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Gyn & Obs Pre-Prof Viva — Group F Answers

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STUDENT 1

Common Ward Round Complaints (Gynaecology)

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Causes of Heavy Menstrual Bleeding (HMB)

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FIGO Classification

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FIGO Classification of Fibroids (Leiomyomas)

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Which Fibroids Cause HMB Most Commonly?

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Other Complaints of Submucosal Fibroids

• Infertility / recurrent miscarriage (distorted cavity, impairs implantation)
• Dysmenorrhoea (uterine cramping to expel fibroid)
• Irregular bleeding / intermenstrual bleeding
• If polyp-like: a Type 0 can prolapse through the cervix causing acute pain

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Surgical Options for Fibroids

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Favourable Fetal Position for Labour

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How to Assess Fetal Position

1. Leopold's manoeuvres (abdominal palpation)
   • 1st: fundal grip — identifies which pole is at fundus
   • 2nd: lateral grip — identifies back and limb side
   • 3rd: pelvic grip — confirms presenting part
   • 4th: Pawlik's grip — engagement
2. Vaginal examination (VE) — palpate the fontanelles and sagittal suture during labour
   • Anterior fontanelle (diamond-shaped) vs. posterior fontanelle (triangular)
   • Direction of occiput relative to maternal pelvis
3. Ultrasound — if clinical assessment uncertain

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Fetal Malpositions

• Occipito-Posterior (OP) — most common malposition
• Occipito-Transverse (OT) — deep transverse arrest
• Face presentation — mento-anterior favourable, mento-posterior unfavourable
• Brow presentation — largest diameter, almost always requires C-section
• Compound presentation (e.g., hand alongside head)

Malpresentations (distinct from malpositions): Breech, Transverse/oblique lie, Shoulder presentation

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Complications of Fetal Malpositions

• Prolonged labour / failure to progress
• Maternal exhaustion
• Obstructed labour
• Increased operative delivery rate (instrumental delivery, C-section)
• Perineal trauma (larger diameters)
• Fetal distress / birth asphyxia
• Uterine rupture (especially with obstructed labour)
• PPH

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STUDENT 2

What is "Position" in Labour?

• In vertex presentation, the denominator is the occiput
• Positions described relative to: Left/Right, Anterior/Posterior/Transverse of maternal pelvis

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What Does Left Occipito-Posterior (LOP) Mean?

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OA vs OP — Which is Preferred?

• The suboccipitobregmatic diameter (~9.5 cm) presents — smallest diameter
• Internal rotation occurs naturally to OA
• Labour is shorter, less painful, fewer complications
• OP position → larger occipitofrontal diameter (~11.5 cm) presents → prolonged labour, more perineal tears, higher operative delivery rate

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What is Station?

• 0 station = at the level of ischial spines
• +1, +2, +3 = 1, 2, 3 cm below ischial spines (advancing)
• -1, -2, -3 = 1, 2, 3 cm above ischial spines (high)
• Engagement = station ≤ 0 (leading bony point at or below spines)

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Mechanism of Labour (for vertex presentation)

1. Engagement — head enters pelvis, usually in transverse diameter
2. Descent — throughout labour
3. Flexion — chin on chest → suboccipitobregmatic diameter presents
4. Internal rotation — occiput rotates anteriorly to OA (at pelvic floor)
5. Extension — head born by extension under symphysis pubis
6. Restitution — head realigns with shoulders (rotates back)
7. External rotation — shoulders rotate to AP diameter
8. Expulsion — anterior shoulder born first, then posterior, then trunk

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STUDENT 2 (Hunukumbura Sir)

Staging of Uterine Prolapse

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Which Part Comes First?

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How to Identify Prolapse in History

• Something coming down per vaginum (lump/bulge sensation)
• Worse on prolonged standing, coughing, straining
• Relieved by lying down
• Dragging or bearing-down sensation in the pelvis
• Urinary symptoms: frequency, urgency, incontinence (stress), voiding difficulty
• Bowel symptoms: constipation, incomplete emptying, need to digitally reduce prolapse to defecate
• Sexual dysfunction, dyspareunia

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Differentiating Grade 2 vs Grade 3 on Examination

• Grade 2: Prolapse descends to the introitus — visible at the vaginal opening when patient strains (Valsalva manoeuvre)
• Grade 3: Prolapse descends beyond the introitus — visible outside the vaginal opening even at rest or with minimal straining

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Bivalve Speculum for Prolapse?

