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Gyn & Obs Pre-Prof Viva — Group F: Complete Answer Guide

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STUDENT 1 — Rukshan Sir (Gyn)

Common complaints seen during ward rounds

Causes for heavy menstrual bleeding (HMB)

• PALM (structural): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
• COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial causes, Iatrogenic, Not yet classified

What does FIGO stand for?

FIGO classification of fibroids (leiomyomas)

Which type of fibroid causes HMB most commonly?

Other complaints of submucosal fibroids

• Dysmenorrhoea (especially if pedunculated — uterus tries to expel it)
• Infertility / recurrent miscarriage (implantation failure)
• Urinary frequency (if large)
• Intermenstrual bleeding
• Passage of clots
• Iron-deficiency anaemia symptoms (fatigue, pallor)

Surgical options for fibroids

• Hysteroscopic myomectomy — for submucosal fibroids (Types 0, 1, 2); preserves uterus
• Abdominal/laparoscopic myomectomy — for intramural/subserosal fibroids; uterus-preserving
• Hysterectomy — definitive; total or subtotal; abdominal, laparoscopic or vaginal
• Uterine artery embolisation (UAE) — minimally invasive; not for women wanting future pregnancy
• MRI-guided focused ultrasound (MRgFUS) — non-invasive ablation

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STUDENT 1 — Hunukumbura Sir (Obs)

Favourable fetal position for labour

How to assess fetal position

1. Abdominal examination (Leopold's manoeuvres) — locate back and limbs; identify presenting part
2. Vaginal examination (VE) — palpate fontanelles and sutures:
   • Anterior fontanelle (diamond-shaped, 4 sutures) → vertex; if felt anteriorly → OP position
   • Posterior fontanelle (triangular, 3 sutures) → OA position
   • Ear pinna points toward occiput
3. Ultrasound — most accurate

Fetal malpositions

• Occiput Posterior (OP) — most common malposition; Right OP > Left OP
• Occiput Transverse (OT) — arrest in transverse position

Complications of fetal malpositions

• Prolonged labour (1st and 2nd stage)
• Perineal tears (larger diameter)
• Instrumental delivery (forceps/vacuum)
• Caesarean section
• Fetal distress / cord prolapse (OT)
• Maternal exhaustion
• Postpartum haemorrhage

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STUDENT 2 — Rukshan Sir

What is "position" in labour?

What does "Left Occiput Posterior" (LOP) mean?

OA vs OP — which do you prefer and why?

• In OA, the suboccipitobregmatic diameter (9.5 cm) presents — smallest diameter
• In OP, the occipitofrontal diameter (11.5 cm) presents — larger, leading to prolonged/obstructed labour
• OA facilitates normal mechanism of labour (flexion → descent → internal rotation → extension)
• OP increases risk of instrumental delivery, perineal tears, maternal exhaustion

What is station?

• 0 station = at ischial spines
• –1, –2, –3 = above spines (in cm)
• +1, +2, +3 = below spines (crowning at +3/+5 depending on system used)
• The WHO system uses a 5-level scale (–3 to +3 or cm above/below)

Mechanism of labour (vertex presentation)

1. Engagement — biparietal diameter passes the pelvic inlet; descent begins
2. Flexion — chin on chest; suboccipitobregmatic diameter presents
3. Descent — throughout all stages
4. Internal rotation — occiput rotates anteriorly to lie under pubic symphysis (usually at pelvic floor)
5. Extension — head extends around pubic symphysis; face, brow, occiput born in sequence
6. Restitution — head rotates back to align with shoulders (45°)
7. External rotation — shoulders rotate to A-P diameter; head rotates further
8. Expulsion — anterior then posterior shoulder, then trunk and legs

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STUDENT 2 — Hunukumbura Sir

Staging of uterovaginal prolapse (POP-Q / Baden-Walker)

Which part comes first in prolapse?

Identifying prolapse in history

• Feeling of "something coming down" (dragging sensation in the perineum)
• Lump at or outside the vaginal introitus
• Worse on standing, straining, coughing; relieved by lying down
• Urinary symptoms: stress incontinence, frequency, incomplete emptying
• Bowel symptoms: constipation, incomplete evacuation, digitation
• Sexual dysfunction, dyspareunia
• Low backache

How to differentiate Grade 2 vs Grade 3 prolapse on examination?

• Grade 2: cervix/vaginal wall descends to the level of the hymen — visible at introitus when patient strains (Valsalva)
• Grade 3: cervix/vaginal wall descends beyond the hymen — palpable/visible outside the introitus at rest or on minimal straining
• Examine in left lateral position using a Sims' speculum with the patient straining (Valsalva/cough)

Can a bivalve (Cusco's) speculum be used?

Risk factors for prolapse

• Obstetric: multiparity, vaginal delivery, prolonged 2nd stage, instrumental delivery, large baby, shoulder dystocia
• Hormonal: menopause (oestrogen deficiency → ligament/fascial atrophy)
• Constitutional: obesity, chronic constipation, chronic cough (raised intra-abdominal pressure), connective tissue disorders
• Age: progressive weakening of pelvic floor

How does age/menopause cause prolapse?

