Obstetrics & Gynaecology

Gynaecology
I. Anatomy of Female Reproductive Organ
Classification: The female reproductive organs are broadly divided into:
1) External genitalia: Vulva or pudendum consists of the following:
✓ Mons pubis (mons veneris).
✓ Labia majora.
✓ Labia minora.
✓ Clitoris.
✓ Vestibule of the vagina.
✓ Vestibular bulb.
✓ Greater vestibular glands.
✓ Perineum.

2) Internal genitalia:
✓ Vagina.
✓ Uterus.
✓ Fallopian tubes.
✓ Ovaries.

3) Accessory reproductive organs: The breasts.

Anatomy of External Genital Organ

Vulva
The vulva includes:
Mons veneris Labia majora Labia minora Clitoris Vestibule Conventionally the perineum.

Mons Veneris (Mons Pubis)

It acts as a coater buffer.

The mons and labia are covered with coarse skin which contains hair follicles, sebaceous glands and sweat glands.
Labia Majora
• Beneath the skin, there are dense connective tissue and adipose tissue.
• The adipose tissue is richly supplied by venous plexus which may produce hematoma, if injured during
childbirth.
• The labia majora are homologous with the scrotum in the male.
• The round ligaments terminate at its anterior third.

Labia Minora
• The labia minora do not contain hair follicle.

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Clitoris
• Clitoris is a small cylindrical erectile body, measuring about 2.5 cm situated in the most anterior part of the
vulva.
• It consists of glans,prepuce, a body and two crura (Corpora cavernosa).
• The glans is covered by squamous epithelium and is richly supplied with nerves.

Vestibule
• There are four openings into the vestibule.

Urethral Opening:
• The opening is situated in the midline just in front of the vaginal orifice about 1–1.5 cm below the pubic arch.
• The paraurethral ducts open either on the posterior wall of the urethral orifice or directly into the vestibule.

Vaginal Orifice and Hymen

• The hymen itself particularly elastic, coitus nearly always causes tearing. The tear is most commonly found
posteriorly or posterolaterally.

The hymen is relatively avascular so its tearing usually causes only a slight loss of blood.

Bartholin’s Gland
(Greater vestibular gland)
The Bartholin’s glands are situated in the superficial perineal pouch
Each gland has got a duct which measures about 2 cm and opens into the vestibule,
The duct is lined by columnar epithelium but near its opening by stratified squamous epithelium.
The Bartholin’s gland corresponds to the bulbourethral gland of male (cowper’s glands).

Vestibular Bulbs:
They are homologous to the single bulb of the penis and corpus spongiosum in the male.
They are likely to be injured during childbirth with brisk hemorrhage.

Blood Supply of The Vulva [Nice to know]

Arteries:
(a) Branches of internal pudendal artery— the chief being labial, transverse perineal artery to the vestibular bulb and
deep and dorsal arteries to the clitoris.
(b) Branches of femoral artery—superficial and deep pudendal.

Veins:
The veins form plexuses and drain into—
(a) Internal pudendal vein
(b) Vesicalor vaginal venous plexus and
(c) Long saphenous vein. Varicosities during pregnancy are not uncommon and may rupture spontaneously causing
visible bleeding or hematoma formation.
Lymphatic of the vulva
• Glans of clitoris: Drains directly into the deep inguinal and external iliac glands.
• Bartholin’s glands: the lymphatics drain into superficial inguinal and anorectal nodes.

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Anatomy of the Vagina

❖ Direction: The canal is directed upwards and backwards forming an angle of 45" with the horizontal in erect
posture.
❖ Diameter: It is gradually increases from below upward. The diameter at the upper end is roughly double in size to
that at the lower end. Diameter at the upper end is about 5 cm & at the lower end is about 2.5 cm.
❖ Walls: The anterior wall of the vagina is about 7 em whereas the posterior wall is about 9 cm.
❖ Fornices: The upper part of the vagina sorrounds the cervix of the uterus. The circular area of vaginal lumen
around the cervix is called fornix of vagina. The fornix of vaagina is divided into four parts-
✓ Anterior fornix.
✓ Posterior fornix.
✓ Two lateral fornix.
✓ The posterior fornix is about 2 cm deeper than the anterior fornix.

❖ Relations;
➢ Anteriorly;
✓ The upper one-third is related with base of the bladder.
✓ The lower two-thirds are with the urethra.
➢ Posteriorly:
✓ The upper one-third is related with the pouch of Douglas.
✓ The middle-third with the anterior rectal wall separated by rectovaginal septum.
✓ The lower-third is separated from the anal canal by the perineal body.

➢ Laterally:
✓ The upper one-third is related to the ureters, which are close to the lateral fornices & are crossed by
uterine artery.
✓ The middle-third is related to the anterior fibres of the levator ani & pelvic fascia.
✓ The lower-third is related to urogenital diaphragm, bulbv of vestibule, bulbospongiosus & greater
vestibular gland (Bartholin's glands).

❖ Structures: Layers from within outwards are

✓ Mucous coat which is lined by stratified squamous epithelium without any secreting glands.
✓ Submucous layer of loose areolar vascular tissues.
✓ Muscular layer consisting of indistinct inner circular & longitudinal.
✓ Fibrous coat derived from the endopelvic fascia and is highly vascular.

❖ Blood supply:
➢ Arterial supply:
✓ Cervicovaginal branch of the uterine artery.
✓ Vaginal artery - a branch of of internal iliac artery (main artery).
✓ Internal pudendal artery.
✓ Middle rectal artery.
✓ Inferior vesical artery.

➢ Venous drainage: Drain into internal iliac veins and internal pudendal veins.

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❖ Lymphatic drainage: On each side, the lymphatics drain into-

➢ Upper two third: Internal & external iliac, coomon iliac & obturator lymph nodes.
➢ Middle third up to hymen: Internal iliac group.
➢ Lower third below the hymen: Superficial inguinal & at times external iliac lymph nodes.

❖ Nerve supply:
➢ The upper two third of vagina is insensitive to pain, touch & temperature but it is sensitive to stretch. It is
supplied by sympathetic (L₁ & L2 spinal segments) and parasympathetic (S₂ & S3 spinal segments) fibres.
➢ The lower one third of the vagina including region of vaginal orifice, is extremely sensitive to touch. It is
supplied by the pudendal nerve via inferior rectal & posterior labial branches of perineal nerve.

❖ Development: Development of vagina is composite, partly from the Mullerian (paramesonephric) ducts & partly
from the urogenital sinus.

Anatomy of Uterus

❖ Position: Its normal position is one of the anteversion & anteflexion.

❖ Shape: Pear shaped, being flattened anteroposteriorly.
❖ Measurement: It is about 8 cm long & 5 cm wide at the fundus and its walls are about 1.25 cm thick.
❖ Weight: 50-80 gm.
❖ Communications: Superiorly the uterus communicates on each side with uterine tube and inferiorly, with the
vagina.
❖ Parts: It has got 3 parts:
1. Body or corpus:
• Fundus.
• Body proper.
2. Isthmus.
3. Cervix.

Structures:
Body: The wall consists of 3 layers, from outside inwards:
• Perimetrium.
• Myometrium.
• Endometrium.

Cervix: The cervix is composed of fibrous connective tissue. The smooth muscle fibers average 10-15%. Only the
posterior surface has got peritoneal coat.

Blood supply:
➢ Arterial supply:
• Uterine artery: One on each side arises from the anterior division of the internal iliac artery either
directly or as a branch of the hypogastric artery.
• Ovarian and vaginal arteries: It anastomoses with uterine arteries.

➢ Venous drainage: The venous channels correspond to the arterial course and drain into internal iliac veins.

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❖ Lymphatic drainage:
➢ Body:
• From the fundus and upper part of the body of the uterus → Aortic and lateral groups of glands.
• Cornu → Superficial inguinal gland along the round ligament.
• Lower part of the body → External iliac groups.
➢ Cervix:
• External iliac, obturator lymph nodes either directly or through para-cervical lymph nodes.
• Internal iliac groups.
• Sacral groups.
❖ Nerve supply:
➢ Sympathetic supply: T5 & T6 (motor) and T10 - L1 spinal segments (sensory).
➢ Parasympathetic supply: S2 -S4 spinal segments (mixed)

Figure: Different parts of uterus. Figure: Supports of uterus.

Figure: (A) Pattern of basal & spiral arteries in the endometrium; (B) Internal blood supply of uterus!

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Figure: Changes in uterus size from birth to 75 years of age. Note the change in the relation of the cervix to the body.

Anatomy of the Cervix

❖ Length: 2.5 cm.

❖ Parts: It has two parts:
a) Supravaginal cervix:
• It is the upper half, lies above the vagina.
• It is lined by simple columnar epithelium.
b) Vaginal cervix or portio-vaginalis:
• It is the lower half and lies in the vagina.
• The vaginal part is covered with stratified squamous epithelium continuous with that of the vagina.
• The columnar epithelium of the cervical canal and the stratified squamous epithelium of the portio-
vaginalis join each other at the external os, the site being known as the squamo-columnar junction.

❖ Relation:
➢ Anteriorly: Base of the bladder from which it is separated by the pubocervical fascia.
➢ Posteriorly: It is covered with peritoneum & forms the anterior wall of the pouch of Douglas containing
coils of intestine.
➢ Laterally: Uterus lies just 1 cm lateral to the supravaginal part of the cervix.

❖ Blood supply:
a) Arterial supply:
• Uterine artery on each side.
• Also from ovarian and vaginal arteries.
b) Venous drainage: In to the internal iliac veins.
❖ Lymphatic drainage: Please write from below description.

Lymphatic drainage of cervix: The lymphatics from the cervix drain into the following lymph nodes coursing along
the uterine veins:

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❖ Primary groups are:

• Parametrial group - inconsistent.
• Internal iliac group.
• Obturator group.
• External iliac - anterior and medial group.
• Sacral group.

Obturator group of lymph node sentinel cervix

❖ Secondary groups are: The lymphatics from all the primary groups drain into common iliac and superior lumbar
group.

Anatomy of the Fallopian Tube / Uterine Tube / Oviduct

❖ Length: 10 cm.
❖ Situation: Each lies in the free upper border of the broad ligament of the uterus.
❖ Extension: Its lumen communicates with the uterine cavity-at its inner end and with the peritoneal cavity at its
outer end.
❖ Parts: The fallopian tube is divided into four parts:
➢ Interstitial or intramural part: This is about 1.25 cm in length and has no peritoneal coat.
➢ Isthmus: This is the straight and narrow portion adjacent to the uterus and measures 2.5 cm in length.
➢ Ampulla: This is wider thin walled and tortuous outer portion approximately 5 cm in length.
➢ Infundibulum: Infundibulum measuring about 1.25 cm long with a maximum diameter of 6 mm.
❖ Structure:
➢ Serous layer: It is derived from peritoneum.
➢ Muscular layer: It is made up of smooth muscle which is arranged into inner circular and outer longitudinal
layers.
➢ Mucous membrane: It is thrown into longitudinal folds. It is lined by columnar epithelium, partly ciliated,
others secretory nonciliated and ‘Peg cells’.
❖ Blood supply:
➢ Arterial supply:
a) Uterine artery (medial 2/3rd).
b) Ovarian artery (lateral l/3rd).
➢ Venous drainage: Into the pampiniform plexus of the ovary and into the uterine veins.
❖ Venous drainage: Into the pampiniform plexus of the ovary and into the uterine veins.
❖ Nerve supply:
➢ Sympathetic: From ovarian and superior hypogastric plexus.
➢ Parasympathetic: From vagus.
❖ Development:
➢ Mucosa: From cranial vertical and middle horizontal part of the para-mesonephric ducts.
➢ Muscle and serous coat: From surrounding mesenchyma.

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Fig: Parts and Cut sections of uterine tube

Anatomy of Ovary

❖ Definition: The ovaries are female gonads (homologous of testis in the male), which produce female gamets
called oocytes (ripa ova).

❖ Location: In nulliparous adult woman, each ovary lies in the ovarian fossa on the lateral pelvic wall below the
pelvic brim. The ovarian fossa is bounded:
➢ Anteriorly by the obliterated umbilical artery.
➢ Posteriorly by the ureter and the internal iliac artery.

❖ Morphology:
➢ Shape: Each gland is oval (almond) in shape.
➢ Colour: Pinkish grey in colour.
➢ Measurement: It measures about 3 cm in length, 2 cm in breadth & 1 cm in thickness.
➢ Before the onset of ovulation, the surfaces of the ovary are smooth, but after puberty they become nodular.
➢ Each ovary has 2 ends- tubal & uterine, 2 borders - mesovarium and free posterior border, and 2 surfaces -
medial & lateral.

Structure: The Ovaries have two zones:

➢ Cortex (outer zone):
• The cortex is the thick peripheral part & contains ovarian follicles in different stages of maturity.
• The cortex is covered with germinal epithelium which consists of a single layer of low cuboidal cells
in younger age.
• In the later life, the epithelial cells become flattened.
• Later the ovary is coated only by the connective tissue tunica albuginia.

Medulla (inner zone):

• The medulla lies deep to the cortex.
• It consists of blood vessels and nerves with a loosely packed fibrous stroma.