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Risk Factors for Prolapse

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How Does Elderly Age Cause Prolapse?

• Progressive weakening of pelvic floor muscles with age
• Reduced muscle mass and neuromuscular function
• Compounded by long-term oestrogen deficiency post-menopause
• Impaired tissue repair and collagen remodelling

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How Does Menopause Cause Prolapse?

• Collagen degradation
• Atrophy of vaginal epithelium and pelvic floor muscles
• Weakening of the Cardinal and uterosacral ligaments
• Reduced tensile strength of supportive structures

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STUDENT 3

Why is Menstrual History Important in Subfertility?

• Regular cycles (21–35 days) → likely ovulatory
• Oligomenorrhoea/amenorrhoea → anovulation (PCOS, hyperprolactinaemia, premature ovarian insufficiency, hypothalamic amenorrhoea)
• Heavy bleeding (HMB) → fibroids, adenomyosis, polyps — may impair implantation
• Dysmenorrhoea → endometriosis (a major cause of subfertility)
• Short luteal phase symptoms → luteal phase defect
• Helps time investigations (Day 2–3 FSH/LH/AMH, Day 21 progesterone)

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Causes of Dysmenorrhoea

• No identifiable pelvic pathology
• Excess prostaglandin (PGF2α) production → uterine hypercontractility and ischaemia
• Onset within 1–2 years of menarche; pain starts just before/at onset of menses

• Endometriosis (most common cause of secondary dysmenorrhoea)
• Adenomyosis
• Fibroids (especially submucous)
• Pelvic inflammatory disease (PID)
• Ovarian cysts (especially endometrioma)
• Cervical stenosis
• Uterine polyps
• IUD (intrauterine device)

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Do Fibroids Usually Present with Dysmenorrhoea?

• A submucosal fibroid acts like a foreign body and the uterus cramps to expel it
• Fibroids cause secondary dysmenorrhoea in the context of adenomyosis
• Red degeneration (acute) causes severe pain, though this is acute, not cyclical

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When Does Fibroid Torsion Occur?

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When Does Red Degeneration Occur?

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What is an Endometrial Cast?

• Primary dysmenorrhoea (excess prostaglandins)
• Deciduosis (ectopic pregnancy — decidual cast)
• Patients on progestogen therapy

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BP Measurement in Pregnant Women

• Patient seated (or left lateral if unable to sit) for ≥5 minutes before measurement
• Left lateral tilt if supine (to relieve aortocaval compression) — especially >20 weeks
• Use the right arm at the level of the heart
• Appropriate cuff size
• Use Korotkoff phase V (disappearance of sound) for diastolic

• Use a large adult cuff (cuff bladder should encircle ≥80% of arm circumference)
• Wrong (small) cuff → falsely high readings
• Consider using forearm or thigh if upper arm too large

1. Seat patient, rest arm at heart level
2. Apply cuff 2–3 cm above antecubital fossa
3. Palpate radial pulse, inflate to ~30 mmHg above when pulse disappears (palpatory SBP estimate)
4. Deflate, wait 15–30 sec
5. Place stethoscope over brachial artery
6. Re-inflate 30 mmHg above estimated SBP
7. Deflate at 2–3 mmHg/second
8. Korotkoff I (first sound) = systolic
9. Korotkoff V (disappearance) = diastolic (in pregnancy, use Korotkoff V)

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STUDENT 4

Antepartum Haemorrhage (APH)

• Placenta praevia (low-lying placenta)
• Placental abruption (retroplacental haematoma)
• Vasa praevia (fetal vessels over os — rare, serious)
• Cervical causes (cervicitis, ectropion, polyp, carcinoma)
• "Unexplained" / show

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Preparation for Emergency LSCS (EM/LSCS)

1. IV access × 2, bloods (FBC, group & crossmatch, coagulation, renal/liver function)
2. Consent
3. Urinary catheter
4. Antacid (sodium citrate/ranitidine) to reduce aspiration risk
5. Anaesthesia assessment — spinal preferred, general if unstable
6. Thromboprophylaxis/TED stockings
7. Neonatal team on standby
8. WHO surgical safety checklist

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Condom Catheter in Placenta Praevia / PPH Prevention