• Uterosacral and cardinal ligaments
• Pubocervical and rectovaginal fascia
• Pelvic floor musculature (levator ani)

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STUDENT 3 — Rukshan Sir

Why is menstrual history important in subfertility?

Causes of dysmenorrhoea

• Endometriosis — most important
• Adenomyosis
• Fibroids (especially submucosal, intracavitary)
• Pelvic inflammatory disease (PID)
• Ovarian cysts
• IUCD (intrauterine contraceptive device)
• Cervical stenosis

Do fibroids usually present with dysmenorrhoea?

When do fibroids cause dysmenorrhoea?

• Submucosal/intracavitary pedunculated fibroid: uterus contracts to expel it, causing severe cramps (similar to labour pain)
• Red (carneous) degeneration: acute pain due to infarction of a rapidly growing fibroid — common in pregnancy
• Torsion of a pedunculated subserosal fibroid: sudden severe pain
• Large intramural fibroids: pressure and distortion

Torsion — when does it occur?

When does red degeneration occur?

What is an endometrial cast?

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STUDENT 3 — Hunukumbura Sir

Precautions when measuring BP in a pregnant woman

• Patient rested for ≥5 minutes, sitting (or left lateral decubitus — never supine after 20 weeks due to aortocaval compression)
• Arm at heart level
• Correct cuff size (bladder should encircle ≥80% of arm)
• Use Korotkoff Phase V (disappearance of sound) for diastolic BP
• Do not measure immediately after activity/anxiety
• Record in both arms at first visit; use the higher reading

Extra precautions for an obese pregnant woman

• Use a large-sized (obese) cuff — undersized cuff gives falsely elevated readings
• Cuff width should be 40% of mid-arm circumference
• Consider wrist cuff or upper arm cuff depending on arm shape
• Validate automated devices for use in pregnancy/obesity

Process of measuring BP with sphygmomanometer

1. Patient seated, arm at heart level, palm upward
2. Apply appropriately-sized cuff 2–3 cm above antecubital fossa
3. Palpate brachial artery; inflate to 30 mmHg above palpated systolic
4. Place stethoscope over brachial artery
5. Deflate cuff at 2 mmHg/second (rate of deflation)
6. Korotkoff I = first sound = systolic BP
7. Korotkoff V = disappearance of sound = diastolic BP (in pregnancy, use Phase V)
8. If sounds persist to zero, use Korotkoff IV (muffling) for diastolic

Rate of deflation

Which Korotkoff sound for diastolic?

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STUDENT 4 — Rukshan Sir

Antepartum haemorrhage (APH) spelling

How was patient prepared for emergency LSCS?

• Resuscitation: IV access (2 large-bore cannulae), IV fluids, crossmatch blood, FBC, coagulation
• Anaesthesia: anaesthetist informed; GA or regional (spinal/epidural)
• Theatre: informed consent (if possible), catheterisation, antiseptic skin prep
• Neonatology team: alerted for neonatal resuscitation
• Prophylactic antibiotics: given intraoperatively

Why was a condom catheter used (intrauterine balloon tamponade)?

How does condom catheter prevent PPH?

• Mechanical compression of bleeding vessels
• Counterpressure against uterine wall exceeds arterial pressure in vessels
• Stimulates reflex uterine contraction
• Temporising measure while awaiting further haemostatic interventions or transfer

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STUDENT 4 — Hunukumbura Sir

Contraceptive methods

• Combined oral contraceptive pill (COCP)
• Progestogen-only pill (POP / mini-pill)
• Injectable (Depo-Provera — DMPA)
• Implant (Implanon/Nexplanon)
• Hormonal IUS (Mirena)

Advice when initiating COCP

• Take one pill daily at the same time, for 21 days, then 7-day pill-free interval (or 28-day packs with 7 inactive pills)
• Start on Day 1 of menstrual cycle (immediate protection) — can start up to Day 5 (use additional contraception for 7 days if Day 2–5)
• Missed pill (>24 hrs late):
  • If 1 pill missed: take immediately, continue pack, no extra precautions
  • If 2+ pills missed (or missed in week 1/3): take last missed pill, use condoms for 7 days; if week 3, skip pill-free interval
• Take at the same time each day (morning or evening with meal reduces nausea)
• Not before or after meals specifically required — but taking with food reduces GI side effects
• Return if: chest pain, severe headache, visual disturbance, leg swelling (VTE warning signs)
• Not suitable if: personal history of VTE, migraine with aura, smoker >35 years, uncontrolled hypertension

COCP — what kind of contraceptive method?

1. Inhibiting ovulation (suppresses LH surge)
2. Thickening cervical mucus
3. Thinning endometrium

Time of day to take pill

What if she missed a dose?

Two types of tablets in COCP (28-day pack)

1. Active pills (21): contain ethinylestradiol + progestogen
2. Inactive/placebo pills (7): contain no hormones (iron, lactose, or inert filler)

What do inactive pills contain?

Can she have bleeding while on COCP?

