Obstetrics & Gynecology (OBGYN) Obstetrics Early Pregnancy: Signs to diagnose pregnancy Preconceptional care — supplementations & vaccinations Parity index Teratogens & associated defects Trimester-wise screenings Leopold maneuvers High-Yield Conditions: Cervical insufficiency — types of cerclage APLA (Antiphospholipid Antibody Syndrome) Ectopic pregnancy — expectant, medical & surgical management Molar pregnancy — partial vs complete Placenta & Amniotic Fluid: Placental abnormalities Amniotic fluid abnormalities Placenta previa vs placental abruption PAS (Placenta Accreta Spectrum) Multiple Pregnancy: Multiple pregnancy mechanics MCDA vs DCDA (USG evaluation) TTTS (Twin-to-Twin Transfusion Syndrome) Medical Disorders in Pregnancy: Hypertension in pregnancy Preeclampsia & eclampsia — management HELLP syndrome Diabetes in pregnancy Labor & Delivery: Modified Bishop score Active management of third stage of labor Breech presentation — management Lovset & Burns Marshall maneuvers Shoulder dystocia — HELPERR algorithm Postpartum hemorrhage — EMOTIVE protocol Gynecology Menstrual Disorders: Mullerian anomalies Primary vs Secondary amenorrhea Abnormal uterine bleeding — FIGO classification Uterine Conditions: Adenomyosis Fibroids Endometriosis — management Endometrial hyperplasia High-Yield Clinicals: Vaginal infections Ovarian cysts & tumors Cervical cancer — screening & diagnosis HPV vaccination PCOS Contraception

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📚 OBGYN Complete Revision Notes

Sources: Rosen's Emergency Medicine, Creasy & Resnik's Maternal-Fetal Medicine, Berek & Novak's Gynecology, and clinical guidelines.

PART 1: OBSTETRICS

1. EARLY PREGNANCY

1.1 Signs to Diagnose Pregnancy

Category	Sign	Details
Presumptive (subjective)	Amenorrhea	Most common symptom
	Nausea/vomiting	Peaks 8-10 weeks
	Breast tenderness, enlargement
	Urinary frequency
	Quickening	Fetal movements felt at 18-20 wks (primi), 16-18 wks (multi)
	Chadwick's sign	Bluish discoloration of vagina/cervix (6 wks)
Probable (objective, not conclusive)	Goodell's sign	Softening of cervix (6 wks)
	Hegar's sign	Softening of lower uterine segment (6-8 wks)
	Ballottement	16-28 wks, fetus bounces back on palpation
	Positive urine/serum hCG	hCG detectable by Day 9-11 post-conception
	Palmer's sign	Regular rhythmic uterine contractions
	Piskacek's sign	Asymmetric uterine enlargement at implantation site
Positive (definitive)	Fetal heart tones	Doppler: 10-12 wks; Fetoscope: 20 wks
	Fetal movements felt by examiner	~20 wks
	USG visualization of fetus	Gestational sac: 4-5 wks TVS; fetal pole + cardiac activity: 6 wks

Memory: Presumptive = Patient feels; Probable = Physician finds; Positive = Proof (USG/FHT)

1.2 Preconceptional Care

Supplementations:

Supplement	Dose	Purpose	Timing
Folic acid	400 mcg/day (normal)	Neural tube defect prevention	1 month before conception through 1st trimester
	5 mg/day (high-risk: prior NTD, epilepsy, DM, obesity, twins)
Iron	60 mg elemental iron + folic acid	Anaemia prevention	From 2nd trimester in normal; preconceptionally in anaemic
Calcium	1000-1200 mg/day	Bone health, preeclampsia prevention	Throughout pregnancy
Vitamin D	600-2000 IU/day
Iodine	150-220 mcg/day	Fetal thyroid development

Vaccinations before pregnancy:

Vaccine	Timing	Notes
MMR (live)	At least 1 month before conception	Contraindicated in pregnancy
Varicella (live)	At least 1 month before	Contraindicated in pregnancy
HPV	Complete before pregnancy (9-26 yrs)	Not given during pregnancy
Rubella	Pre-conception if non-immune

Vaccinations SAFE/recommended during pregnancy:

Vaccine	Trimester	Notes
Tdap	27-36 weeks (ideally 27-32 wks)	Every pregnancy; protects newborn from pertussis
Influenza	Any trimester	Inactivated only
COVID-19	Any trimester
Hepatitis B	Any trimester if non-immune

1.3 Parity Index (GTPAL / Obstetric Formula)

G-T-P-A-L:

G = Gravida (total pregnancies, including current)
T = Term deliveries (≥37 weeks)
P = Preterm deliveries (20-36+6 weeks)
A = Abortions (spontaneous + induced, <20 wks)
L = Living children

Term	Definition
Nulligravida	Never been pregnant
Primigravida	Currently/previously pregnant for 1st time
Multigravida	≥2 pregnancies
Nullipara	Never delivered a viable infant
Primipara	Delivered once (≥20 wks, alive or dead)
Multipara	≥2 deliveries
Grand multipara	≥5 deliveries

1.4 Teratogens & Associated Defects

Teratogen	Defect/Association
ACE Inhibitors / ARBs	Renal tubular dysgenesis, oligohydramnios, skull hypoplasia, neonatal renal failure (2nd/3rd trimester)
Warfarin	Warfarin embryopathy: nasal hypoplasia, stippled epiphyses, chondrodysplasia punctata (1st trimester); CNS defects (any trimester)
Thalidomide	Phocomelia (limb reduction defects), ear abnormalities
Isotretinoin (Accutane)	Craniofacial, cardiac, CNS defects; microtia
Valproic acid	Neural tube defects (spina bifida), cardiac defects, IUGR
Carbamazepine	Neural tube defects (spina bifida), fingernail hypoplasia
Phenytoin	Fetal hydantoin syndrome: growth restriction, hypoplastic phalanges/nails, craniofacial anomalies
Lithium	Ebstein anomaly (tricuspid valve)
Diethylstilbestrol (DES)	Clear cell adenocarcinoma of vagina/cervix; T-shaped uterus; cervical incompetence
Alcohol	Fetal alcohol syndrome: microcephaly, smooth philtrum, thin vermillion, growth restriction, intellectual disability
Cocaine	Placental abruption, microcephaly, limb reduction defects
Tetracyclines	Teeth discoloration, inhibited bone growth (2nd/3rd trimester)
Aminoglycosides	CN VIII toxicity - deafness
Misoprostol (early)	Moebius sequence, limb defects
Methimazole	Aplasia cutis, choanal atresia
Radiation >10 rad	Microcephaly, growth restriction (safe threshold: <5 rad)
Rubella (1st trimester)	Classic triad: cataracts, PDA/pulmonary stenosis, sensorineural deafness
CMV	Periventricular calcifications, sensorineural deafness, chorioretinitis
Toxoplasma	Hydrocephalus, intracranial calcifications, chorioretinitis
Syphilis	Hutchinson's triad, saddle nose, interstitial keratitis, bone changes
Varicella	Limb hypoplasia, skin scarring, eye defects (if 1st/2nd trimester)

Memory (SAFE antibiotics in pregnancy): Penicillins, Cephalosporins, Erythromycin, Azithromycin, Clindamycin (PCEAC)

1.5 Trimester-Wise Screenings

First Trimester (11-13+6 weeks)