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❖ Blood supply of ovary:

➢ Arterial supply:
• The ovary is mainly supplied by the ovarian artery, which arises from the aorta at the level of L1
vertebra.
• The ovary is also supplied by an ovarian branch of the uterine artery through mesoovarium.

➢ Venous drainage:
• Through pampiniform plexus, to form the ovarian veins which drain into inferior vena cava on the
right side and left renal vein on the left side.
• Part of the venous blood from the placental site drains into the ovarian veins and thus may become the
site of thrombophlebitis in puerperium.

❖ Lymphatic drainage: The lymphatics from the ovary follow the ovarian vein and drain into the preaortic and
para-aortic lymph nodes.
❖ Nerve supply: The ovary is innervated by the post ganglionic sympathetic (T10 and T11) and parasympathetic (S2,
S3 and S4).

❖ Development of ovary: The ovary is developed on either side from the genital or gonadal ridge
[Ref- Vishram Singh's Anatomy / 3rd / Vol-II / 253-256 + D.C. Dutta Gynecology / 9th / 9-10, 301]

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Common Congenital Anomalies of Female Genital Tract

External genitalia • Perineal or vestibular anus.
• Ectopic ureter.
Vaginal anomalies • Narrow introitus.
• Hymen abnormality:
✓ Absence of hymen.
✓ Imperforate hymen.
✓ Tough hymen.
• Longitudinal septum.
• Agenesis of vagina (partial/complete).
• Failure of vertical fusion.
• Failure of lateral fusion.
• Associated abnormalities:
✓ Vesicovaginal fistula.
✓ Rectovaginal fistula.
✓ Persistent urogenital sinus.
Uterine anomalies • Please see anomalies of the Mullerian duct.
Fallopian tube anomalies • Unduly elongated tubes.
• Accessory ostia.
• Accessory tubes.
• Accessory diverticula.
Ovarian anomalies • Streak gonads or gonadal dysgenesis.
• Accessory and supernumerary ovaries.
Wolffian remnant anomalies • Parovarian cyst.
Abnormalities of labia minora • Labial fusion:
• True.
• Inflammatory
Abnormalities of labia majora • Hyperplastic or hypoplastic labia.
• Abnormal fusion in Adrenogenital syndrome.
Clitorial abnormalities • Clitorial duplication.
• Clitoromegaly.
• Phalic urethra.
Perineum • Imperforated anus.
• Anal stenosis.
• Anal fistula.
• Anal agenesis.

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II. Physiology of Reproduction

Puberty

Causes of precocious puberty.

GnRH dependent – 80% (complete, central, isosexual or true)
Constitutional – most common
CNS lesions (30%)- trauma, infection (tuberculosis, encephalitis), and some degenerative, neoplastic or
congenital defects

Incomplete
• Premature thelarche
• Premature pubarche
• Premature menarche
GnRH independent (precocious puberty of peripheral origin) (excess estrogen or androgen)
Ovary Adrenal
• Granulosa cell tumor Hyperplasia
• Theca cell tumor Tumor
• Leydig cell tumor
• Chorionic epithelioma
• Androblastoma
• McCune-Albright syndrome
Liver
Hepatoblastoma
Iatrogenic (factitious)
Estrogen or androgen, combined oral contraceptives (COCs)

Causes of Delayed Puberty.

▪ Hypergonadotropic hypogonadism
• Gonadal dysgenesis, 45 XO
• Pure gonadal dysgenesis 46 XX, 46XY
• Ovarian failure 46 XX
▪ Hypogonadotropic hypogonadism
• Constitutional delay
• Chronic illness, malnutrition
• Primary hypothyroidism
• Isolated gonadotropin deficiency (Kallmann’s syndrome)
• Intracranial lesions – tumors: Craniopharyngioma, pituitary adenomas
▪ Eugonadism
• Anatomical causes
• Mullerian agenesis
• Imperforate hymen
• Transverse vaginal septum
• Androgen insensitivity syndrome

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Menstruation

Cervical cycle in follicular and luteal phase.

Cervical characters Follicular phase Luteal phase
Internal OS Funnel-shaped Tightly closed Thick and viscid
Cervical mucus Thin and watery Thick and viscid
Stretchability (spinberkeit) Increased to beyond 10cm Lost
Fern tree pattern Present Lost
Glycoprotein network Parallel, thus facilitation sperm Interlacing bridges, preventing sperm
penetration penetration
Glandular epithelium Taller More branched

Phases of menstrual cycle and the related changes.

Menstrual
Cycle days 1-5 6-14 15-28
Endometrial phase Menstrual (Bleeding) phase Proliferative phase Secretory phase
Ovarian phase Early follicular Late follicular Luteal
Estrogen/Progesterone Low Estrogen↑ Progesterone↑
Gonadotropins FSH/LH Low FSH↑ LH↑

Vaginal cycle follicular and luteal phase

Cellular characters Follicular phase Luteal phase
Cytology Showing preponderance of superficial Preponderance of intermediated cells
large cornified cells with pyknotic with folded edges (navicular cells)
nuclei
Background of the smear Clear Dirty due to presence of leukocytes
and bacilli.

Ovulation
Diagnosis of ovulation

❖ Clinical features:
1) Cyclical bleeding: The occurrence of regular normal menstrual losses is strong presumptive evidence of
regular ovulation.
2) Ovulation pain (Mittelschmerz): Many women feel some discomfort in the hypogastrium, or in one or other
iliac fossa, for 12-24 hours just before or just after ovulation.
3) Ovulation bleeding or discharge (Mittelblut): Some women experience a slight loss of blood or of mucous
tinged with blood at the time of ovulation.
4) Premenstrual mastalgia: Premenstrual pain & tenderness in the breasts is in some way related to corpus
luteum action.
5) Temperature changes: The body temperature is raised by progesterone & is therefore higher during the luteal
phase of the cycle. The temperature is raised by progesterone & is therefore higher during the luteal phase of the
cycle. The temperature remains 0.2-0.50C higher than in the follicular phase until the onset of the next period.

❖ Investigations:
➢ Indirect:
◆ Evaluation of peripheral or end organ changes:
1. BBT.

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2. Cervical mucus study: Disappearance of fern pattern of following positive fern test earlier in the
cycle.
3. Hormone estimation:
✓ Serum progesterone.
✓ Serum LH.
✓ Serum estradiol.
✓ Urine LH.
4. Endometrial biopsy: subnuclear vacuolation (earliest evidence of ovulation)
5. Vaginal smear: A single smear taken in the second half of the cycle show reliably whether a corpus
luteum has formed.
◆ Sonography (TVS).
➢ Direct: Laparoscopy.
➢ Conclusive: Pregnancy.

Important Events and Ovulation:

• Occurs 34-36 hours after onset of LH surge
• 10-12 hour after LH peak
• 83 hours after E2 rise
• Ovulation is preceded by completion of 1st meiotic division
• Extrusion of 1st polar body in perivitelline space
• Luteinization of granulosa cells
• Formation of corpus luteum
• Synthesis of progesterone
• Beginning of secretory phase
• Ovulation occurs around D14 of a regular 28 days cycle.

Fertilization and Implantation

Fertilization: Fertilization is the process of fusion of the spermatozoon with the mature ovum.
Fusion of spermatozoon with ovum produces a mononucleated single cell called the zygote.
Hundreds of million numbers of sperms are deposited in the vagina after ejaculation. Only thousands capacitated
spermatiozoa enter the fallopian tube & only 300-500 reach the ovum. The tubal transport facilitated by muscular
contraction & aspiration action of the uterine tube. It takes only few minutes for the sperm to reach the fallopian tube.

Normal site of fertilization: Ampullary part of the uterine tube.

Fertilisable life span:
Oocyte : 12-24 hours.
Sperm : 48-72 hours.
Objectives of fertilization:
1) To initiate the embryonic development of the egg.
2) To restore the chromosome number of the species.

Implantation/Nidation:
Implantation is the process of burrowing of blastocyst into the uterine lining.
Implantation occurs in the endometrium of the anterior or posterior or posterior wall of the body of uterus near the
fundus on the 6th day which corresponds to the 20th day of a regular menstrual cycle.
Implantation occurs through four stages; e.g apposition, adhesion, penetration & invasion.

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III. Bleeding in Early Pregnancy

Abortion

Abortion is the expulsion or extraction from its mother of an embryo fetus weighing 500g or less when it is not
capable of independent survival (WHO). This 500g of fetal development is attained approximately at 22 weeks (154
days) of gestation. The expelled embryo or fetus is called abortus. The word miscarriage is the recommended
terminology for spontaneous abortion.

Flowchart: classification of abortion

Common Causes of Miscarriage:
First trimester: Second trimester:
1. Genetic factors (50%) 1. Anatomic abnormalities
2. Endocrine disorders (LPD, a) Cervical incompetence (congenital or acquired),
thyroid abnormalities, diabetes), b) Mullerian fusion defects (bicornuate uterus, septate uterus),
3. Immunological disorders c) Uterine synechiae, and
(autoimmune and alloimmune), d) Uterine fibroid
4. Infection, and 2. Maternal medical illness.
5. Unexplained. 3. Unexplained.

Threatened miscarriage
Definition: It is a clinical entity where the process of miscarriage has started but has not progressed to a state from
which recovery is impossible.

Clinical features:
Symptoms:
1) Bleeding per vagina: Slight or mild, bright red in colour.
2) Usually painless but there may be mild cramp, backache or dull pain in lower abdomen. Pain appears usually
following haemorrhage.
Signs:
1) On general examination:
• Anaemia.
• Signs of early pregnancy
2) On per abdominal examination: Height of the uterus corresponds to the period of amenorrhoea.

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3) On per vaginal examination:

• Closed external OS.
• Uterus & cervix feels <soft.

Investigation:
1) Blood for Hb%.
2) Blood grouping and cross matching.
3) Urine for R/M/E.
4) Pregnancy test: Positive.
5) USG (TVS) shows a living foetus.

Differential diagnoses:
1) Ectopic pregnancy.
2) Molar pregnancy.

Treatment:
1) Rest in bed until 1 week after stoppage of bleeding.
2) No intercourse.
3) Treatment with progesterone improves outcome.
Advice on discharge: Patient is to be followed up with repeat sonography at 2-3 weeks of time.

Inevitable abortion

It is a clinical type of abortion where the changes have progressed to a state from where continuation of
pregnancy is impossible.

Management of a case of inevitable abortion:

❖ Diagnosis:
➢ Clinical features:
▪ Symptoms:
1. Symptoms & signs-of pregnancy coincide with its duration.
2. Vaginal bleeding is excesive and may be accompanied with clots.
3. Pain is colicky, felt in the suprapubic region radiating to the back.
▪ Signs:
✓ On general examination:
1) Anaemia: Corresponds to vaginal bleeding.
2) Features of shock if bleeding is profuse.
✓ On per abdominal examination: Height of the uterus corresponds to the period of
amenorrhoea.
✓ On per vaginal examination:
• Closed external OS.
• Internal examination reveals dilated internal os of the cervix through which the
products of conception are felt.
• Uterus & cervix feels soft.

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➢ Investigation:
1) Blood for Hb%.
2) Blood grouping and cross matching.
3) USG (TVS): Foetus amy be dead.

Treatment:
General treatment:
1) If excessive bleeding: Methergine 0.2 mg or oxytocin 10 IU IM if the cervix is dilated & the size of
the uterus is less than 12 weeks.
2) Intravenous fluid.
3) Blood transfusion if needed.

Active management:
If the pregnancy • Dilatation & evacuation followed by curettage of the uterine cavity by blunt
< 12 weeks curette using analgesia or under general anaesthesia.
• Alternatively, suction evacuation followed by curettage is done.
If the pregnancy • IV oxytocin and wait for spontaneous expulsion.
>12 weeks • If the foetus is expelled and the placenta is retained, it is removed by ovum
forceps, if lying separated.
• If the palcenta is not separated, digital separation followed by its evacuation is
to be done under GA.

Complete abortion

When the products of conception are expelled completely, it is called complete abortion.

Management of complete abortion:

❖ Diagnosis:
➢ Clinical features:
▪ Symptoms:
1. There is history of expulsion of a fleshy mass per vaginam followed by:
a) Subsidence of abdominal pain.
b) Vaginal bleeding becomes trace or absent.
▪ Signs:
✓ On general examination:
1. Anaemia: Mild.
2. General condition usually good.
✓ On per abdominal examination: Uterus may not be palpable. If palpable, uterus is smaller than
the period of amenorrhoea & a little firmer.
✓ On per vaginal examination:
1) Cervical os is closed.
2) Bleeding is trace.
✓ Examination of the expelled fleshy mass: Intact.

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Investigations:
1) Blood for Hb%.
2) Blood grouping and cross matching.
3) USG (TVS): Reveals empty uterine cavity.

❖ Treatment:
1) Transvaginal sonography is useful to see that uterine cavity is empty, otherwise evacuation of uterine
curettage should be done.
2) In Rh-negative women: Anti-D gamma globulin 50 microgram or 100 microgram IM in cases of early
abortion or late abortion respectively within 72 hours.