• Inserted into the uterine cavity
• Inflated with saline (200–500 mL)
• Applies direct mechanical pressure to the bleeding placental bed
• Reduces bleeding by tamponade effect, allowing time for surgical intervention or transfer
• A form of uterine balloon tamponade (UBT)

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STUDENT 4 (Hunukumbura — COCP)

Contraceptive Methods

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COCP: Type of Contraceptive Method

1. Suppresses ovulation (inhibits LH surge — primary mechanism)
2. Thickens cervical mucus (impairs sperm penetration)
3. Thins endometrium (impairs implantation)

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Advice When Initiating COCP

• Take at the same time each day
• When to start: Day 1 of cycle (immediate protection), or any day (use extra precautions for 7 days if not Day 1–5)
• If vomiting within 2 hours of taking pill — take another pill
• Missed pill: See below
• Watch for danger signs: ACHES — Abdominal pain, Chest pain, Headache (severe), Eye problems, Severe leg pain
• Drug interactions (rifampicin, anticonvulsants reduce efficacy)
• Does not protect against STIs

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Missed Pill (COCP)

• Missed by <12 hours: Take immediately, continue as normal, no extra precaution needed
• Missed by >12 hours (>24 hours late):
  • Take missed pill immediately (even if means 2 at once)
  • Continue remaining pills
  • Use additional contraception (condoms) for 7 days
  • If missed in Week 1: emergency contraception if UPSI in previous 7 days
  • If missed in Week 3: skip pill-free interval and start new pack immediately

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COCP: Before or After Meal?

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Two Types of Tablets in COCP

1. Active pills (21 or 24 pills): Contain oestrogen + progestogen — prevent ovulation
2. Inactive/Placebo pills (7 or 4 pills): Contain no hormones (just filler/iron in some brands) — maintain the habit of daily pill-taking and allow withdrawal bleed

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Bleeding on COCP?

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When to Start COCP?

• Preferred: Day 1 of the cycle (immediate protection)
• Can start up to Day 5 without additional contraception
• Quick start / any day start: Can start any day of the cycle — use extra precaution for 7 days
• Post-delivery: After 6 weeks (oestrogen-containing pills not used before due to VTE risk); POP can be started at 3 weeks

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STUDENT 5

Labour — Definition

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Importance of Menstrual History in Subfertility

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Conditions Causing Painful Periods (Dysmenorrhoea)

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Stages of Labour

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Importance of 3rd Stage

• PPH is the leading cause of maternal mortality worldwide
• The placenta separates and the uterus must contract firmly to control bleeding
• Without active management, PPH risk is significantly higher

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Active Management of the 3rd Stage of Labour (AMTSL)

1. Uterotonic drug: Oxytocin 10 IU IM (preferred) or Ergometrine/Syntometrine immediately after baby is born (before or after delivery of placenta)
2. Controlled cord traction (CCT): After signs of placental separation (cord lengthening, uterine fundus rising, gush of blood)
3. Uterine massage: After placenta delivered (sustained uterine tone)

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Complications if 3rd Stage Not Managed

• Primary PPH (blood loss >500 mL within 24 hours; >1000 mL for C-section)
• Retained placenta
• Uterine inversion
• Maternal haemorrhagic shock
• Maternal death

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STUDENT 6

Complications of GDM

• Pre-eclampsia / hypertension
• Urinary tract infections
• Operative delivery (C-section, instrumental)
• Progression to Type 2 DM later in life
• Recurrence in future pregnancies
• Polyhydramnios

• Macrosomia (large for gestational age) → shoulder dystocia
• Neonatal hypoglycaemia (most commonly asked — see below)
• Respiratory distress syndrome (RDS)
• Polycythaemia
• Hyperbilirubinaemia (jaundice)
• Hypocalcaemia, hypomagnesaemia
• Stillbirth (if poorly controlled)
• Long-term risk of obesity and T2DM in the child

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Pathophysiology of Neonatal Hypoglycaemia in GDM

1. Maternal hyperglycaemia → glucose crosses the placenta freely
2. Fetal pancreas responds with fetal hyperinsulinism (hypertrophy of β-cells — Nesidioblastosis)
3. At birth, the maternal glucose supply is suddenly cut off
4. The neonate retains high insulin levels but glucose supply is gone
5. This causes neonatal hypoglycaemia within the first few hours of life