Test	Timing	What it screens
Combined First Trimester Screen	11-13+6 wks	NT (nuchal translucency) + free β-hCG + PAPP-A → T21, T18, T13
Cell-Free DNA (cfDNA/NIPT)	10 wks+	T21, T18, T13, sex chromosome aneuploidies (screening, not diagnostic)
Dating USG	8-13 wks (CRL)	Gestational age, viability, chorionicity in twins
Blood group, Rh, antibody screen	1st visit
CBC, urine culture, rubella/varicella immunity	1st visit
HIV, syphilis, Hep B, Hep C	1st visit
Chorionic villus sampling (CVS)	10-13 wks	Diagnostic - karyotype/microarray

Second Trimester (14-28 weeks)

Test	Timing	What it screens
Quadruple screen (AFP, hCG, uE3, Inhibin A)	15-20 wks	T21, T18, NTDs
Anomaly USG	18-20 wks	Structural anomalies
Amniocentesis	15-20 wks	Diagnostic karyotype
AFP (elevated)	15-20 wks	NTDs, abdominal wall defects, multiple gestation
Cervical length (high-risk)	18-24 wks	Preterm birth risk
GDM screening (1-hr GCT)	24-28 wks	Gestational diabetes

Quad Screen Patterns:

Condition	AFP	hCG	uE3	Inhibin A
Trisomy 21 (Down)	↓	↑	↓	↑
Trisomy 18 (Edwards)	↓	↓	↓	Normal
NTD (Open)	↑	Normal	Normal	Normal
Molar pregnancy	-	↑↑↑	-	-

Third Trimester (29-40 weeks)

Test	Timing	Purpose
GBS (Group B Strep) culture	35-37 wks	Intrapartum prophylaxis if positive
Repeat antibody screen (Rh-)	28 wks	Anti-D prophylaxis
BPP/NST	28+ wks (high-risk)	Fetal well-being
Kick counts	28+ wks	Daily monitoring

1.6 Leopold Maneuvers

Systematic abdominal palpation at ≥28 weeks to determine fetal lie, presentation, position, and engagement.

Maneuver	Technique	Determines
1st (Fundal grip)	Both hands cup the fundus	What is in the fundus (head = hard, round, ballotable; breech = soft, irregular)
2nd (Lateral grip)	Hands moved to sides of uterus	Fetal back (firm, smooth) vs. limbs (irregular, nodular) - determines position
3rd (Pawlik's grip)	Single hand grasps presenting part above pubis	Presentation; engagement (if moveable = not engaged)
4th (Pelvic grip)	Face toward patient's feet; fingertips feel into pelvis	Degree of descent/engagement; attitude (flexion vs. extension)

Memory: 1 = Fundal (What's up there?); 2 = Sides (Back or Limbs?); 3 = Presentation; 4 = Descent

2. HIGH-YIELD CONDITIONS

2.1 Cervical Insufficiency

Definition: Painless cervical dilation in 2nd trimester without uterine contractions, leading to recurrent mid-trimester pregnancy loss.

Features:

History of 2nd trimester losses with painless dilation
Short cervix on USG (<25 mm at 16-24 wks)
Associated with: DES exposure, prior LEEP/cone biopsy, Mullerian anomalies, connective tissue disorders

Types of Cerclage:

Type	Technique	Indication	Timing
McDonald cerclage	Purse-string suture at cervicovaginal junction	Standard; history-indicated or USG-indicated	12-14 wks (history) or when cervix shortens
Shirodkar cerclage	Suture placed at internal os level (submucosal) after bladder reflection	Preferred when McDonald fails; anatomically superior	12-14 wks
Transabdominal cerclage (TAC)	Open or laparoscopic suture at uterine isthmus	Failed vaginal cerclage; very short cervix; prior trachelectomy	Pre-pregnancy or 10-13 wks
Rescue/Emergency cerclage	Placed when cervix is already dilated (1-4 cm, bulging membranes)	Acute cervical dilation in 2nd trimester	16-24 wks

Cerclage removal: 36-37 weeks (allow vaginal delivery); removed earlier if labor, PPROM, chorioamnionitis

Progesterone supplementation: Vaginal progesterone 200 mg/night or 17-OHPC IM weekly for short cervix

2.2 Antiphospholipid Antibody Syndrome (APLA)

Definition: Autoimmune thrombophilia causing arterial/venous thrombosis and pregnancy morbidity.

Diagnostic Criteria (Revised Sapporo/Sydney Criteria - need ≥1 clinical + ≥1 lab):

Clinical criteria:

Vascular thrombosis (arterial, venous, or small vessel)
Pregnancy morbidity:
- ≥3 unexplained consecutive 1st trimester losses (<10 wks)
- ≥1 morphologically normal fetal loss ≥10 wks
- ≥1 preterm birth ≤34 wks due to severe preeclampsia or placental insufficiency

Laboratory criteria (positive on ≥2 occasions, ≥12 weeks apart):

Lupus anticoagulant (LA)
Anticardiolipin antibodies (IgG or IgM) - medium/high titre (>40 GPL/MPL or >99th percentile)
Anti-β2 glycoprotein-I antibodies (IgG or IgM) - >99th percentile

Management in Pregnancy:

Situation	Treatment
APLA + obstetric morbidity only (no thrombosis)	Low-dose aspirin (75-100 mg/day) + LMWH (prophylactic dose) from conception
APLA + prior thrombosis	Low-dose aspirin + LMWH (therapeutic/prophylactic dose)
APLA + SLE	Add hydroxychloroquine
Postpartum	Continue anticoagulation for at least 6 weeks (switch to warfarin)

⚠️ Warfarin is contraindicated in 1st trimester; LMWH used throughout pregnancy.

2.3 Ectopic Pregnancy

Definition: Implantation outside the uterine cavity. Sites: Fallopian tube (95% - ampulla most common 70%), cervix, ovary, abdominal, cornual/interstitial.

Risk factors (from Rosen's EM): Tubal surgery, PID, smoking, IUD, prior ectopic, infertility, assisted reproduction.

Diagnosis:

Serum β-hCG + TVS
Discriminatory zone: hCG >1500-2000 IU/L → IUP should be visible on TVS
TVS findings: No IUP + adnexal mass ± free fluid = ectopic until proven otherwise

Management:

Approach	Criteria	Details
Expectant	hCG <1000 IU/L AND declining (>15%/48h), no pain, no rupture, small mass <3.5 cm	Serial hCG monitoring every 48 hrs until undetectable; 50-70% resolution
Medical - Methotrexate	hCG <5000 IU/L (some say <10,000), no cardiac activity, mass <3.5-4 cm, no rupture, renal/hepatic/hematologic normal	Single-dose: MTX 50 mg/m² IM; check hCG day 4 & 7 (expect 15% drop by D4-7); Multi-dose: MTX day 1,3,5,7 + leucovorin rescue
	MTX contraindications: hCG >5000, cardiac activity, rupture, IUD in situ, immunocompromised, abnormal LFT/renal, breast-feeding
Surgical	Ruptured ectopic, hemodynamic instability, contraindication to MTX, failed medical Rx, heterotopic	Salpingostomy (preserve tube, higher recurrence risk) vs. Salpingectomy (preferred, definitive); Laparoscopy preferred over laparotomy

Post-treatment: Anti-D immunoglobulin if Rh-negative; serial hCG until undetectable.

