Gynaecology and Obstetrics Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 18)

Gynaecology & Obstetrics Review
A Free Booklet Series by Dr. Aryan

Preface:
• This is the study material designed by Dr. Aryan with creation and
compilation of the best of the best and the most finest slides on the
subject. I would like to offer a billion heartily thanks for everyone who
contributed directly or indirectly to the creation of the material through
creation and dissemination of the scientific information.
• Covering everything in one study material is next to impossible. Hence,
refer to gold standard textbooks for building solid concepts or in case of
any doubt. Textbooks are acknowledged at the end of the presentation. If
any source has been missed to acknowledge, it doesn’t lessen their impact
and contribution in any way.
• Don’t keep searching for pattern between the consecutive slides. You won’t
find many. Rather to boost your recall and review, I have constructed many
slides and are deliberately placed with no much relation between the
preceding and the succeeding ones.
• The main rule of a review material is that it must make you recall or learn
maximum amount of information in minimum amount of time and space.
• Motivational quotes and articles are included within the slides. Always
remember that every good idea, nice piece of information and everything
else is literally and absolutely worthless unless you execute.
• If you know everything in the slides in much detail, you probably wouldn’t
need this material.
Best of luck WORK & SUCCESS! Dr. Aryan
(Anish Dhakal)

Rotterdam Criteria for PCOS
• At least two out of three criteria should be present:
I. Oligo/amenorrhoea, anovulation, infertility
II. Clinical or biochemical signs of hyperandrogenism
III. Ultrasound findings
– Performed in early follicular phase
• Enlarged ovaries, size, increased stroma (volume >10
mm3 )
• 12 or more small follicles each of 2-9 mm in size placed
peripherally: Necklace appearance
• Rules out ovarian tumor
• Shows endometrial hyperplasia if present
Dr. Aryan (Anish Dhakal)

PCOS Pathophysiology in a Nutshell

Treatment of Infertility in PCOS:

Structures cut during episiotomy
1. Posterior vaginal wall
2. Superficial and deep transverse perineal muscles,
bulbospongiosus, part of levator ani
3. Fascia covering those muscles
4. Transverse perineal branches of pudendal vessels and
nerves
5. Subcutaneous tissue
6. Skin

Indication of Episiotomy:
 Inelastic perineum: causing arrest or delay in
descent
 Anticipating perineal tear: Big baby, face
presentation, breech delivery, shoulder dystocia
 Operative delivery: forceps delivery, ventouse
delivery
 Previous perineal surgery: pelvic floor repair,
perineal reconstruction surgery
Objectives of Episiotomy:
i. To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the
fetus (spontaneous or manipulative)
ii. To minimize the overstretching and rupture of the perineal muscles and fascia;
reduce strain and stress on the fetal head Dr. Aryan (Anish Dhakal)

Timing
Bulged thin perineum during contraction just prior to
crowning (when 3-4 cm of head is visible)
Advantage:
Maternal
Easy to repair and heal better than lacerated wound
Reduction in the duration of second stage
Reduction of trauma to pelvic floor muscles
Fetal
Diminish intracranial injuries especially in premature babies
or after coming heads of breech

The repair in episiotomy is done in 3 layers:
i. Vaginal mucosa & submucosal tissues (continuous)
ii. Perineal muscles (interrupted)
iii. Skin & subcutaneous tissues (interrupted: mattress)
Principles to be followed :
i. Perfect hemostasis
ii. To obliterate the dead space
iii. Suture without tension

Complication of episiotomy:
Immediate
• Extension of incision
• Vulval hematoma
• Infection
Remote
• Dyspareunia
• Perineal laceration
• Scar endometriosis

Birth canal (vagina and perineum) tear
Grading:
• First degree: involve fourchette, perineal skin, and
vaginal mucous membrane
• Second degree: involve in addition fascia and muscle
of perineal body
• Third degree: extend further to involve the anal
sphinter
• Fourth degree: extend through the rectum’s mucosa
to expose its lumen

Use of Foley Catheter in Gynecology
& Obstetrics
Tamponade in PPH
Induction of labor
HSG
As a tourniquet in uterine artery ligation

Normal Labour Definition:
• A series of events that take place in female
genital organs to expel the product of
conception that are fetus, placenta,
membranes out of womb through the vagina
into the outer world.

NORMAL LABOR/ EUTOCIA
Spontaneous in onset and at term
With vertex presentation
Without undue prolongation
Natural termination with minimal aids
Without having any complications affecting the health of
the mother and/or the baby

TRUE AND FALSE LABOR
• True labor
o Uterine contractions at
regular intervals
o Contraction frequency,
intensity, interval shortens
o Associated with show
o Progressive effacement and
dilatation of cervix
o Descent of presenting part
o Formation of “bags of
water”
o Not relieved by enema/
sedative
• False labor
o Dull pain confined to groin
and abdomen
o No regularity
o Pain interval doesn’t shorten
o Pain intensity remains same
o No cervical dilatation
o No hardening of uterus
o Relieved by enema or
sedative

 The uterus becomes globular and as a rule,
firm- woody
 Sudden gush of blood
 Uterus rises in abdomen because the
placenta, having separated, passes down in
the lower uterine segment and vagina.
 Umbilical cord protrudes farther out of the
vagina, indicating that the placenta has
descended.
Signs of placental separation

Signs of Pregnancy Description
Goodell’s sign Softening of cervix as early as 6 weeks
Jacquemier’s or
Chadwick’s sign
Dusky hue of vestibule and anterior vaginal wall (local
vascular congestion). Visible at 8th week of pregnancy
Hegar’s sign During bimanual examination, the two fingers in the
anterior fornix can be approximated to fingers of the
abdominal hand behind the uterus due to softening of
the lower part of the uterus and its emptiness. This
sign can be elicited between 6-10 weeks
Palmar sign Uterine contraction felt during bimanual examination
as early as 4-8 weeks. Later after 10 weeks, the
relaxation phase is increased and detection of
contraction phase is hard.

Benefits of Active Management of
Third Stage of Labor
IM oxytocin 10 units or methergin 0.2 mg within 1
minute of delivery of baby followed by controlled
cord traction and uterine massage
 Early placental separation
 Effective uterine contractions following
separation of placenta
 Duration of 3rd stage reduced
 Blood lost is minimized
Only disadvantage is increased incidence of
retained placenta and subsequent incidence of
manual removal.

Septic Abortion in a Nutshell:
 Clinical evidence of infection is required (raised temperature >38°C, purulent
foul smelling discharge and pelvic tenderness)
 Grading is important (I: confined to uterus to III: generalized peritonitis,
endotoxic shock, jaundice or acute renal failure)
 Complications are very obvious. Hemorrhage, injury to bowel, peritonitis to
later chronic pelvic pain, ectopic pregnancy, infertility
 Antibiotics, blood transfusion and evacuation of uterus are the mainstays of
therapy for grade I or any grade of septic abortion. Prophylactic antitetanus
serum of 8000 units and 3000 units is indicated.
Antibiotics coverage is corresponding to the causative organisms:
 For Gram-positive: Aqueous penicillin G 5 million units IV 6 hourly or Ampicillin
0.5-1 g IV 6 hourly
 For Gram-negative: Gentamicin 1.5 mg/kg IV 8 hourly or Ceftriaxone 1 g IV 12
hourly
 For anaerobes: Metronidazole 500 mg IV 8 hourly or Clindamycin 600 mg IV 6
hourly
 Withheld evacuation in grade II abortion till infection is controlled and localized.
Posterior colpotomy is indicated if infection localized in pouch of Douglas
 Active surgery in grade III is indicated if injury to uterus present, suspected
bowel injury, retained foreign material and unresponsive peritonitis or septic
shock

The discriminating zone of serum β-hCG (DZ)
The level of β-hCG at which an intrauterine pregnancy
should be detectable on ultrasound: Discriminating
zone
• By transabdominal scanning, DZ is 6000 IU/l,
whereas by transvaginal scan this is 1500 IU/L.
• If the uterus is empty at the discriminating zone (DZ)
of serum β-hCG, ectopic pregnancy should be
diagnosed, until and unless proven otherwise.