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STUDENT 6 (Madura Sir — Cervical Cancer Screening)

Importance of Cervical Screening

• Cervical cancer has a long pre-invasive phase (CIN → invasive cancer, 10–20 years)
• Pre-invasive lesions (CIN) are asymptomatic — screening detects them before symptoms
• Early treatment prevents progression to invasive cancer
• Invasive disease has high morbidity/mortality; pre-invasive is curable
• It is one of the most preventable cancers with effective screening

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Methods of Cervical Screening

1. Pap smear (conventional cytology) — cells scraped from transformation zone
2. Liquid-based cytology (LBC) — cells placed in liquid preservative; more sensitive, fewer inadequate samples
3. HPV DNA testing — detects high-risk HPV types (16, 18, 31, 33, 45, etc.); newest and most sensitive primary screening method
4. Colposcopy — not a screening tool but a diagnostic/triage tool following abnormal screen
5. Visual inspection with acetic acid (VIA) — used in low-resource settings

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Commonest Causative Organism

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HPV DNA Test

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Visible Cervical Lesion Management

1. Do NOT perform a Pap smear on a clearly visible lesion
2. Refer urgently for colposcopy + directed biopsy
3. Await histological diagnosis before treatment
4. If clinically suspicious of invasive cancer → urgent referral even without waiting for cytology result

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Staging Cervical Cancer (FIGO Staging)

• Stage I: Confined to cervix
• Stage II: Beyond cervix, not to pelvic wall/lower 1/3 vagina
• Stage III: Pelvic wall / lower 1/3 vagina / hydronephrosis
• Stage IV: Bladder/rectum or distant metastasis

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If No CT/MRI — Staging Method

• Bimanual vaginal examination + rectal examination under anaesthesia
• Palpation of parametrium, pelvic sidewalls, uterus, adnexae
• Allows cystoscopy and sigmoidoscopy if needed
• Per FIGO rules, clinical staging with EUA is still acceptable in resource-limited settings

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STUDENT 7

Partogram Monitoring

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Indicators of Labour Progress in Partogram

• Cervical dilatation — should progress ≥1 cm/hr in active phase
• Alert line — expected rate of progress
• Action line — 4 hours to the right of alert line; if reached, intervention needed
• Descent of presenting part
• Contraction frequency/duration

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Assessing Contractions

• Frequency: Number of contractions in 10 min (normal: 3–5/10 min in active labour)
• Duration: Each contraction (mild <20 sec, moderate 20–40 sec, strong >40 sec)
• Strength: By uterine palpation (mild = feel but can indent easily; strong = cannot indent)

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Hydatidiform Mole (H Mole)

• Complete mole: No fetal tissue, diploid (46XX usually), all chromosomes paternal, high β-hCG, classic snowstorm USS
• Partial mole: Some fetal tissue, triploid (69XXY), lower β-hCG, less dramatic USS

• Vaginal bleeding (may pass grape-like vesicles)
• Uterus large-for-dates
• Hyperemesis gravidarum (very high β-hCG)
• Pre-eclampsia before 20 weeks
• Hyperthyroidism (β-hCG cross-reacts with TSH receptor)
• Theca lutein cysts (bilateral, ovarian)

• "Snowstorm" appearance — heterogeneous, echogenic intrauterine mass with multiple small cystic spaces
• No identifiable fetal parts (complete mole)
• Bilateral theca lutein cysts in ovaries

• Persistent GTD / invasive mole
• Choriocarcinoma (malignant transformation — highly chemosensitive)
• Pulmonary embolism of trophoblastic cells

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STUDENT 8

Episiotomy

• To enlarge the vaginal outlet during delivery to prevent uncontrolled perineal tears
• Indications: Operative delivery (forceps/vacuum), prolonged 2nd stage, fetal distress, shoulder dystocia, very rigid perineum
• Mediolateral episiotomy is preferred (reduces risk of 3rd/4th degree tear extension)

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Limits of Active Phase of 1st Stage

• Starts: 4 cm cervical dilatation
• Ends: 10 cm (full dilatation)
• Rate of progress: ≥1 cm/hour
• Cervix dilates up to a maximum of 10 cm (fully dilated)