2.4 Molar Pregnancy (Gestational Trophoblastic Disease)

Complete vs. Partial Hydatidiform Mole:

Feature	Complete Mole	Partial Mole
Karyotype	46,XX (90%) or 46,XY - all paternal (androgenetic)	69,XXX or 69,XXY - triploid (1 egg + 2 sperm)
Origin	Empty egg + 2 sperm (dispermy) or 1 sperm that duplicates	Normal egg + 2 sperm
Fetal tissue	Absent	Present (abnormal fetus/fetal RBCs)
Villi	Diffuse trophoblastic hyperplasia, all villi edematous	Focal trophoblastic hyperplasia, some normal villi
USG	"Snowstorm" appearance, no fetus	Fetus present (non-viable), Swiss-cheese placenta
hCG	Very high (>100,000)	Moderately elevated
Symptoms	Hyperemesis, early preeclampsia (<20 wks), theca lutein cysts, hyperthyroidism, uterus LGA	Milder; often presents as missed abortion
Malignant transformation	15-20% → GTN	<5% → GTN
p57 immunostain	Negative (no maternal chromosomes)	Positive

Management:

Suction curettage (method of choice) - even for large moles
Anti-D if Rh-negative
Serial β-hCG monitoring: Weekly until undetectable x3, then monthly x12 months
Contraception for 12 months (OCPs preferred - do NOT delay hCG normalization)
Hysterectomy option in women with completed family (does not eliminate GTN risk monitoring)

GTN criteria: hCG plateau (±10% x4 values over 3 wks), rise (>10% x3 values over 2 wks), persistence at 6 months, or histologic choriocarcinoma → Chemotherapy (single-agent MTX or actinomycin-D for low-risk; EMA-CO for high-risk)

3. PLACENTA & AMNIOTIC FLUID

3.1 Placenta Previa vs. Placental Abruption

Feature	Placenta Previa	Placental Abruption
Definition	Placenta covers internal cervical os (partially or completely)	Premature separation of normally implanted placenta
Bleeding	Painless, bright red, sudden	Painful (may be concealed - 20%); dark blood
Uterus	Soft, non-tender	Rigid/board-like, tender
Presentation	Often malpresentation (head not engaged)	Normal presentation
Fetal condition	Often stable initially	Fetal distress common
Diagnosis	USG (do NOT do digital PV exam!)	Clinical + USG (retroplacental clot) - USG has low sensitivity (50%)
Risk factors	Prior CS/uterine surgery, multiparity, smoking, prior previa, IVF	Hypertension (most common), trauma, cocaine, smoking, PROM, polyhydramnios
DIC	Rare	Common (Couvelaire uterus → severe)
Management	Stable + <37 wks: expectant; ≥37 wks or bleeding: CS	Stable + preterm: conservative; fetal distress/severe: emergency delivery

Types of Placenta Previa:

Complete (major): Completely covers os
Partial: Partially covers os
Marginal: Edge reaches but doesn't cover os
Low-lying: Within 2 cm of os but not covering it

⚠️ Vasa previa: Fetal vessels cross internal os → at risk of rupture with ROM → sinusoidal FHR + Apt test positive → emergency CS

3.2 Placenta Accreta Spectrum (PAS)

Type	Invasion	Frequency
Accreta	Villi attach to myometrium (no decidua basalis)	75-78%
Increta	Villi invade into myometrium	17%
Percreta	Villi penetrate through serosa (may invade bladder/bowel)	5-7%

Risk factors: Previous CS (strongest - risk rises with each CS: 1CS→0.3%, 2CS→0.6%, 3CS→2.1%), placenta previa, uterine surgery, Asherman's syndrome, advanced maternal age.

Diagnosis: USG (loss of retroplacental clear space, lacunae, bladder wall interruption) + MRI (when USG equivocal)

Management:

Planned cesarean hysterectomy at 34-36 weeks (elective, before labor)
Multidisciplinary team: MFM, gynecologic oncologist, urology, IR (interventional radiology), blood bank
Leave placenta in situ if accreta (do not attempt manual removal)
Conservative management (uterus-sparing): possible in carefully selected cases with fertility desire

3.3 Amniotic Fluid Abnormalities

Polyhydramnios (AFI >24 cm or MVP >8 cm)

Feature	Details
Definition	AFI >24 cm or maximum vertical pocket >8 cm
Causes	Idiopathic (60-70%), fetal: GI obstruction (duodenal/esophageal atresia, tracheoesophageal fistula), CNS abnormalities (anencephaly, NTD), neuromuscular conditions; Maternal: gestational diabetes (most common maternal cause), immune hydrops
Associations	Duodenal atresia → "double bubble"; Anencephaly
Complications	Preterm labor, PPROM, malpresentation, cord prolapse, PPH (uterine atony)
Management	Treat underlying cause; therapeutic amniocentesis if severe symptoms; indomethacin (reduces fetal urine output - use <32 wks)

Oligohydramnios (AFI <5 cm or MVP <2 cm)

Feature	Details
Definition	AFI <5 cm or MVP <2 cm; Severe: AFI <2 cm (anhydramnios)
Causes	Fetal: IUGR (uteroplacental insufficiency), posterior urethral valves, renal agenesis (Potter sequence), polycystic kidneys; Maternal/iatrogenic: Prolonged pregnancy (post-term), PROM, ACE inhibitors, NSAIDs
Associations	Renal agenesis → Potter sequence (pulmonary hypoplasia, limb contractures, flattened facies)
Complications	Cord compression, fetal distress, pulmonary hypoplasia, limb contractures (if early onset)
Management	Serial monitoring; amnioinfusion intrapartum (for recurrent variable decelerations); delivery if at term or fetal compromise

3.4 Other Placental Abnormalities

Abnormality	Description
Placenta succenturiata	Accessory lobe separate from main placenta; risk of retained lobe → PPH
Bilobed placenta	Two equal lobes; vessels may run between → vasa previa risk
Circumvallate placenta	Chorionic plate smaller than basal plate with folded-back edges; ↑ APH, preterm labor
Placenta membranacea	Placenta covers most of uterine surface; ↑ hemorrhage risk
Battledore placenta	Cord inserts at placental margin (marginal insertion)
Velamentous cord insertion	Cord inserts into membranes; vessels exposed → vasa previa risk; ↑ IUGR, fetal anomaly
Circumvallate	Associated with 2nd trimester bleeding, IUGR, preterm

4. MULTIPLE PREGNANCY

4.1 Chorionicity & Amnionicity - USG Evaluation

Feature	DCDA (Dichorionic Diamniotic)	MCDA (Monochorionic Diamniotic)	MCMA (Monochorionic Monoamniotic)
Zygosity	Dizygotic (mostly) or early division (<3 days) monozygotic	Monozygotic (division 4-8 days)	Monozygotic (division 8-13 days)
USG marker (1st trimester)	Twin peak (Lambda/λ) sign - triangular wedge of placental tissue between membranes	T-sign - thin membrane arises perpendicular to uterine wall	No dividing membrane
Membrane thickness	Thick (>2 mm), 4 layers	Thin (<2 mm), 2 layers	Absent
Placenta	2 separate or fused	1	1
Best time to determine	11-14 weeks (most accurate)
Risk	Lowest	Intermediate (TTTS, sIUGR)	Highest (cord entanglement, TTTS)

Memory: Lambda (λ) = DCDA ("Lambda" sounds like "large" - more tissue between); T = MCDA (thin membrane)

4.2 Twin-to-Twin Transfusion Syndrome (TTTS)

Mechanism: Unbalanced arteriovenous anastomoses in monochorionic placenta → donor twin becomes oliguric/anhydramniotic; recipient twin becomes polyuric/polyhydramniotic.