Incomplete abortion

When the entire products of conception are not expelled, instead a part of it is left inside the uterine cavity, it
is called incomplete abortion.

Clinical features:
Symptoms: History of expulsion of a fleshy mass per vagina, followed by-
1) Continuation of pain in lower abdomen.
2) Persistence of vaginal bleeding of varying magnitude

Sings:
✓ On general examination:
1) Anaemia: Corresponds to vaginal bleeding.
2) Features of shock if bleeding is profuse.
✓ On per abdominal examination: Size of uterus is smaller than the period of amenorrhoea.
✓ On per vaginal examination:
1) Cervix is opened and retained contents may be felt through it.
2) Cervix is soft with varying amount of bleeding.
✓ Examination of the expelled fleshy mass: Incomplete.

Investigations:
1) Blood for Hb%.
2) Blood grouping and cross matching.
3) USG (TVS): Reveals heterogenous echogenic material (products of conception) within the cavity.

Treatment:
a) General treatment:
• Hospitalization of the patient.
• IV fluids & blood transfusion if patient is in shock.
• Excessive bleeding should be controlled by administering methergin 0.2 mg.

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b) In recent cases: Evacuation of the retained products of conception (ERCP) is done.

c) Early abortion: Dilatation & evacuation under analgesia or G/A. Evacuation of the uterus may be done
using MVA also.
d) Late abortion: The uterus is evacuated under general anaesthesia & the products are removed by ovum
forceps or by blunt curette. The removed materials are subjected to a histological examination.
e) Medical management: Tablet misoprostol mg is used vaginally every 4 hours.

Missed abortion

When foetus is dead and retained inside the uterus for a viable period, it is called missed abortion or silent
miscarriage or early fetal demise.

Septic abortion:
Any abortion associated with clinical evidences of infection of the uterus & its contents, is called septic
abortion.

Causative organisms of septic abortion:

❖ Anaerobic:
✓ Bacteroides group (fragilis).
✓ Anaerobic Streptococci.
✓ Clostridium welchii.
✓ Tetanus bacillus.

Management of septic abortion:

Diagnosis:
➢ History:
1) The patient usually gives history of induction of abortion unhygenically by untrained person.
2) She may complain of lower abdominal pain & foul-smelling vaginal discharge.
➢ Clinical features:
1) The woman looks sick & anxious.
2) Temperature > 38°C.
3) Chills & rigor (suggest bacteraemia).
4) Persistent tachycardia > 90bpm (spreading infection).
5) Hypothermia (endotoxic shock) < 36’C.
6) Abdominal or chest pain.
7) Tachypnoea (RR) > 20/min.
8) Impaired mental state.
9) Diarrhoea and/or vomiting.
10) Renal angle tenderness.
11) Pelvic examination:
✓ Offensive, purulent vaginal discharge.
✓ Uterine tenderness.
✓ Boggy feel in POD (pelvic abscess).

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Investigations:
1) Routine investigations:
a) Cervical or high vaginal swab is taken prior to internal examination for:
✓ Culture in aerobic & anaerobic media to find out the dominant microorganisms.
✓ Sensitivity to microorganisms to antibiotics.
✓ Smear for gram stain.

b) Blood for:
✓ Hb%, TC of WBC, DC of WBC.
✓ ABO & Rh grouping.
c) /Urine analysis including culture.

2) Special investigations:
a) Ultrasonography of pelvis & abdomen.
b) Blood:
✓ Culture.
✓ Serum electrolytes.
✓ C-reactive protein.
✓ Serum lactate.
c) Coagulation profile.
d) Plain X-ray abdomen in suspected cases of bowel injury.
e) Plain X-ray chest for cases with pulmonary complications (atelectasis).
3) Urine routine examination & culture sensitivity.

Treatment:
➢ Principles of management:
✓ To control sepsis.
✓ To remove source of infection.
✓ To give supportive therapy to bring back the normal haemostatic & cellular metabolism.
✓ To assess the response of treatment.

➢ General management:
✓ Hospitalization and should be kept in isolation.
✓ Collection of high vaginal swab for culture, drug sensitivity & Gram stain.
✓ Vaginal examination is done to note the state of the abortion process % extension of the infection.
✓ Overall assessment of the case.
✓ Investigations protocols.

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➢ Supportive treatment:
✓ I.V fluids.
✓ Blood transfusion.
✓ Broad spectrum antibiotics:
• Pipercillin-tazobactum and carbapenems.
• Vancomycin or teicoplanin.
• Clindamycin.
• Gentamycin.
• Co-amoxiclav.
• Metronidazole.
✓ Prophylactic antigas gangrene serum & antitetanus serum.
✓ An I/M injection of syntometrine will assist in controlling bleeding

Operative treatment:
✓ Evacuation and curettage (E <& C)
✓ Posterior colpotomy
✓ If patient is not responding to the conservative treatment, laparotomy is indicated.

Ectopic Pregnancy

Definition: An ectopic pregnancy is none is which the fertilized ovum (blastocyte) is implanted and develops outside
the normal endometrial cavity.

Risk Factors of Ectopic Pregnancy

• History of PID
• History of tubal ligation
• Contraception failure
• Previous ectopic pregnancy
• Tubal reconstructive surgery
• History of infertility
• ART particularly if the tubes are patent but damaged
• IUD use
• Previous induced abortion
• Tubal endometriosis
• Salpingitis
• Transperitoneal migration of ovum
• Developmental defects of the tube:
▪ Elongation
▪ Diverticulum
▪ Accessory ostia

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Clinically three distinct types are described.

✓ Acute (tubal rapture or abortion)
✓ Unruptured.
✓ Subacute (Chronic or old)

Acute ectopic pregnancy:

An acute ectopic is fortunately less common (about 30%) and it is associated with cases of tubal rupture or
tubal abortion with massive intraperitoneal hemorrhage.

Patient profile:
1) The incidence is maximum between the age of 20 and 30 years, being the maximum period of fertility.
2) The prevalence is mostly limited to nulliparity or following long period of infertility.

Mode of onset: The onset is acute. The patients, however, have got persistent unilateral uneasiness in about one-third
of cases before the acute symptoms appear.

Symptoms: The classic triad of symptoms of disturbed tubal pregnancy are: abdominal pain (100%), preceded by
amenorrhea (75%) and lastly, appearance of vaginal bleeding (70%).
■ Abdominal pain (100%) is the most constant feature. It is acute, agonizing or colicky. Otherwise it may be a vague
soreness. Pain is located at lower abdomen: unilateral, bilateral or may be generalized.
Shoulder tip pain (25%) (referred pain due to diaphragmatic irritation from hemoperitoneum) may be present.
■ Vaginal bleeding (70%) may be slight and continuous. Expulsion of decidual cast (5%) may be there.
■ Amenorrhea: Short period of 6-8 weeks (usually); there may be delayed period or history of vaginal spotting.
Amenorrhea may be absent even.
■ Syncope (10%): Dizziness, high headedness may be an initial presentation. It is often due to intra- abdominal
bleeding following rupture of a tubal ectopic pregnancy.
Signs:
▪ General look (diagnostic): The patient lies quiet and conscious, perspires and looks blanched (due to
hemoperitoneum).
▪ Pallor: Severe and proportionate to the amount of internal hemorrhage.
▪ Features of shock: Pulse—rapid and feeble, hypotension, extremities—cold clammy.

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▪ Abdominal examination: Abdomen (lower abdomen)—tense, tumid, tender. No mass is usually felt, shifting
dullness present, bowels may be distended. Muscle guard—usually absent.
▪ Pelvic examination is less informative due to extreme tenderness and it may precipitate more intraperitoneal
hemorrhage due to manipulation. The findings are:
i) Vaginal mucosa—blanched white,
ii) Uterus seems normal in size or slightly bulky and soft,
iii) Extreme tenderness on fornix palpation or on movement of the cervix. Cervical motion -
tenderness (75%).
iv) No mass is usually felt through the fornix,
v) The uterus floats as if in water. Caution: Vaginal examination may precipitate more hemorrhage
due to manipulation.
D/D:
1. Acute appendicitis
2. Ruptured corpus luteum [Clinical presentation is similar to ruptured tubal ectopic pregnancy, but pregnancy
test negative]
3. Tainted ovarian tumor.
4. Ruptured chocolate cyst.

Fate of ectopic pregnancy:

• Tubal mole
• Tubal abortion
• Tubal rupture
• Tubal perforation
• Continuation of pregnancy
• Rarest

Acute principles of surgical management.

Acute
Principle: The principle in the management of acute
ectopic is resuscitation and laparotomy and not
resuscitation followed by laparotomy.

Antishock treatment: Antishock measures are to be

taken with simultaneous preparation for urgent
laparotomy.
• Ringer's solution (crystalloid) is started, if-
necessary with venesection
• Arrangement is made for blood transfusion. Even if
Fig: Salpingectomy. Note the placement of the
availability of blood is delayed, laparotomy is to be
clamps
done desperately.
• After drawing the blood samples for grouping and cross matching, volume replacement with crystalloids is to be
done.
Laparotomy: Indications of laparotomy are -
i) Patient hemodynamically unstable,
ii) Laparoscopy contraindicated,
iii) Evidence of rupture. The principle in laparotomy is 'quick in quick out.

Medical management:
• Methotrexate
• potassium chloride
• prostaglandin (PGF2α)
• hyperosmolar glucose or actinomycin.

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Trophoblastic Tumour

The neoplasm which arises from the fetal tissue within the maternal host and are composed of both syncytiotrophoblastic
and cytotrophoblastic cells is called trophoblastic tumour.
Gestational trophoblastic disease (GTD): Abnormal growth & development of the trophoblast continue even beyond
the end of pregnancy is called gestational trophoblastic disease (GTD).
Names of trophoblastic tumours (types):
1) Benign (relatively); Hydatidiform mole (vesicular mole).
2) Malignant: Choriocarcinoma.
3) In between benign and malignant: Invasive mole (chorioadenoma destruens).
4) Placental site trophoblastic tumour Which, whilst it may be self-limiting, may also behave in a malignant
manner.

Classification of gestational trophoblastic disease (GTD):

1) Hydatidiform mole: 2) Gestational trophoblastic neoplasia (GTN):
• Complete. • Persistent hydatidiform mole.
• Incomplete. • Invasive mole.
• Choriocarcinoma.
• Placental site trophoblastic tumour (rare).

Hydatidiform Mole

Important features of complete and partial moles.

Features Complete mole Partial mole
Embryo/fetus Absent. Present.
Hydropic degeneration of villi Pronounced and diffused. Variable and focal.
Trophoblast hyperplasia Diffuse. Focal.
Uterine size More than the date (30-60%). Less than the date.
Theca lutein cysts Common (25-50%). Uncommon.
Karyotype 46, XX (85%), or XY, paternal in Triploid (90%), (69, XXX or
origin. 69.XXY) diploid (10%).
Trophoblast atypia Marked. Mild.
ß-hCG High (>50,000). Slight elevation (<50,000).
Medical complications Uncommon. Rare.
Classic clinical symptoms Common. Rare.
Amnion, fetal erythrocytes Absent. Often present.
Risk of persistent GTN 20%. <5%.
Immunostaining (p57KIP2) Negative. Positive.

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Choriocarcinoma

Management of a case of choriocarcinoma:

❖ Diagnosis:
➢ Patient profile: History of molar pregnancy in recent past. (GTN after a nonmolar pregnancy is always a
choriocarcinoma).
➢ Clinical features:
a) Symptoms:
1) Usual symptoms:
• Persistent ill health.
• Irregular vaginal bleeding.
• Continued amenorrhoea.
2) Metastasis: Metastatic site of choriocarcinoma:
• Lungs
• Vagina
• Brain
• Liver
b) Signs:
On general examination:
• Ill looking.
• Pallor of varying degrees.

Investigations:
1. HCG titres.
2. Chest X-ray.
3. Pelvic sonography.
4. Diagnostic uterine curettage.
5. Histopathology.
6. For diagnosis of metastatic disease:
• Vagina: Excision biopsy and histopathology
• Liver function tests.
• USG.
• CT scan.

Treatment:
A) Preventive:
• Prophylactic chemotherapy: In 'at risk' women following evacuation of molar pregnancy.
• 'At risk' women are:
✓ Age of the patient > 35 years.
✓ Initial levels of serum hCG > 100,000 mIU/mL.
✓ Evidence of metastasis irrespective of the level of hCG.
✓ Previous history of a molar pregnancy.
✓ Women who is unreliable for follow-up.

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B) Curative:
• Chemotherapy
• Surgery
• Radiation

Follow-up:
✓ Follow-up is mandatory for all patients at least for 2 years.
✓ Physical examination including pelvic examination.
✓ Serum hCG value monitoring weekly once negative.
✓ Monthly for 1 year → every 6-12 months for lifetime or at least 3-5 years.
✓ Chest X-Ray monthly until remission, then monthly for 1 year, and then 6-monthly for lifetime.