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2nd Stage — Limits

• Starts: Full dilatation (10 cm)
• Ends: Delivery of the baby
• Prolonged 2nd stage:
  • Nullipara: >2 hours without epidural; >3 hours with epidural
  • Multipara: >1 hour without epidural; >2 hours with epidural

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Complications of 2nd Stage of Labour

• Fetal: Fetal distress, birth asphyxia, birth trauma (cephalhaematoma, fractures)
• Maternal: Perineal tears (1st–4th degree), PPH, uterine rupture, bladder injury, prolapse
• Specific: Shoulder dystocia, cord prolapse, uterine inversion (complication of 3rd stage but can be precipitated by 2nd stage)

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Management of Delayed 2nd Stage

1. Assess cause — "4 Ps": Powers (contractions), Passenger (position/size), Passage (pelvis), Psyche
2. Encourage — correct maternal position (upright, left lateral)
3. Amniotomy if membranes intact
4. Oxytocin augmentation (if poor contractions, no CPD)
5. Operative delivery: Ventouse (vacuum) or forceps if head is low enough (station ≥+2, suitable position)
6. Caesarean section if operative vaginal delivery not possible or fails

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Uterine Inversion

• Causes: Excessive cord traction before placental separation, fundal pressure, short cord, uterine atony, placenta accreta
• Presentation: Sudden PPH + severe pain + shock disproportionate to blood loss + inability to palpate fundus abdominally
• Management: Do NOT remove placenta first if attached; immediate IV access/fluids; manual repositioning (Johnson's manoeuvre); tocolytics (GTN/terbutaline) to relax uterus if needed; O'Sullivan's hydrostatic method; surgical correction if manual fails

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45-Year-Old with Dysmenorrhoea — DDs

• Adenomyosis (most common at this age)
• Endometriosis
• Fibroids (especially submucosal)
• Pelvic inflammatory disease
• Ovarian cysts / endometrioma
• Cervical stenosis
• Psychological/psychosomatic

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Adenomyosis

• History: progressive dysmenorrhoea, HMB, enlarged tender uterus
• Ultrasound: Heterogeneous myometrium, asymmetric myometrial thickening, myometrial cysts, "venetian blind shadowing", poorly defined junctional zone (>12 mm), subendometrial echogenic nodules
• MRI: Gold standard — junctional zone thickness ≥12 mm is diagnostic
• Definitive: Histology after hysterectomy

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STUDENT 9

Episiotomy Repair — Layers Sutured

1. Vaginal mucosa (continuous locking or subcuticular suture)
2. Deep muscle layer (bulbocavernosus, transverse perineal muscles) — interrupted or continuous
3. Superficial muscle/subcutaneous tissue
4. Skin — subcuticular continuous suture (avoids skin sutures that require removal)

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Technique for Vaginal Mucosa Suturing

• Achieves haemostasis at each pass
• Prevents gaps/dead space (reduces haematoma risk)
• Maintains mucosal edge apposition
• The first suture is placed above the apex of the laceration to secure any bleeding retracted vessels

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Prolonged 2nd Stage — Definition, Causes, Management

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First Trimester Complications

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Types of Miscarriage

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USS Features of H Mole

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STUDENT 10

Calculating EDD from LRMP (Naegele's Rule)

• Assumes a 28-day cycle with ovulation on Day 14
• Irregular cycles: If cycle is >28 days, add extra days; if <28 days, subtract — Naegele's is unreliable
• Uncertain LRMP (patient unsure of date)
• Implantation bleeding mistaken for LMP
• Lactational amenorrhoea / recent pill use altering cycle

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Issues with Irregular Cycles

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Other Method for EDD

• Crown-rump length (CRL) at 8–13+6 weeks (most accurate, ±3–5 days)
• Biparietal diameter (BPD) at 14–20 weeks (less accurate, ±7–10 days)
• Dating scan at 10–13+6 weeks is the most accurate method

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Lifespan of Corpus Luteum

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STUDENT 10 (Madura Sir — Partogram / Labour)

Active Management of Labour

1. Active management of 3rd stage (most common usage — covered above)
2. In the context of first stage: Active management of labour = early amniotomy + oxytocin augmentation if progress <1 cm/hr after assessment, targeting delivery within 12 hours

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Primary Arrest vs Secondary Arrest (Poor Progress)