Occurs in: 10-15% of MCDA twins

Quintero Staging:

Stage	Features
I	Donor: MVP <2 cm; Recipient: MVP >8 cm. Bladder still visible in donor
II	Donor bladder not visible on USG (absent filling)
III	Critically abnormal Dopplers in either twin (absent/reversed EDF in UA, reversed DV flow, pulsatile UV)
IV	Hydrops in either twin
V	Demise of one or both twins

Management:

Stage I: Close monitoring (some centers treat)
Stages II-IV: Fetoscopic laser photocoagulation (FLP) of placental anastomoses - treatment of choice before 26 weeks
Amnioreduction: alternative/adjunct, palliative
Selective feticide: if one twin anomalous or after single fetal demise risk assessment

5. MEDICAL DISORDERS IN PREGNANCY

5.1 Hypertension Classification in Pregnancy

Type	Definition	Notes
Chronic hypertension	BP ≥140/90 before 20 wks or pre-existing
Gestational hypertension	New BP ≥140/90 after 20 weeks, no proteinuria, resolves by 12 wks postpartum
Preeclampsia	Gestational HTN + proteinuria (>300 mg/24h or PCR >0.3 or dipstick 2+) OR end-organ damage (without proteinuria)	After 20 wks
Superimposed preeclampsia	Chronic HTN + new proteinuria or worsening features
Eclampsia	Preeclampsia + seizures (not attributable to other causes)

5.2 Preeclampsia & Eclampsia Management

Preeclampsia Features of Severity (any one = severe):

SBP ≥160 or DBP ≥110 (on two readings 4h apart)
Thrombocytopenia <100,000
Renal insufficiency (creatinine >1.1 mg/dL or doubling)
Impaired liver function (transaminases 2x normal) or RUQ/epigastric pain
Pulmonary edema
New-onset headache not responsive to medication / visual disturbances

Management:

Scenario	Management
Preeclampsia without severe features at <37 wks	Outpatient monitoring; antihypertensives if BP ≥160/110; deliver at 37 weeks
Preeclampsia with severe features at <34 wks	Hospitalize; MgSO₄ for seizure prophylaxis; antihypertensives; corticosteroids (if <34 wks); deliver at 34 weeks
Preeclampsia with severe features at ≥34 wks	Stabilize and deliver
Eclampsia (seizures)	MgSO₄ + airway protection + antihypertensives + delivery after stabilization

Antihypertensives in Pregnancy:

Drug	Route	Notes
Labetalol	IV/PO	First-line acute; avoid in asthma
Hydralazine	IV	Classic IV agent; can cause maternal hypotension
Nifedipine	PO	First-line oral; do NOT give sublingual
Methyldopa	PO	Chronic hypertension in pregnancy (safe, oldest)
Magnesium sulfate	IV	Seizure prophylaxis/treatment (NOT antihypertensive)

MgSO₄ Protocol:

Loading: 4-6 g IV over 15-20 min
Maintenance: 1-2 g/hr infusion
Monitor: Urine output (>25 mL/hr), respirations (>12/min), patellar reflexes (present)
Toxicity signs: Loss of reflexes (first) → respiratory depression → cardiac arrest
Antidote: Calcium gluconate 1 g IV

5.3 HELLP Syndrome

Definition: Severe variant of preeclampsia - Hemolysis, Elevated Liver enzymes, Low Platelets

Diagnostic Criteria:

Parameter	Criterion
Hemolysis	Abnormal peripheral smear (schistocytes), LDH >600 U/L, bilirubin >1.2 mg/dL
Elevated liver enzymes	AST/ALT >70 U/L
Low platelets	<100,000/µL

Tennessee Classification:

Class I: Platelets <50,000
Class II: Platelets 50,000-100,000
Class III: Platelets 100,000-150,000

Mississippi Classification (Martin):

Class 1: Platelets <50,000 + LDH ≥600 + AST/ALT ≥40
Class 2: Platelets 50,000-100,000
Class 3: Platelets 100,000-150,000

Management:

Delivery is definitive treatment (after stabilization)
MgSO₄ seizure prophylaxis
Corticosteroids (dexamethasone) may improve lab parameters
If platelets <20,000 or active bleeding → platelet transfusion
If DIC develops → FFP/cryo
Watch for subcapsular hepatic hematoma (RUQ pain → CT liver)

5.4 Diabetes in Pregnancy

Classification:

Type	Definition
Pre-gestational DM	DM diagnosed before pregnancy (T1DM or T2DM)
Gestational DM (GDM)	Glucose intolerance first diagnosed in pregnancy

GDM Screening (24-28 weeks):

Two-step approach:

1-hr GCT (50g): Positive if ≥130-140 mg/dL → proceed to 3-hr OGTT
3-hr OGTT (100g): GDM if ≥2 values meet/exceed:

Time	Carpenter-Coustan	NDDG
Fasting	≥95 mg/dL	≥105 mg/dL
1 hour	≥180 mg/dL	≥190 mg/dL
2 hours	≥155 mg/dL	≥165 mg/dL
3 hours	≥140 mg/dL	≥145 mg/dL

One-step approach (IADPSG): 2-hr 75g OGTT - GDM if any value ≥:

Fasting: 92 mg/dL; 1-hr: 180 mg/dL; 2-hr: 153 mg/dL

Fetal Complications:

Macrosomia (most common), shoulder dystocia, birth injuries
Neonatal hypoglycemia, hypocalcemia, polycythemia, hyperbilirubinemia
RDS (delayed lung maturity)
Stillbirth (poorly controlled)
Congenital anomalies (only in pre-gestational DM - organogenesis in 1st trimester): cardiac (VSD, TGA), NTDs (caudal regression syndrome - pathognomonic for maternal DM)

Management:

Diet + exercise first (medical nutrition therapy)
Insulin (drug of choice if pharmacologic needed); Metformin/glyburide: acceptable alternatives in GDM
Target glucose: Fasting <95, 1-hr postprandial <140, 2-hr postprandial <120 mg/dL
Delivery timing: GDM controlled on diet → 40-41 wks; on medication → 39-40 wks; Pre-gestational DM → 39 wks

White Classification (Pre-gestational DM):

Class	Criteria
A1	GDM, diet-controlled
A2	GDM, medication-required
B	Onset ≥20 yrs, duration <10 yrs, no vascular disease
C	Onset 10-19 yrs or duration 10-19 yrs
D	Onset <10 yrs or duration ≥20 yrs or benign retinopathy
F	Nephropathy
R	Proliferative retinopathy
T	Post-renal transplant
H	Ischemic heart disease

6. LABOR & DELIVERY

6.1 Modified Bishop Score

Used to assess cervical favorability for induction of labor. Score ≥8 = favorable (predict successful induction like spontaneous labor).

Parameter	0	1	2	3
Dilation (cm)	Closed	1-2	3-4	≥5
Effacement (%)	0-30	40-50	60-70	≥80
Station	-3	-2	-1/0	+1/+2
Consistency	Firm	Medium	Soft	-
Position	Posterior	Mid	Anterior	-

Total max = 13. Score ≥8 → favorable; Score <6 → cervical ripening needed (prostaglandins/mechanical methods)

Memory: DECSP - Dilation, Effacement, Consistency, Station, Position

6.2 Active Management of Third Stage of Labor

Third stage: from delivery of baby to delivery of placenta (normally <30 min)

AMTSL components (WHO recommended):

Uterotonic within 1 minute of birth - Oxytocin 10 IU IM (drug of choice); alternatives: ergometrine, misoprostol, carbetocin
Controlled cord traction (CCT) - Brandt-Andrews method (uterine stabilization + gentle traction during contraction)
Uterine massage after placenta delivery (controversial - some guidelines omit)

Normal blood loss: <500 mL vaginal delivery; <1000 mL cesarean

6.3 Breech Presentation - Management

Types of breech:

Frank breech (65%): Hips flexed, knees extended (pike position)
Complete breech (10%): Hips + knees flexed (lotus position)
Footling/Incomplete (25%): One or both feet presenting

External Cephalic Version (ECV):

Attempt at 36-37 weeks
Tocolysis (terbutaline) used
Success rate: ~50-60%
Contraindications: PPROM, placenta previa, fetal compromise, multiple pregnancy, uterine scar (relative)

Mode of delivery:

Planned cesarean preferred for singleton breech at term (Term Breech Trial)
Vaginal breech delivery: only at experienced centers - Frank or complete breech, adequate pelvis, flexed fetal head, EFW 2500-4000g, no contraindications

6.4 Lovset Maneuver & Burns Marshall Maneuver

Lovset Maneuver (for delivery of arms in breech):

Used when arms are extended/nuchal.