Confusion Corner: Transabdominal Vs. Transvaginal
Ultrasound in Ectopic Pregnancy Diagnosis
 Transabdominal ultrasound can demonstrate gestational sacs when
the corresponding ß-hCG levels are above 6000 IU/L
 Transvaginal ultrasound can detect gestational sacs when serum ß-
hCG is as low as 1500 IU/L (even much lower in some cases)
 If transvaginal ultrasound fails to reveal an intrauterine or adnexal
sac in the setting of ectopic pregnancy, serial ß-hCG needs to be
measured
 Slower rise of ß-hCG or inability to double in 48 hours points
towards the diagnosis of ectopic pregnancy
 Serum ß-hCG levels above 1500 IU/L and an empty uterine cavity is
also very suggestive of extra-uterine implantation
 If ß-hCG level is <1000 IU/L, repeat both serum ß- hCG and
transvaginal ultrasound in 2 to 3 days.

Around 25% of pregnancies have breech presentation before
28 weeks of gestation. What are the factors preventing
spontaneous version?
Prematurity is thus the commonest cause of breech
Breech with extended legs
Twins
Oligohydraminos
Congenital malformation of uterus viz. bicornuate or
septate uterus
Short cord (relative or absolute)
Intrauterine fetal death
Favorable adaptions are also fairly common. Associated adaptations include
hydrocephalus to accommodate the wide fundus, placenta previa and contracted
pelvis.

Non-pharmacological Methods of Labor Induction
 Stripping the membrane (digital separation of chorioamniotic
membranes from the wall of cervix and lower uterine segment)
 Artificial rupture of membranes/Amniotomy & Low rupture of
membranes
 Mechanical dilators, Osmotic dilators (laminaria: dessicated seaweed;
lamicel: magnesium sulphate in polyvinyl alcohol)
 Transcervical balloon catheter
 Extra-amniotic saline infusion
With favorable preinduction cervical score, both oxytocin and prostaglandins are effective.
When the score is unfavorable, PGs have a distinct advantage over oxytocin. Again, PGE1
(Misoprostol) have certain advantages over PGE2. For augmentation of labor, oxytocin is
preferred though PGs are equally effective. For induction of abortion, PGs are superior and
oxytocin may act as a supplement.

Complications of Fibroid Uterus
 Degeneration
 Hyaline degeneration (commonest)
 Cystic degeneration
 Fatty degeneration
 Calcified degeneration
 Red degeneration (Carneous degeneration)
 Necrosis
 Infection
 Sarcomatous changes
 Torsion of subserous fibroid
 Hemorrhage
 Polycythemia (erythropoietic function of tumor or
altered function of kidney via pressure effects)

Indications of Dilation & Curettage
Diagnostic Therapeutic Both
Infertility Removal of IUD Dysfunctional Uterine
Bleeding (DUB)
Postmenopausal
bleeding
Incomplete abortion Endometrial polyp
Pathological
amenorrhea
Endometrial TB
Endometrial carcinoma
Chorioepithelioma

Krukenberg Tumor in a Nutshell
 Metastatic tumor of ovary but regarded as atypical because
histological appearance is very different
 Histology shows highly cellular stroma with scattered signet
ring looking cells (mucin within these epithelial cells push
nucleus to one pole)
 Common primary sites from which Krukenberg tumors
originate:
 Stomach
 Large bowel
 Pancreas
 Gall bladder
 Breast
 Endometrial carcinoma
 Very rarely no primary site can be identified and the
Krukenberg tumor may have to be recognized as the primary
tumor

Local ablative methods Excisional methods Surgery
Cryotherapy
 Crystallizing the intracellular
water at temperature -90°C with
N2O or CO2
 Double freeze technique
increases effectiveness
Large loop (electrosurgical)
excision of transformation zone
(LLETZ)
 Low cost, relatively simple
 Excision therapy can cause
stenosis of cervix, abortion
and preterm labor
Conization
 Smaller cone in young patients
to avoid abortion or preterm
labor
 More beneficial when
endocervical dysplasia present
obscuring the TZ and there is
discrepancy between cytology,
colposcopy and biopsy
Cold coagulation
 Destroys cervical tissue at 100 to
120 °C
Loop electrosurgical excision
procedure (LEEP)
 Similar to LLETZ
 Applicable to any area in
lower genital tract
Hysterectomy
 Older, parous women
 Follow up unlikely
 Associated with fibroids, DUB
or prolapse
 Recurrence or micro invasion
Electrodiathermy
 Destruction of cervical tissue
with unipolar electrode
Needle excision of transformation
zone (NETZ)
Hysterectomy with removal of
vaginal cuff (if carcinoma in situ
extends to vaginal vault)
Laser vaporization
 CO2 laser through coloposcopic
guidance
 Beneficial when CIN extends
onto vaginal fornices
Conization or Laser conization
CIN II and II must be treated, preferably with LEEP. For CIN I, follow up with 6 months & 12 months pap smear or
HPV testing at 12 months. After two negative pap smear or one HPV test, resume annual screening. If lesions
progress on follow up or persists at 2 years, local ablative methods is indicated. Treatment of Cervical Carcinoma is
based on staging from conization, simple trachelectomy, simple hysterectomy to modified radical hysterectomy,
radical hysterectomy and pelvic lymphadenectomy.

Alpha Fetoprotein in a Nutshell
Increased Decreased
Inaccurate gestational age Inaccurate gestational age
Neural tube defects Down syndrome
Patau Syndrome (Trisomy 13) Edwards syndrome (Trisomy 18)
Abdominal wall defects
(Gastroschisis, Omphalocele)
Multiple gestation
hCG and Inhibin A are high in Down syndrome (@hI are high). Most common
cause of increased or decreased maternal serum alpha fetoprotein is a mistaken
date. Confirm the date via ultrasound before moving on to chorionic villous
sampling or amniocentesis.

Confusion Corner: Nonstress Test Vs. Contraction Stress Test
NST CST
Positive means good outcome
(Reactive)
Positive means bad outcome
≥ 2 accelerations needed in 20
minutes
Oxytocin sufficient to cause 3
contractions in 10 minutes is
administered
Criteria for accelerations:
I. If >32 weeks, ≥ 15 beats/min for
15 secs
II. If <32 weeks, ≥ 10 beats/min for
10 secs
Contraction results in decreased blood
supply to the fetus, hence decreased
oxygen and decreased HR.
Decelerations can be:
I. Early: Fetal head compression
II. Variable: Umbilical cord
compression
III. Late: Uteroplacental insufficiency
leading to fetal hypoxia and fetal
acidosis

Confusion Corner: Menopause & Obesity
 Menopause is characterized by a drop in the level of many
hormones including estrogen
 Estrogen is mainly derived from conversion of androgens in
the granulosa cells and to a lesser degree from adipose cells
in peripheral fat tissues, both of which is because of the
enzyme aromatase
 After menopause, the ovarian conversion to estrogen start to
cease but the peripheral conversion from adrenal androgen
continues, even more so in obese women
 This may help to minimize symptoms including hot flashes,
heat intolerance, insomnia, headache, night sweats and
dyspareunia
 Additionally due to increased weight bearing and increased
production of endogenous estrogen, obesity is in fact
protective against the development of osteoporosis but
rather is associated with osteoarthritis.

