistency Firm Medium Soft

Position Posterior Medium Anterior

Head Station -3 -2 -1,0 +1, +2

OBSTETRICS & GYNAECOLOGY
103

Start the partogram: When the patient

OBSTETRICS & GYNAECOLOGY
104

Recording observations:
FHR, Maternal Pulse BP

Uterine Contractions …

Temperature and Urine examination…

Per Vaginal Examination

Expected Progress of labour hence is

Benefits of Partogram
Reduces Prolonged labour and complications of it

Early recognition of CPD … hence reduction of …

Uterine Rupture

Post Partum Hemorrhage, Puerperal Sepsis

Reduction of prolonged labour also reduces…

Reduces Neonatal Morbidity and mortality

Cesarean section rates …

Also, Informs when to do

Also, a Handover tool…

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
105
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
106
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
106

INSTRUMENTAL DELIVERY:-
Indications:

Maternal Fetal

Maternal Exhaustion Non-Reassuring fetal heart rate

Prolonged Second stage of Labour Premature placental separation
Severe or acute pulmonary compromise

Neurological disease

Serious cardiac disorders

Pre-Requisites

Forceps Vacuum

Cervix Fully Dilated Cervix >6 cms Dilated

Fully Rotated head Can be rotated or non-Rotated
or < 45 Deg Remaining Rotation

Engaged Head
Vertex Presentation
Empty Bladder
No Fetal Coagulopathy
Membranes Absent
Good Contractions
Station +2 or below

Outlet Scalp is visible at the perineum

without spreading the labia

Sagittal Suture is in the anterior

Posterior Diameter of the pelvis

Fetal head is at the perineum

Low Leading part of the skull is at +2 or below

Remaining Rotation is less than 40Deg

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
108

Forceps Vacuum

Fetal Facial Injuries Scalp Injuries

Sub Galeal Hemorrhage
Mild post-natal Jaundice
Shoulder Dystocia

Complete perineal tears more likely Much lesser vaginal and vault
injuries. Much lesser CPTs
Can be used in After Coming head of Can be used for second of twin
breech instrumental Delivery
Good for fetal distrees in
second stage of labour
More force can be applied for fetal Can be applied without Maternal
extraction Analgesia

CAPUTSUCCADENEUM CEPHALHEMATOMA

Soft tissue edema Blood Subperiosteal H’age

Limited by suture lines

Dependent head Seen few hours after birth

Extends across suture lines Gradually increases in size

Present at birth Resolves in few weeks

Does not increase in size

Disappears over 48 hours Complications

Complications are rare Skull fracture

Coagulation defects
Intracranial bleeding
Jaundice
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
109
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
110

Shoulder Dystocia: Incidence: 1% of all deliveries:-

Reason:

Seen in obesity, postterm pregnancy, multiparity, and diabetes

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
111

Preterm Labour: Incidence: 10% of all pregnancies:-

Late preterm Labour

Moderate preterm labour
Early preterm Labour

Diagnosis:
Contractions:

PV Examination:

Etiology:-
Uterine Over distention

Infections: 20-40% of all Preterm Labour

Causes: PID like organisms:

Diagnosis of Chorioamnionitis:-
Any 2 of the following

Increased TLC
Increased CRP
Uterine Tenderness
Increased Pulse Rate
Foul Smelling Discharge
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
112

Uterine Anomalies:-
Septate, Bicornuate, Unicornuate

Short Cervix

Prediction of Pre-Term Labour:-

USG at 12-13 weeks

Funneling of cervix

T Y

U
V

Funneling of cervix

Fetal Fibronectin

Tocolysis: Purpose

Indications of Tocolysis:-

Dilatation

Gestation
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
113

Drugs: Tocolytics:-
B Agonists

Calcium Channel Blockers

Calcium Channel Antagonists

PG Synthetase Inhibitors

Progesterone

Nitric Oxide Donors

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
114

Lung maturity:-
LS Ratio

Phosphatidylglycerol: Found in Amniotic Fluid ONLY

Phosphatidylcholine: Found in AF, Maternal and fetal Serum

70% of Surfactant

Best part of Surfactant

Starts Production at 24 weeks by…

Based on the Presence of Fats in the Amniotic Fluid: Can do these tests
Aspirate amniotic Fluid---- Add NaOH ( Saponifying agent)