Hold baby's pelvis (thumbs on sacrum)
Rotate baby 180° (back remains anterior) while applying downward traction
The arm that was posterior (under pubic arch) rotates to anterior and can be swept down
Repeat rotation in opposite direction for second arm

Burns Marshall Maneuver (for aftercoming head in breech):

Used for delivery of the head after trunk is delivered.

After trunk delivery, allow baby to hang by its own weight (1-2 minutes) to increase flexion of head
Grasp baby's ankles with both hands
Swing the trunk upward in a wide arc toward maternal abdomen
The chin, face, brow, vertex deliver over perineum
Suboccipital region is fulcrum on perineum - pivot point is critical

Alternative: Mauriceau-Smellie-Veit maneuver (MSV) for flexion of aftercoming head - finger in mouth + 2 fingers on occiput, traction while assistant applies suprapubic pressure

6.5 Shoulder Dystocia - HELPERR Algorithm

Definition: Failure of fetal shoulders to deliver after delivery of the head; anterior shoulder impacted behind symphysis pubis.

Risk factors: Macrosomia, maternal DM/obesity, prolonged 2nd stage, operative vaginal delivery, prior shoulder dystocia.

Recognition: Turtle sign (head retracts after delivery), failed gentle downward traction.

HELPERR Mnemonic:

Letter	Action	Details
H	Help	Call for help immediately (senior OB, anesthesia, NICU, extra nurses)
E	Evaluate for Episiotomy	Gives more room for maneuvers (doesn't directly resolve bony dystocia)
L	Legs (McRoberts)	Hyperflexion of maternal thighs against abdomen → flattens lumbar lordosis → rotates pubic symphysis superiorly → frees anterior shoulder
P	Pressure (Suprapubic)	Assistant applies suprapubic pressure (NOT fundal) in downward/lateral direction to dislodge anterior shoulder
E	Enter (internal rotational maneuvers)	Rubin II: Push anterior shoulder toward fetal chest (adduction); Woods screw: Push posterior shoulder toward back; Reverse Woods (Rubin II + Woods simultaneously)
R	Remove posterior arm	Sweep posterior arm across chest and deliver → reduces shoulder-to-shoulder diameter
R	Roll (Gaskin maneuver)	All-fours position → gravity shifts anterior shoulder

Last resort: Zavanelli maneuver (head replacement → CS), deliberate clavicle fracture, symphysiotomy

⚠️ Do NOT apply fundal pressure (worsens impaction)

6.6 Postpartum Hemorrhage - EMOTIVE Protocol

Definition: Blood loss >500 mL (vaginal) or >1000 mL (CS) within 24 hours; or any amount causing hemodynamic instability.

Primary PPH: <24 hours postpartum | Secondary PPH: 24 hrs - 12 weeks

4 T's Causes:

Tone (uterine atony) - 80% most common
Trauma (lacerations, uterine rupture, hematomas)
Tissue (retained placenta/membranes, placenta accreta)
Thrombin (coagulopathy, DIC, APLA)

EMOTIVE Protocol (Active Management of PPH):

Letter	Action
E	Examine (assess cause - 4 T's), Estimate blood loss
M	Massage uterus (bimanual compression); give Misoprostol 1000 mcg PR/SL if oxytocin unavailable
O	Oxytocin IV (10-40 IU in 500 mL NS); IV access x2, send bloods (CBC, coag, X-match)
T	Transfuse (blood products: pRBC, FFP 1:1 ratio, platelets, cryoprecipitate); also Tamponade (Bakri balloon)
I	Interventional radiology (uterine artery embolization - UAE)
V	Vasopressors (if hemodynamic compromise); Ventilate if needed
E	Evaluate for surgery: B-Lynch suture, uterine artery ligation (O'Leary), internal iliac ligation, hysterectomy (definitive)

Uterotonics Stepwise:

Drug	Dose	Notes
Oxytocin	10 IU IM or IV infusion	First-line
Ergometrine	0.2 mg IM/IV	Avoid in hypertension
Oxytocin + ergometrine (Syntometrine)	IM	Combined
Misoprostol	800-1000 mcg PR/SL	When oxytocin unavailable; low-resource settings
Carboprost (PGF2α)	250 mcg IM q15-90 min (max 8 doses)	Avoid in asthma
Tranexamic acid	1 g IV (within 3 hours)	Anti-fibrinolytic; reduces death from bleeding

PART 2: GYNECOLOGY

7. MENSTRUAL DISORDERS

7.1 Mullerian Anomalies (ASRM/AFS Classification)

Class	Type	Description	Associated Conditions
I	Hypoplasia/Agenesis	Uterine/vaginal agenesis; includes Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome	Primary amenorrhea, 46,XX, normal ovaries
II	Unicornuate	One horn develops; rudimentary horn may be communicating or non-communicating	Renal anomalies (50%), ectopic pregnancy risk
III	Didelphys	Complete duplication: 2 uteri, 2 cervices, 2 vaginas (or single vagina)	Best reproductive outcomes of fusion defects
IV	Bicornuate	Partial fusion failure; 2 horns, 1 cervix; arcuate = minor form	Recurrent pregnancy loss, preterm birth
V	Septate	Most common Mullerian anomaly; complete septum (to os) or partial	Highest recurrent miscarriage rate; resectable (hysteroscopic metroplasty)
VI	Arcuate	Minimal indentation of fundus; often considered normal variant	Minimal clinical significance
VII	DES-related	T-shaped uterus	Associated with DES exposure in utero

Memory: Septate = most common + most abortions (septum has poor blood supply)

7.2 Primary vs. Secondary Amenorrhea

Primary Amenorrhea (no menses by age 15 with secondary sexual characteristics, or age 13 without any):

Condition	FSH	Karyotype	Key Features
Gonadal dysgenesis (Turner 45,X)	↑↑	45,X	Short stature, webbed neck, shield chest, coarctation of aorta; streak gonads
MRKH syndrome	Normal	46,XX	Absent uterus/vagina; normal breasts; normal ovaries
Androgen Insensitivity Syndrome (AIS) - Complete	Normal/↑	46,XY	Female phenotype, absent uterus/cervix, blind vagina, testes in labia/inguinal; ↑ LH, testosterone in male range
Constitutional delay	Normal	46,XX	Bone age delayed; family history
Imperforate hymen / Transverse vaginal septum	Normal	46,XX	Cyclic pelvic pain, hematocolpos → bluish bulging at introitus
Hypothalamic/pituitary causes	↓	46,XX	Kallmann syndrome (+ anosmia), prolactinoma

Secondary Amenorrhea (cessation of previously regular menses for >3 months or irregular menses for >6 months):

First test: Pregnancy test (rule out pregnancy)