• Wrigley forceps: light, a third of weight of an
ordinary long-curved forceps. Marked cephalic
curve with a slight pelvic curve (@Ligligey
race: light weight man)
• Kielland’s forceps: almost straight, no axis-
traction device, facilitates correction of
asynclitism

Forceps Procedure:
Four steps:
1. Identification of the blades and their
application
2. Locking of the blades
3. Traction
4. Removal of the blades

Application of the Forceps:
 The left or lower blade is inserted first
 The four fingers of semi-supinated hand are inserted along the lateral
vaginal wall. The palmar surface of the fingers rests against the side of
the head. The fingers are to guide the blade application and to protect
the vaginal wall
 The handle of the left blade is taken lightly by three fingers of the left
hand –index, middle and thumb in a pen holding manner and is held
vertically almost parallel to the right inguinal ligament
 The fenestrated portion of the blade is placed on the right palm with
the tip (toe) pointing upwards. The right thumb is placed between the
junction of blades and shank (heel)
 When correctly applied the blades should be over parietal eminence,
the shank in contact with perineum and superior surface of the handle
directing upwards
 Similar procedure with the right blade

Contraindications for ventuose
• Less than 34 weeks (scalp avulsion and sub
aponeurotic hemorrhage)
• Any presentation other than vertex
• Fetal coagulopathy
• Suspected fetal macrosomnia (>4 kg)

Contraindications for Instrumental
delivery:
• Head not engaged
• Fetal unacute bleeding disorder like Haemophilia
• Patient refusal
• Obvious CPD

Vacuum: unrotated/malroated head, not space occupying, high position of head, lesser force
required, comfortable for mother
Forceps: more traction force, less time so suitable for fetal distress, premature babies, after
coming head of breech, less fetal injuries including cephalohematoma

Assisted Expulsion:
Controlled Cord Traction (modified
Brandt-Andrews method)
Fundal Pressure
 Palmar surface of left hand placed just
above pubic symphysis (junction of
upper and lower uterine segment)
 The body of the hardened and
contracted uterus is pushed upward and
backward by left hand while by the right
hand downward and forward steady
traction is applied holding the clamp
until the placenta comes out of the
introitus
 Four fingers behind the
fundus, thumb in front using
the uterus as a piston
 Pressure given when uterus
hard, withdraw applied
pressure as soon as placenta
passes through the introitus
 Preferred when less tensile
strength is required as when
baby is macerated or
premature

Drugs MOA Dose S/E
CCB
(nifedipine, verapamil)
Blocks the entry of
calcium inside cell
10-20mg every 3-6
hours(oral)
Hypotension,
headache, nausea
Magnesium sulfate Competitive
inhibition of calcium
ions
Loading dose 4-6 g IV
over 20 minutes
followed by infusion of
1-2gm/hour for 12
hours
Relatively safe
Flushing, perspiration,
muscle weakness
Betamimetics Activation of
intracellular enzyme(
adenylate cyclase,
cAMP) reduces
intracellular free
calcium
Ritodrine: IV 50ug/min
and increased by 50ug
in every 10 minute till
contraction cease and
infusion cont. for 12
hours after that
Terbutaline:
subcutaneous, 0.25 mg
every 3-4 hours
Headache, palpitation,
hypotension, cardiac
arrest, hypokalemia
Oxytocin antagonist
(Atosiban)
Blocks myometrial
oxytocin receptors
300ug/min IV Nausea, vomiting,
chest pain (rare)
Nitric oxide ( GTN) Smooth muscle
relaxant
Patches Headache

Principles of Management in Preterm Labour
• Crystalline penicillin (Penicilin G)
• 5 million unit, IV, one dose at the onset of labour
• 2.5 million unit, IV, every 4 hourly till delivery
• Dexamethasone: 6 mg IM every 12 hourly for 4 doses
• Betamethasone: 12 mg IM 24 hours apart for 2 doses
(@72 Singh with Dexa first two numbers)

Misoprostol for Abortion:
Gestational age Dosage
1st trimester Missed abortion: 800 mcg 3 hourly (max. 2 doses)
Incomplete abortion: 600 mcg single dose ORAL
2nd trimester Induced abortion: 400 mcg 3 hourly (max. 5 doses)
13 to 17 weeks: 200 mcg 6 hourly (max. 4 doses)
18 to 26 weeks: 100 mcg 6 hourly (max. 4 doses)
3rd trimester
(27-43 weeks)
IFD
25-50 mcg 4 hourly (max. 6 doses)

Amniotic Fluid Colors:
Note: Amniotic Fluid is colorless in early pregnancy but straw colored at term.

Station is 0 when BPD is at the level of ischial spines. Negative values for above
and positive values for below the ischial spines level.

Effacement
• Effacement is the process in which cervical muscular
fibers are pulled upwards and merges with that of
lower uterine segment
• In primigravida, effacement occurs prior to dilatation
while in multiparas, both occur simultaneously (@E
before D in primi!)
• Effacement actually reflects cervical length. With labor,
the cervix thins out and softens thus length is reduced.
• When the cervix becomes as thin as the lower uterine
segment it is said to be 100% effaced.

Note that gestational age is calculated from LMP which is around 14 days prior to
when fertilization occurred. Strictly speaking, embryonic age would be 2 weeks
lesser than gestational age.

Cardiff method: Report if <10 movements occurring in 12 hours on 2 successive
days or no movement perceived even after 12 hours on a single day.
Daily Fetal Movement Count (DFMC): Three count on a day each lasting one hour
*4. Report if <10 movements in 12 hours or <3 in each individual hours.
Dr. Aryan (Anish Dhakal

Intrapartum Fetal Monitoring:
Methods Description
Clinical Auscultation
Passage of meconium
Biophysical Doppler ultrasound
Continuous Electronic Fetal
Monitoring
External: Maternal abdominal wall, by
Cardiotocography (assess FHR,
uterine contraction and fetal
movement)
Internal: Electrode on fetal scalp
Biochemical Fetal blood sampling (< 7.20 indicates
fetal acidosis)

Why GDM in pregnancy?
• As pregnancy progresses after around 20
weeks, increased levels of human
placental lactogen (hPL), cortisol,
prolactin, progesterone and estrogen
lead to insulin resistance in peripheral
tissues.

Cervical Cerclage

Symphysio-Fundal Height:
Weeks Fundal Height
12 weeks Above pubic symphysis
16 weeks Midway between umbilicus & pubic symphysis
24 weeks Umbilicus
28 weeks Junction between lower 1/3rd & upper 2/3rd of distance
between umbilicus and xiphisternum
32 weeks Midway between umbilicus & xiphisternum
36 weeks Xiphisternum
42 weeks Junction between upper 1/3rd and lower 2/3rd of
distance between xiphisternum and umbilicus
After around 20 weeks, the weeks of gestation approximates around the SFH in centimeters.

WHO recommends a minimum of four antenatal care visits:
1. At around 16 weeks
2. 24 to 28 weeks
3. 32 weeks
4. 36 weeks

High level of alpha fetoprotein levels is associated with neural tube
defects or multiple gestations.

Ectopic pregnancy:
Suspect ruptured ectopic pregnancy when the patient is unstable
(hypotension, tachycardia) and there are signs of peritoneal
irritation (guarding, rigidity).