Common Sites of Metastasis in GTN

Common sites of metastasis in GTN:

1. Lung (80%)
2. Anterior vaginal wall (30%)
3. Pelvis (20%)
4. Liver (10%)
5. Brain (10%)

IV. Vaginal Discharge

Differential Diagnosis of Vaginal Discharge:
Characteristics Trichomoniasis Candidiasis Bacterial vaginosis Chlamydia Normal vaginal
discharge
Color Gray, yellow or Curdy white Gray white to green Mucopurulent White, clear
green yellow white
Consistency Thin, frothy, Thick, no Thin, adherent Thick Thin
adherent, mal odor homogeneous
odor
Whiff test Negative Has Negative Positive (Fishy Negative Negative
unpleasant odor amine)
pH 45 <45 45 <4.5
Pruritus +++, dysuria ++ -
Diagnosis (Wet Motile Hyphae and Clue cells (>20%), Chlamydia -
mount trichomonas buds, spores amine odor after NAAT
microscopy) Increased white adding KOH to wet
cells mount; 4 lactobacilli
Treatment Metronidazole Clotrimazole Metronidazole Azithromycin -
500mg PO BID intravaginal 500mg PO BID  7 1 g orally
x 7 days Or 200 1-3 days days single dose
mg TID x 7day Fluconazole
150mg PO
weekly for 6
weeks

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V. Menstrual Disorder

Amenorrhoea

Most common causes of primary amenorrhoea:

1) Anorexia nervosa
2) Primary ovarian failure.
3) Turner’s syndrome (45 X). [Most common cause]
4) Androgen insensitivity syndrome (Testicular feminization syndrome), 46XY
5) Imperforate hymen
6) MRKH syndrome
7) Adrenogenital syndrome

The following guidelines may be of help:

• No period by 16 years of age in the presence of normal secondary sexual characters.
• No period by the age of 14 in the absence of growth or development of secondary sexual characters.

Surgical treatment:
• Imperforate hymen or transverse vaginal septum: Cruciate incision of the membrane & drainage of the blood
under G/A
• Vaginal agenesis: Vaginal reconstructive surgery.
• Bilateral wedge resection of the polycystic ovaries.

Secondary Amenorrhoea

Common causess of secondary amenorrhoea:

Hypothalamus Pituitary Ovary Uterine Systemic
• Stress • Adenoma • Polycystic ovary • Synechiae • Malnutrition
• Postpill • Sheehan’s syndrome (PCOS) • (Spontaneous • Hypothyroid
• Weight: Either too much loss • Premature ovarian or induced) state
or too much gain failure • Diabetes
• Drugs: Psychotropic and
antihypertensive drugs

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Dysmenorrhoea

Definition: Dysmenorrhea literally means painful menstruation. But a more realistic and practical definition
includes cases of painful menstruation of sufficient magnitude so as to incapacitate day to day activites
Types:
1. Primary
2. Secondary

❖ Common cause of secondary dysmenorrhea (Congestive):

1) Endometriosis
2) Adenomyosis
3) IUCD in utero
4) Obstruction due to Mullerian anomalies
5) Cervical stenosis
6) Pelvic adhesions
7) Uterine Fibroid
8) Pelvic congestion
9) Endometrial polyp
10) Chronic pelvic infection

❖ Investigations:
1) Transvaginal sonography (Can detect Leiomyoma, Adenomyosis)
2) Saline infusion sonography (Submucous fibroid, Polyp)
3) Laparoscopy (endometriosis, PID)
4) Hysteroscopy- Both diagnostic & therapeutic.

Menorrhagia

Definition: Menorrhagia is defined as cyclic bleeding at normal intervals; the bleeding is either excessive in
amount (> 80 ml) or duration (> 8 days) or both.

Common causes of menorrhagia:

1) Fibroid uterus.
2) Pelvic endometriosis.
3) Adenomyosis
4) Chronic tubo-ovarian mass.

➢ Medical treatment:
1) Non-steroidal anti-inflammatory drugs (NSAIDs). 5) Danazol.
2) Oral contraceptive pills. Progestin therapy. 6) Conjugated estrogen.
3) Levonorgestrel intrauterine system. 7) Tranexamic acid.
4) Gonadotrophin releasing hormone agonists.

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➢ Surgical treatment:
1) Dilatation and curettage (D & C)
2) Transcervical resection of the endometrium
3) Thermal balloon therapy
4) Endometrial ablation
5) Myomectomy
6) Hysterectomy

Metrorrhagia (Intermenstrual Bleeding)

Occurs between normal menses (earlier metrorrhagia)

• Pre and postmenstrual spotting
• Postcoital bleeding.
▪ Irregular, acyclic bleeding from the uterus.
▪ In fact, it is mostly related to surface lesion in the uterus

Causes of contact bleeding Causes of acyclic bleeding

• Carcinoma cervix • DUB—usually during adolescence, following
• Mucus polyp of cervix childbirth and abortion and preceding
• Vascular ectopy of the cervix especially during menopause
pregnancy, pill use cervix • Submucous fibroid
• Infections—chlamydial or tubercular cervicitis • Uterine polyp
• Cervical endometriosis • Carcinoma cervix and endometrial carcinoma

Abnormal Uterine Bleeding

Definition: Any uterine bleeding outside the normal volume, duration, regularity or frequency is considered abnormal
uterine bleeding (AUB). Nearly 30% of all gynecological outpatient attendants are for AUB.

Normal Menstruation
Cycle interval 28 days (24-38 days)
Menstrual flow Less than 8 days
Menstrual blood loss 35 mL (5-80 mL)

Common Causes of Abnormal Uterine Bleeding

Classification of AUB
Structural causes (PALM) Nonstructural systemic causes (COEIN)
Polyp AUB-P Coagulopathy AUB-C
Adenoinyosis AUB-A Ovulatory dysfunction AUB-0
Leiomyoma AUB-L Endometrial AUB-E
■ Submucosal myoma AUB- Iatrogenic AUB-I
■ Other myoma LSM
AUB-LO
Malignancy and hyperplasia AUB-M Not yet identified AUB-N

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Diagnosis and Management:

Management protocol of abnormal uterine bleeding (AUB)

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VI. Genital Tract Infection

a) Defensive mechanism of genital tract

Vulvar defense Anatomic ✓ Apposition of the cleft by labia.
✓ Compound racemose type Bartholin’s glands
Physiologic ✓ Inherent resistance to infection of the vulva and perineum.
✓ Fungicidal action of apocrine glands.
✓ Natural high resistance to infection of the vulval & perineal skin.
Vaginal defense Anatomic ✓ Apposition of its anterior and posterior walls with its transverse rugae.
✓ Stratified squamous epithelium devoid of glands.
Physiologic ✓ Vaginal acidity.
✓ Vaginal flora.
✓ The mucosal immune response- antibodies are present although titres are low.
✓ Phagocytic cells & cytokines have also been identified.
Cervical defense Anatomic ✓ Racemose type glands.
✓ Mucus plug.
Physiologic ✓ Bactericidal effect of the mucus.
Uterine defense ✓ Cyclic shedding of the endometrium during menstruation.
✓ Closure of the uterine ostium of the fallopian tube with slightest inflammatory
reaction in the endometrium.
Tubal defense Anatomic ✓ Integrated mucus plicae.
✓ Ciliated columnar epithelium
Physiologic ✓ Peristalsis of the tube & also the movement of the cilia are towards the uterus.

Pelvic Inflammatory Disease (PID)

Definition:
Pelvic inflammatory disease (PID): It is a spectrum of infection & inflammation of the upper genital tract organs
typically involving the uterus (endometrium), fallopian tubes, ovaries, pelvic peritoneum & surrounding structures
(parametrium). The clinical syndrome is not related to pregnancy & surgery.

Causative organisms of pelvic inflammatory disease (PID):

The primary organisms The secondary organisms
• N. gonorrhoea (30%). Aerobic organisms:
• Chlamydia trachomatiis (30%). • Non haemolytic Streptococcus.
• Mycoplasma hominis (10%). • E. coli.
• Group B Streptococcus.
• Staphylococcus.
Anaerobic organisms:
• Fragilis.
• Bivius.
• Peptostreptococcus.
• Peptococcus.

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Women who are risk of developing PID:

• Sexually active teenagers.
• Younger age (> 19 years).
• Multiple sex partners.
• Absence of contraceptive pill use.
• Previous history of acute PID.
• Intrauterine contraceptive device (IUCD) users.
• Lower socioeconomic status.
• Husband / sexual partners with urethritis or STI.
• Genetic predisposition.

Clinical features of acute PID:

1) Fever >38°C.
2) Bilateral lower abdominal tenderness with radiation to the legs.
3) Abnormal vaginal discharge.
4) Abnormal uterine bleeding.
5) Deep dyspareunia.
6) On bimanual examination:
a) Cervical motion tenderness.
b) Adnexal tenderness/mass.
7) Raised ESR.

Differential diagnosis of pelvic inflammatory disease (PID):

1) Appendicitis.
2) Disturbed ectopic pregnancy.
3) Torsion of ovarian pedicle, haemorrhage or rupture of ovarian cyst.
4) Endometriosis.
5) Diverticulitis.
6) Urinary tract infection.

Criteria of hospital admission in acute pelvic infection:

1. Suspected tubo-ovarian abscess.
2. Severe illness, vomiting, temperature > 38°C.
3. Uncertain diagnosis—where surgical emergencies, (e.g. appendicitis) cannot be excluded.
4. Unresponsive to outpatient therapy for 48 hours.
5. Intolerance to oral antibiotics.
6. Co-existing pregnancy.
7. Patient is known to have HIV infection

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Clinical diagnostic criteria / Cardinal features for diagnosis of acute PID: (CDC-2015):
Minimum criteria 1) Lower abdominal pain.
2) Adnexal tenderness.
3) Cervical motion tenderness.
Additional criteria 1) Oral temperature > 38.3°C.
2) Mucopurulent cervical or vaginal discharge.
3) Abundant WBCs on saline microscopy or cervical secretions.
4) Raised C-reactive protein.
5) Raised ESR.
6) Laboratory documentation of positive cervical infection with gonorrhoea or
Chlamydia tracomatis.
Definitive criteria 1) Histopathologic evidence of endometritis on biopsy.
2) Imaging study (TVS / MR1) evidence of thickened fluid filled tubes, ± free pelvic
fluid or tubo-ovarian complex.
3) Laparoscopic evidence of PID.
4) Although initial treatment can be made before bacteriological diagnosis of
Chlamydia trachomatis or N. gonorrhoeae infection, such a diagnosis emphasizes the
need to treat sex partners.

Complications of pelvic inflammatory disease (PID):

Immediate 1) Pelvic peritonitis or even generalized peritonitis.
2) Septicaemia- producing arthritis or myocarditis
Late 1) Dyspareunia.
2) Infertility.
3) Chronic pelvic inflammation (25%).
4) Formations of adhesions or hydrosalpinx or pyosalpinx & tuboovarian abscess.
5) Chronic pelvic pain & ill health.
6) Increased risk of ectopic pregnancy (6-10-fold)

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Sexual Transmitted Diseases (STI)

Disease Agent Prevention of STIs and RTIs

■ Bacterial:
• Gonorrhea Neisseria gonorrhoeae ■ Safe sex as STIs are entirely
• Non-gonococcal urethritis Chlamydia trachomatis (D-K serotypes) preventable
• Syphilis Treponema pallidum ■ Use of barrier contraception:
• Lymphogranuloma venereum Chlamydia trachomatis (L serotypes) Condom, diaphragm, spermicides
• Chancroid Haemophilus ducreyi
• Granuloma inguinale Donovania granulomatis
• Nonspecific vaginitis Haemophilus vaginalis
• Mycoplasma infection Mycoplasma hominis (gentalium)
■ Viral:
• AIDS Human immunodeficiency virus ■ Reducing the number of sexual
(HIV1 or HIV 2) partners— monogamous relationship
• Genital herpes Herpes simplex virus (HSV2) reduces the risk of
• Condyloma acuminata Human papilloma virus (HPV) STIs and RTIs
• CIN HPV- 16,18 or 31 ■ Contact tracing and effective
• Molluscum contagiosum Pox virus treatment
• Viral hepatitis Hepatitis B and C virus
■ Protozoal
• Bacterial vaginosis (8V) Gardenella vaginalis ■ Screening in asymptomatic or
• Trichomonas vaginitis Trichomonas vaginalis symptomatic cases for STIs and RTIs
■ Fungal
• Monilial vaginitis Candida albicans
■ Ectoparasites
• Scabies Sarcoptes scabiei ■ Aseptic procedures in delivery, MTP
• Pediculosis pubis Crab louse (Pthirus pubis) procedures and IUCD insertion

Painful genital ulcers:

Common Uncommon
1. Herpes simplex 1. Secondary syphilis
2. Chancroid 2. Scabies
3. Erosive balanitis 3. Reiter’s disease
4. Trauma with 2ndary infection

Painless genital ulcers:

1. Primary syphilis
2. LGV
3. Lymphogranuloma
4. Venerum
5. Donovanosis
6. Bechet’s disease

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Urethritis
1. Gonococcal urethritis
• Neisseria gonorrhea

2. Nongonococcal Urethritis
• Chamydia trachomatis
• Mycoplasma genitalicum
• Ureaplasma genitalicum
• Trichomonas vaginalis
• Herpes simplex virus