• Withdrawal bleed during the 7 pill-free days (not a true period — lighter, shorter)
• Breakthrough bleeding (BTB) — especially in first 3 months; also with missed pills, vomiting/diarrhoea, drug interactions (rifampicin, anticonvulsants)

Starting day for COCP

• Day 1 of menstrual cycle = immediate protection
• Quick start (any day) = possible, use additional contraception for 7 days, rule out pregnancy
• Sunday start (some regimens) = use additional contraception for 7 days

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STUDENT 5 — Rukshan Sir

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STUDENT 5 — Madura Sir

Definition of labour

Stages of labour

Importance of 3rd stage

• Period of highest risk for primary PPH
• Physiologically: placenta separates (Brandt's signs), uterus contracts → living ligature mechanism
• Improper management → uterine atony, retained placenta → haemorrhage
• A healthy 3rd stage is critical for maternal survival

Active management of 3rd stage of labour (AMTSL)

1. Uterotonic drug within 1 minute of delivery (Oxytocin 10 IU IM — first choice; or syntometrine, carbetocin)
2. Controlled cord traction (CCT) — Brandt-Andrews manoeuvre; after signs of placental separation
3. Uterine massage after placenta delivery (some guidelines have removed routine fundal massage)

Complications if 3rd stage not managed

• Primary PPH (≥500 mL blood loss within 24 hrs of delivery)
• Uterine atony (commonest cause of PPH)
• Retained placenta (placenta not delivered within 30 minutes — requires manual removal under anaesthesia)
• Haemorrhagic shock
• Maternal death

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STUDENT 6 — Rukshan Sir

Complications of GDM

• Pre-eclampsia, gestational hypertension
• Polyhydramnios
• Operative delivery (instrumental / CS) due to macrosomia
• Shoulder dystocia
• Progression to Type 2 DM (50% risk over lifetime)
• Increased risk of UTI, candidiasis

• Macrosomia (large for gestational age > 4 kg)
• Neonatal hypoglycaemia ← most commonly asked
• Respiratory distress syndrome (RDS)
• Neonatal jaundice (polycythaemia → haemolysis)
• Polycythaemia
• Hypocalcaemia, hypomagnesaemia
• Stillbirth (if poorly controlled)
• Birth trauma (shoulder dystocia → Erb's palsy, clavicle fracture)

Pathophysiology of neonatal hypoglycaemia in GDM

1. Maternal hyperglycaemia → glucose crosses placenta freely → fetal hyperglycaemia
2. Fetal pancreatic β-cells undergo hyperplasia → produce excess insulin (fetal hyperinsulinaemia)
3. Fetal hyperinsulinaemia → macrosomia, organomegaly
4. At birth, maternal glucose supply abruptly stops, but neonatal insulin levels remain high
5. Neonatal hyperinsulinaemia continues to suppress glycogenolysis and gluconeogenesis
6. Result: neonatal hypoglycaemia (typically within 1–4 hours of birth)
7. Managed with early feeding, IV dextrose if symptomatic

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STUDENT 6 / STUDENT 11 / STUDENT 17 — Madura Sir: Cervical Cancer Screening

Importance of cervical screening

Screening methods (all methods)

1. Pap smear (cervical cytology) — Papanicolaou smear; exfoliated cells from transformation zone
2. Liquid-based cytology (LBC) — improved sensitivity; cells suspended in fixative liquid
3. Colposcopy — not a primary screening tool; used for diagnostic evaluation of abnormal smear
4. HPV DNA testing — newest/primary screening method; detects high-risk HPV types (16, 18, 31, 33, 45 etc.)
5. VIA (Visual Inspection with Acetic acid) — for low-resource settings; acetowhite areas suspicious
6. VILI (Visual Inspection with Lugol's Iodine)

Commonest causative organism

Newest screening method

Visible cervical lesion — what to do?

1. Colposcopy + directed biopsy for histological confirmation
2. Do NOT do a smear alone
3. If invasion confirmed → staging required

Staging of cervical cancer

• Clinical staging (FIGO) — Stages I–IV based on extent of local spread, parametrial involvement, bladder/rectal involvement, distant metastases
• Imaging: MRI (best for local extent), CT (lymph node assessment, distant mets), PET-CT
• Where imaging unavailable: Examination Under Anaesthesia (EUA) — bimanual examination to assess parametrial spread; cystoscopy, sigmoidoscopy; chest X-ray

Risk factors for cervical cancer

• Early age at first intercourse
• Multiple sexual partners
• HPV infection (types 16, 18)
• Smoking
• Immunosuppression (HIV)
• Long-term OCP use (>5 years)
• High parity
• Co-infection with other STIs (Chlamydia, HSV)
• Low socioeconomic status

Prevention of cervical cancer

• HPV vaccination: Cervarix (bivalent — 16, 18), Gardasil (quadrivalent — 6, 11, 16, 18), Gardasil 9 (nonavalent)
• Screening programmes (Pap smear / HPV testing)
• Safe sexual practices, condom use
• Smoking cessation

When is HPV vaccine given in EPI schedule?