Cause	FSH/LH	Estrogen	Key Features/Diagnosis
Hypothalamic amenorrhea	↓/normal	↓	Weight loss, exercise, stress; FHA; GnRH pulsatility disrupted
Hyperprolactinemia	↓	↓	Galactorrhea; elevated prolactin; MRI pituitary (prolactinoma)
Hypothyroidism	-	-	TSH elevated; TRH stimulates prolactin
PCOS	LH:FSH >2:1	Normal/↓	Oligomenorrhea, hyperandrogenism, polycystic ovaries
POI/POF (Premature Ovarian Insufficiency)	↑↑	↓	Age <40; FSH >25-40 IU/L on 2 occasions; may be autoimmune
Asherman's syndrome	Normal	Normal	Post-curettage intrauterine adhesions; hysteroscopy diagnostic + therapeutic
Sheehan's syndrome	↓	↓	Pituitary necrosis after PPH; failure to lactate, loss of pubic hair

Workup algorithm: Pregnancy test → Prolactin + TSH → FSH/LH → Progestogen challenge test (withdrawal bleed = estrogen present, intact outflow) → Estrogen + progestogen challenge (no bleed = outflow obstruction/Asherman's)

7.3 Abnormal Uterine Bleeding - FIGO Classification (PALM-COEIN)

Category	Acronym	Notes
P	Polyp	Endometrial or cervical polyp
A	Adenomyosis	Ectopic glands within myometrium
L	Leiomyoma	Submucosal (most symptomatic), intramural, subserosal
M	Malignancy / hyperplasia	Endometrial carcinoma, atypical hyperplasia
C	Coagulopathy	Von Willebrand disease (most common), platelet disorders
O	Ovulatory dysfunction	PCOS, thyroid, hyperprolactinemia, perimenopause
E	Endometrial	Primary endometrial disorder (PALM-COEIN E)
I	Iatrogenic	Anticoagulants, hormonal contraception, tamoxifen
N	Not yet classified	Arteriovenous malformations, myometrial hypertrophy

PALM = structural causes (detected on imaging/histology); COEIN = non-structural causes

Terminology:

Heavy menstrual bleeding (HMB): >80 mL per cycle
Intermenstrual bleeding (IMB)
Postmenopausal bleeding (PMB): Any bleeding >12 months after LMP → endometrial biopsy mandatory

8. UTERINE CONDITIONS

8.1 Adenomyosis

Feature	Details
Definition	Ectopic endometrial glands and stroma within myometrium
Pathology	"Junctional zone" thickening >12 mm on MRI; heterogeneous myometrium on USG
Typical patient	Multiparous woman, 35-50 years (perimenopausal); often with endometriosis
Symptoms	Dysmenorrhea (progressive), menorrhagia, dyspareunia, tender globular uterus ("boggy")
Diagnosis	MRI (gold standard) - junctional zone thickness; USG - heterogeneous myometrium, asymmetric thickening
Treatment	Hormonal (LNG-IUS/Mirena, OCP, progestogens, GnRH analogues); Definitive: hysterectomy (only cure)

8.2 Uterine Fibroids (Leiomyomata)

Feature	Details
Definition	Benign smooth muscle tumors (monoclonal); most common benign gynecologic tumor
Hormone-dependence	Estrogen and progesterone dependent; shrink postmenopausally
Types	Submucosal (→ AUB, most symptomatic), Intramural (→ bulk symptoms), Subserosal (→ pressure), Pedunculated, Cervical, Broad ligament
Symptoms	Menorrhagia (most common), dysmenorrhea, bulk symptoms (urinary frequency, constipation), infertility (submucosal)
Degeneration types	Red (carneous - in pregnancy, most common), hyaline (most common overall), cystic, calcific, sarcomatous
Diagnosis	USG (hypoechoic, well-defined masses); MRI (best for mapping pre-myomectomy)

FIGO Leiomyoma Classification (Type 0-8):

0: Pedunculated intracavitary
1: <50% intramural
2: ≥50% intramural
3: Contacts endometrium; 100% intramural
4: Intramural
5: Subserosal ≥50% intramural
6: Subserosal <50% intramural
7: Subserosal pedunculated
8: Other (cervical, parasitic)

Management:

Option	Details
Medical	NSAIDs, tranexamic acid (bleeding); Progestogens, OCP; GnRH agonists (leuprolide) - shrink fibroids 30-50%, pre-op; Ulipristal acetate (SPRMs)
Surgical	Myomectomy (fertility-sparing; hysteroscopic for submucosal, laparoscopic/open for intramural); Hysterectomy (definitive)
Radiological	Uterine artery embolization (UAE) - not for women desiring pregnancy; MRI-guided focused ultrasound (MRgFUS)

8.3 Endometriosis - Management

Definition: Ectopic endometrial glands and stroma outside uterus (ovaries most common → endometrioma/"chocolate cyst", Douglas pouch, uterosacral ligaments, bowel, bladder).

Triad: Dysmenorrhea + Dyspareunia + Dyschezia (painful defecation)

Gold standard diagnosis: Laparoscopy with biopsy (powder burn/blue lesions, "chocolate cysts")

ASRM Staging (I-IV):

I (Minimal), II (Mild), III (Moderate), IV (Severe - extensive adhesions, bilateral endometriomas)

Management by Goal:

Goal	Treatment
Pain relief (no fertility desire)	NSAIDs; Combined OCP (first-line); Progestogens (norethisterone, DMPA, LNG-IUS); GnRH agonists + add-back therapy; Danazol (androgenic SE, less used)
Fertility	Surgical (laparoscopic excision/ablation of lesions, cystectomy for endometrioma); IVF (stage III-IV or tubal involvement)
Definitive (completed family)	Total hysterectomy + bilateral salpingo-oophorectomy (BSO); HRT may be needed post-op
Endometrioma	Laparoscopic cystectomy (preferred over drainage); cyst >4 cm should be operated before IVF

8.4 Endometrial Hyperplasia

Type	EIN Classification	Malignant Risk	Treatment
Without atypia	Non-EIN	~1-3%	Progestogen therapy (LNG-IUS preferred, or MPA 10-20 mg/day); repeat biopsy at 6 months
With atypia (EIN)	Endometrial Intraepithelial Neoplasia	~30-40% concurrent carcinoma; ~50% progress to carcinoma	Total hysterectomy + BSO (recommended if family complete); progestogen if fertility-sparing desired

Risk factors: Unopposed estrogen, obesity, PCOS, HRT (estrogen-only), tamoxifen, nulliparity, late menopause.

9. HIGH-YIELD GYNECOLOGY CLINICALS

9.1 Vaginal Infections

Feature	Bacterial Vaginosis	Candidal Vaginitis	Trichomoniasis
Organism	Gardnerella vaginalis (+ anaerobes)	Candida albicans (90%)	Trichomonas vaginalis (STI)
pH	>4.5 (alkaline)	<4.5 (normal/acidic)	>4.5 (alkaline)
Discharge	Thin, gray-white, homogenous, fishy odor	Thick, white, cottage cheese, no odor	Frothy, yellow-green, malodorous
Symptoms	Odor (worse after intercourse/menstruation); minimal itching	Pruritus vulvae, burning, dysuria	Dysuria, pruritus, dyspareunia
Whiff test	Positive (10% KOH → fishy amine odor)	Negative	May be positive
Microscopy	Clue cells (epithelial cells coated with bacteria)	Pseudohyphae/budding yeast	Motile flagellated protozoa; strawberry cervix
Amsel criteria (3/4 = BV)	pH >4.5, thin discharge, clue cells >20%, positive whiff test
Treatment	Metronidazole 500 mg PO BD x7d or 0.75% gel; Clindamycin	Clotrimazole (topical) or Fluconazole 150 mg PO single dose	Metronidazole 2g PO single dose; treat partners

9.2 Ovarian Cysts & Tumors

Functional Cysts:

Follicular cyst: Most common; failure of follicle to rupture; resolves spontaneously in 4-8 weeks; <8 cm
Corpus luteum cyst: After ovulation; may hemorrhage (can mimic ectopic)
Theca lutein cysts: Bilateral; associated with molar pregnancy/high hCG; multiple large cysts

Ovarian Tumor Classification:

Origin	Benign	Malignant
Epithelial (70%)	Serous cystadenoma (most common benign), Mucinous cystadenoma	Serous cystadenocarcinoma (most common malignant), Mucinous, Endometrioid, Clear cell
Germ cell (20-25%)	Mature teratoma/Dermoid (most common in young women; contains hair/teeth/fat; ↑ torsion risk)	Dysgerminoma (most common malignant germ cell), Yolk sac tumor (AFP↑), Choriocarcinoma (βhCG↑), Immature teratoma
Sex cord-stromal (5%)	Fibroma (Meigs' syndrome: fibroma + ascites + pleural effusion), Thecoma	Granulosa cell tumor (estrogen-secreting → endometrial hyperplasia/cancer; Call-Exner bodies), Sertoli-Leydig (androgen-secreting → virilization)

Tumor Markers:

Marker	Associated Tumor
CA-125	Epithelial ovarian cancer (serous); also elevated in endometriosis, PID, fibroids
AFP	Yolk sac tumor, immature teratoma
β-hCG	Choriocarcinoma, dysgerminoma (occasionally)
LDH	Dysgerminoma
Inhibin	Granulosa cell tumor, mucinous tumors
CEA	Mucinous tumors
CA-19.9	Mucinous tumors

IOTA Criteria / ADNEX model: Used on USG to assess malignancy risk; ROMA score (CA-125 + HE4) for ovarian cancer risk.

9.3 Cervical Cancer - Screening & Diagnosis

Cervical Screening Guidelines:

Age	Screening Recommendation
<21 years	No screening regardless of sexual history
21-29 years	Pap smear every 3 years (cytology alone)
30-65 years	Pap + HPV co-test every 5 years (preferred) OR Pap alone every 3 years OR HPV alone every 5 years
>65 years	Discontinue if adequate negative prior screening (3 consecutive negative Paps or 2 consecutive negative co-tests in past 10 years)
After hysterectomy (benign)	Discontinue

Cervical Cytology (Bethesda System):

Result	Management
NILM (Negative for intraepithelial lesion)	Routine screening
ASC-US (Atypical squamous cells of undetermined significance)	Reflex HPV testing; colposcopy if HPV+; repeat in 1 year if HPV-
ASC-H (Cannot exclude HSIL)	Colposcopy
LSIL (Low-grade squamous intraepithelial lesion)	Colposcopy (women ≥25)
HSIL (High-grade squamous intraepithelial lesion)	Colposcopy + biopsy; consider LEEP
AGC (Atypical glandular cells)	Colposcopy + endocervical curettage + endometrial biopsy (if >35 yrs)
Carcinoma	Colposcopy + biopsy → staging

Cervical Intraepithelial Neoplasia (CIN) Management:

CIN Grade	Definition	Management
CIN 1	Mild dysplasia (1/3 epithelium)	Observe; repeat in 1 year
CIN 2	Moderate dysplasia (2/3 epithelium)	Treat (LEEP/CKC) or observe (young women, small lesion)
CIN 3	Severe dysplasia / CIS (full thickness)	LEEP (Loop Electrosurgical Excision Procedure) or Cold Knife Cone biopsy

Cervical Cancer Staging (FIGO 2018):

Stage	Description
I	Confined to cervix
IA	Microscopic invasion only
IA1	Stromal invasion ≤3 mm
IA2	Stromal invasion >3-5 mm
IB	Visible lesion or >5 mm invasion, confined to cervix
II	Beyond cervix but not pelvic wall or lower 1/3 vagina
IIA	Upper 2/3 vagina involved, no parametria
IIB	Parametrial invasion
III	Pelvic wall / lower 1/3 vagina / hydronephrosis
IV	Bladder/rectum (IVA) or distant mets (IVB)

9.4 HPV Vaccination

Vaccine	Types Covered	Schedule	Target
Gardasil 9 (9-valent)	HPV 6, 11, 16, 18, 31, 33, 45, 52, 58	9-14 yrs: 2-dose (0, 6-12 months); ≥15 yrs: 3-dose (0, 2, 6 months)	Most widely used; prevents ~90% of cervical cancers
Gardasil 4 (4-valent)	HPV 6, 11, 16, 18	2 or 3 dose
Cervarix (2-valent)	HPV 16, 18	3-dose

HPV 16 & 18 → Cervical cancer (70%), oropharyngeal cancer, anal cancer HPV 6 & 11 → Genital warts (condylomata acuminata), recurrent respiratory papillomatosis

WHO recommendation: Primary target: girls 9-14 years (before sexual debut); Catch-up: up to age 26 routinely; 27-45: shared decision-making.

Contraindications: Severe allergy to yeast or vaccine components; pregnancy (defer, not harmful if given inadvertently).

9.5 PCOS (Polycystic Ovary Syndrome)

Diagnosis - Rotterdam Criteria (2 of 3):

Oligo-/anovulation (irregular cycles or anovulatory cycles)
Clinical or biochemical hyperandrogenism (hirsutism by Ferriman-Gallwey >8, acne, alopecia; or elevated testosterone/DHEAS)
Polycystic ovaries on USG (≥20 follicles 2-9 mm per ovary or ovarian volume >10 mL, in absence of dominant follicle/CL)

Must exclude other causes: congenital adrenal hyperplasia (17-OHP), Cushing's, androgen-secreting tumor, thyroid disease, hyperprolactinemia.

Hormonal Profile:

LH:FSH ratio >2:1 (or 3:1)
Elevated LH, normal/low FSH
Elevated androgens (testosterone, DHEAS, androstenedione)
Low SHBG (elevated free androgen index)
AMH elevated
Insulin resistance (elevated fasting insulin)

Associations:

Metabolic syndrome, T2DM (6-7x risk)
Endometrial hyperplasia/cancer (chronic anovulation → unopposed estrogen)
Subfertility
Obstructive sleep apnea
Cardiovascular disease risk

Management:

Goal	Treatment
Lifestyle	Weight loss (5-10% body weight → restores cycles in up to 80%); exercise
Menstrual regulation	Combined OCP (first-line: suppresses LH, increases SHBG, treats hyperandrogenism); Cyclic progestogens (to prevent endometrial hyperplasia)
Hyperandrogenism	OCP; Anti-androgens: Spironolactone (100-200 mg/day), cyproterone acetate; Metformin
Fertility/ovulation induction	Letrozole (aromatase inhibitor - first-line per ASRM); Clomiphene citrate (anti-estrogen, traditionally used); Metformin (adjunct); Gonadotrophins; Laparoscopic ovarian drilling (LOD)
Insulin resistance/Metabolic	Metformin (reduces insulin resistance, improves cycles, reduces GDM/miscarriage risk in pregnancy)

9.6 Contraception

Efficacy Classification (Pearl Index - pregnancies per 100 woman-years):

Method	Typical Use Failure	Perfect Use Failure	Notes
No method	85%	85%
Condom (male)	13%	2%	Also STI protection
Combined OCP	7%	0.3%
Progestogen-only pill (POP)	7-9%	0.3%
DMPA (Depo-Provera)	4%	0.2%	Injection every 3 months
Implant (Nexplanon)	0.05%	0.05%	Most effective reversible
LNG-IUD (Mirena)	0.1-0.2%	0.1%	5-7 years; also treats HMB
Copper IUD	0.8%	0.6%	Non-hormonal; also emergency contraception
Female sterilization	0.5%	0.5%	Permanent
Vasectomy	0.15%	0.1%
Emergency contraception (LNG - Plan B)	-	75-89% reduction in pregnancy risk if taken <72h