Difference between Primary Syphilis and Chancroid

Traits Primary syphilis (chancre) Chancroid

1. Causative agent Treponema pallidum Haemophylus ducreyi
2. Pain in ulcer Painless Painful
3. Edge of ulcer Punched out Ragged, undermined
4. draining lymph nodes Painless Painful
5. Response to penicillin Penicillin is the drug of choice Not the drug of choice

Genital Tuberculosis

Mode of Spread:
♦ Hematogenous (90%)
♦ Lymphatic
♦ Direct to other organ
♦ Ascending (rare)

Affection Rates of Genital Organs with Tuberculosis (%)

♦ Fallopian tubes 100%
♦ Endometrium 50-60%
♦ Cervix 5-15%
♦ Ovaries 30%
♦ Pelvic peritoneum 40-50%
♦ Vulva, vagina 1%

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Investigation:
Table- 11.7: Antitubercular chemotherapy for initial treatment.
Drug Daily oral Nature Toxicity Comments
dosage (adult)
Isoniazid (H) Maximum Bactericidal Hepatitis, peripheral ■ Check liver function
300 mg neuropathy ■ Combine pyridoxine 50 mg daily
Rifampicin Maximum Bactericidal Hepatic dysfunction, ■ Drug interaction
(R) 600 mg orange discoloration of ■ Oral contraceptives to be avoided
urine. Febrile reaction ■ Monitor liver enzymes aspartate
aminotransferase (AST)
Pyrazinamide 1.5 g/day Bactericidal Hepatitis, hyperuricemia, ■ Active against intracellular dividing
(2) G1 upset and arthralgia forms of Mycobacterium
■ Monitor (AST)
Ethambutol 1200 mg/day Bacteriostatic Visual disturbances, ■ Ophthalmoscopic examination prior
(E) optic to therapy

VII. Urinary Incontinence

Clinical presentation and diagnosis of GSI and urge incontinence (sensory and motor).
Genuine stress incontinence Urge incontinence Overactive bladder (OAB)
(GSI) (sensory)
Definition Involuntary escape of urine Involuntary leakage of Leakage of urine due to
when intravesical pressure urine, accompanied by or sudden, spontaneous,
exceeds maximum urethral immediately preceeded detrusor contraction
pressure in the absence of by urgency (detrusor instability) without
detrusor activity any clinical cause
Clinical presentation
Stress prior to Always present Nil Nil (urodynamic diagnosis
leakage
Urge prior to Nil Present Present except in disease
leakage diagnosis
Awareness Present Present Not present
Control of loss Can control Can control with Cannot control despite
adequate encouragement strong encouragement
Amount Small Large Large
Midstream urine Not informative Evidences of infection Usually non-informative
examination
Uroflowmetry Normal Normal High in idiopathic group
Cystometry During strain, there is Normal Urge to pass urine is
significant lowering of the provoked at much lower
urethral pressure, (urethral bladder filling
pressure profile) Detrusor pressure is
increased during filling
Cystourethroscopy Normal Offending factor present Diminished bladder capacity
Lateral Funneling of the proximal Normal Normal
cystourethrography urethra

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Vesico vaginal Fastula (VVF)

There is communication between the bladder, the he urine escapes into the vagina causing true incontinence, this is
the most common type of genitourinary fistula.

Following Are the type of Fistula (ACQUIRED)

Bladder Urethra
• Vesicovaginal (most common) • Urethrovaginal Ureter
• Vesicourethrovaginal • Ureterovaginal
• Vesicouterine • Ureterovaginal
• Vesicocervical • Ureterouterine
• Ureterocervicaf
• Vesicoureterovaginal

Causes:
A. Obstetrical
B. Gynecological

A. Obstetrical: In the developing countries, the most common cause is obstetrical and constitutes about 80-90% of
cases.
1. Ischemic:
• It results from prolonged compression effect on the bladder base between the head and symphysis pubis in
obstructed labor
• It takes few days (3-5) following delivery to produce such type of fistula
2. Traumatic:
• Instrumental vaginal delivery such as destructive operations or forceps especially with Kielland
• Abdominal operations such as hysterectomy for ruptured uterus or cesarean section.
• This type of direct traumatic fistula usually follows soon after delivery. (1-15 days)

B. Gynecological:
1. Operative injury: anterior colporrhaphy, abdominal hysterectomy (open or laparoscopic method).
2. Traumatic: the anterior vaginal wall and the bladder may be injured following fall on a pointed object.
3. Malignancy: advanced carcinoma of the cervix, vagina or bladder may produce fistula by direct spread.
4. Radiation: there may be ischemic necrosis by endarteritis obliterans due to radiation effect, when the carcinoma
cervix is treated by radiation.
5. Infective: chronic granulomatous lesions such as vaginal tuberculosis, LGV, schistosomiasis or actinomycosis may
produce fistula.
Thus, the fistula tract may be lined by fibrous, granulation tissue.
Other causes are: Infection (lymphogranuloma sexual) assault.

Investigations:
1. To confirm the diagnosis, followings are helpful:
2. Examination under anaesthesia.
3. Dye test.
4. Metallic catheter test.
5. Three swab (tampon) test

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6. Imaging studies:
• Intravenous urography (IVU) or contrast enhanced CT scan.
• Retrograde pyelography
• Voiding cystourethrography
• Sonography
• Hysterosalpingography
• USG
• CT scan
• MRI
• cystourethroscopy

Management:
1. Preventive
2. Immediate management
• Once the diagnosis is made continuous catheterization for 4-8 weeks is maintained
• This may help spontaneous closure of small size (2 mm to 2 cm diameter) fistula tract in about 50-60 %
cases
3. Operative
• Timing of repair: The ideal time of surgery is usually after 6 weeks to 3 months following delivery
• Surgery:
✓ Local repair by flat splitting method is the preferred surgery (vaginal route).
✓ Saucerization (paring & suturing).
✓ Interpositional graft ( Martius graft).

VIII. Other Genital Tract Injuries

A. Perineal tear:

Classification of Obstetric (RCOG) Anal Sphincter Injury

First degree Injury to perineal skin only
Second degree Injury to perineum involving perineal muscles but not the anal sphincter
Third degree Injury to perineum involving anal sphincter complex
■ 3a: <50% of EAS thickness torn
■ 3b: >50% of EAS thickness torn
■ 3c: Both EAS and IAS torn
Fourth degree Injury to perineum involving anal sphincter complex (EAS and IAS) and anal epithelium

Structures torn in CPT

• Posterior perineal skin or/and vaginal wall • Anal sphincter complex
• Perineal muscles • Varying degrees of anorectal mucous
• Perineal body membrane

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Rectovaginal fistula (RVF)

Causes of RVF:
➢ Acquired:
a) Obstetrical:
1) Incomplete healing or unrepaired recent complete perineal tear (commonest cause)
2) Obstructed labour.
3) Instrumental injury during destructive operation.
b) Gynaecological:
1) Following incomplete healing of repair of old complete perineal tear.
2) Gynaecological operation Posterior colpoperineorrhaphy. Repair of enterocele. Vaginal tubectomy. Posterior
colpotomy. Reconstruction of vagina.
3) Fall on sharp pointed object.
4) Carcinoma of the vagina, cervix, bowel.
5) Radiotherapy.
6) Infection: Vaginal tuberculosis, lymphogranuloma venerum.
7) Crohn's disease involving the anal canal or lower rectum.
8) Diverticulitis of the sigmoid colon → abscess → burst into vagina.
➢ Congenital: The anal canal may open into the vestibule or in the vagina.

Management of RVF:
Diagnosis:
➢ Involuntary escape of flatus and or faeces into the vagina.
➢ Rectovaginal examination reveals the site & size of the fistula.
➢ Confirmation of diagnosis: By passing a probe through the vagina into the rectum.
➢ If necessary, methylene blue dye test.
➢ Barium enema, or CT scanning proctoscopy, colonoscopy may be needed when malignancy or inflammatory
bowel disease are suspected.

Treatment:
Preventive:
1) Good intranatal care.
2) Identification of complete perineal tear & its effective repair.
3) Consciousness about the possible injury of the rectum in gynaecology surgery mentioned & its effective
and appropriate surgery minimize the incidence of fistula.
Conservative: Small size fistula may be followed up conservatively for spontaneous healing. > Definitive:
1) Transvaginal approach is commonly done.
2) Transvaginal fistulotomy & purse string met

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IX. Genital Prolapse

Types of genital prolapse:
A) Vaginal 1) Anterior wall • Cystocele.
prolapse • Urethrocele.
• Cystourethrocele.
2) Posterior • Relaxed perineum.
• Rectocele.
3) Vault prolapse • Primary: Enterocele.
• Secondary: Following abdominal/ vagina hysterectomy.
B) Uterine a) Uterovaginal • First degree: The uterus descends down from its normal anatomical
prolapse prolapse position but the external os still remains inside the vagina.
• Second degree: The external os protrudes outside the vaginal
introitus but the uterine body still remains inside the vagina.
• Third degree: The uterine body descends to lie outside the introtitus.
b) Congenital

Factors responsible for genital prolapse:

❖ Anatomical factors:
1) Gravitational stress due to human bipedal posture.
2) Anterior inclination of pelvis directing the force more anteriorly.
3) Stress of parturition.
4) Pelvic floor weakness: Enlarged genital hiatus.
5) Inherent weakness (genetic) of the collagen fibers.
6) Denervation of levator muscle with childbirth trauma & weakness.

❖ Predisposing factors:
1) Acquired: Trauma of vaginal delivery causing 2) Congenital:
injury (tear or break) to: ✓ Genetic (connective tissue disorders),
✓ Ligaments. decrease ratio of type I collagen.
✓ Endopelvic fascia. ✓ Woman with Marfan or Ehlers-Danlos
✓ Levator muscle (myopathy). syndrome.
✓ Perineal body. ✓ Spina bifida.
✓ Nerve (pudendal) & muscle damage due to
repeated child birth.

❖ Aggravating factors:
1) Post-menopausal atrophy. 6) Obesity, smoking.
2) Poor collagen tissue repair with age. 7) Increased weight of the uterus as in fibroid
3) Increased intra-abdominal pressure as in chronic myohyperplasia.
lung disease (COPD) & constipation. 8) Multiparity
4) Occupation (weight lifting). 9) Woman having android or anthropoid pelvic have
5) Asthenia & under-nutrition. higher risk.

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Support of Uterus:
Primary support Muscular or active support Pelvic diaphragm
Perineal body
Urogenital diaphragm
Fibromuscular or mechanical Uterine axis
Pubocervical ligaments of mackenrodt
Uterosacaral ligaments
Secondary supports Round ligaments
Broad ligaments
Uterovesical fold of peritoneum
Rectovaginal fold of peritoneum

Differential diagnoses of genital prolapse:

1) Cystocele (Gartner’s cyst).
2) Uterine prolapse:
a) Congenital elongation of the cervix.
b) Chronic inversion of uterus.
c) Fibroid polyp.

Types of prolapse and the common surgical repair procedure

Organ Descent Clinical Condition Type of Operation
Vaginal Wall
Anterior (Upper 2/3rd) or whole Cystocele / Cystourethrocele Anterior colporrhaphy.
Paravaginal defect. Paravaginal defect repair.
Posterior (Lower 2/3rd) Rectocele. Colpoperineorrhaphy.
Posterior (Upper 1/3rd) Enterocele. Vaginal repair of Enterocele with PFR.
McCall culdoplasty.
Moscowitch procedure.
Combined anterior & posterior Cystocele & rectocele. Pelvic floor repair (PFR).
Uterovaginal
Uterus along with vaginal walls Uterovaginal prolapse Vaginal hysterectomy.
Fothergill's operation.
Vaginal Wall
Following hysterectomy- Vaginal prolapse (secondary) Vaginal:
Vaginal/ abdominal Repair of vaginal vault along with PFR.
Sacrospinous colpopexy.
Colpocleisis.
Abdominal: Sacral colpopexy
Uterus (Without vaginal walls)
Congenital or nulliparous prolapse Cervicopexy or Sling (Purandare's
operation)

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Complications of genital prolapse:

1) Vaginal mucosa: The mucosa becomes stretched & if exposed to air, becomes thickened & dry with
surface keratinization. There may be pigmentation.
2) Decubitus ulcer: It is a trophic ulcer. There is initial surface keratinization → cracks infection →
sloughing → ulceration.

3) Cervix:
a) Vaginal part: Chronic congestion which may lead to hyperplasia and hypertrophy of the
fibromusculoglandular components. These lead to vaginal part becoming bulky and congested.
b) Supravaginal part: The supravaginal part becomes elongated.

4) Urinary system:
a) Bladder:
✓ Incomplete emptying of the bladder that causes bladder hypertrophy & trabeculation.
✓ Incomplete evacuation also favours cystitis.
b) Ureters:
✓ Hydroureter.
✓ Hydronephrosis.
c) Incarcerations: At times, infection of the para-vaginal and cervical tissues makes the entire prolapsed
mass edematous and congested. As a result, the mass may be irreducible.
d) Carcinoma: Carcinoma rarely develops in decubitus ulcer.