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STUDENT 7 — Rukshan Sir: Partogram

Monitoring via partogram

• Fetal: FHR (every 30 min in active phase), fetal descent (station), caput succedaneum, moulding, presentation, position
• Maternal: Pulse (every 30 min), BP (every 4 hrs), temperature (every 4 hrs), urine output (volume, protein, ketones), contractions (frequency, duration, strength per 10 min)
• Labour progress: Cervical dilatation, descent of presenting part, membrane status, liquor colour

Things indicating progression of labour

• Cervical dilatation: plotted on alert line (1 cm/hr in active phase); if crosses to the right of the action line (4 hrs after alert line) → need intervention
• Descent of presenting part (in fifths palpable abdominally, or station vaginally)
• Regular, adequate contractions

Assessing better contractions (number and frequency)

• Frequency: number per 10 minutes (normal active labour: 3–5/10 min)
• Duration: each contraction duration in seconds (adequate: ≥45 seconds)
• Strength/quality: mild (felt on palpation but uterus can be indented), moderate (firm), strong (board-like, cannot be indented)

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STUDENT 7 — Madura Sir: H Mole and Fibroids

First trimester problems

Hydatidiform mole (H mole)

• Vaginal bleeding (dark, "prune juice" — characteristic; may pass grape-like vesicles)
• Uterus large for dates
• No fetal heart sounds
• Hyperemesis gravidarum (very high hCG)
• Early pre-eclampsia (<20 weeks)
• Hyperthyroidism (hCG cross-reacts with TSH receptor)
• Theca lutein cysts (bilateral ovarian cysts)

• Snowstorm appearance — heterogeneous intrauterine mass with multiple echogenic foci
• No fetal parts (complete mole)
• Theca lutein cysts on ovaries
• No gestational sac or fetal pole (complete)

• Malignant transformation to Gestational Trophoblastic Neoplasia (GTN):
  • Invasive mole
  • Choriocarcinoma — highly malignant, haematogenous spread (lungs most common)
  • Placental site trophoblastic tumour (PSTT)
• Haemorrhage
• Infection
• Theca lutein cysts
• Pulmonary complications (trophoblastic emboli)

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STUDENT 8 — Rukshan Sir: Episiotomy and Stages of Labour

Why is episiotomy done?

• Prevent severe/uncontrolled tears
• Facilitate delivery of large baby (macrosomia)
• Expedite delivery in fetal distress
• Facilitate instrumental delivery (forceps/vacuum)
• Persistent perineal rigidity delaying delivery
• Shoulder dystocia

Stages of labour and their demarcating points

Active phase of 1st stage — limits

• Starts: 4 cm dilatation (with effacement)
• Ends: 10 cm (full dilatation)
• Normal rate: ≥1 cm/hour
• Normal duration: ≤6 hours (primigravida); ≤4 hours (multigravida) — varies by guidelines

Maximum cervical dilatation

2nd stage — start and end points

• Start: Full dilatation (10 cm)
• End: Delivery of the baby

Complications of 2nd stage

• Fetal distress (hypoxia, abnormal CTG)
• Cord prolapse
• Maternal exhaustion
• Perineal tears (1st–4th degree)
• Shoulder dystocia
• Instrumental delivery (forceps/vacuum)
• Uterine rupture (especially VBAC)
• Postpartum haemorrhage

Management of delayed 2nd stage

1. Assess cause: power (contractions), passenger (position, size), passage (pelvis)
2. Encourage active pushing; optimize position (upright, lateral)
3. Ensure adequate analgesia (epidural if not in place)
4. Augment with oxytocin (if not contraindicated and no obstructed labour)
5. Instrumental delivery (forceps or vacuum) if criteria met
6. Caesarean section if criteria not met or fetal distress

Uterine inversion

• Causes: Mismanaged 3rd stage (fundal pressure with unseparated placenta, excessive cord traction), short cord, uterine atony, placenta accreta
• Grades: I (fundus inverts but doesn't reach cervix) → IV (complete prolapse outside vagina)
• Clinical features: Sudden severe pain, profound shock (vagovagal), massive PPH, inability to palpate fundus abdominally
• Management: O'Sullivan's hydrostatic method (warm saline); manual replacement under anaesthesia; Johnson manoeuvre; haemodynamic resuscitation

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STUDENT 8 — Madura Sir: Dysmenorrhoea and Adenomyosis

45-year-old woman with dysmenorrhoea — differentials

• Adenomyosis (top differential in this age group)
• Endometriosis
• Uterine fibroids (especially submucosal, intracavitary)
• Pelvic inflammatory disease (PID)
• Ovarian cysts (endometrioma)
• Cervical stenosis
• IUCD

Primary dysmenorrhoea

Adenomyosis

• Affects women age 35–50
• Presents with: dysmenorrhoea (progressive, worsens with age), menorrhagia, bulky tender uterus, dyspareunia

Diagnosis of adenomyosis

• Clinical: globular, symmetrically enlarged, tender uterus; softer than fibroids
• USS (transvaginal): best initial investigation
  • USS findings: asymmetric myometrial thickening, heterogeneous myometrium, myometrial cysts (anechoic lacunae), poor delineation between endometrium and myometrium, increased vascularity, "venetian blind" shadowing, globular uterus
• MRI: gold standard imaging — shows junctional zone thickening >12 mm
• Histology: definitive diagnosis — only confirmed on hysterectomy specimen

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STUDENT 9 — Rukshan Sir: Episiotomy Repair

Layers sutured in episiotomy repair

1. Vaginal mucosa (vaginal epithelium)
2. Deep perineal muscles (bulbospongiosus, transverse perineal muscles, external anal sphincter if involved)
3. Subcutaneous tissue
4. Perineal skin

Suture material

• Vaginal mucosa and muscles: Polyglycolic acid (Vicryl/Dexon) — absorbable
• Skin: Vicryl Rapide (absorbable, dissolves quickly) or subcuticular Vicryl; avoid non-absorbable sutures on perineum

Technique for mucosa and rationale

• Runs from apex of vaginal wound down to introitus
• Rationale: distributes tension evenly, reduces risk of suture breaking through friable tissue, reduces tissue ischaemia compared to interrupted sutures, faster, reduces suture material used, associated with less short-term pain.
• The apex must be sutured above the highest point of the wound to prevent haematoma formation.