 The women should be haemodynamically stable
 Ectopic pregnancy should be unruptured
 Serum Beta-HCG should not exceed 6500-10,000
mIU/ml
 The size of gestation sac should not exceed 3-5 cm in its
longest diameter
 Fetal cardiac activity should be absent
 The patient should be willing to comfort follow up
 There should be no contraindication to methotrexate
(liver disease, anaemia)
Indication for Methotrexate Therapy
in Ectopic Pregnancy

Medical Treatment for Ectopic Pregnancy
 The single dose regime is more commonly used as it
has lesser side effects.
 Methotrexate 50mg/m2 IM. βhCG is measured on Day
0, 4 and 7. There should be a fall of 15% between Day
4 and 7. Repeat dose if <15% decline.
 In the multidose regime, methotrexate 1mg/kg IV or
IM followed by leucovorin 0.1mg/kg orally 24 hours
later and the dose repeated every alternate day up to
a maximum of 4 doses until βhCG level declines by
15%. Serum βhCG should be assessed at day 0, 3, 5
and 7 until hCG declines by 15%
 After response is achieved, the patient is monitored
with weekly βhCG levels until these are undetectable.

Anti-D antibody prophylaxis

Risk of Rh Sensitization even in 1st pregnancy
Amniocentesis
Chorionic Villus Sampling
Antepartum hemorrhage
Threatened abortion
External cephalic version
Blood transfusion with Rh +ve blood
Fetus is affected if antibody concentration in maternal serum is more than or
equal to critical titer, usually considered as 1:16

How to differentiate fibroid from
ovarian tumors?
Ovarian tumors are:
 Felt separately from the uterus
 Groove felt between mass and uterus
 On moving the mass per abdomen, the cervix
doesn’t move
 Lower pole of the mass can be felt through
the fornix

Primary Amenorrhea Secondary Amenorrhea
Menstruation has never
occurred
At 14 years of age in absence
of menstruation and
secondary sexual
characteristics
At 16 years of age absence of
menstruation regardless of
secondary sexual characters
Established mensuration has
ceased for longer than 6
months without any
physiological reasons

Circulatory diseases Diseases of liver Others
 Arterial or venous
thrombosis
 Severe HTN, stroke
 Valvular heart disease
 Ischemic heart disease
 Angina
 Diabetes with vascular
complications
 Migraine with Focal
neurological symptoms
 Active liver
diseases
 Liver
adenoma,
carcinoma
 Pregnancy
 Undiagnosed genital
tract bleeding
 Estrogen dependent
neoplasm eg: Breast
cancer
 Breast feeding (within
6 weeks postpartum)
 Major surgery or
prolonged
immobilization
Absolute Contraindications of OCP

Relative Contraindications of OCP
• Age > 40 years
• Smoker < 35 years
• History of jaundice
• Mild Hypertension
• Gall bladder disease
• Diabetes
• Sickle cell disease
• Cancer cervix or CIN
• Unexplained vaginal
bleeding
• Hyperlipidemia
• Breast feeding (postpartum
6 weeks to 6 months)
• Past breast cancer
Advantage overweigh risk Risk overweigh advantage

Effects of OCPs Component in a Nutshell
Estrogen Component Progesterone Component
Increased fluid retention (Risk of
Hypertension)
Increased risk for depression (decreased
serotonin levels)
Increased risk of cholelithiasis (Risk of
cholestatic jaundice)
Androgenic effects (acne, weight gain)
Increased venous & arterial stasis Unhealthy lipid changes
Healthy lipid changes (rise in HDL & fall
in LDL)
Increased hepatic protein production
(coagulation factors, carrier protein,
angiotensinogen)
Other minor complications include headache, leg cramps, mastalgia,
cholasma, menstrual abnormalities, diminished libido and leucorrhea.

Most cancers occur in upper outer quadrant

Pregnancy Requirements

Few medical advice in pregnancy
• Folic acid: 0.4 mg (ideally before conception)
• Iron: 60 mg elemental iron (1 Tab Ferrous
sulphate) unless Hb <10 gm/dL, then 2-3
tablets per day might be needed
• Air travel is contraindicated in placenta
previa, pre-eclampsia, severe anemia and
sickle cell disease
• Live vaccines (Measles, Mumps, Rubella,
Yellow fever) are contraindicated.

Contraindications in Pregnancy

Puerperal pyrexia:
• A rise of temperature reaching 100.40F (380C) or more
(measured orally) on 2 separate occasions at 24 hrs
apart (excluding first 24 hrs) within first 10 days
following delivery.

 Puerperal sepsis (Infection)
• An infection of the genital tract which occurs as
a complication of delivery.
• (Puerperal pyrexia is considered to be due to
genital tract infection unless proven otherwise.)
Commonly due to:
• Endometritis
• Endomyometritis
• Endoparametritis
• Pelvic cellulitis (combination of all)

Antepartum factors for Puerperal Sepsis:
Malnutrition and anemia
Antenatal intrauterine infection
Preterm labor
Premature rupture of the membrane
Prolonged rupture of membrane >18 hours
Non-Obstetric: Obesity, Diabetes, HIV

Intrapartum factors for Puerperal Sepsis:
 Repeated vaginal examinations
 Dehydration and keto-acidosis during labor
 Traumatic vaginal delivery
 Hemorrhage-antepartum or post partum
 Retained products of conception
 Prolonged labor
 Obstructed labor
 Cesarean delivery
 Instrumental delivery
 Manual removal of placenta

Puerperal Sepsis Treatment
• Isolation of the patient hemolytic streptococcus on culture
• Adequate fluid and calorie
• Correction of anemia oral iron or blood transfusion
• Catheterization for urinary retention
• Maintenance of chart Pulse, Temp, RR, lochial discharge,
fluid intake and output
• Antibiotics (sensitive is used). In case of pending report:
• GENTAMICIN (2mg/kg iv loading dose, 1.5 mg/kg iv every 8hr)
• CLINDAMYCIN (900 mg iv in every 8 hr)
• METRONIDAZOLE (500 mg iv in every 8 hr ) for anaerobic
control.

Breast Complications in Puerperium
a) Breast engorgement
b) Cracked and retracted nipple
c) Mastitis
d) Breast abscess
e) Lactation failure

Color of Lochia Odour Amount Duration
Lochia rubra (red): 1 to 4 days. Consists
of blood, shreds of fetal membranes,
decidua, vernix caseosa, lanugo and
meconium
Lochia serosa (yellowish/pink/pale
brownish): 5 to 9 days. Few RBCs,
leuckocytes, wound exudate, mucus,
microorganisms
Lochia alba (whitish/yellowish white): 10
to 15 days. Leukocytes, mucus,
microorganisms, decidual cells, cholesterin
crystals, fatty and granular epithelial cells
Note: Presence of red color beyond the
normal limit signifies subinvolution or
retained bits of conceptus. Presence of
microorganisms is not pathognomonic
unless associated with clinical signs of
sepsis.
If
malodourous
indicates
infection.
Retained plug
or cotton
piece inside
vagina.
250 mL for first
5 to 6 days.
Scanty in
premature
labors, infection
or lochiometra.
If excessive,
indicates
infection, twin
pregnancy or
hydramnios
Normal
duration
may extend
up to 3
weeks. If
beyond 3
weeks,
suspect
genital
lesion.

Sims’ Double bladed metallic posterior
vaginal speculum
Uses in Obstetrics Uses in Gynaecology
Following delivery to inspect cervix
and vagina for any injury
To retract posterior vaginal wall in
D&C, D&E, anterior colporrhaphy,
vaginal hysterectomy
Following delivery to clean the vagina To visualize cervix and anterior vaginal
wall for cystocele, VVF or Gartner’s
cyst
To inspect cervix and vagina for any
local cause for bleeding in APH
(Cusco’s preferred)
To collect material from vaginal pool
for cytology, Gram stain or culture
For Dilation & Evacuation operation

What is Sim’s Triad?
1. Sims’ speculum
2. Sims’ position and
3. Sims’ silver wire
used to repair vesicovaginal fistula.