This will change FATS, if present, to SOAPS

Shake test

Tap Test

Nile Blue Sulphate test:-

Aspirated Amniotic Fluid Has Desquamated fetal Skin cells
Centrifuge and take the sediment cells
Add Nile Blue Agent : If > 50% cells …

To Accelerate lung Maturity: Antenatal Steroids:

Inj. Dexamethasone

Inj. Betamethasone

If Born Premature:

AXOSURF SURVANTA
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
115

Perineal Tears:-

Complete Perineal tear:

Repair of CPT:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
116

Episiotomy: Perineal tear Type:

Indications:-
Anticipating perineal injury
Instrumentation
Rigid perineum

Types:

mediolateral is at:

Median episiotomy Medi-Lateral Episiotomy

Lesser bleeding More
Easier repair
Healing is better Ragged scar often
Post op Pain is lesser More
Dyspareunia is lesser More
Wound Disruption is rare More common
Extension to CPT is Common Rare

Structures Cut: From outside to in

1. Skin
2. Subcutaneous Tissue

4. Fibers of Bulbospongiosus and Levator Ani

5. Transverse perineal Branches of Pudendal Nerves and vessels
6. Posterior Vaginal Wall
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
117

Whats Not cut?

Repair:-

A. Vaginal Mucosa B. Muscle layer C. Skin

Continuous Interrupted Interrupted

Suture material Used:-

Vicryl: Polyglactin,
Dexon: Polyglycolic acid
Monocryl
Catgut
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
118
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
119

Hypertension in pregnancy:-

Gestational Hypertension Chronic Hypertension

Essential HTN
Phaeochromocytoma
Preeclampsia Renal Artery Stenosis

Eclampsia

Liver and Renal Failure

Intracerebral Bleeding
Abruption
HELLP Syndrome
Pulmonary Edema
DIC -> Death!

Imminent Eclampsia (Stage of Worsening Hypertension)

Headache, Nausea vomiting

Blurring of vision
Exaggerated knee Jerks, Epigastric Pain
Pulmonary edema, Low platelets, rising liver enzymes, deranged
renal function
BP > 110 diastolic

Proteinuria

Etiology of HTN In Pregnancy: Poor Placentation!

>20 wks:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
120

Pathology:-

So the mother increases blood pressure… to…

Also Contributory:-

Immune System:
T-Helper 1 cells Function increases (Normal Pregnancy T-Helper
2 bias is seen)

Imbalance between Vasodilators Vs Vasoconstrictors:

Imbalance Between Angiogenic Vs Anti-angiogenic

Factors

Other Factors Like:-

Primi-gravidas
Molar, Twins
Grand-multigravidas
Pre-Existing Diseases Like Renal Diseases and DM

APLA, SLE
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
121

Pathology of organs:-

Liver

Kidney: Glomerular Endotheliosis

ENDOTHELIAL
SWELLING

ENDOTHELIUM

FENESTIRATIONS
SWOLLEN
FENESTRA

BASEMENT
MEMBRANE

NORMAL GLOMERULI PRE ECLAMPSIA

GLOMERULAR CAPILLARY ENDOTHELIOSIS

RBC:- Hemolysis

Due to endothelial cell activation causing microangiopathic Hemolysis

Brain:-
Intracerebral Hemorrhages
Visual Scotomas
Convulsions due to….

Treatment of HTN in Pregnancy:-

OPD Management:

Contra-Indicated Drugs:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
122

Treatment of eclampsia:-

DOC:

Regime of choice

Dose:

Continue MgSO4:

MgSO 4 Toxicity:

Treatment of Toxicity:

For Hypertension control:

Timing of delivery:

Mild Hypertesnion controlled on Drugs

Hypertension uncontrolled

Prevention of HTN in pregnancy:

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
123

Diabetes In Pregnancy:-

Gestational Diabetes Overt Diabetes

Pre-Existing Diabetes Mellitus
>24 weeks: Years:

Associated with:

Screening: Screening:

Hb A1C:

Sr. Fructosamine: umol

Maternal Complications:-

Due to Large baby Others Like:

Neonatal Complications:-

Anomalies:

Cardiac

Structural
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
124

Management:-
Diet:

Sugars:-
Fasting <95

PP< 120

Drugs: DOC

Fundus Examination:

Timing of Delivery:
GDM Well Controlled on Diet:40
GDM on Medication: 38-39
DM Controlled on Drugs:
Dm uncontrolled:

Fetal Surveillance:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
125

Antepartum Fetal Surveillance:-

FHR:

Non Stress Test: Assessment of Sympathetic Vs Parasympathetic

Nervous System

Can be done > 28 weeks. Usually Started at:

Normal Pregnancy
High Risk Pregnancy
Controlled DM and Severe HTN
Uncontrolled DM:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
126

NST
On Usg Fetal Movements
Fetal Tone
Fetal Breathing
AFI

Normal Oligohydramnios Polyhydramnios

AFI
Amount
Single Pocket
Causes Renal Anomalies

Liquor with Gestational Age:

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
127

Vibroacoustic Stimulation Test

Doppler of Umbilical Arteries, Uterine arteries:-

Intra-Partum fetal Surveillance:-

Fetal Heart Rate with:

Fetal Scalp blood PH

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
128

Cardiotocography

FHR

TOCO

Type I Deceleration Type II Deceleration

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
129

Normal Fertilization:-

Fertilization
Egg- no nucleus Day 1
PN stage zygote Day 2 Day 3

23X =

F M

4 cell
Genetic material G.M will
is dispersed condense to
in the cytoplasm form a
pronuclei

1CM Day 4
Day 6
Day 5
16-32

TE Blastocyst
Hatching !
Trophoectoderm: Placenta IVF
Implantation !!
Inner cell mass : Fetus
Day 5 : 1-2 Trancsferred to uterus
Day 3 : 2-3 Trancsferred to uterus

TWINS:-

Incidence
Predisposition

Monochorionic Problems:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
130

Twin to Twin Transfusion Syndrome TTTS

Twin Anemia Polycythemia Sequence

Twin Reversed Arterial Perfusion

Cord Entanglement

Single/both fetal:

Discordant twins

Abruption, PROM, Sepsis

Dizygotic Twins:-
Incidence
Predisposition

Superfecundation

Superfetation
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
131

Di CHO
Di AMN

Chorionicity Scan
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
132

Problems in Twins;

Special Management:-
Diet:

Normal Pregnancy: Calories:

Split is: Carb Proteins Fats

Twins Pregnancy: Calories:

Split is Carb Proteins Fats 424

Timing of delivery:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
133

69XXX

Scalloping of Villi

Chances of Chorio Carcinoma:

Presentation:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
134

Empty Oocyte:-

23X

Endoduplication

Fetus:
Degen of villi
Chances of Choriocarcinoma

Presentation:- Symptoms
Due to increase hCG
αhCG = αTSH causes
Increase hCG: Hyperemesis
Also, ovary has….

Uterine Size:
Empty Uterus:
Early Onset:
M/C Presentation:
Rare:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
135

Remember that: At the time of Diagnosis of V mole, if

hCG is higher than 100,000
Theca Luetin Cyst is
Uterine size is
Then there is…

Management: Only 1 answer:-

After 1 week:
Do a Check Curettage:
Chest X Ray
Sr HCG

Continue Sr. hCG

Complete Mole

Partial Mole

Then weekly for

Then Monthly for

Remember, during the follow up:

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
136

COMPLETE MOLE PARTIAL MOLE

Diploid Triploid

46XX with haploid sperm enduplication 69XXY or 69XXX with dispermic

46XY with dispermic fertilization fertilization

All chromosome are paternal Extra set of chromosome is

(androgenesis) paternal (one maternal and two
paternal sets)
No fetal/embryonic tissue Triploid fetus which is not viable

Focal hydropic swelling of villi

Focal trophoblast hyperplasia

P57 staining is negative P57 staining is positive (maternal
component)

Vesicular Mole ---------------------------------------- Choriocarcinoma

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
137

Finally: Choriocarcinoma

Prognosis also depends upon: The WHO prognostic Scoring system:-

0 1 2 4

Age (years) <39

- >39
Antecedent pregnancy Hydatidiform Abortion Term
mole
Interval between end of <4 4-6 7-12 >12
antecedent pregnancy &
start of chemotherapy
(months)
Human chorionic <10 3 10 3-10 4 10 4-10 5 >10 5
gonadotropin (IU/L) at
the time of GTN
diagnosis
ABO groups 0 or A B or AB
Largest tumor, <3 3-5 >5
including uterine (cm)
Site of metastases Spleen, GI tract Brain, Liver
Kidney
Number of metastases 1-3 4-8 >8
Prior chemotherapy 1 drug >2
- drugs
The total score for a patient is obtained by adding the individual scores for each prognositic
factor. Total score: <7, low- risk; >7, high risk.