Combined OCP:

Contains: Estrogen (ethinyl estradiol) + progestogen
Mechanism: Inhibit ovulation (primary), thicken cervical mucus, thin endometrium
Benefits: Regular cycles, reduced dysmenorrhea, improved acne/hirsutism, reduced endometrial/ovarian cancer risk, improved endometriosis/fibroids
Contraindications (UKMEC 4 - absolute): Known/suspected pregnancy, undiagnosed vaginal bleeding, current DVT/PE, migraine with aura, >35 yrs + smoking >15/day, current breast cancer, active hepatitis/cirrhosis, hypertriglyceridemia, peripartum cardiomyopathy

Progestogen-Only (Mini-Pill):

Safe in: Breastfeeding (preferred; start after 6 weeks), smokers >35 yrs, migraine with aura, history of DVT/PE
Mechanism: Primarily thickens cervical mucus; inhibits ovulation at higher doses (desogestrel POP - Cerazette)
Key point: Must be taken within 3-hour window daily (12-hour window for desogestrel)

Intrauterine Devices:

Feature	Copper IUD	LNG-IUD (Mirena)
Duration	5-10 years (Cu-380A up to 10 yrs; also emergency contraception up to 5 days post-coitus)	5-7 years
Mechanism	Copper toxic to sperm + prevents fertilization	Thickens mucus, thins endometrium, partial ovulation suppression
Effect on periods	Heavier, more painful	Lighter or absent (amenorrhea in 20% by 1 yr) - treats HMB
Best for	Non-hormonal option; heavy period contraindication	Women with HMB; fibroids; endometriosis; breastfeeding

Emergency Contraception:

Method	Timing	Efficacy
Levonorgestrel (Plan B, 1.5 mg PO)	Within 72 hours (up to 120h)	75-89% effective
Ulipristal acetate (Ella, 30 mg PO)	Within 120 hours	Slightly superior to LNG; affected by progestogens
Copper IUD	Within 5 days	>99% effective (most effective EC)

🔑 HIGH-YIELD SUMMARY TABLE

Key Numbers to Remember

Topic	Key Value
Folic acid (normal)	400 mcg/day, start 1 month before conception
Folic acid (high-risk)	5 mg/day
GDM screening	24-28 weeks (1-hr GCT)
GBS culture	35-37 weeks
Tdap	27-36 weeks every pregnancy
Discriminatory zone (hCG)	1500-2000 IU/L → IUP visible on TVS
MTX criteria (hCG)	<5000 IU/L (single dose)
Preeclampsia seizure prophylaxis	MgSO₄ 4-6g loading, 1-2g/hr maintenance
Bishop score (favorable)	≥8
PPH definition	>500 mL vaginal, >1000 mL CS
PPH most common cause	Uterine atony (80%)
Most common Mullerian anomaly	Septate uterus
Complete mole karyotype	46,XX (androgenetic)
Partial mole karyotype	69,XXX or 69,XXY
TTTS treatment of choice	Fetoscopic laser photocoagulation
Cervical cancer screening start age	21 years
CIN 3 treatment	LEEP
PCOS Rotterdam criteria	2 of 3
Most common ovarian tumor (young women)	Mature cystic teratoma (dermoid)
Most common malignant ovarian tumor	Serous cystadenocarcinoma
Most common benign uterine tumor	Fibroid (leiomyoma)
Dysgerminoma marker	LDH
Granulosa cell tumor marker	Inhibin
BV treatment	Metronidazole 500 mg BD x7 days
Trichomoniasis treatment	Metronidazole 2g single dose (treat partner)
Candida treatment	Fluconazole 150 mg single dose

🧠 Quick Mnemonics

Topic	Mnemonic
Shoulder dystocia	HELPERR (Help, Episiotomy, Legs McRoberts, Pressure suprapubic, Enter internal maneuvers, Remove posterior arm, Roll all-fours)
PPH causes	4 T's - Tone, Trauma, Tissue, Thrombin
Bishop score	DECSP - Dilation, Effacement, Consistency, Station, Position
AUB classification	PALM-COEIN (structural vs non-structural)
First trimester combined screen markers	NT + PAPP-A + free β-hCG
Quad screen for T21	↓AFP, ↑hCG, ↓uE3, ↑Inhibin A
Ectopic risk factors	SHIP - Sterilization/Salpingitis, History of ectopic, IUD/Infertility, Prior PID/procedure
Leopold maneuvers	FSPE - Fundal, Sides, Presentation, Engagement
TORCH infections	Toxoplasma, Other (syphilis/VZV), Rubella, CMV, HSV/HIV

Sources: Rosen's Emergency Medicine (Ectopic Pregnancy, Hypertension in Pregnancy sections); Creasy & Resnik's Maternal-Fetal Medicine; Berek & Novak's Gynecology; WHO, ACOG, FIGO, RCOG clinical guidelines.Here's your complete OBGYN revision guide - all topics covered with structured tables. Here's a quick orientation:

What's Covered

OBSTETRICS (Sections 1-6)

Section 1 - Early Pregnancy: All three categories of pregnancy signs (presumptive/probable/positive), preconception folic acid dosing and vaccination timing, GTPAL parity index, full teratogen table with defects, trimester-wise screening (quad screen patterns, diagnostic vs screening tests), Leopold maneuvers with what each determines
Section 2 - High-Yield Conditions: All four cerclage types with indications, APLA Sapporo diagnostic criteria + LMWH/aspirin management, ectopic pregnancy management tiers (expectant/medical/surgical with exact criteria and MTX contraindications), complete vs partial mole comparison table including p57 staining and malignancy rates
Section 3 - Placenta & Fluid: Previa vs abruption side-by-side, PAS spectrum with CS risk percentages, polyhydramnios/oligohydramnios causes and management, placental variants (succenturiata, velamentous, battledore, etc.)
Section 4 - Multiple Pregnancy: Lambda vs T sign for chorionicity, Quintero staging for TTTS, fetoscopic laser as treatment of choice
Section 5 - Medical Disorders: HTN classification, MgSO₄ protocol with toxicity monitoring, HELLP criteria (Tennessee + Mississippi classification), GDM two-step/one-step screening with cut-off values, White classification, fetal complications
Section 6 - Labor & Delivery: Full Modified Bishop Score table (DECSP), AMTSL components, breech types + ECV details, Lovset + Burns Marshall step-by-step, HELPERR algorithm with what each step does, EMOTIVE protocol with uterotonic ladder

GYNECOLOGY (Sections 7-9)

Section 7 - Menstrual Disorders: ASRM Mullerian classification I-VII with reproductive impact, primary vs secondary amenorrhea FSH-based workup algorithm, PALM-COEIN table
Section 8 - Uterine Conditions: Adenomyosis (MRI junctional zone criterion), fibroid FIGO 0-8 classification + degeneration types, endometriosis stepwise management by goal, endometrial hyperplasia risk stratification and treatment
Section 9 - GYN Clinicals: BV/Candida/Trichomoniasis comparison (pH/microscopy/treatment), ovarian tumor classification with tumor markers, cervical screening age-based guidelines + Bethesda CIN management, HPV vaccine schedules, PCOS Rotterdam criteria + Rotterdam management ladder, contraceptive Pearl Index + MEC4 contraindications + emergency contraception timing

The Key Numbers table and Mnemonics at the end serve as your last-day revision anchors. Let me know if you want any section expanded, a practice MCQ set, or a condensed one-page summary for any topic.

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