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OBSTETRICS & GYNECOLOGY - HIGH-YIELD EXAM NOTES

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PART 1: OBSTETRICS

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A. EARLY PREGNANCY

Signs of Pregnancy

Mnemonic for Probable signs: "Good Hegar's Chadwick Browne Braxton Ballots" = Goodell, Hegar, Chadwick, Braun von Fernwald, Braxton Hicks, Ballottement

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Preconceptional Care

• Folic acid: 400 mcg/day (begin 1 month before conception, continue through 12 weeks) - prevents neural tube defects
  • High-risk (prior NTD, antiepileptics): 4-5 mg/day
• Iron: 30 mg/day elemental iron in pregnancy
• Iodine: 150 mcg/day (prevents cretinism)
• Calcium: 1000-1200 mg/day (prevents preeclampsia in low-intake populations)
• Vitamin D: 600 IU/day

• Influenza (inactivated) - any trimester
• Tdap (tetanus, diphtheria, pertussis) - 27-36 weeks each pregnancy (passive immunity to newborn)
• COVID-19 mRNA vaccines - safe, recommended
• Hepatitis B - safe if indicated

• MMR, Varicella, Zoster, Yellow Fever (avoid in pregnancy)
• Give MMR/Varicella postpartum if non-immune

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Parity Index (GTPAL)

• G3T1P1A1L2 = 3 pregnancies; 1 term, 1 preterm, 1 abortion; 2 living children
• Nulligravida = never pregnant | Nullipara = never delivered past 20 weeks
• Grand multipara = ≥5 deliveries ≥20 weeks

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Teratogens and Associated Defects

Key rule: Critical period for organogenesis = weeks 3-8 of gestation (most vulnerable to teratogens)

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Trimester-wise Screenings

• Nuchal translucency (NT) USG: 11-13+6 weeks - screens Down syndrome (T21), T18, T13
• Cell-free fetal DNA (cfDNA/NIPT): From 10 weeks onward - screens T21, T18, T13, sex chromosome aneuploidies
• First trimester combined screen: NT + PAPP-A + free beta-hCG (detection rate ~85%)
• Dating ultrasound: best at 11-14 weeks (CRL)
• Chorionic villus sampling (CVS): 10-13 weeks for definitive karyotype

• Quad screen (15-20 weeks): AFP, hCG, Estriol, Inhibin A
  • Down (T21): ↓AFP, ↑hCG, ↓E3, ↑Inhibin A
  • T18 (Edwards): ↓AFP, ↓hCG, ↓E3, normal Inhibin A
  • NTD (open): ↑AFP
• Anomaly scan (morphology scan): 18-22 weeks - structural survey
• Amniocentesis: 15-20 weeks for karyotype
• Glucose challenge test (GCT): 24-28 weeks (screen for GDM)
• GBS screen: 35-37 weeks (Group B Streptococcus rectovaginal swab)

• Biophysical profile (BPP), Non-stress test (NST), growth scans
• Repeat CBC, HIV, syphilis in high-risk
• GBS culture: 35-37 weeks

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Leopold Maneuvers

Engagement = leading edge of presenting part at level of ischial spines (0 station)

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B. HIGH-YIELD CONDITIONS

Cervical Insufficiency (Incompetent Cervix)

• History-indicated (prophylactic): 12-14 weeks
• Ultrasound-indicated: When cervical length <25 mm at <24 wks
• Rescue (emergency): Dilated cervix with bulging membranes - highest risk

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Antiphospholipid Antibody Syndrome (APLA)

• Vascular thrombosis (arterial, venous, or small vessel)
• Pregnancy morbidity:
  • ≥3 consecutive unexplained early (<10 wks) pregnancy losses
  • ≥1 unexplained fetal death (≥10 wks morphologically normal fetus)
  • ≥1 preterm birth <34 wks due to preeclampsia, eclampsia, or placental insufficiency

• Lupus anticoagulant (LA)
• Anti-cardiolipin antibodies (aCL) IgG or IgM (medium-high titer)
• Anti-β2 glycoprotein-I antibodies IgG or IgM

• Low-dose aspirin (81 mg/day) + prophylactic LMWH (enoxaparin)
• Thrombotic APLA: therapeutic LMWH dose
• Switch to IV unfractionated heparin at term (reversible with protamine)
• Do NOT use warfarin in pregnancy

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Ectopic Pregnancy

• Serum β-hCG: rises abnormally (<66% rise in 48h is suspicious)
• Discriminatory zone: β-hCG >1500-2000 mIU/mL should show IUP on transvaginal USG
• USG: adnexal mass, empty uterus, free fluid in POD

Post-methotrexate: avoid folic acid supplements, NSAIDs, sun exposure; contraception for 3 months

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Molar Pregnancy (Gestational Trophoblastic Disease)

1. Suction evacuation (preferred method)
2. Serial weekly β-hCG monitoring until undetectable (3 consecutive normals)
3. Contraception for 6 months (complete mole) - OCP preferred
4. Chemotherapy if persistent GTD: methotrexate or actinomycin-D

• β-hCG plateau for ≥4 weeks (4 values over 3 weeks)
• β-hCG rise ≥10% for 3 values over 2 weeks
• Metastatic disease
• Persistent elevated hCG >6 months