When is 2nd stage prolonged?

• Primigravida: >2 hours (without epidural); >3 hours (with epidural)
• Multigravida: >1 hour (without epidural); >2 hours (with epidural)

Causes of prolonged 2nd stage (3 Ps)

• Power: inadequate contractions, poor maternal pushing effort, exhaustion
• Passenger: malposition (OP, OT), malpresentation (face, brow), macrosomia, head extension
• Passage: cephalopelvic disproportion (CPD), contracted pelvis, perineal rigidity

Management

1. Assess cause (3 Ps)
2. Optimise: encourage pushing, change position, ensure bladder is empty
3. Augment with oxytocin (if power issue, no obstruction)
4. Instrumental delivery: vacuum (ventouse) or forceps if criteria met:
   • Station +2 or below (or engaged)
   • Vertex, fully dilated, membranes ruptured
   • No CPD
   • Adequate analgesia
5. Caesarean section if instrumental not possible or fails

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STUDENT 9 — Madura Sir: First Trimester Complications and H Mole

First trimester complications and presentation

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STUDENT 10 — Rukshan Sir: EDD and Naegele's Rule

How to calculate EDD using LNMP (Last Normal Menstrual Period)

EDD = LNMP + 9 months + 7 days (or: LNMP + 1 year − 3 months + 7 days)

Name of the formula

Can you rely on it?

• Irregular cycles
• Uncertain LNMP
• Recent use of COCP (suppresses ovulation beyond day 14)
• Lactational amenorrhoea
• Postpartum conception

Errors in using LNMP for EDD

• Irregular cycles (ovulation not on day 14)
• Patient uncertainty about exact date of LNMP
• Implantation bleeding mistaken for LNMP
• Recent OCP use (delayed ovulation)
• LNMP not truly "normal" (light/short period may be implantation bleed)

Issue with irregular cycles

Other method for EDD

• Crown-Rump Length (CRL) in 1st trimester (most accurate, best before 13+6 weeks)
• Biparietal diameter (BPD) + femur length in 2nd trimester (less accurate)
• First trimester USS is the most accurate dating method (±5 days)

Which is more accurate?

Lifespan of corpus luteum

• If no fertilisation: 14 days → degenerates → progesterone falls → menstruation
• If fertilisation occurs: hCG from trophoblast maintains corpus luteum → persists for approximately 8–10 weeks (until placenta takes over progesterone production — "luteo-placental shift")

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STUDENT 10 — Madura Sir: Active Management of Labour and Partogram

Active management of labour (1st stage)

• Regular VE every 4 hours to plot on partogram
• Early amniotomy (ARM) if membranes intact with slow progress
• Oxytocin augmentation if labour crosses the action line
• Goal: cervical dilatation ≥1 cm/hour in active phase

Partogram — basis/purpose

• Cervical dilatation (y-axis) vs time (x-axis)
• Station of presenting part
• Fetal and maternal observations
• Alert line: expected rate (1 cm/hr); Action line: 4 hours to right of alert line
• Developed by WHO; reduces prolonged labour, CS rates, PPH, perinatal mortality

First stage of labour on partogram

• Begins when regular contractions noted + in active phase (4 cm)
• Cervical dilatation plotted every 4 hours (or 2 hours if concern)
• If dilatation falls to the right of alert line → closer monitoring/augmentation
• If crosses action line → active management/oxytocin/delivery decision

Primary arrest (failure to progress/active phase arrest)

• CPD (absolute or relative)
• Malposition (OP, OT)
• Inadequate uterine contractions

Secondary arrest (protracted active phase / arrest of descent)

• CPD (relative)
• Malposition
• Uterine inertia

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STUDENT 11 — Rukshan Sir: Previous Emergency CS

What to do first with a woman with previous EmCS

• Take a full obstetric history:
  • Indication for previous CS (was it a recurring or non-recurring indication?)
  • Type of uterine incision (lower segment transverse vs classical — affects VBAC eligibility)
  • Any complications (uterine rupture, infection)
  • Interval between previous CS and current pregnancy
  • Outcome of previous pregnancy

Causes of emergency Caesarean section

• Cephalopelvic disproportion (CPD)
• Contracted pelvis

• Fetal distress (CTG changes, cord prolapse)
• Placenta praevia
• Placental abruption
• Antepartum haemorrhage (APH)
• Failed induction/augmentation
• Malpresentation (breech, transverse lie)
• Eclampsia / severe pre-eclampsia
• Cord prolapse
• Failed instrumental delivery
• Uterine rupture

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STUDENT 11 / STUDENT 6 — Madura Sir: Cervical Cancer (continued) + Postmenopausal Bleeding

