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🩺 FMGE High-Yield: Obstetrics & Gynecology

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OBSTETRICS

1. Normal Labor & Partograph

• Stages of labor: I (0–10 cm dilation), II (full dilation → delivery), III (delivery → placenta)
• Alert line = starts at 4 cm; Action line = 4 hrs to the right
• Engagement: when biparietal diameter crosses pelvic inlet (head 2/5 palpable abdominally)
• Cardinal movements: Engagement → Descent → Flexion → Internal rotation → Extension → External rotation (restitution) → Expulsion

2. Fetal Monitoring

• Type I (early) deceleration: Head compression — benign
• Type II (late) deceleration: Uteroplacental insufficiency — ominous
• Variable deceleration: Cord compression
• Sinusoidal pattern: Fetal anaemia (Rh isoimmunization, vasa previa)

3. Antepartum Haemorrhage (APH)

4. Hypertensive Disorders

• Gestational HTN: BP ≥140/90 after 20 weeks, no proteinuria
• Pre-eclampsia: HTN + proteinuria (≥300 mg/24h) or end-organ damage after 20 weeks
• Eclampsia: Convulsions in a preeclamptic patient
• HELLP syndrome: Haemolysis, Elevated Liver enzymes, Low Platelets
• MgSO₄ (Pritchard regimen): 4g IV loading + 10g IM (5g each buttock); maintenance 5g IM 4-hourly
• Antidote for MgSO₄ toxicity: Calcium gluconate 1g IV
• Drug of choice for severe HTN in pregnancy: Labetalol IV (or hydralazine IV); oral – methyldopa

5. Gestational Diabetes (GDM)

• Diagnosis: 75g OGTT at 24–28 weeks (Carpenter & Coustan or IADPSG criteria)
• Fasting ≥92 mg/dL OR 1h ≥180 OR 2h ≥153 → GDM
• Drug of choice: Insulin (Metformin acceptable in many guidelines)
• Complication: Macrosomia → shoulder dystocia

6. Preterm Labor

• < 37 weeks; Tocolytics: Nifedipine (first-line), ritodrine, MgSO₄
• Betamethasone (12 mg IM × 2 doses, 24h apart) for fetal lung maturity — 24–34 weeks
• Cervical cerclage (McDonald/Shirodkar) for cervical incompetence

7. Postpartum Haemorrhage (PPH)

• Primary: ≥500 mL loss within 24h of vaginal delivery (≥1000 mL for LSCS)
• 4 Ts: Tone (most common, 80%) > Trauma > Tissue > Thrombin
• Oxytocin = first-line uterotonic; Carboprost = most potent uterotonic (contraindicated in asthma)
• B-Lynch suture, uterine artery ligation, internal iliac ligation, hysterectomy (ascending order)

8. Malpresentations

• Breech: Frank (extended legs, most common) > Complete > Footling
• Face presentation: Mentum anterior → vaginal delivery possible; Mentum posterior → LSCS
• Brow: Always LSCS (largest diameter — mento-vertical 13.5 cm)
• Transverse lie: LSCS; Oblique lie: unstable, may convert

9. Cord Complications

• Cord prolapse: Emergency LSCS; knee-chest position to relieve pressure
• Vasa previa: Fetal vessels over internal os; sinusoidal CTG; Apt test (pink → fetal blood)

10. Rh Isoimmunization

• Anti-D (Rho-GAM): 300 μg IM within 72h of delivery/abortion
• Given at 28 weeks antenatally
• Kleihauer-Betke test: Estimates fetomaternal hemorrhage
• Hydrops fetalis: Fetal ascites, scalp edema, pleural effusion → treat with intrauterine transfusion

11. Ectopic Pregnancy

• Most common site: Ampulla of fallopian tube
• Triad: Amenorrhea + pain + bleeding
• β-hCG discriminatory zone: 1500–2000 mIU/mL (should see sac on TVS)
• Medical: Methotrexate (single dose IM); criteria: unruptured, <4 cm, β-hCG <5000, no fetal cardiac activity
• Surgical: Salpingostomy (conservative) or salpingectomy

12. Gestational Trophoblastic Disease (GTD)

• Follow-up: Serial β-hCG until negative × 3 weeks; contraception for 1 year
• Choriocarcinoma: Most chemosensitive — Methotrexate (low-risk EMA-CO for high-risk)

13. PROM / PPROM

• PROM: Rupture of membranes before onset of labor at term
• PPROM: Rupture before 37 weeks; ferning + nitrazine test + pooling
• GBS prophylaxis: Penicillin G (ampicillin if unavailable)
• Latency period: Time from ROM to onset of labor

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GYNECOLOGY

14. Menstrual Disorders

• Normal cycle: 21–35 days; duration 2–7 days; blood loss 20–80 mL
• Dysfunctional Uterine Bleeding (DUB): Diagnosis of exclusion; mostly anovulatory
• AUB-PALM-COEIN classification (FIGO 2011)
• Treatment: Tranexamic acid, NSAIDs, OCP, LNG-IUS (Mirena), GnRH agonists, endometrial ablation