Treatment of Choriocarcinoma:-

Initial Resistance
Stage I Single Agent Chemo Combination chemo
Stage II & III:Low risk Single Agent Chemo Combination chemo
Stage II & III:High risk Combination Chemo Second line chemo
Stage IV Combination Chemo Second line chemo
Brain: Radiation
Liver: Resection
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
138

Single agents : Methotrexate, Actinomycin-D

Combination : MAC
Second Line Combination Chemotherapy : E MAC O
Abortions:-
Spontaneous Induced

Spontaneous:-
First Trimester Abortion: M/C Causes are:

Management:
Previously H/O Anomalous Babies

Elderly Gravida
Prenatal test:

Screening test Aneuploidy Risk Diagnostic Test

is more if :
Dual marker 12 weeks Chorionic Villus Biopsy
PAPP-A 10-13 weeks
hCG
NT NB Scan 12 weeks
NT (Nuchal Translucency) >3mm
<3mm NB (Nasal Bone)
Triple Marker From 16 th Amniocentesis
weeks 16-18 weeks
UE3 (Unconjugated Estriol)
AFP
hCG

Quadruple Marker From Cordocentesis >18 wks

16 th weeks
UE3 (Unconjugated Estriol)
AFP
hFP
Inhibin
Non-Invasive Prenatal Pre-Implantation
testing:NIPT Genetic Testing:PGT
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
139

Second Trimester Abortions:-

M/C Causes are:

Short Cervix:

Surgeries are:-

McDonalds

Wurms

Shirodkar
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
140

Summary:-

1 st Trimester
2 nd Trimester
Recurrent Pregnancy Loss

Presentation of an abortion:-
M/C Presentation is Bleeding PV and Pain Abdomen

Uterine size

External OS

Pain abdomen and Bleeding PV:-

PV os:
Uterine Size

Pain abdomen and Bleeding:-

PV os is open, Products are bulging

Pain abdomen and Bleeding:-

History of passage of Products
PV: OS is Open

Pain abdomen and Bleeding:-

History of passage of Products
PV: OS is closed, Uterine size is Normal
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
141

8 Weeks 12 Weeks

G.sac Yolk sac Fetal node Fetus

5 6 6+ 7-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
142

Induced Abortions:-

Latest Update: Can now be done till…

For Abortion done from 20th to 24th week:

Also Included are the following

Extension of abortion right to single, unmarried women

Inclusion of marital rape under the MTP Act

Exemption to medical practitioners from disclosing identity of the Minor

These will be decided by….Medical Board

(a) Gynaecologist;

(b) Paediatrician;

(c) Radiologist or Sonologist;

Union territory
Who can do the abortion?
MBBS Doctor:
Or, Who has: Experience of

Indications of Abortions:
Maternal

Fetal

Humanitarian

Contraceptive Failure
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
143

Techniques of Abortion: 1 St Trimester:-

1. Medical Abortion:
T. Mifepristone

T. Misoprostal

If done till 9 weeks: Success is

If done till 7 weeks: Success is

Pre-Requisites of Medical Abortion are
Always check the Location of the fetus
Then advice regarding the drugs
Administer drugs
Wait for bleeding to be over

2. Dilatation and Curettage: can be done till…

Suction evacuation: Using a Cannula called …

a) Suction can be built by:

1. Electrical Suction
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
144

2. Manual Vacuum Aspiration

Can be done till

On OPD basis:
Pressure generated

Second Trimester:-
Prostaglandins are DOC !

Misoprostal

Dinoprost

Carboprost

Dilatation and Evacuation:-

Dilatation by:
A. Hegar’s dilator

B. Laminaria Tent: Dried sea weed:

Works by …

C. Dilapan:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
145

Evacuation by: Ovums Forceps

If nothing works , then Hysterotomy:

Complications of MTPs:-
Bleeding

Perforation

A. Small Instrument

B. Large Instruments

Septic Abortion

Rise of temperature of at least 100.4 0F (38 0C)for 24 hours or more

Other evidences of pelvic infection such as lower abdominal pain and

tenderness

Grade-I: The infection is localized in the uterus

Grade-II: The infection spreads beyond the uterus to the parametrium

tubes and ovaries or pelvic peritoneum

Grade-III: Generalized peritonitis and/or endotoxic shock or jaundice

or renal failure.
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
146

Ectopic Pregnancy:- Incidence

Ectopic Pregnancy Physiology

Fate of an Ectopic Pregnancy:-

-Tubal Abortion
-Ruptured Ectopic pregnancy

MC Site:- Tubal
Tubal Site Time of Rupture
Isthmic

Ampullary

Interstitial/cornual

Rare sites of Ectopic Pregnancy:-

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
147

Abdominal
Secondary Primary

SUDDIFORD CRITERIA

Ovarian
Secondary Primary

SPEIGELBERG

Etiology:-

MC Cause

Most Important Cause:

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
148

H/O Infertility Treatment

H/O Tubal Surgeries

H/O Previous Disease Like:

IUCD & Ectopic

POP & Ectopic

Symptoms of Ectopic Pregnancy:-

Un-Ruptured EP

Ruptured Ectopic Pregnancy:

MC is Pain abdomen

Vaginal Bleeding

A period of Amenorrhea:

Also, abdominal Bloating

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
149

Signs
Low BP, Increased PR:
Abdominal Distention

Evidence of Hemoperitoneum

Per Vaginal Examination:

Cervical Motion Tenderness

Fullness in POD

POD

Cul-de-sac

Imaging:
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
150

Management of Ectopic Pregnancy:-

Ruptured Ectopic Pregnancy:

Un Ruptured Ectopic Pregnancy

Medical Management Surgical Management

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
151

Early diagnosis of location of pregnancy:-

Gestational Sac Cardiac activity

TVS
TAS

If This does not Show: Then HCG Helps by doing the ‘doubling titer’
This is valid if done till

And if the HCG level is less than the …

Discriminatory Zone Levels of hCG

Today 48 H Later Interpretation Doubling

Sr. Progesterone Levels

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
152

Obstetric Hemorrhage:-
Abortion Related
Antepartum

Postpartum

Definition of PPH:-

Mild PPH

Moderate PPH

Severe PPH

Primary PPH: Bleeding within 1st

Most Common Cause:

Secondary PPH: Bleeding after…

Most Common Cause:

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
153

Fundamental of PPH:-

Causes of PPH:

MC Cause is :Due to Large Uterus

:Prolonged Labour

:Infection

Injuries :Uterine Lacerations

Coagulation Defects :

Retained Placental Bits :

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
154

Prevention of PPH: Active Management of third Stage of Labour:-

1. Oxytocin: Administer after

2. Delayed cord Clamping

3. Controlled cord Traction

4. Uterine massage

Drugs for PPH Management:-

DOC for Management: Oxytocin;

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
155

Carbetocin

Methylergometrine

Misoprostal

Carboprost

Tranexemic Acid

Uterine Tamponade
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
156

B Lynch Hemostatic suture

Uterine Artery Embolization

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
157

Uterine Devascularization:-
Uterine artery Ligation
Posterior division of Branches of
Ovarian Artery Ligation internal iliac artery posterior division

Internal Illiac Artery ligation

1. Iliolumbar artery
Common iliac artery
2. Superior gluteal
artery
External iliac artery

Internal iliac artery

Anterior division of Internal iliac artery

3. Lateral sacral
arteries

Inferior epigastric artery

Branches of
anterior division

1. Superior vesical artery

2. Obturator artery
3. Uterine artery

4. Inferior vesical artery

5. Middle rectal artery

6. Inferior gluteal artery

7. Internal pudendal artery
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
158

Best Method Of Placental Delivery:-

How not to delivery: Sudden cord Traction!

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
159

Signs of placental Separation:-

Retained Placenta Retained Placental Bits

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
160

Placental separation occurs at the interphase of ‘Nitabuch’s Membrane

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
161

Types of placenta

Human placenta is

Weight is

Maternal Surface has

Fetal surface has

Umbilical Cord: 2 Arteries 1 Vein

M/C Defect is a single umbilical artery

More common in twin gestation
The most frequent anomalies are cardiovascular and genitourinary
Amniocentesis is recommended for Karyotype abnormalities
IUGR, Perinatal Death

Normal Length Short Long

Battledore placenta

Circumvallete Placenta
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
162

Succenturiate lobe

Vellamentous cord

Vasa Previa:-
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
163

RH ISOIMMUNIZATION:-

Rh antigen group of 5 antigens and is present on Chromosome 1.

These are c, C, D, E, e.

of these…

Thus Rh positive essentially means 'D' positive.