How Pap smear is performed

1. Patient in dorsal/lithotomy position
2. Bivalve (Cusco's) speculum inserted to visualise cervix
3. Ayre's spatula or endocervical brush (cytobrush) used to sample the transformation zone (squamocolumnar junction)
4. Spatula rotated 360° at cervical os; brush inserted into endocervical canal and rotated
5. Sample spread on glass slide, fixed with 95% ethanol immediately (conventional) — or placed in liquid preservative (LBC)
6. Stained with Papanicolaou stain; examined for cellular abnormalities (CIN, dysplasia)

Cervical Intraepithelial Neoplasia (CIN) — what to do

• CIN 1 (mild dysplasia): usually regresses; observe with repeat cytology/colposcopy
• CIN 2 / CIN 3 (moderate/severe dysplasia): treatment required
  • Large Loop Excision of the Transformation Zone (LLETZ) — most common, outpatient
  • Cone biopsy (cold knife)
  • Laser ablation / cryotherapy (older methods)

How colposcopy is performed

1. Patient in lithotomy position; speculum inserted
2. Cervix visualised under colposcope (binocular magnifying instrument, x6–40)
3. 3–5% acetic acid applied — acetowhite areas (abnormal epithelium) become visible
4. Lugol's iodine (Schiller's test) applied — normal glycogen-containing epithelium stains brown; abnormal areas remain unstained (iodine negative)
5. Directed biopsies taken from abnormal areas
6. Histology confirms grade of CIN

Differential diagnoses of postmenopausal bleeding (PMB)

• Malignant: Endometrial carcinoma (most important), cervical cancer, vulval/vaginal cancer, ovarian cancer (with endometrial involvement)
• Benign: Atrophic vaginitis/endometritis (commonest cause), endometrial polyps, cervical polyps, HRT side effects, uterine fibroids, trauma

Endometrial carcinoma — diagnosis

1. Transvaginal USS (first line): endometrial thickness
   • Postmenopausal: >4–5 mm = abnormal, requires further investigation
   • Normal postmenopausal endometrium: <4 mm
2. Endometrial biopsy (Pipelle suction biopsy) — office procedure
3. Hysteroscopy + D&C — gold standard; direct visualisation + biopsy
4. MRI/CT for staging

USS features of uterus in endometrial carcinoma

• Thickened endometrium (>4–5 mm postmenopausal)
• Heterogeneous / irregular echogenicity of endometrium
• Loss of endometrial-myometrial interface
• Irregular endometrial outline
• Fluid in uterine cavity (haematometra/pyometra)
• May show myometrial invasion

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STUDENT 12 — Rukshan Sir: PPH

Primary PPH

4 Ts — causes of PPH

Commonest cause

Management of PPH — HAEMOSTASIS approach

1. H — call for Help; rub up uterine fundus (bimanual compression)
2. A — Assess (vital signs, blood loss, IV access ×2, FBC, coagulation, crossmatch)
3. E — Establish aetiology (4 Ts), IV fluid resuscitation
4. M — Massage uterus; Medical management:
   • Oxytocin 10 IU IV/IM (1st line)
   • Ergometrine 0.5 mg IM (if no hypertension)
   • Syntometrine (oxytocin + ergometrine)
   • Carboprost (PGF2α) IM (if oxytocin fails; contraindicated in asthma)
   • Misoprostol 800 mcg sublingual/rectal (PGE1)
   • Tranexamic acid 1g IV (within 3 hours)
5. O — blood transfusion, FFP, platelets, cryoprecipitate
6. S — Surgical:
   • Intrauterine balloon tamponade (Bakri balloon, condom catheter)
   • B-Lynch suture (uterine compression suture)
   • Bilateral uterine artery ligation
   • Internal iliac artery ligation
   • Hysterectomy (life-saving, last resort)
7. T — Treat coagulopathy
8. A — check Anatomy (rule out trauma, retained products)
9. S — Interventional radiology (uterine artery embolisation)
10. I, S — ICU care if needed

Drugs and mechanism

• Oxytocin: binds oxytocin receptors → myometrial contraction via ↑intracellular Ca²⁺
• Ergometrine: α-adrenergic + dopaminergic agonist → sustained uterine contraction
• Carboprost (PGF2α): prostaglandin → uterine contraction
• Misoprostol (PGE1): prostaglandin → uterine contraction; used for PPH, also cervical ripening/medical management of miscarriage

Types of prostaglandins used in obstetrics

• PGE1: Misoprostol — cervical ripening, induction of labour, medical management of miscarriage, PPH
• PGE2: Dinoprostone — cervical ripening, induction of labour
• PGF2α: Carboprost (15-methyl PGF2α) — PPH refractory to oxytocin

Secondary PPH

• Causes: retained products of conception (RPOC), endometritis, coagulopathy, placental site subinvolution
• Management: septic screen + antibiotics, surgical evacuation if RPOC confirmed

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STUDENT 12 — Madura Sir: Miscarriage

Definition of miscarriage

Types of miscarriage

Septic miscarriage

• Fever, rigors
• Offensive/purulent vaginal discharge
• Uterine tenderness
• Systemically unwell (sepsis)
• History of unsafe abortion or prolonged retained products