X. Endometriosis

Definition:
• Presence of functioning endometrium (glands and stroma) in sites other than uterine mucosa is called
endometriosis. It is not a neoplastic condition, although malignant transformation is possible.
• These ectopic endometrial tissues may be found in the myometrium when it is called endometriosis interna or
adenomyosis.

Sites of endometriosis
Common sites Rare and remote sites
• Ovaries • Umbilicus
• Pelvic peritoneum • Abdominal scar a Episiotomy scar
• Pouch of Douglas • Lungs
• Uterosacral ligaments • Pleura
• Rectovaginal septum • Ureter a Kidney a Arms
• Sigmoid colon a Appendix • Legs
• Pelvic lymph nodes a Fallopian tubes • Nasal mucosa

Symptoms
• About 25% patients with endometriosis have no symptom, being accidentally discovered dither during
laparoscopy or laparotomy.
• Dysmenorrhea (70%)
• Abnormal uterine bleeding (AUB) (15-20%)
• Infertility (40-60%)
• Dyspareunia (20-40%)

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Causes of pain in endometriosis:

■ Peritoneal inflammation (PGF, cytokines)
■ Tissue necrosis
■ Adhesion formation
■ Nerve irritation due to deep penetration
■ Release of local inflammatory' mediators
■ Endometrioma formation. The pain aggravates during the period. Abdominal pain: There may be variable.

Diagnosis
Clinical Diagnosis
• Secondary dysmenorrhea
• Dyspareunia
• Infertility

Speculum examination: Bluish powder-burn lesions may be seen on the cervix or the posterior fornix of the vagina.
Bimanual examination:
• Reveal nodularity in the pouch of Douglas
• Nodular feel of the uterosacral ligaments
• Fixed retroverted uterus and
• Unilateral or bilateral adnexal mass (chocolate cysts)

Serum marker:
• Cancer antigen (CA) 125
• Monocyte Cheinotactic Protein (MCP-1) level is increased
• Glycodelin

Imaging
Ultrasonography Transvaginal scan ovarian endometriomas

Magnetic resonance imaging (MRI): It is the best diagnostic tool

Sensitivity and specificity is 91-95% it is superior compared to TVS and much better resolution and soft tissue
interfaces.

Laparoscopy: It is an important diagnostic tool. Confirmation is done by double puncture laparoscopy.

Treatment
1. Expectant management (observation only)
2. Medical therapy:
● Hormones
● Others
● Combined estrogen
● Progestogens
● Medroxyprogesterone

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XI. Neoplasia of Reproductive Organs

Premalignant lesion of vulva:

1. Vulvar intraepithelial neoplasia
2. Paget’s disease
3. Lichen sclerosus
4. Squamous cell hyperplasia
5. Condyloma accuminata
6. Melanoma in situ

Vaginal Cysts:

i) Mullerian cyst
• Tiny
• Single or multiple
• Lined by tissue similar to that of cervical epithelium

ii) Wolffion/ Gartner's duct cyst → Commonest vaginal cyst

• Position → Lateral or Anterolateral wall of the vagina
• Lining → single layer of flattened columnar or cuboidal, can be transitional
• Content is free from mucin
iii) Epidermoid cyst/implantation dermoid
iv) Endometriotic cyst → arise in scars

Classification of tumours of the cervix:

Benign tumours 1) Cyst of embryonic tissues.
2) Cervical polyp.
3) Nebothian follicles or Cysts.
4) Condyloma/Papilloma.
5) Leiomyoma.
6) Angioma & allied tumours.
Malignant tumours 1) Squamous cell carcinoma (90%): Micro invasive and invasive.
2) Adenocarcinoma (5%): Both in situ and invasive.
3) Adenosquamous carcinoma.
4) Neuroendocrine tumours.
5) Others:
a) Melanoma.
b) Metastasis.

Correlation of dysplasia, CIN (WHO) and Bethesda 1 system.

Dysplasia CIN Limit of histologic changes Bethesda
Mild CIN I Basal one-third LSIL
Moderate CIN II Basal half to two-third
Severe
CIS
CIN III Whole thickness except one or two superficial layers
Whole thickness } HSIL

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Human Papillomavirus (HPV)

♦ High oncogenic risk—types 16,18,31,33,35,45,56,58,59,68.

♦ Low oncogenic risk—types 6,11,42,43,44.

Types of Ca. Cervix

1) Invasive Squamous.cell carcinoma (80%)

• 3 sub classifications
- Large cell Keratinizing (Good prognosis)
- Large cell non-Keratinizing (Bad prognosis)
- Small cell Keratinizing (Bad prognosis)
- Rare varities → Verrucous Sq. cell carcinoma
Papillary Sq. cell carcinoma
2) Adenocarcinoma (15%)
• Sub types of adenocarcinoma cervix:
- Mucinous adenocarcinoma – 65%
- Endometroid adenocarcinoma – 30% (Endometriotic → Best prognosis, Glassy cell → Worst
prognosis)
- Clear cell Adenocarcinoma – 4% (Related to DES)
3) Adenosquamous carcinoma (1-2%)
4) Small cell carcinoma
5) Undifferentiated carcinoma

Benign & malignant tumours of overy:

Hormone secreting tumour of Epithelial tumour of the Ovary: Sex cord stromal tumour of the
overy: a. Serous tumour ovary:
• Theca cell tumour b. Mucinous tumour a. Granulosa cell tumours
• Brenner’s tumour c. Endometrioid tumour b. Sertoli Leydig cell turnour
• Dermoid cyst d. Clear cell tumours C. Gynandroblastoma
• Arrhenoblastoma e. Brenner tumours d. Tumours of the thecoma-fibroma
f. Mixed epithelial tumour group
Solid tumours of the Ovary: Germ cell tumour of the Ovary: Hormone producing tumour of the
a. Dysgerminoma a. Granulosa cell and theca cell ovary:
b. Choriocarcinoma tumour a. Krukenberg tumour
c. Teratoma b. Sertoli-Leydig cell and Hilus b. Granulosa cell tumour
d. Embryonal carcinoma cell tumour c. Thecoma
e. Endodernal sinus tumour c. Struma ovarii (thyroid d. Malignant teratoma
f. Polyembryoma hormones) e. Fibroma.
d. Choriocarcinoma
Common benign ovarian tumour:
a. Mucinous cyst adenoma
b. Serous cyst adenoma
c. Dermoid cyst
d. Brenner tumour

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Benign & malignant lesion of uterus:

Neoplasm of corpus uteri:
Benign tumour: Malignant tumour:
1) Leiomyoma (Most common): 1) Carcinoma of endometrium.
✓ Myoma. 2) Leiomyosarcoma.
✓ Fibromyoma. 3) Endometrial stromal sarcoma.
2) Benign endometrial polyps:
✓ Mucosal polyp.
✓ Endometrial hyperplasia.

XII. Infertility

Common causes of male infertility Causes of Female Infertility (FIGO)

• Hypothalamic-pituitary disorders (1-2%) • Ovulatory dysfunction (30-40%)
• Primary testicular disorders (30-40%) • Tubal disease (25-35%)
• Disorders of sperm transport (10-20%) • Uterine factors (10%)
• Idiopathic (40-50%) • Cervical factors 5%
• Pelvic endometriosis (1-10%)

Male factors:
Pre-testicular Genetic ✓ 47, XXY.
✓ Microdeletion (Y chromosome, Yq).
✓ Single gene mutations.
✓ Sperm DNA fragmentation.
Psychosexual ✓ Erectile dysfunction.
✓ Impotence.
Endocrine ✓ Gonadotrophin deficiency.
✓ Obesity.
✓ Thyroid dysfunction.
✓ Hyperprolactinaemia.
Testicular ✓ Immotile cilia (Kartagener) syndrome.
✓ Cryptochidism.
✓ Infection (mumps orchitis).
✓ Toxins: Drugs, smoking & radiation.
✓ Varicocele.
✓ Immunologic.
✓ Sertoli-cell-only syndrome.
✓ Primary testicular failure.
✓ Oligoastheno-teratozoospermia.
✓ Idiopathic.
Post-testicular Obstruction of ✓ Congenital:
efferent duct • Absence of Vas deference (cystic fibrosis).
• Young's syndrome.
✓ Acquired:
✓ Tuberculosis.
✓ Gonorrhoea.
• Surgical.
• Herniorrhaphy.

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Male factors:
✓ Vasectomy.
Others ✓ Ejaculatory failure.
✓ Retrograde ejaculation.
✓ Hypospadias.
✓ Bladder neck surgery.
✓ Surgical:
✓ Herniorraphy.
✓ Vasectomy.
Drugs ✓ Antihypertensives.
✓ Antipsychotics.
✓ Impair spermatogenesis: Radiation, cytotoxic drugs,
nitrofurantoin.
✓ Antiandrogenic effects: Cimetidine, spironolactone Erectile
dysfunction: Beta-blockers (metoclopramide). Ejaculatory
failure: Antidepressants, alphablockers. Pituitary suppression:
GnRH analogs.

Female factors:
Ovarian factors ✓ Ovulatory dysfunction (30-40%).
✓ Anovulation or oligo-ovulation.
✓ Decreased ovarian reserve.
✓ Luteal phase defect (LPD).
✓ Luteinized unruptured follicle (LUF).
Tubal factors (Obstruction ✓ Tubal disease:
of the tube due to) • Following tubal infection.
• Pelvic endometriosis.
Pelvic factors ✓ Tubal & peritoneal adhesions.
✓ Endometriosis.
✓ Disovulatory.
✓ Elderly women (> 35 years).
Uterine factors ✓ Failure of implantation.
✓ Chronic endometritis (TB).
✓ Fibroid uterus.
✓ Synechiae.
✓ Congenital malformation
Cervical factors ✓ Anatomic:
• Congenital elongation of the cervix.
• Second degree uterine prolapse.
• Acute retroverted uterus.
✓ Physiologic:
• Scanty mucous following amputation, conization or deep
cauterization of the cervix.
• Chronic cervicitis.
• Presence of antisperm or sperm immobilizing antibodies.
Vaginal factors ✓ Vaginal atresia.
✓ Transverse vaginal septum.
✓ Septate vagina.
✓ Narrow introits causing dyspareunia.

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Special investigations:
➢ For male:
1) Semen analysis.
2) Serum FSH, LH, testosterone, prolactin & TSH.
3) Testicular biopsy.
4) Karoyotyping & genetic testing.
5) DNA fragmentation.
6) Immunological test: Sperm agglutinating & sperm immobilizing antibodies.
7) Sperm function tests.
8) Presence of plenty of pus cells requires prostatic massage.

➢ For female:
1) To see evidence of ovulation:
Indirect 1) Evaluation of peripheral or end organ changes:
• Basal body temperature.
• Cervical mucus study.
• Vaginal cytology.
• Hormone estimation:
✓ Serum progesterone: Rise in level.
✓ Serum LH: Midcycle surge.
✓ Urine LH. Serum estradiol: midcycle rise.
• Endometrial biopsy.
2) Sonography TVS.
Direct Laparoscopy

2) To see the tubal pathology:

• Dilatation & insufflation (Rubin's test).
• Hysterosalpingography (HSG).
• Saline infusion sonography.
• Hysterosalpingo contrast sonography (Hycosy).
• Sonohysterosalpingography.
• Laparoscopy & chromopertubation.
• Falloposcoру.
• Salpingoscopy.

3) To see the uterine pathology:

• Hysterosalpingography.
• Hysteroscopy.

4) To see the cervical pathology:

• Post-coital test.
• Sperm cervical mucus contact test (Huner's test).

5) Immunological test: Antibody against sperm can be detected in the female serum by immunological test.

6) Hormone assay: Estimation of FSH, LH, prolactin, oestrogen, progesterone, and testosterone can be done
depending upon history and examination.

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Normal semen analysis report: Normal semen values as suggested by WHO (2010 and 2021):
Semen analysis Normal reference value & lower reference (within parenthesis) limit
2010 2021
Volume 1.5 mL ≥ 1.4 mL
pH 7.2-7.8 ≥ 7.2
Sperm concentration 15-16 million/mL ≥ 15 million/mL
Total sperm number 39 million / ejaculate ≥ 39 million / ejaculate
Motility Total motility: 40% (progressive motility = Total motility: ≥ 42% (Non-progressive
32%) motility: ≥ 1%, Progressive motility ≥
30% Immobile sperm ≥ 20%)
Normal morphology 4% ≥ 4%
Viability 58% ≥ 54% live spermatozoa
Leukocytes Less than 1 million/ml
Round cells < 5 million / ml
Sperm agglutination < 10% spermatozoa with adherent particles

Concepts of medical biotechnology in relation to Obstetrics

1. ART
2. Prenatal Genetic Screening & Dx
3. Fetal Gene therapy
4. Stem cell application
5. Vaccination &
6. Drug development

Methods of Assisted Reproductive Techniques (ART)

1) In Vitro Fertilization and Embryo Transfer (IVF- ET).