Mixing of blood can occurs at the time of

Delivery (5-30 ml) (Most Common time of mixing):
At the time of placental separation after delivery

Other Causes
Abortion, Molar Pregnancy
Ectopic pregnancy, IUFD (Intrauterine fetal death)
Abruption, Placenta previa
Injury of abdomen, Amniocentesis
Chorionic Villi Sampling
ECV: external cephalic version

After mother gets exposed to the Fetal Rh(D) Antigen

Mother gets sensitized and starts making Anti-D antibody.

These Anti-D antibodies cause lysis of ‘D carrying fetal RBCs’ in the

maternal circulation and not in the baby as it is already born…..

The Rh Sensitized mother starts making progressive number of Anti-Rh

(Anti-D) Antibodies. This mother is now loaded with anti D antibodies in
her circulation.

In the next pregnancy if the baby is Rh positive then all the anti-D from
the maternal circulation gets transferred through the placenta and a
Ag(D) & Antibody (Anti-d) reaction occurs on the fetal RBCs which
causes Hemolysis in the baby.
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
164

Antigen / Antibody reaction on Fetal RBCs

Hemolysis
Anemia
Increased Bilirubin Jaundice, Kernicterus (> 20mg/dl)

There is increased third space collections

Erythroblastosis Fetalis: Increased hemolysis is compensated by bone

marrow hyperplasia to increase red cell production. This is called
erythroblastosis fetalis.

To prevent this: Anti-D is given 300 µg

Timing…

Dose: 300 mcg anti-D (or 1500 IU) will neutralize 30 ml blood (15 mL RBCs)

Dose: For Abortions and Ectopic pregnancy:

Should we not calculate the Dose of anti-D required ?

Kliehauer Betke Test (Acid Elution Technique): measures feto-maternal Hge
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
165

Antenatal Management in Rh Neg Pregnancy

Mother Rh -ve, Father Rh +ve

Do ICT at the diagnosis of pregnancy: this checks for

If ICT Negative (Meaning that the mother is not yet Sensitized to D antigen)

DO monthly ICT from 20weeks

20 Weeks ICT Negative

24 Weeks ICT Negative

28 Weeks ICT Negative

32 Weeks ICT Negative

36 Weeks ICT Negative

40 Weeks ….
 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
166

Contraception in special situations

Vesicular Mole

Heart Diseases

Diabetes

HIV/STD etc

Newly Married couples

Couples in separate Cities

Lactational Amenorrhea

When can COCP be started if a Lady desires them?

 OBSTETRICS & GYNAECOLOGY
OBSTETRICS & GYNAECOLOGY
167

PP IUCD:-
Timing of PPIUCD insertion

1. Immediate Postpartum

Postplacental: Insertion within 10 minutes of placental delivery

Intracesarean: Insertion that takes place during a cesarean delivery

Within 48 hours after delivery: Insertion within 48 hours of delivery

and prior to discharge from the postpartum ward.

Remember…

Between 48 hours of delivery and till 6 weeks of delivery…

OBSTETRICS & GYNAECOLOGY
168
 “Healthy babies are the
future of the world, &
the world’s future is in
the hands of midwives
and obstetricians...”

ARISE-Chennai ARISE-Kerala (Kannur)

+91-96337 99504, +91-8136932666
+91-89779 41723, +91-89779 42723
arisemedicalacademy.kerala@yahoo.com
arisemedicalacademychennai@gmail.com

No. A Super 20, Thiru Vi Ka Industrial 2nd Floor, Kingdom Tower, Manna Rd,
Estate, SIDCO Industrial Estate, Guindy, Opposite Kareems Hotel, Taliparamba,
Chennai, Tamil Nadu 600032 Kerala 670141

ARISE-Hyderabad ARISE-Delhi
+91-76809 29292, +91-7396757585
+91-95600228-36 / 37 / 38
arisemedicalacademy@gmail.com arisemedicalacademy.delhi@gmail.com
# 2nd Floor 9-4-84, 11/A&B, Langar
Lane no. 5, Westend Marg, Saidulajab,
House Rd, Kakatiya Nagar, Tolichowki,
Saket, New Delhi.
Hyderabad, Telangana 500008

ARISE- Jaipur
+91 9929113115 / 9929113116

arisemedicalacademyjpr@gmail.com

Plot No-26, Krishna Vihar, Sector-5,

Near Pushp Enclave, Pratapnagar,
Tonkroad, Sanganer, Jaipur-302033