Management of septic miscarriage

1. Resuscitation: IV access, fluids, FBC, cultures (blood + HVS), blood gas
2. Broad-spectrum IV antibiotics (before evacuation):
   • e.g., IV Cefuroxime + Metronidazole ± Gentamicin
3. Surgical evacuation (ERPC — Evacuation of Retained Products of Conception) under antibiotic cover — do not delay surgery waiting for antibiotics to work
4. Anaesthetic referral; ICU if septic shock
5. Monitor for complications: DIC, renal failure, septic emboli
6. Prophylaxis: Anti-D if Rh-negative

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STUDENT 13 — Rukshan Sir

Condition where misoprostol is used (other than PPH)

• Medical management of incomplete/missed miscarriage (800 mcg vaginal or sublingual)
• Cervical ripening / induction of labour (25–50 mcg vaginal/oral)
• Medical termination of pregnancy (with mifepristone — regimen for early pregnancy)
• Gastric ulcer prophylaxis with NSAIDs (its original indication — PGE1 protects gastric mucosa)

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STUDENT 14 — Rukshan Sir: GDM in Previous Pregnancy

Assessment of patient with previous GDM

• Gestational age, fetal wellbeing
• Symptoms of hyperglycaemia (polyuria, polydipsia, recurrent infections)
• Current diet and exercise
• Previous obstetric history (macrosomia, unexplained stillbirth, shoulder dystocia)

• Fasting blood glucose (FBG) or HbA1c — to detect pre-existing T2DM
• FBC, urinalysis, midstream urine (MSU)
• OGTT at booking (if high risk — previous GDM, obesity, family history, glycosuria): Fasting glucose + 1-hr + 2-hr post 75g glucose load
• Blood group, Rh, rubella, hepatitis, HIV, syphilis, thyroid function

Is OGTT performed at first visit?

Why is it difficult to perform OGTT at first visit?

• Nausea and vomiting (especially hyperemesis gravidarum) common in 1st trimester — woman cannot fast adequately or tolerate glucose load
• If vomiting, test is unreliable
• Alternative: fasting glucose or HbA1c at first visit (more practical); formal OGTT at 24–28 weeks

OGTT cut-off values (WHO/IADPSG criteria for GDM)

• Fasting ≥7.0 mmol/L, or 2-hr OGTT ≥11.1 mmol/L, or random glucose ≥11.1 mmol/L with symptoms → Pre-existing diabetes mellitus

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STUDENT 15 — Rukshan Sir: 10-week Bleeding

DDs for 10 weeks POA with abdominal pain + bleeding

1. Threatened miscarriage (most common)
2. Inevitable miscarriage
3. Incomplete miscarriage
4. Ectopic pregnancy (if location uncertain — though IUP confirmed → less likely)
5. Missed miscarriage
6. Gestational trophoblastic disease (H mole)

Types of miscarriage and clinical differentiation

• Cervical os open vs closed (VE — only after ruling out placenta praevia)
• Bleeding: colour, amount, passage of products
• Pain: crampy (inevitable/incomplete) vs absent (missed)
• USS: FHR present or absent, products retained or not

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STUDENT 15 — Madura Sir: 34 weeks + vaginal discharge

DDs for 34 weeks POA with vaginal discharge

1. Prelabour Rupture of Membranes (PPROM) — most important to exclude
2. Physiological discharge (leucorrhoea of pregnancy — increased)
3. Infection: bacterial vaginosis, Trichomonas, Candida, STI (Chlamydia, gonorrhoea)
4. Premature labour with blood-stained mucous show
5. Cervical pathology (polyp, erosion/ectropion)
6. Placenta praevia (if blood-stained)

Diagnosis

• Speculum examination (sterile): visualise cervix, pool of amniotic fluid
• Ferning test: amniotic fluid on glass slide → fernlike pattern on drying
• Nitrazine/pH test: amniotic fluid pH >7 (vaginal pH normally acidic 3.8–4.5)
• Amniosure/PAMG-1 test: detects placental alpha-microglobulin-1 (highly specific for PPROM)
• High vaginal swab (HVS) for culture
• CTG, USS (AFI — amniotic fluid index; fetal wellbeing)

Management of PPROM at 34 weeks

1. Admit to hospital
2. Confirm diagnosis (see above)
3. Maternal and fetal monitoring: CTG, temperature every 4 hrs, WBC, CRP
4. Antenatal corticosteroids (betamethasone 12 mg IM × 2 doses, 24 hrs apart) — for fetal lung maturity (usually given up to 34–35 weeks)
5. Prophylactic antibiotics (erythromycin 250 mg QID for 10 days — ORACLE trial) to reduce chorioamnionitis and prolong latency
6. Monitor for chorioamnionitis: fever, uterine tenderness, offensive discharge, maternal tachycardia, fetal tachycardia, ↑WBC/CRP → if present → deliver
7. Delivery: At 34 weeks, many guidelines recommend delivery at 34–37 weeks; weigh risks of prematurity vs infection. Induction of labour if cervix favourable or delivery if chorioamnionitis/fetal distress.