2) Gamete Intra-fallopian Transfer (GIFT).
3) Zygote intra-fallopian transfer (ZIFT).
4) Peritoneal oocyte and sperm transfer (POST).
5) Pronuclear Stage Tubal Transfer.
6) Tubal Embryo Transfer (TET).
7) Sub Zonal Insemination (SUZI).
8) Intracytoplasmic Sperm Injection (ICSI).
9) Assisted hatching (AH). 1
0) In vitro Maturation of Oocyte (IVM).
11) Pre-implantation Genetic Diagnosis (PGD).
12) Cryopreservation: Embryo / oocyte / ovarian tissue / sperm.
13) Gestational Surrogacy.
14) Sperm retrieval techniques:
a) Testicular sperm extraction (TESE).
b) Microsurgical epididymal sperm aspiration (MESA).
c) Percutaneous epididymal sperm aspiration (PESA).

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XIII. Menopause
Definition:
Permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity cycle is
called menopause.

Important symptoms & health concerns of menopause / Effects of menopause on different systems:
Menstrual changes ✓ Shorter cycle (common).
✓ Irregular bleeding.
Vasomotor symptoms ✓ Hot flushes. (Hot flush is sudden feeling of heat followed by profuse sweating)
✓ Upper body sweating.
✓ Anxiety.
✓ Lack of sleep.
Psychological ✓ Irritability.
✓ Mood swing.
✓ Poor memory.
✓ Depression.
Sexual dysfunction ✓ Vaginal dryness.
✓ Dyspareunia.
✓ Decreased libido
Urinary ✓ Incontinence.
✓ Urgency.
✓ Dysuria.
Others ✓ Bach aches.
✓ Joint aches.
✓ Weight gain.
✓ Palpitations.

Diagnosis:
• Cessation of menstruation for consecutive 12 months during climacteric
• Average age of menopause: 50 years
• Appearance of menopausal symptoms: hot flush & night sweats
• Vaginal cytology: Showing maturation index of at least 10/85/5
• Serum oestradiol: < 20 pg/ml
• Serum FSH & LH: > 40 mIU/ml

Short term health hazards 1) Hot flashes.

2) Difficulty to fall asleep.
3) Vaginal dryness.
4) Mood swings.
5) Body changes:
✓ Headache.
✓ Palpitation.
✓ Increase body hair.
Long term health hazards 1) Osteoporosis.
2) Coronary artery disease.

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Principles of Management:
A. Non-hormonal management:
1. Lifestyle modification
2. Nutritious diet
3. Supplementary calcium
4. Exercise
5. Vitamin D
6. Cessation of smoking and alcohol
7. Bisphosphonates
✓ Romosozumab
✓ Calcitonin
✓ Selective estrogen receptor modulators (SERMs)
8. Bazedoxifene
9. Clonidine
10. Paroxetine
11. Gabapentin
12. Parathyroid hormone (PTH)
13. Phytoestrogens
14. Soy protein
15. Vitamin E

B. Hormone therapy

Hormone Replacement Therapy (HRT)

It may be defined as a therapy which is given to menopausal woman to overcome the short term & long-term,
consequences of oestrogen deficiency.

Drugs used for HRT/MHT:

1) Oestrogen alone: Conjugated oestrogen or micronized oestradiol. It can be given continuously in
hysterectomies women.
2) Progestin alone: Medroxyprogesterone acetate, micronized progesterone or dydrogesterone.
3) Combined oestrogen and progestogens to women with uterus to reduce risk of endometrial cancer.
4) Tibolone.

Indications of HRT/MHT:
1) Relief of menopausal symptoms.
2) Prevention of osteoporosis.
3) To maintain the quality of life in menopausal years.
4) Special group of women:
• Premature ovarian failure.
• Gonadal dysgenesis.
• Surgical or radiation menopause.

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Advantages of HRT/MHT:
1) Improvement of vasomotor symptoms (70-80%).
2) Improvement of urogenital atrophy.
3) Increase in bone mineral density (2-5%).
4) Decreased risk in vertebral & hip fractures (25-50%).
5) Reduction in colorectal cancer (20%).
6) Possibly cardio protection.

Disadvantages/risks/complications of HRT/MHT:
1) Endometrial carcinoma.
2) Breast carcinoma.
3) Colorectal cancer.
4) Venous thromboembolism disease.
5) Coronary heart disease.
6) Stroke.
7) Gallbladder disease.
8) Type 2 diabetes.
9) Dementia & Alzheimer disease are increased.

Contraindications of HRT/MHT:
1) Known, suspected breast cancer. 5) Untreated hypertension.
2) Undiagnosed genital tract bleeding. 6) Active liver disease, prior cholestatic jaundice
3) Oestrogen dependent neoplasm in the body. (caution).
4) History of venous thromboembolism or active 7) Gallbladder disease.
deep vein thrombosis (DVT). 8) Prior endometriosis (caution).
9) Prior stroke, myocardial infarction.

XIV. Principles of Common Gynaecological Operation

Hysterectomy:
Common indications of abdominal hysterectomy:
Total DUB.
Fibroid uterus.
Tubo-ovarian mass.
Endometriosis.
Subtotal Difficult tubo-ovarian mass.
Endometriosis.
Obstetric causes.
Panhysterectomy Indications for total hysterectomy in perimenopausal age.
Extended Carcinoma endometrium.
Radical Carcinoma cervix- stage I & II.

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Indications of vaginal hysterectomy:

Genital prolapse 1) Third degree utero-vaginal prolapse.
2) Second degree utero-vaginal prolapse.
Utero-vaginal prolapse 1) Fibroid uterus: Size < 12weeks.
associated with. 2) Pelvic adhesions.
3) Pelvic malignancу.
4) Post-menopausal women.
Benign conditions of 1) Where uterus is < 12 weeks.
uterus without prolapse

Indications of D & C operation:

Diagnostic Therapeutic Combined
1) Infertility. 1) DUB. 1) DUB.
2) DUB. 2) Endometrial polyp. 2) Endometrial polyp.
3) Pathological amenorrhoea. 3) Removal of IUD.
4) Endometrial tuberculosis. 4) Incomplete abortion.
5) Endometrial carcinoma.
6) Postmenopausal bleeding.
7) Chorioneepithelioma.

MVA (Manual vacuum aspiration):

The procedure of evacuation of the uterus or termination of pregnancy by creating a vacuum by MVA syringe, is
called manual vacuum aspiration (MVA). It is used up to 12 weeks of pregnancy with minimal cervical dilatation.

Procedure:
✓ Termination of pregnancy is done up to 12 weeks with minimal cervical dilatation.
✓ A hand operated double valve plastic syringe (60ml) is attached to a Karman’s cannula (up to 12 mm size).
✓ The cannula is inserted transcervically into the uterus & the vacuum is activated.
✓ A negative pressure of 660 mm Hg is created.
✓ Aspiration of the products of conception is done.
Indications of MVА:
1) Medical termination of pregnancy up to 12 weeks of pregnancy (most common).
2) Menstrual regulation.
3) Incomplete / missed abortion (up to 12 weeks)
4) Molar pregnancy (up to 12 weeks).
5) Blighted ovum.
6) Endometrial sampling/ biopsy.

Merits/ Advantages of MVA over D & C:

1) It is simple.
2) More safer
3) Can be performed as an outpatient basis.
4) More effective (98-100%)
5) Less traumatic.
6) Less complications.
7) It takes less time (needs 10-15 minutes).

Demerits / complications:
1) Haemorrhage.
2) Retained products of conception.
3) Uterine perforation.
4) Post-operative infection.

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XV. Contraception
Contraceptive effectiveness chart (WHO-2007) Pregnancy /100 WY
Top tier (Most effective methods): Implants, IUDs, sterilization (male & female) 0.5-0.8
Second tier (Very effective methods): Injectables, COCs, POPs, patch, vaginal rings 0.3-9
Third tier (Effective methods): Male condom, diaphragm, female condom, fertility 2-20
awareness methods
Fourth tier (Least effective methods): Spermicidal 10-30
No WHO category: Withdrawal, no method 4-85

Barrier methods of contraception:

1. Mechanical:
o Male: Condom.
o Female:
▪ Female condom.
▪ Vaginal diaphragm.
▪ Cervical occlusion cap.
2. Chemical (Vaginal Contraceptives):
o Cream: Delfen
o Foam: Aerosol foam, sponge
3. Combination:
o Combining mechanical and chemical methods (e.g., condom together with spermicidal jelly).

Advantages of condom: Disadvantages of condom:

1. Cheaper with no contraindication. 1. May accidentally break or slip
2. No side effects. off during coitus.
3. Easy to carry, simple to use, and disposable. 2. Inadequate sexual pleasure.
4. Protection against sexually transmitted diseases (e.g., 3. Allergic reaction (latex).
gonorrhoea, syphilis, Chlamydia, HPV & HIV). 4. Must be discarded after one
5. Protection against pelvic inflammatory disease. coital act.
6. Reduces the incidence of tubal infertility & ectopic pregnancy.
7. Protection against cervical cell abnormalities.
8. Useful when the coital act is infrequent & irregular.

Hormonal Contraceptives (Steroidal contraception):

a) Oral contraceptives (pills): b) Parenteral Preparations (Progestogens)
Combined pills: Injectable:
• Monophasic • DMPA
• Biphasic • NET-EN
• Triphasic • Combined (once a month injection)
• Emergency (Post-coital pill) Implants:
Single preparation: • Implanon
• Progesterone-only pill (minipill) • Norplant-II
• Oestrogen only (emergency) • LNG Rod
c) Devices d) Transdermal Patches
IUD: LNG-IUS • Nesterone
Vaginal Ring:
• LNG ring
• Combined (Oestrogen & Progesterone) ring
Transcervical: Essure

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Mechanism of action of oral pill:

1) Inhibition of ovulation:

2. Producing static endometrial hypoplasia: There is stromal oedema, decidual reaction and regression of the
glands making endometrium nonreceptive to the embryo.

3) Alteration in the character of cervical mucus: The cervical mucus becomes thick, viscid, and scanty
and prevents sperm penetration.
4) Interference with the motility and alters tubal transport.

Non-contraceptive uses of hormonal contraceptives / oral pill:

1) Dysmenorrhoea.
2) Pre-menstrual tension.
3) Dysfunctional uterine bleeding (DUB).
4) Endometriosis.
5) Regulation of menstrual cycle.
6) Idiopathic hirsutism.

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Disadvantages or complications or side effects of oral contraceptives pill:

Minor complications: Major complications
1) Nausea & vomiting, headache & leg cramps. 1) Depression.
2) Mastalgia. 2) Hypertension.
3) Weight gain. 3) Vascular complications: Venous
4) Chloasma & acne. thromboembolism, arterial thrombosis
5) Menstrual abnormalities: 4) Cholestatic jaundice.
• Breakthrough bleeding or spotting 5) Neoplasia: Breast & cervical cancer.
• Hypomenorrhoea 6) Death.
• Menorrhagia
• Amenorrhoea
6) Loss of libido.
7) Leucorrhoea.

Contraindications of oral contraceptive pill:

Relative contraindications (WHO category-2 & 3):
WHO category-2 1) Age ≥ 40 years.
2) Smoker <35 years.
3) History of jaundice.
4) Mild hypertension.
5) Gallbladder disease
6) Diabetes.
7) Sickle cell disease.
8) Headache.
9) Cancer cervix or CIN.
WHO category-3 1) Unexplained vaginal bleeding.
2) Hyperlipidaemia.
3) Liver tumours (Benign).
4) Breast feeding (postpartum 6 weeks to 6 months).
5) Heavy smoker (> 20 cigarettes/day).
6) Past breast cancer.

Absolute contraindications (WHO category-4):

a) Circulatory disease: b) Disease of the liver:
1. Arterial or venous thrombosis. 1. Active liver disease.
2. Severe hypertension. 2. Liver adenoma, carcinoma.
3. History of stroke. c) Others:
4. Valvular heart disease. 1. Pregnancy.
5. Ischaemic heart disease. 2. Breastfeeding (postpartum 6 weeks).
6. Diabetes with vascular complications. 3. Major surgery or prolonged immobilization.
7. Migraine with focal neurological symptoms. 4. Oestrogen-dependent neoplasm, e.g. breast cancer.

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Mini pill (Progesterone-Only Pill)

The mini pill contains only a very low dose of progesterone and is devoid of estrogen. The following forms of
progesterone are used:
1. Levonorgestrel 75 µg
2. Norethisterone 350 µg
3. Desogestrel 75 µg
4. Norgestrel 30 µg
5. Lynestrenol 500 µg

Advantages:
1. Eliminates side effects attributed to estrogen in combined pills
2. No adverse effects on lactation, making it suitable for breastfeeding women (hence called the “Lactation
Pill”)
3. Easy to take—no “on and off” regimen
4. Can be prescribed for patients with hypertension, fibroids, diabetes, epilepsy, smoking history,
thromboembolism, and HIV-positive women
5. Reduces the risk of pelvic inflammatory disease (PID) and endometrial cancer
Disadvantages/Complications:
1. Possible acne, breast tenderness, headaches, breakthrough bleeding, and amenorrhea in 20-30% of cases
2. Side effects attributed to progesterone may be evident
3. Simple ovarian cysts may form, but they usually do not require surgery
4. Increased risk of ectopic pregnancy (1 in 10 cases)
5. Failure rate of approximately 0.3-2 per 100 women-years of use

Contraindications:
1. Pregnancy
2. Unexplained vaginal bleeding
3. Breast cancer
4. Arterial disease
5. Severe hepatic disease
6. Women taking antiseizure drugs

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Emergency Contraception

Indications:
1. Unprotected intercourse.
2. Condom rupture.
3. Missed pill.
4. Delay in taking POP for more than 3 hours (12 hours of DSG POP).
5. Sexual assault or rape.
6. First time intercourse, as known to be always unplanned

Methods of emergency contraception:

Method/drug Dose Timing of use
Cu IUCD ---- Up to 120 hours of unprotected sexual intercourse or within 5 days of ovulation;
whichever is later.
UP A 30 mg Up to 120 hours of unprotected sexual intercourse
LNG (E. pills) 1.5 mg Up to 72 hours of unprotected sexual intercourse (ineffective after 96 hours)

Complications:
1) Nausea and vomiting in case of hormone therapy.
2) Failure leading to pregnancy.
3) Ectopic pregnancy.