• Failure of labour to establish normal active phase progress from the outset
• Cervix dilates at <1 cm/hr from the start of active phase
• Causes: Uterine hypotonia, CPD (cephalopelvic disproportion), malposition
• Management: Amniotomy, oxytocin augmentation; reassess in 4 hours

• Labour was progressing normally but slows or stops after a period of normal progress
• Causes: Exhaustion of uterine contractions, malrotation, CPD becoming apparent as head descends, epidural
• Management: Same initially (oxytocin); if no progress → C-section if CPD suspected

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STUDENT 11

Pregnant Woman with Previous Emergency C-Section

1. Take a detailed history — determine indication for previous C-section (recurrent vs. non-recurrent cause)
2. Review old notes/operative records (type of uterine incision — lower segment vs. classical)
3. Assess this pregnancy

• Indication for previous C-section (CPD, fetal distress, malpresentation, failure to progress)
• Type of incision (lower segment = VBAC possible; classical/inverted T = contraindication to VBAC)
• Any complications (uterine rupture, wound dehiscence)
• Number of previous sections
• Gestational age and presentation in this pregnancy
• Current maternal and fetal wellbeing

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Causes of Emergency C-Section

• Acute fetal distress (abnormal CTG, cord prolapse)
• Failure to progress / arrested labour (dystocia, CPD)
• Placental abruption
• Cord prolapse
• Uterine rupture
• Severe pre-eclampsia / eclampsia
• Antepartum haemorrhage (placenta praevia)
• Maternal collapse
• Malpresentation in labour (transverse lie, brow)

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Postmenopausal Bleeding (PMB) — Differential Diagnoses

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Endometrial Carcinoma — Diagnosis

• Trans-vaginal ultrasound (TVS): First-line investigation
  • Normal endometrial thickness ≤4 mm (postmenopause) → very low risk

  • 4 mm (or any heterogeneous thickening) → further investigation

• Endometrial biopsy (Pipelle biopsy or hysteroscopy + directed biopsy) → histological diagnosis
• Hysteroscopy: Direct visualisation + biopsy — gold standard

• Thickened, irregular, heterogeneous endometrium
• Loss of normal endometrial-myometrial interface
• Irregular myometrial invasion (if advanced)
• ± Fluid in the uterine cavity (haematometra)

• Premenopausal: varies with cycle (up to 14–16 mm in late secretory)
• Postmenopausal: ≤4 mm (on TVS; some use ≤5 mm)

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STUDENT 12

Stages of Labour and Demarcating Points

Position of Uterus After Delivery

Uterus Not Palpable in Usual Place After Delivery

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Primary PPH

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Management of PPH

1. Call for help — senior obstetrician, anaesthetist, haematologist
2. Assess — bimanual examination for tone, inspect for trauma
3. IV access ×2, bloods (FBC, coag, X-match), fluid resuscitation
4. Bimanual uterine compression massage
5. Uterotonics:
   • Oxytocin 10 IU IV/IM (1st line)
   • Ergometrine 0.5 mg IM/IV (avoid in hypertension)
   • Syntometrine (combined)
   • Misoprostol 1000 mcg PR (if others fail)
   • Carboprost (15-methyl PGF2α) 250 mcg IM (if atony persists; avoid in asthma)
   • Tranexamic acid (antifibrinolytic — early use reduces mortality)
6. Bakri balloon / condom catheter tamponade (uterine tamponade)
7. Surgical:
   • Uterine compression sutures (B-Lynch suture)
   • Uterine artery ligation (O'Leary sutures)
   • Internal iliac artery ligation
8. Hysterectomy — last resort (life-saving)

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STUDENT 13

Secondary PPH

• Retained products of conception (RPOC) — most common
• Subinvolution of the placental site
• Infection (endometritis)
• Rarely: trophoblastic disease, arteriovenous malformation

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Uterotonics and Mechanism

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Types of Prostaglandins Used in Obstetrics/Gynaecology

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STUDENT 14

GDM Patient — Antenatal Assessment (2nd Pregnancy)

• Glycaemic control in previous pregnancy and outcome
• Current dietary habits, weight, BMI
• Current symptoms of hyperglycaemia (polyuria, polydipsia)
• Other medical conditions