Cusco’s Bivalve self retaining metallic
vaginal speculum
Uses in Obstetrics Uses in Gynaecology
To visualize cervix and vaginal fornices
for any local cause (polyp, ectopy) of
APH
To have cervicovaginal swabs for gram
stain and culture
To visualize cervix and prepare cervical
smear for cytological screening
To insert or remove IUCD or check
threads
To detect leakage of liquor from the
cervical os in suspected PROM
To perform minor operations like punch
biopsy or snipping a small polyp

Tenaculum forceps
(Single tooth vulsellum)

What do you understand by blighted ovum?
A blighted ovum is a pregnancy where a sac
and placenta grow, but a baby does not.
Also called an anembryonic pregnancy as there
is no embryo (developing baby).
Because a blighted ovum still makes hormones,
it can show up as a positive pregnancy test.

Magnesium Sulphate as Tocolytic
IM (Pritchard regimen) IV (Zuspan/Sibai regimen)
Loading dose: 4 g (20%
solution) in 3 to 5 mins. Follow
by 10 g im (50% solution) in
each buttocks (5/5 g)
Loading dose: 4 to 6 g iv in 15
to 20 mins
Maintenance: 5 g (50%
solution) in alternate buttocks
every 4 hours
Maintenance: 1-2 g/hr iv
infusion
Continue only if:
• Knee jerk present
• Urine output >30 ml/hr
• Respiratory rate >12 per minute
• Serum magnesium value is 4 to 7 mEq/L

Fetal Skull - Areas
• Vertex
– Quadrangular area bounded anteriorly by the bregma and coronal
sutures behind by the lambda and lambdoid sutures and laterally by
lines passing through the parietal eminences.
• Brow
– Area bounded on one side by the anterior fontanelle and coronal
sutures and on the other side by the root of the nose and supraorbital
ridges of either side.
• Face
– Area bounded on one side by root of the nose and supraorbital ridges
and on the other, by the junction of the floor of the mouth with neck.
• Sinciput
– Area lying in front of the anterior fontanelle and corresponds to the
area of brow

Fetal skull – Diameters
Diameters Measurement
(cm)
Remarks
Suboccipito-
bregmatic
9.5 Extends from the nape of the neck to the
center of the bregma
Suboccipito-
frontal
10 Extends from the nape of the neck to the
anterior end of the bregma
Occipito-frontal 11.5 Extends from the occipital eminence to the
root of the nose
Mento-vertical 14 Extends from the mid point of the chin to the
highest point on the sagittal suture
Submento-
vertical
11.5 Extends from junction of floor of the mouth
and neck to the highest point of the sagittal
suture
Submento-
bregmatic
9.5 Extends from junction of floor of the mouth
and neck to the center of bregma

Fetal skull – Diameter (Transverse)
Diameters Measurement
(cm)
Remarks
Biparietal 9.5 Greatest transverse diameter of the
head, which extends from one parietal
eminence to the other
Super-
subparietal
8.5 Extends from a point placed below one
parietal eminence to a point placed above
the other parietal eminence on the
opposite side
Bitemporal 8 Distance between the antero-inferior
ends of the coronal suture
Bimastoid 7.5 Distance between tips of mastoid process

Types of Female Pelvis

Boundaries of Pelvic inlet

False Pelvis Boundaries
• Anteriorly anterior abdominal wall
• Posteriorly lumbar vertebrae
• Laterally iliac fossa

Diameter Landmarks Measurement
True conjugate (AP) Midpoint of sacral promontory to
inner and upper border of pubic
symphysis
11 cm
Obstetric conjugate Midpoint of sacral promontory to
inner and midline bony projection
of pubic symphysis
10 cm
Diagonal conjugate Midpoint of sacral promontory to
inner and lower border of pubic
symphysis
12 cm
Transverse diameter Two farthest points on pelvic brim
illiopectineal line
13 cm
Oblique diameter Sacroiliac joint to opposite
iliopubic eminence
12 cm
Sacrocotyloid Sacral promontory midpoint to
iliopubic eminence
9.5 cm

Cavity Boundaries

Pelvic Outlet
• Obstetric outlet:
Anterior: deficient at pubic arch
Laterally: ischial bones
Posterior: whole of coccyx
Transverse or Bispinous diameter: 10.5 cm
(@spine dissects so in decimal)
Anteroposterior: 11 cm

Pelvic Outlet
• Anatomic outlet:
Anteriorly: Lower border of symphysis pubis
Laterally: ischiopubic rami, ischial tuberosity
and sacrotuberous ligament
Posteriorly: tip of coccyx
Transverse or Intertuberous diameter: 11 cm
Anteroposterior: 13 cm

What is the gynaecological and obstetric
clinical significance of Ischial spines?
Engagement of fetal head: station
Internal rotation of fetal head
Pudendal nerve block
Insertion of levator ani muscle
Ring pessary kept at this level
Obstetric curve (J shaped) takes forward direction
at this level
Plane of obstetric outlet (plane of least pelvic
dimension is at this level)

@One: Single during menopause
Triol: Involvement of 3

Primary dysmenorrhea Secondary dysmenorrhea
No identifiable pelvic pathology Secondary to pelvic pathology
Mostly in adolescents Usually in elderly, parous
women
Pain starts with or just before
the onset of bleeding. Occurs
for few hours, may extend up
to 24 hours but very rarely
more than 48 hours
Pain starts 3 to 5 days before
the start of menstruation.
Intermenstrual period is not
completely free of pain.

1st stage: Primi= 12 hrs/ Multi= 6 hrs
2nd stage: Primi= 2 hrs/ Multi= 30 mins
3rd stage: 15 mins but active management= 5 mins
Active phase of first stage is again divided into further 3 stages according to rate of cervical dilation.

Presence of fetal fibronectin between 24 and 34 weeks is a predictor
of preterm labor.

The purpose of Progesterone Challenge test is to access the level of
endogenous estrogen and competence of outflow tract. Bleeding typically
occurs 2 to 7 days after the conclusion of progesterone (usually oral therapy with
10 mg daily for 5 days is performed).

Postpartum Status
In lactating women In non-lactating women
Menstruation could resume
by 6 months
3rd contraception from third
postpartum month onwards
(Better to avoid combined
OCPs if breastfeeding though
there is lack of concrete
evidence against it)
Menstruation could resume
by 6 weeks
Start contraception from 3rd
postpartum week onwards

Postpartum Hemorrhage
• Any amount of bleeding from or into the genital tract following
birth of the baby up to the end of puerperium which adversely
affects the general condition of patients evidenced by rise in pulse
rate and falling BP
Primary Postpartum
Hemorrhage
Secondary Postpartum
Hemorrhage
Hemorrhage occurring within 24 hours of
delivery. In majority, it occurs within 2 hours
following delivery
i. Third stage hemorrhage: Bleeding
before expulsion of placenta
ii. True postpartum hemorrhage: Bleeding
after the expulsion of placenta.
Hemorrhage beyond 24 hours and within
puerperium (6 weeks). Also called delayed
or late puerperal hemorrhage

Primary PPH Causes
The most common cause of primary PPH within 24 hours is uterine atony. The most
common cause of secondary PPH (24 hrs-2 weeks) is retained placenta.