15. PCOS

• Rotterdam criteria (2 of 3): Oligo/anovulation + Clinical/biochemical hyperandrogenism + Polycystic ovaries on USG
• LH:FSH ratio > 2:1
• Drug of choice for ovulation induction: Clomiphene citrate (first-line); Letrozole (better in PCOS per recent evidence)
• Metformin for insulin resistance
• LOD (laparoscopic ovarian drilling) if resistant

16. Endometriosis

• Chocolate cyst = Endometrioma (ovary)
• Powder burn/gun-shot lesions on laparoscopy (gold standard diagnosis)
• CA-125 elevated (not specific)
• Medical: Danazol (androgenic), GnRH agonists, combined OCP, progestins
• Surgical: For infertility or failed medical Rx

17. Fibroids (Leiomyoma)

• Most common benign tumor of uterus; estrogen-dependent
• Submucosal → most symptomatic (menorrhagia); Intramural → most common
• Red degeneration: Occurs in pregnancy (carneous degeneration)
• Rx: Myomectomy (fertility-preserving); hysterectomy (definitive)
• Mifepristone/GnRH agonists: Preoperative shrinkage
• Uterine Artery Embolization (UAE): Non-surgical option

18. Cervical Cancer

• HPV 16, 18 → most common cause (squamous cell carcinoma most common type)
• Pap smear: Screening; Colposcopy: Diagnostic
• FIGO staging: Clinical
  • Stage I: Limited to cervix
  • Stage IIA: Upper 2/3 vagina
  • Stage IIB: Parametrial involvement (but not pelvic wall)
  • Stage IIIB: Hydronephrosis/pelvic wall
  • Stage IVA: Bladder/rectum involvement
• Wertheim's hysterectomy: Stage IB1–IIA2
• CIN treatment: LLETZ/LEEP (most common), cryotherapy, cone biopsy

19. Endometrial Cancer

• Most common gynecological malignancy in developed countries
• Type I (endometrioid): Estrogen-related, better prognosis; Type II (serous/clear cell): Estrogen-independent
• Risk factors: PCOD, obesity, nulliparity, HRT (unopposed estrogen), tamoxifen use
• Postmenopausal bleeding = endometrial cancer until proven otherwise
• Diagnosis: Pipelle biopsy (office); staging: surgical (FIGO)

20. Ovarian Cancer

• Most lethal gynecological malignancy
• CA-125: Marker for epithelial ovarian cancer
• Serous cystadenocarcinoma: Most common malignant; Serous cystadenoma: Most common benign
• Krukenberg tumor: Metastatic (mucin-secreting cells from GI tract — stomach most common)
• Meigs' syndrome: Ovarian fibroma + ascites + pleural effusion
• Dermoid cyst (mature teratoma): Most common ovarian tumor in young women; Rokitansky nodule (tooth)
• Dysgerminoma: Most common malignant germ cell tumor; marker — LDH, β-hCG, AFP

21. Contraception

22. Infertility

• Primary: Never conceived; Secondary: After at least one pregnancy
• Semen analysis (WHO 2021): Volume ≥1.4 mL, concentration ≥16 million/mL, motility ≥42%, morphology ≥4%
• HSG: Tubal patency (gold standard for tubes)
• Day 21 progesterone: Confirms ovulation
• IVF indications: Tubal factor, severe MFI, failed IUI, endometriosis

23. STIs

• Syphilis (Treponema pallidum): Primary — painless chancre; Secondary — condylomata lata, maculopapular rash; Treatment — Benzathine penicillin 2.4 MU IM
• Gonorrhea: Gram-negative diplococci; Rx — Ceftriaxone 500 mg IM single dose
• Chlamydia: Most common bacterial STI; intracellular; Rx — Azithromycin 1g stat or doxycycline
• Chancroid (Haemophilus ducreyi): Painful ulcer + inguinal bubo; Rx — Azithromycin/ceftriaxone
• LGV (C. trachomatis L1–L3): Groove sign of Greenblatt; Rx — Doxycycline

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QUICK MNEMONICS

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HIGH-FREQUENCY EXAM TRAPS

1. Placenta previa + previous LSCS → suspect Placenta accreta spectrum
2. Couvelaire uterus → abruption (concealed); may still bleed despite firm uterus
3. Ritodrine = beta-mimetic tocolytic; side effect = pulmonary edema, tachycardia
4. MgSO₄ is NOT an antihypertensive — it prevents/treats seizures in eclampsia
5. Asherman syndrome: Intrauterine adhesions post-D&C → secondary amenorrhea; Rx — hysteroscopic adhesiolysis
6. Sheehan syndrome: Postpartum pituitary necrosis → failure to lactate, amenorrhea
7. DIC in obstetrics: Abruption, amniotic fluid embolism, IUFD, sepsis, eclampsia
8. Non-immune hydrops: More common than immune (Rh); causes — cardiac defects, infections (parvovirus B19)

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🧠 Section 1 — OBG Mnemonics (16 cards)

💊 Section 2 — OBG Drugs (15 cards)