• At booking (first visit): Fasting blood glucose or HbA1c (to screen for pre-existing diabetes)
• OGTT at 24–28 weeks: 75 g oral glucose load; fasting, 1-hr, 2-hr glucose
  • Diagnostic thresholds (WHO 2013): Fasting ≥5.1, 1-hr ≥10.0, 2-hr ≥8.5 mmol/L
• Growth scans (for macrosomia), Doppler, liquor assessment

• At early gestation, the physiological insulin resistance of pregnancy has not yet developed (peaks at ~26 weeks)
• OGTT at booking may give false negatives for gestational (pregnancy-specific) DM
• However, fasting glucose or HbA1c at booking screens for pre-existing/undiagnosed T2DM
• OGTT is specifically targeted at 24–28 weeks when gestational insulin resistance is maximal

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First-Trimester Bleeding — Differential Diagnoses

• Miscarriage (threatened/inevitable/incomplete/complete)
• Ectopic pregnancy
• Gestational trophoblastic disease (H mole)
• Implantation bleeding
• Cervical causes (ectropion, polyp, cervicitis, carcinoma)
• Trauma

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Primary vs Secondary Dysmenorrhoea

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Causes of Secondary Dysmenorrhoea

• Endometriosis
• Adenomyosis
• Fibroids (especially submucosal)
• Pelvic inflammatory disease / chronic pelvic pain
• Ovarian cysts (endometrioma)
• Cervical stenosis
• IUD

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Adenomyosis: Management

• NSAIDs (symptomatic relief)
• Combined oral contraceptive pill
• Levonorgestrel IUS (Mirena) — highly effective; reduces HMB and dysmenorrhoea
• GnRH analogues (temporary; side effects limit long-term use)
• Progestins (norethisterone, medroxyprogesterone)

• Hysterectomy — definitive cure; only for women who have completed family
• Endometrial ablation — limited benefit in adenomyosis

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STUDENT 15

POA 10 Weeks with Abdominal Pain and Bleeding — DDs

• Threatened miscarriage (most common)
• Inevitable miscarriage
• Incomplete miscarriage
• Ectopic pregnancy (though intrauterine at 10 weeks less likely if USS confirmed; still consider if not confirmed)
• Corpus luteal cyst rupture
• Gestational trophoblastic disease (H mole)
• Cervical pathology (polyp, ectropion — painless usually)

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Differentiating Types of Miscarriage Clinically

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POA 34 Weeks with Vaginal Discharge — DDs

• Premature rupture of membranes (PROM) / preterm PROM (pPROM) — watery, clear/yellowish
• Preterm labour ± "show" (mucus plug)
• Bacterial vaginosis
• Candidiasis (thick, white, curdy)
• Trichomoniasis (frothy, offensive)
• Group B Streptococcus (GBS) colonisation
• Amnionitis (chorioamnionitis) — offensive, offensive-smelling discharge + fever

• Speculum examination — visualise os, liquor pooling, ferning, nitrazine/pH test (amnion fluid pH >7 = alkaline)
• PAMG-1 test (AmniSure) or IGFBP-1 — detect amniotic fluid proteins
• USS — assess liquor volume (AFI/deepest pool), fetal wellbeing
• Cervical/vaginal swabs
• FBC, CRP (rule out chorioamnionitis)

• Admit, rest, fetal monitoring (CTG)
• Antibiotics (erythromycin/co-amoxiclav — reduces neonatal infection)
• Corticosteroids (betamethasone if <34–35 weeks — fetal lung maturity)
• Monitor for chorioamnionitis (fever, tachycardia, uterine tenderness, offensive discharge, fetal tachycardia)
• Delivery if chorioamnionitis develops, or expectant management to term depending on gestation and condition
• At 34 weeks: delivery versus expectant management — balance risk of prematurity vs. infection

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STUDENT 16

6 Weeks POA, Pallor and Tachycardia, Confirmed IUP — Management

• This is likely a haemorrhage — first exclude ectopic pregnancy if USS confirmation was not recent
• Most likely diagnosis: Threatened/incomplete miscarriage with significant blood loss, or a concurrent ectopic (heterotopic — rare)