Injectable Contraceptives

Types of injectable contraceptives:

1) Depot medroxy progesterone acetate (DMPA) 150 mg 3 monthly.
2) Norethisterone oenanthate (NET-EN) 200 mg 2 monthly.

Mode of action of injectable contraceptives:

1) Inhibition of ovulation by suppressing the mid cycle LH peak.
2) Making cervical mucus thick, thus prevent implantation of sperm.
3) Endometrium is atrophic preventing blastocyst implantation.

Complications of injectable contraceptives:

1) Irregular bleeding
2) Amenorrhoea
3) Weight gain
4) Delayed return of fertility.
5) Galactorrhoea.
6) Mild androgenic effect.
7) Enuresis.
8) Subjective effects:
• Depression. • Bloatedness.
• Loss of libido. • Leg cramps.
• Vaginal dryness. • Headache
• Dizziness.

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Intrauterine contraceptive device (IUCD)

Types of IUCDs:
1. Unmedicated or inert IUCDs:
o Lippes loop.
2. Medicated IUCDs:
a) Copper-releasing IUCDs:
o Cu T 380A.
o LNG-IUS.
o Multiload 375.
o Skyla.

b) Hormone-releasing IUCDs:
o Progestasert.
o Levonorgestrel IUCD.

Mechanism of Action of IUCDs (Cu-T380):

The exact antifertility mechanism of all IUDs isn't fully understood, but several factors contribute:
• Biochemical & Histological Changes in the Endometrium:
o There is a nonspecific inflammatory reaction and biochemical alterations in the endometrium. This
accumulates throughout the uterine lumen and cervical canal, affecting gamete viability, preventing
fertilization, and reducing chances of zygote formation and implantation.
o Macrophages attached to the device release prostaglandins, which help in phagocytosing spermatozoa.
• Endometrial Inflammatory Response:
o Decreases sperm transport and impairs sperm ability to fertilize the ovum.
• Copper Devices:
o Ionized copper has got an additional antifertility effect, preventing blastocyst implantation through
enzyme interference.
• Levonorgestrel-IUS (Mirena):
o It includes strong and uniform suppression of the endometrium.
o Cervical mucus becomes thick and scanty.
o It impedes sperm motility and access to the upper genital tract.
o Anovulation and insufficient luteal phase activity has also been mentioned.

Time of insertion of IUCD:

Interval: (When the insertion is made in the interconceptional period beyond 6 weeks following childbirth or abortion).
• It is preferably to insert 2-3 days after the period is over.
• But it can be inserted any time during the cycle, provided she is not pregnant.
• During lactational amenorrhoea. it can be inserted at any time.

Post-abortal: Immediately following termination of pregnancy by evacuation or D & E, or following

spontaneous abortion.

Cu-T380A: It can be used as an emergency contraception up to 5 days following unprotected coitus.

Immediate postpartum:
• Post-placental: Within 10 minutes, after expulsion of placenta following vaginal delivery.
• Intercesarean: Insertion during casarean delivery, after removal of the placenta & before closure of the
uterine incision.
• Within 48 hours (MEC-1): After delivery before the patient is discharged from the hospital.
• Extended postpartum/interval (between 48 hours to 4 weeks: MEC-3): Any time after 4 weeks (MEC-1)

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Natural Contraception
Natural contraception:
These methods are based on the recognition of the fertile and infertile phases of a menstrual cycle from the symptoms
and signs of ovulation and to remain abstain from sexual intercourse during the fertile period.

Methods:
1) Safe period / Calendar method / Rhythm method.
2) Basal body temperature method.
3) Cervical mucus method.
4) Lactational amenorrhoea method (LAM).
5) Coitus interruptus.

Permanent Methods of Contraception / Sterilization

Surgical methods of contraception:

1) Male sterilization: Vasectomy.
2) Female sterilization: Tubal occlusion or tubectomy

Indications of female sterilization:

1) For the purpose of family planning.
2) Socioeconomic.
3) Medicosurgical indications (therapeutic):
a) Some medical diseases where further pregnancy will be hazardous for the maternal health-
• Heart disease.
• Diabetes.
• Chronic renal failure.
• Hypertension.
b) During third time repeat cesarean section or repair of prolapse operation.
4) Risk-reducing salpingectomy: As preventive measure against serous ovarian & peritoneal cancer.

Selection criteria of a patient for tubal ligation:

• Family must be completed.
• Age of the last child must above 3 years.
• Consent of the husband.

Timing of sterilization:
• During puerperium (puerperal): Can be done 24-48 hours following delivery.
• Interval: The operation is done beyond 3 months following delivery or abortion.
• Concurrent with Medical Termination of pregnancy (MTP) and at the time of cesarean section.
• Concurrent with cesarean delivery with prior consent.

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MCQ For BCS

01.Most conclusive sign of pregnency - 06. 2nd stage of labour means-
a) Braxton hicks contraction a) From onset of true labour pain to full dialatation of
b) Increase fetal height cervix
c) Fetal heart sound b) From full dialatation of cervix to delivery of fetus
d) Enlargement of uterus c) Fron expulsion of fetus to expulsion of placenta
Ans: C d) Observation for at least 1 hour after expulsion of
afterbirth
02.Objective of ANC- Ans: B
a) To screen the 'high-risk' cases
b) To prevent or to detect and treat at the earliest any 07. Lochia rubra persist for-
complication. a) 1-4 days
c) To ensure continued risk assessment and to provide b) 5-9 days
ongoing primary preventive health care. c)10-15 days
d) to ensure a normal pregnancy with delive1y of a d) 15-28 days
healthy baby from a healthy mother. Ans: A
Ans: D 08.In lactating mother ovulation usually occurs
after which week of delivery-
03.A 20 weeks pregnant lady comes with LAP.Her a) 4 weeks
LMP was 10/02/25.Her EDD- b)10 weeks
a)17th November c)12 weeks
b)16 th November d)18 weeks
c)16th October Ans: B
d)17th December
Ans: A 09. Galactokinesis means-
a) Preparation of breast
04. Partograph is a composite graphical record of b) synthesis & secretion from breast alveoli
cervical dialatation and descent of the head. Which c) Ejection of milk
type of shape of the cervical dialation is? d) Maintainance of lactation
a) Straight curve Ans: C
b) Sigmoid curve
c) Circular curve 10. True regarding positioning of breast feeding-
d) Elliptical curve a) Body's chin is touching the breast
Ans: B b) Baby's mouth is widely open
c) Body is partially supported
05. Normal labour is initiated by- d) Straight head & body
a) Fetal CRH Ans: D
b) Fetal ACTH
c) Prostaglandin 11. When does we give contraceptive in non-
d) Oxytocin lactating mother-
Ans: A a) 3rd postpartam week
b) 3rd postpartam month
c) 6th postpartam month
d) 6 th postpartam week
Ans: A

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12. Most sensitive marker for IDA- 18. Features of placenta previa-
a) MCHC a) Painless
b) S.Ferritin b) Painful
c) S.Iron c) Dark colour
d) MCH d) Placenta in upper segment
Ans: B Ans: A

13.Etiopathogenesis of pre-eclampsia 19. APH means-

a) Endothelial dysfunction a) Bleeding from genital tract before 20 weeks of
b) Vascular damage pregnancy
c) Trophoblast invasion b) Bleeding from genital tract before 28 weeks of
d) Irregular secretion of Prostaglandin pregnancy
Ans: A c) Bleeding from genital tract after 20 weeks of
pregnancy
14.Which of the following is last feature of pre- d) Bleeding from genital tract after 28 weeks of
eclampsia- pregnancy
a) Hypercoagulibility Ans: D
b) Vulval oedema
c) Protienurea 20. Fetal complication of Placenta previa-
d) Hyperprotinemia a) PPH
Ans: C b) Preterm labour
c) Subinvolution
15. Which of the following is the most common d) IUD
cardiac disease in pregnancy- Ans: D
a) Mitral stenosis
b) Mitral regurgitation 21.Which of the following antibody is responsible
c) Aortic dissection for Rh isoimmunization-
d) Co-arctation of aorta a) IgA
Ans: A b) IgG
c) IgM
16. Which of the following is the most common d) IgD
cause in pregnancy- Ans: B
a) Obstetric cholestasis
b) Viral hepatits 22. When does anti-D is administered into the
c) Obstructive jaundice mother to prevent Rh-isoimmunization-
d) Acute Fatty liver a) Immediately after delivery
Ans: B b) Within 72 hours of delivery
c) After 72 hours of delivery
17. Screening of the GDM is done between- d) After 5 days of delivery
a) 24-28 weeks Ans: B
b) 20-24 weeks
c) 28-32 weeks 23.which type of pregnancy having T sign?
d) 16-20 weeks a) Monochorionic monoamniotic
Ans: A b) Monochorionic diamniotic
c) Diamniotic dichorionic
d) Conjoined twin
Ans: B

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24.Which of the following feature suggest 30. Hormone replacement therapy mainly given
monozygotic twin- for-
a) 2 placenta a) To reduce risk of carcinoma
b) Communicating vessel absent b) Increase bone mineral density
c) Two amnion c) Improvement of vasomotor symptoms
d) Different sex d) Cardio protection
Ans: C Ans: C

25. Normal baseline fetal heart rate- 31. How does estrogen prevent osteoporosis?
a) 100-160 bpm a) It increases PTH & IL1
b) 110-160 bpm b) Inhibits aborption of calcium
c) 100-180 bpm c) Increases 1,25 dihydroxyvitamin D
d) 110-180 bpm d) It increses osblastic activity
Ans: B Ans: C

26.Whuch of the following parameter is used to 32. Which of the following is the cause of post
detect gestational at 2nd trimester? menopausal bleeding?
a) CRL a) Fibroid uterus
b) FL b) Ovarian tumor
c) AC c) Bladder tumor
d) BPD d) Endometrial hyperplasia
Ans: D Ans: D

27. Amniocentesis is done- 33. Which of the following is the vasomotor

a)10-13 weeks symptom of menopause?
b) After 13 weeks a) Vaginal dryness
c) After 15 weekz b) Mood swing
d) After 18-20 weeks c) Depression
Ans: C d) Hot flush
Ans: D
28. Quadriple screening is done to detect-
a) Turner syndrome 34. Which of the following feature favours
b) Klinfilter syndrome tibolone?
c) Down syndrome a) Strong estrogenic property
d) Patau syndrome b) Promotes osteoporosis
Ans: C c) Increases libido
d) Causes atropic change in vagina
29.Causes of hot flush in menopausal lady- Ans: C
a) Decrease estradiol
b) Increase Estrone 35. Blood supply of cervix-
c) Increase FSH a) Vaginal artery
d) Increase LH b) Femoral artery
Ans: A c) External pudental artery
d) Lateral rectal artery
Ans: A

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36. External female genital organ includes- 41. Which of the following is the most common
a) Labia minora cause of puberty menorrhagia-
b) Vagina a) PCOS
c) Cervix b) Hypothyroidism
d) Uterus c) Hyperthyroidism
Ans: A d) DUB
Ans: D
37. Homologous organ for labia majora-
a) Penis 42. Ovulation occurs when-
b) Testes a) Primary ocyte is released
c) Scrotum b) Secondary ocyte is released
d) Seminiferous tubule c) Mature ovum is released
Ans: C d) Premordial follicle is released
Ans: B
38.Which of the following is most common uterine
anomaly- 43. Average age of menarche-
a) Arcuate uterus a) 11 years
b) Uterus didelphys b) 12 years
c) Septate uterus c) 13 years
d) Uterus unicornis d) 14 years
Ans: C Ans: C

39. Which of the following is the most common 44. Complete miscarriage means-
cause of precocious puberty- a) Product of cenception are expelled.
a) Primary hypothyroidism b) Cervical dialatation & abdominal pain
b) Granulosa cell tumor c) Recovery is possible
c) Constitutionaly d) Product of conception are not expelled
d) Adrenal hyperplasia Ans: A
Ans: C

40. Hypogonadotropic hypogonadism includes -

a) ovarian failure
b) mullerian agenesis
c) Imperforate hymen
d) transverse vaginal septum
Ans: A

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