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STUDENT 16 — Rukshan Sir: 6 weeks + pallor + tachycardia (IUP confirmed)

Management as HO

1. A-B-C: Airway, Breathing, Circulation
2. IV access × 2 large bore; IV fluid resuscitation (crystalloid bolus)
3. Blood tests: FBC, blood group + crossmatch, coagulation screen, serum β-hCG, renal/liver function
4. Oxygen via face mask
5. Call for senior (SpR/Consultant); alert theatre
6. Urgent USS to confirm IUP, viability, and rule out retained products
7. If haemorrhage: blood transfusion; surgical evacuation (ERPC) under GA
8. Anti-D immunoglobulin if Rh-negative

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STUDENT 17 — Rukshan Sir: Antepartum Haemorrhage (APH)

Definition of APH

Does bleeding during delivery count as APH?

Causes of APH

Most dreadful causes

Do you always need USS to diagnose placental abruption?

Clinical features of placental abruption

Concealed haemorrhage

Mode of delivery in placenta praevia

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STUDENT 18 — Madura Sir: Urinary Incontinence

Types of urinary incontinence

1. Stress urinary incontinence (SUI): involuntary urine leakage on coughing, sneezing, laughing (raised intra-abdominal pressure). Urethral sphincter/support mechanism weakness.
2. Urge urinary incontinence (UUI): sudden compelling urge to void followed by leakage; overactive bladder (detrusor instability).
3. Mixed incontinence: features of both SUI and UUI.
4. Overflow incontinence: incomplete bladder emptying → overflow; chronic retention (neurological, obstructed outflow).
5. Functional incontinence: inability to reach the toilet (mobility issues, cognitive impairment).

Management of stress incontinence

• Pelvic floor muscle training (PFMT) — supervised, minimum 3 months; Kegel exercises (most effective first-line)
• Weight loss (if obese)
• Reduce caffeine/fluid intake
• Bladder training
• Vaginal pessary (for associated prolapse)
• Topical oestrogen (if atrophic vaginitis in postmenopause)

• Duloxetine (SNRI) — increases urethral sphincter tone; 2nd line

• Mid-urethral sling (MUS) — Tension-free vaginal tape (TVT) or Trans-obturator tape (TOT); gold standard surgical treatment
• Colposuspension (Burch) — open/laparoscopic; for cases unsuitable for MUS
• Urethral bulking agents (injectable — for unfit surgical candidates)

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STUDENT 19 — Madura Sir: Ectopic Pregnancy

Definition of ectopic pregnancy

Most common site

Risk factors for ectopic pregnancy

• Previous ectopic pregnancy (highest risk — 10–15% recurrence)
• Previous pelvic/tubal surgery
• PID / Chlamydia (tubal scarring/adhesions)
• IUCD (relative risk — if pregnancy occurs with IUCD in situ)
• Assisted reproduction (IVF) — higher rate of ectopic
• Endometriosis
• Previous CS (scar ectopic)
• Smoking
• Multiple sexual partners

Other ectopic sites

• Ovarian ectopic
• Cervical ectopic — rare; painless bleeding; can be confused with abortion
• Abdominal/peritoneal ectopic — can rarely carry to late pregnancy
• Caesarean scar ectopic — increasing in incidence; serious
• Interstitial/cornual ectopic (in the intramural part of the tube — late rupture, massive haemorrhage)
• Broad ligament

Management of ectopic pregnancy

• Small ectopic (<30 mm), falling/low β-hCG (<1000 mIU/mL), asymptomatic, no fetal cardiac activity
• Serial β-hCG monitoring twice weekly until undetectable

• Methotrexate IM (50 mg/m²): inhibits DNA synthesis (folic acid antagonist)
• Criteria: unruptured, ≤35 mm, no fetal cardiac activity, β-hCG <5000 mIU/mL, haemodynamically stable, no contraindications (renal/hepatic disease, immunodeficiency, breastfeeding)
• Follow-up β-hCG on days 4 and 7 (expect 15% fall)

• Laparoscopic salpingotomy (incision and removal of ectopic — tube preserved): if other tube abnormal and fertility desired
• Laparoscopic salpingectomy (tube removal — preferred): if other tube normal; lower recurrence rate
• Laparotomy: if haemodynamically unstable/ruptured

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STUDENT 14 / STUDENT 8 — Madura Sir: Primary vs Secondary Dysmenorrhoea / Adenomyosis

Primary vs Secondary Dysmenorrhoea

Causes of secondary dysmenorrhoea

• Endometriosis — most common (also causes infertility, deep dyspareunia)
• Adenomyosis
• Uterine fibroids (submucosal especially)
• PID / chronic pelvic pain
• Ovarian cysts / endometrioma
• IUCD
• Cervical stenosis
• Uterine malformations (bicornuate, septate uterus)

Management of adenomyosis

• Levonorgestrel-releasing IUS (Mirena) — most effective; reduces menorrhagia and dysmenorrhoea; first-line in women wishing to preserve fertility
• Combined oral contraceptive pill (COCP) — reduces symptoms
• Progestogen therapy (norethisterone, medroxyprogesterone)
• GnRH agonists (temporary medical menopause; bridges to surgery; bone loss limits use to 6 months)
• Danazol

• Hysterectomy — definitive treatment; total hysterectomy (curative)
• Endometrial ablation (limited benefit; may recur)
• Adenomyomectomy (focal adenomyosis only; technically difficult)

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