1. Call for senior help immediately
2. A-B-C: Airway, Breathing, Circulation
3. Large-bore IV access × 2, urgent bloods: FBC, G&XM, β-hCG, coagulation
4. IV fluid resuscitation (crystalloid initially)
5. Blood transfusion if needed
6. Urgent USS — confirm intrauterine location, viability, and exclude other causes
7. Continuous monitoring (vital signs, urine output)
8. Consent patient for possible surgical intervention (ERPC if miscarriage, laparoscopy if ectopic)
9. Oxygen if saturations low

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GDM — Definition

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Screening for GDM

• At booking: Fasting plasma glucose, HbA1c (to assess glycaemic control)
• HbA1c ≥48 mmol/mol at booking = overt/pre-existing diabetes
• OGTT may not be needed (already diagnosed)

• 75 g OGTT at 24–28 weeks

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STUDENT 17

Antepartum Haemorrhage (APH) — Definition

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Causes of APH

• Placenta praevia — placenta partially or completely covering the os
• Placental abruption — premature separation of a normally sited placenta

• Cervical ectropion, cervical polyp, cervicitis, cervical carcinoma
• Vaginal/vulval varicosities
• Vaginitis, trauma

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Clinical Features of Placental Abruption

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Is Ultrasound Always Needed to Diagnose Abruption?

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Concealed Haemorrhage

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Cervical Cancer Screening — Age Groups, Risk Factors, Prevention

• Start: 25 years (or at sexual debut in some guidelines)
• Repeat: Every 3–5 years
• Stop: 65 years (if adequate negative screens)

• Early sexual debut, multiple sexual partners
• HPV infection (16, 18 — high risk)
• Smoking
• Immunosuppression (HIV, transplant)
• High parity
• Low socioeconomic status / poor access to screening
• Non-use of barrier contraception
• Coexisting STIs (herpes, chlamydia)

• HPV vaccination (primary prevention)
• Regular cervical screening (secondary prevention)
• Safe sex practices (condoms)
• Smoking cessation

• Given to girls (and boys) aged 9–14 (2-dose schedule; if ≥15 years, 3 doses)
• In Sri Lanka: 10-year-old girls as part of the national immunisation programme (school-based)
• Vaccines: Gardasil 9 (9-valent), Cervarix (bivalent HPV 16, 18)

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STUDENT 18

Mode of Delivery in Placenta Praevia

• Caesarean section is the delivery of choice for major placenta praevia (Type III/IV or grade 3/4 covering the os)
• Vaginal delivery may be considered for minor/marginal praevia (placental edge >2 cm from os on USS) if the presenting part is well-applied
• Emergency C-section if haemodynamically unstable regardless of gestation

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Types of Urinary Incontinence

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Management of Stress Incontinence

• Pelvic floor muscle exercises (Kegel exercises) — supervised physiotherapy, ≥3 months
• Weight loss (if BMI elevated)
• Reduce caffeine and fluid intake
• Treat constipation/chronic cough

• Duloxetine (SNRI — increases sphincter tone) — moderate efficacy, significant side effects

• Mid-urethral sling (TVT / TOT) — gold standard surgical treatment; tape placed under mid-urethra
• Colposuspension (Burch) — laparoscopic/open
• Bulking agents (periurethral injection) — for those unfit for surgery

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STUDENT 19

Ectopic Pregnancy

• Isthmus of tube
• Fimbrial end of tube
• Interstitial / cornual (high risk — rupture can be catastrophic)
• Ovarian
• Cervical
• Abdominal (rare, but can reach viable gestation)
• Caesarean scar (increasingly recognised)
• Heterotopic (simultaneous IUP + ectopic — rare, risk with IVF)

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Risk Factors for Ectopic Pregnancy

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Management of Ectopic Pregnancy

• Haemodynamically stable, β-hCG <1500 IU/L and falling, mass <3 cm, no fetal heartbeat, no pain
• Serial β-hCG monitoring

• Folic acid antagonist → inhibits trophoblast growth
• Criteria: Stable, unruptured, β-hCG <3000–5000 IU/L, mass <3.5–4 cm, no FH, no significant pain
• IM injection; follow-up β-hCG days 4 and 7 (15–25% fall expected between D4–D7)

• Laparoscopy preferred over laparotomy
• Salpingotomy (linear incision, remove ectopic, preserve tube) — if other tube damaged and fertility desired
• Salpingectomy (remove affected tube) — preferred if other tube normal; lower recurrence of persistent trophoblast
• Laparotomy — if haemodynamically unstable, massive haemoperitoneum

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