Third Stage Placental site bleeding
Management
(Other is traumatic bleeding)
1. Palpate fundus and massage uterus to make it hard, If still bleeds,
genital tract injury is present
2. Start crystalloid with oxytocin (1L, 20 units): 60 drops/min, arrange
blood
3. Oxytocin 10 units IM or IV methergin 0.2 mg
4. Catheterize bladder
5. Antibiotics Ampicillin 2g and Metronidazole 500mg IV
6. If features of placenta separation  expression placenta either by
fundal pressure or controlled cord traction
7. If not separated  manual removal under GA

Secondary PPH
• Usually between 8th to 14th day of delivery
• Causes:
 Retained bits of cotyledons or membranes (most
common)
 Infection
 Endometritis & subinvolution of placental site
 Secondary hemorrhage from cesarean section
wound (between 10-14 days)
 Withdrawal bleeding following estrogen therapy for
suppression of lactation

Antepartum Hemorrhage:
• It is defined as bleeding from or into the
genital tract after the period of viability (28th
week of gestation) till the delivery of the baby
(first and second stage of labor thus included)

Definition: Placenta previa & Abruptio
placentae
• When the placenta is implanted partially or
completely over the lower uterine segment
(over or adjacent to the internal os)
• Form of antepartum hemorrhage in which
bleeding occurs due to premature separation
of normally situated placenta

Type or degree of Placenta previa
Four type depending upon degree of extension of placenta to the lower segment:
Type I (low lying)- Major part of the placenta is attached to the
upper segment and only the lower margin encroaches onto the
lower segment but not up to the os
Type II- placenta reaches the margin of the internal os but does
not cover
Type III- incomplete or partially cover the internal os
Type IV- placenta complete cover the internal os even after
the full dilatation of lower segment
In fact this dilatation against the inelastic placenta is the cause of opening of
uteroplacental vessels and thus bleeding.

• Type III and IV constitute about 1/3 of cases, for clinical purpose
 Mild degree(type I and type II anterior)
 Major degree(type II posterior, III, IV)
Stallworthy sign: slowing of FHR pressing the head down the pelvis and recovery once
the pressure is released: Seen in low lying placenta previa especially of posterior type.

Diagnostic tests for PROM
1. Pool test (sterile speculum to look posterior fornix)
2. Fern test (high estrogen content of amniotic fluid
produces delicate ferning pattern in contrast to
thick and wide arborization pattern of dried cervical
mucus)
3. Nitrazine test (turns yellow to blue because of
alkaline amniotic fluid). Blood, semen and vaginal infection
with Trichomonas vaginalis can produce false negative result in
nitrazine test
Never confuse fern test in PROM with cervical mucus study of ovulation in which
disappearance of fern pattern (due to NaCl crystals under the influence of estrogen) is
suggestive of ovulation.

Effect of Ovulation

Delivery of the after coming head in
breech
1. Burns Marshall method
2. Forceps delivery
3. Malar flexion and shoulder traction

Endometriosis Vs Adenomyosis
• Endometriosis is presence of functional
endometrium (glands and stroma) outside the
uterine mucosa
• Adenomyosis is the ingrowth of endometrium
(glandular and stromal component) into the
myometrium)

Mode of Action of IUCD
• Mechanism is not identified till now clearly
• Probable mechanism can be:
1. Biochemical and histological changes in the
endometrium inflammatory reaction along with
biochemical changes in the endometrium which
have got gametotoxic and spermicidal property.
2. Lysosomal disintegration from the macrophages
attaches to device liberates prostaglandins, which is
toxic to spermatozoa
3. Macrophages causes phagocytosis of spermatozoa

Mode of Action of IUCD
4. Increased tubal motility which prevent
fertilization of the ovum
5. Ionized Copper  prevent blastocyst
implantation through enzymatic interference
6. Copper initiates the release of cytokines which
are cytotoxic

@AIP (AIB: Youtube channel)

What is caput?
• Caput succedaneum is a neonatal condition
involving a serosanguinous, subcutaneous,
extra periosteal fluid collection with poorly
defined margins caused by the pressure of the
presenting part of the scalp against the
dilating cervix (tourniquet effect of the cervix)
during delivery.

Oxytocin (Half life: 3-4 mins; Action: 20 mins)

ADRs of Oxytocin

Ergometrine

Methergine action starts at 1.5 hrs and lasts for 3 hrs.
They can precipitate rise in blood pressure, stroke, infarction, gangrene,
bronchospasm and can decrease prolactin level in lactation.

PGE2 PGF2α
Dinoprostone (@DONe: 5 times
potent)
Dinoprost
Amnion secretes it Decidua secretes it
Acts as collagenolytic (cervical
dilatation and effacement)
Promotes myometrial contractibility
PGE1: secreted by Myometrium: Misoprostol

Misoprostol Uses
Obstetrics Gynaecology
To initiate cervical ripening and cause
induction of labor
Medical termination of pregnancy
(with Mifepristone or Methotrexate)
Treatment and Prevention of PPH Cervical ripening before
instrumentation
Intrauterine insemination
Missed abortion

Oxytocics: drugs of variable chemical nature that has
power to excite contractions of uterine muscles

GDM Complications in mother:
Pregnancy Labor Puerperium
Abortion Shoulder dystocia Puerperal sepsis
Preterm labor Perineal injuries Lactation failure
Diabetic nephropathy,
retinopathy and CAD
Instrumental delivery
Infection Prolonged labor
Polyhydramnios PPH
Maternal distress
Preeclampsia

Pre-eclampsia: Defination
Preeclampsia is a multisystem complication in
pregnancy of unknown etiology characterized by
development of hypertension to the extent of
140/90 mm Hg or more on two occasions 4 hours
apart and proteinuria in a previously
normotensive and nonproteinuric woman.
Serum uric acid level (>4.5 mg/dl) is the marker.

Preeclampsia

 Rest
 increase uterine blood flow improves placental perfusion
 increase renal blood flow diuresis
 decrease the BP
 Diet
 Adequate protein (100gm/day) and caloric diet
(1600cal/day) with calcium and vitamins is important
Pre-eclampsia & Eclampsia
Management

Diuretics
Use should be careful as it may harm the fetus
by dyselectrolytemia and reducing placental
perfusion
 Indications:
 Cardiac failure
 Pulmonary edema
 Massive edema not relieved by rest and causing discomfort
 Commonly used diuretic is furosemide 40 mg, given orally after
breakfast for 5 days in a week. In acute condition IV route
preferred.

Antihypertensives
Indications:
Persistent rise in BP (esp. when diastolic pressure
is >110)
In severe preeclampsia to bring down the BP
during pregnancy and in the period of labor
If there is proteinuria
Commonly used antihypertensive:
Methyl dopa (200-250 mg TDS)
Nifedipine (10-20 mg BD)
Hydralazine (10-25 mg BD)
Labetalol (100 mg TDS/QID)

Management of Severe Pre-eclampsia
• Hypertensive crisis
(BP≥160/110mmHg or MAP ≥125mmHg)
• Use any of the following drugs
– Labetalol
• (10-20 mg IV every 10 min)  max. 300 mg IV
– Hydralazine
• (5 mg IV every 30 min)  max. 30 mg IV
– Nifedipine
• (10-20 mg PO every 30 min)  max. 240 mg/24hr
– Short term (when others have failed)
• Nitroglycerin (5 μg/min IV)
• Sodium nitroprusside (0.25 – 5 μg/kg/min IV)

Seizure prophylaxis
 During labor and for 24 hours postpartum is recommended for all patients
with preeclampsia
 Magnesium sulfate (MgSO4) is agent of choice for seizure prophylaxis
 IM
• Loading dose: 4gm IV over 3-5 min followed by 10 gm deep IM (5 g in
each buttock)
• Maintenance dose: 5 gm IM 4 hourly in alternate buttock
 IV
• Loading dose: 4 - 6 g IV over 15-20 min
• Maintenance dose: 1 - 2 g/hr IV infusion
• Antidote is Injection calcium gluconate 10ml (10%
solution), iv

Progress Chart
1. Daily clinical evaluation for symptoms
2. Blood Pressure (4x a day)
3. State of edema and Daily weight record
4. Fluid intake and urine output
5. Urine RE (daily protein  24hr proteinuria)
6. Blood (Hct, Plt, Uric acid, Cr, LFT once a wk)
• coagulation profile if Platelet ≤ 100,000/ml
7. Ophthalmoscopic exam on admission
8. Fetal wellbeing assessment (USG, Biophysical
profile, amniotic fluid level)

Grouping of Patients
 Depending up on the response to the treatment patients are
groups into
A) Pre-eclamptic features subside and HTN is mild
B) Partial control of the pre-eclamptic feature but
BP maintain the steady high levels
C) Persistently increasing BP to severe levels,
despite use of anti-HTN and features such as
headache, epigastric pain, oliguria, blurring of
vision or HELLP syndrome

Group C
• Couple is counselled
• Termination of pregnancy is considered irrespective of gestational age
• Seizure prophylaxis (Magnesium sulphate)
• Steroid therapy is consider if duration of pregnancy <34 weeks of
gestation to prevent neonatal RDS, IVH and maternal thrombocytopenia
Group A
• Patient is discharge if EDD remote
from date and ask to follow up
ANC visit weekly
• If near term admit & wait till 37
weeks for delivery
• Not allow pregnancy beyond
EDD
Group B
• If pregnancy is 37 completed week,
delivery is to be consider
• <37 weeks, treatment may be
extended at least up to 34 weeks
• Careful maternal & foetal well are
monitor

Management during Labor
Anti-HTN given if BP becomes high
Prophylactic MgSO4
– if systole ≥ 160 mmHg
– if diastole ≥ 110 mmHg
– if MAP ≥ 125 mmHg
Reduce duration of labor by
– 1st stage- Low rupture of membrane
– 2nd stage- Forceps or ventouse delivery
• Oxytocin IM or slow IV

Method of delivery
Induction of labour Caesarean section
• Aggravation of the
preeclampsia feature
• Hypertension persists
• Acute fulminating
preeclampsia
• Tendency of pregnancy to
overrun the expected date
• Termination if cervix is
unfavourable for induction
• Severe preeclampsia with
tendency to prolong the induction
– delivery interval
• Associated complicating factors
(elderly primi gravida, contracted
pelvis, malpresentation)
If the cervix is ripe surgical induction by low rupture of the membranes is the choice
and oxytocin infusion –added
If the cervix is unripe, prostaglandin(PGE2) gel 500 micro gm intracervical or 1-2mg
in the post. Fornix is inserted to make the cervix ripe when low rupture of the
membranes can be performed
Indications

Acute Fulminant Preeclampsia
Treatment
– If detected at home adequately sedate by
• Pethidine 75-100 mg
• Diazepam 10 mg IM
– Shift gently to hospital setting
– Start prophylactic anticonvulsant therapy
– Start parenteral anti-HTNs
– Monitor BP, Urine output, Blood parameters,
Proteinuria
– If condition fails to improve within 6-8 hrs 
plan delivery

Anti-HTN and Diuretics: Same regimen as in the preeclampsia
Management during Fits: ABC, prevent tongue bite, prevent aspiration, suction,
elevate legs, O2 inhalation.
Status Eclampticus:
• Thiopentone 0.5 gm in 20 mL of D5 IV slowly,
• if fails give complete anesthesia, muscle relaxants, assisted ventilation.
• In unresponsive case: Caesarean section (life saving)
Treatment of complications:
• Pulmonary edema: Furosemide 40mg IV followed by 20 mg mannitol IV
• HF: O2 inhalation, parenteral Furosemide, Digitalis.
• Anuria management
• Hyperpyrexia: antipyretics and cold sponging
• Psychosis: Chlorpromazine
• Intensive care monitoring: Multidisciplinary approach.

Cervical Incompetence
• Inability of the cervix to retain an intra-uterine pregnancy
till term as a result of structural and functional defects
with painless spontaneous dilation of the cervix
• 2nd trimester pregnancy failure
• Normal cervix should at least be 30 mm in length. Less
than 25 mm at or before 24 weeks is usually consistent
with cervical incompetence.
• Treatment include bed rest, tocolysis, cervical cerclage,
trans abdominal suture placement or administration of
steroid to accelerate fetal lung maturity

Cryptomenorrhea

Causes of Postmenopausal Bleeding:

Violin string like adhesions in the pelvis and around liver suggests Chlamydial infection.

Initial surface keratization occurs which leads to cracking, infection,
sloughing and ulceration.

Supports of the Uterus
Upper Tier Middle Tier Inferior Tier
Endopelvic fascia covering
uterus
Pericervical ring (pubocervical
ligament and vesicovaginal
septum anteriorly, cardinal
ligaments laterally, uterosacral
ligaments and rectovaginal
septum posteriorly)
Pelvic floor muscles (Levator ani)
Round ligaments Pelvic cellular tissues Endopelvic fascia
Broad ligaments with
intervening pelvic cellular
tissues
Levator plate
Perineal body
Urogenital diaphragm
Another classification is of primary vs. secondary (false) support. Primary support is by muscular or fibromuscular
support, pubocervical ligament , transverse cervical ligament, uterosacral ligament, round ligament.
False/Secondary support is by broad ligament and folds of peritoneum (uterovesical or rectovaginal folds of
peritoneum). Risk factors of pelvic organ prolapse include anatomical factors (gravitational stress, anterior
inclination of pelvis, stress of parturition, direction of obstetric axis through the urogenital hiatus) & clinical
factors (trauma of childbirth, inborn weakness of supporting structures, poor collagen repair in old age,
postmenopausal atrophy, increased abdominal pressure in chronic lung disease or constipation, weight lifting,
increased weight including in fibroid uterus).

Uterine Prolapse Management in a Nutshell
Conservative Treatment Operative Treatment
Reduction of risk factors Anterior colporrhaphy
Estrogen replacement therapy may improve
minor degree of prolapse in postmenopausal
women
Posterior colporrhaphy
Pelvic floor exercises (Kegal exercise) Fothergills/Manchester operation
Pessary treatment Shirodkar’s Modification of Manchester
Vaginal hysterectomy with Pelvic Floor
Repair
Lefort’s repair
Abdominal Sling Operation:
 Abdominocervicopexy
 Shirodkar Abdominal Sling Operation
 Khanna’s Abdominal Sling Operation

Stress test
• Asked to cough, check for urine escaping
– Pt. is asked to void  Catheterize to remove any
residual urine USG to measure any residual urine
 urine sample send for culture  Instill 250 mL
of warn NS in bladder  Pt wears a preweighed
sanitary pad  Asked to cough, strain  objective
evidence of urine leak is noted  Pt is asked for
lithotomy position and asked to strain or cough for
further evidence of stress incontinence Weight
the pad  if increase in wt by ≥ 2 gm : USI

Cotton Swab stick test or Q-tip test
Sterile cotton tipped swab dipped in xylocaine jelly
inserted through urethra up to level of bladder neck
The patient is asked to strain and cough
Initially the cotton swab stick will be parallel to the
floor
No USI: the cotton swab stick will normally reach an
angle not exceeding 10°-15° above the horizontal
Angle increases by 30° or more, commonly 50°-70° in
most positive cases
Positive test indicates: Sufficient degree of bladder
neck descent.
Test if positive obviates the need for a head chain
cystourethrogram

Marshall and Boney Test
• Positive stress test
• Bonney's test:
– 2 fingers are placed in the vagina at the urethrovesical
junction, on either side of the urethra and the bladder
neck region elevated
– On straining or coughing absence of leakage of urine
• Marshall test:
– Vagina in the region of the bladder neck is infiltrated with
local anaesthetic, and elevated with an open Allis clamp
– No leakage of urine

Bonney test incorporates application of light pressure immediately to the sides of
the upper urethra and directed forwards. Original description by Victor Boney
didn't contain the “uplift” suggestion. The effect of such pressure merely tightens
or closes the internal sphincter and will prevent incontinence.

Obstetrical causes of Genitourinary Fistula
• Ischaemic
– prolonged compression effect on the bladder base
between the head and symphysis pubis in obstructed
labor ischemic necrosis infection sloughing fistula
• Traumatic
– Instrumental vaginal delivery
• Destructive operations (craniotomy, symphysiotomy)
• Forceps delivery
– Abdominal operation
• Hysterectomy
• Caesarean section (specially repeat one)

• Operative injury
– Anterior colporrhaphy, abdominal hysterectomy for benign or malignant
lesion, removal of Gartner’s cyst
• Traumatic
– Fall on a pointed object, stick used for criminal abortion, fracture of pelvic
bone, retained or forgotten pessary
• Malignancy
– Advanced carcinoma of cervix, vagina, bladder
• Radiation
– Ischaemic necrosis by endarteritis obliterans d/t radiation effect
• Infective
– Chronic granulomatous lesions like vaginal TB, lymphogranuloma venereum,
schistosomiasis, actinomycosis
Gynecological causes of Genitourinary Fistula

Surgery for Vesicovaginal Fistula
• Latzko procedure:
– Fistula repaired vaginally
– suitable for a fistula which is small and high
• Chassar Moir technique:
– Vagina and bladder are separated
– Suture line should not overlap
– Graft (martius graft) is needed in case of extensive
fibrosis

Definition of Delayed Puberty
• Delayed puberty is defined as one
– who fails to develop any secondary sex
characteristics by the age of 13
– no menarche by the age of 16
OR
– In whom 5 or more years have passed since the onset
of pubertal development without attainment of
menarche
• In the boys puberty is said to be delayed if there
is no change by the age of 15

Definition of Precocious Puberty
• Girls who exhibit any secondary sex characteristic
before the age of 8 or menstruate before the age
of 10
• Isosexual excess production of estrogen
• Heterosexualexcess production androgen(from
ovarian and adrenal neoplasm)

Diagnosis of Turner Syndrome
Signs: Classic anatomic abnormalities
Amniocentesis or chorionic villus sampling
Confirmation of clinical diagnosis is by the following:
 Karyotype analysis
 Serum E2 very low
 Serum FSH and LH elevated
There is hypergonadotrophic hypogonaidsm
state
USG streaked ovaries or absence of ovaries
and uterus. Occasionally menstruation can occur
for a few cycles until the follicles are exhausted.
Pregnancy has also been reported

Risk of HRT

Progesterone role in HRT
• Prevents endometrial hyperplasia and cancer
• Implant may replace estrogen if estrogen contraindicated or
sensitive
• Improves bone mineral density
• Prevents breast cancer
Duration of HRT use:
– Use for 3-5 years is advised
– Reduction of dose be done as soon as possible
– Individual informed choice as regard to merits & demerits and
possible risk of continuing HRT be given

Major Types of Androgen Insensitivity
Syndrome
CAIS (completely insensitive to AR gene)
External female genitalia
Lacking female internal organs (Sertoli cells markers AMH
and inhibin B present)
PAIS (partially sensitive-varying degrees)
External genitalia appearance on a spectrum (phenotypic
women with mild virilization to phenotypic men with
undervirilization and gynecomastia or infertility
MAIS (mildly sensitive, rare)
Impaired sperm development and/or impaired
masculinization

Presentation Mullerian
agenesis
Androgen
insensitivity
Inheritance pattern Sporadic X-linked recessive
Karyotype 46,XX 46,XY
Breast development Yes Yes
Axillary and pubic hair Yes No
Uterus No No
Gonad Ovary Testis
Testosterone Female levels Male levels
Associated anomalies Yes No

Sex assignment
Usually assigned at birth with the expectation that
future gender identity will develop in alignment with
physical anatomy, initially assigned sex and rearing.
Gender identity: Personal sense of one’s own
gender
Sex assignment of an intersex individual may
contradict their future gender identity
Usually not attempted to change gender identity
after age 3 unless requested by the patient
(Possibility of gender dysphoria)

Hormonal Regulation of Spermatogenesis
•LH: stimulates Leydig cells to produce Testosterone
•FSH : stimulates Sertoli cells (helps in the conversion
of spermatids into the spermatozoa)
•Inhibin: Inhibits secretion of FSH

Causes of Oligospermia

Semen analysis (WHO-2010)
Semen analysis Normal reference value
Volume 2ml or more (2-5ml)
pH 7.2-7.8
Sperm concentration 20million/mL
Total sperm count >40million/ ejaculate
Motility >50% progressive forward motility
Morphology >14% normal form
WBC < 1 million /ml
Viabilty 75% or more viable

Post Coital Test
Done on day 12 or 13 of menstrual cycle
Reported to clinic within 2 hours of intercourse
Endocervical mucus is collected and placed on a
slide
Number and motility of sperms seen under
microscope
Normally 10 to 50 sperms per high power field is noted. Less than 10 sperms then
proper semen analysis is done. Look for progressive movement not rotatory.

Miller-Kurzrok Test
• Cervical mucus is placed on a glass slide alongside
the specimen of husband’s semen
• Penetration of sperms is checked under microscope
• Normally cervical mucus permits invasion by motile
sperm
• Penetration <3 cm at 30 minutes abnormal

Emergency Contraception in a Nutshell
ECPs with UPA, taken as a single dose of 30 mg
ECPs with LNG taken as a single dose of 1.5 mg, or
alternatively, LNG taken in 2 doses of 0.75 mg each, 12
hours apart.
COCs, taken as a split dose, one dose of 100 μg of
ethinyl estradiol plus 0.50 mg of LNG, followed by a
second dose of 100 μg of ethinyl estradiol plus 0.50 mg
of LNG 12 hours later. (Yuzpe method)
The number of oral contraceptive pills required for
Yuzpe method of emergency contraception depends on
the specific company brand but usually its 2 to 3 pills
for each dose (Ethinyl estradiol: 30-35 μg and LNG:
0.05-0.15 mg in a tablet of OCP).

Steps in IVF
1. Down regulation of pituitary hormones
2. Ovarian stimulation
3. Monitoring of follicular growth
4. Egg retrieval
5. Fertilization
6. Embryo culture
7. Embryo transfer

Acknowledgements:
Best of the best slides, pictures and information on the
web. Special thanks to all those brilliant minds for their
act of creation and compilation of scientific material
without which this work would not be possible
• Padubidri V.G., Daftary S. N., Howkins and Bourne Shaw’s
Textbook of Gynaecology
• Gyanecology by Ten Teachers
• DC Dutts’s Textbook of Obstetrics
• Shaw’s Textbook of Gyanecology
• DC Dutta’s Textbook of Gyanecology
• Williams Gynecology
• Williams Obstetrics

How to make immense peace and
tranquility with your past and future?
• https://medium.com/@anishdhakal718/only-truth-
you-need-to-know-for-making-immense-peace-
with-past-and-future-e7fbba0d9525

Gynaecology and Obstetrics Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 18)

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