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C. PLACENTA & AMNIOTIC FLUID

Placental Abnormalities

• Battledore placenta: cord inserts at margin (not center)
• Velamentous cord insertion: cord inserts into membranes before reaching placenta; risk of vasa previa
• Vasa previa: Fetal vessels traverse over internal os; causes painless bleeding with FHR changes at ROM; Dx: color Doppler; deliver by C-section at 34-35 wks

• Succenturiate lobe: accessory lobe separate from main placenta (risk of retained placenta)
• Bilobate placenta: two equal lobes

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Amniotic Fluid Abnormalities

• Amniotic fluid enters maternal circulation
• Classic triad: hypoxia + hypotension + DIC during/after delivery
• Management: aggressive supportive care, ICU, correct coagulopathy

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Placenta Previa vs Placental Abruption

• Complete (central): Placenta completely covers internal os
• Partial: Partially covers os
• Marginal: Edge within 2 cm of os
• Low-lying: 2-3.5 cm from os

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Placenta Accreta Spectrum (PAS)

• USG: loss of retroplacental clear space, lacunae (Swiss cheese appearance), bladder wall irregularity
• MRI: confirms invasion depth, surgical planning

• Planned C-section at 34-35 weeks (before labor)
• Multidisciplinary team: OB, urology, interventional radiology, blood bank
• Cesarean hysterectomy (planned) - placenta left in situ
• Cell salvage, balloon occlusion catheters preoperatively

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D. MULTIPLE PREGNANCY

Multiple Pregnancy Mechanics

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MCDA vs DCDA on Ultrasound

Mnemonics: DC = DickyChick (Lambda/Twin peak); MC = Monochorionic (T-sign)

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TTTS (Twin-to-Twin Transfusion Syndrome)

• Occurs in MCDA twins (shared monochorionic placenta)
• Arteriovenous anastomoses cause unidirectional blood flow
• Donor twin: Oligohydramnios, small/hydropic, anemia, IUGR, "stuck twin"
• Recipient twin: Polyhydramnios, large, polycythemia, cardiac overload, hydrops

• Stage I: close surveillance
• Stage II-IV: Fetoscopic laser photocoagulation (FLP) of anastomosing vessels - treatment of choice
• Amnioreduction: temporizing measure

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E. MEDICAL DISORDERS IN PREGNANCY

Hypertension in Pregnancy - Classification

• Mild-moderate HTN: Methyldopa (1st choice), labetalol, nifedipine, hydralazine
• Acute severe HTN (≥160/110): IV labetalol, IV hydralazine, oral nifedipine (immediate release)
• Avoid: ACEi, ARBs, direct renin inhibitors

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Preeclampsia

• New-onset HTN (≥140/90) after 20 weeks PLUS:
  • Proteinuria ≥300 mg/24h (or PCR ≥0.3, or dipstick ≥2+) OR
  • Any of the following (severe features):

• BP ≥160/110 on two occasions ≥4h apart
• Thrombocytopenia (<100,000/µL)
• Renal insufficiency (Cr >1.1 mg/dL or doubled)
• Impaired liver function (AST/ALT >2× normal) or severe RUQ/epigastric pain
• Pulmonary edema
• New-onset headache unresponsive to medication OR visual disturbances

• Mild (without severe features) ≥37 weeks: Deliver
• Mild (without severe features) <37 weeks: Expectant management, steroids if <34 wks, weekly monitoring
• Severe features: Deliver at ≥34 weeks; between 24-34 weeks consider stabilization + corticosteroids
• Seizure prophylaxis: Magnesium sulfate (4-6 g IV loading dose, then 1-2 g/h maintenance)
• MgSO4 toxicity: loss of patellar reflexes (first sign), respiratory depression, cardiac arrest; Antidote: Calcium gluconate 1g IV

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Eclampsia

• Definition: Preeclampsia + grand mal (generalized tonic-clonic) seizure not attributable to other causes
• Can occur antepartum (most common), intrapartum, or postpartum (up to 48h after delivery)

• Magnesium sulfate (seizure control and prevention of recurrence)
• Antihypertensives (control BP)
• Right lateral decubitus (left lateral positioning)
• Ventilate/airway management
• Electronic fetal monitoring
• Labor and delivery (definitive treatment)
• Steroids if <34 weeks

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HELLP Syndrome

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

• Class 1: Platelets <50,000
• Class 2: Platelets 50,000-100,000
• Class 3: Platelets 100,000-150,000 (partial HELLP)

• Delivery (definitive treatment) - at any gestational age if ≥34 weeks or deteriorating
• MgSO4 for seizure prophylaxis
• Antihypertensives
• Corticosteroids (dexamethasone) - may improve platelet count temporarily; allow delivery preparation
• Avoid platelet transfusion unless <20,000 or active bleeding
• Most labs normalize within 48-72h postpartum

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Diabetes in Pregnancy

• Pre-gestational DM (PGDM): Type 1 or Type 2 existing before pregnancy
• Gestational DM (GDM): Diagnosed during pregnancy

• Universal screening at 24-28 weeks
• One-step (IADPSG): 75g OGTT - fasting ≥92, 1h ≥180, 2h ≥153 mg/dL
• Two-step (ACOG): 50g GCT (non-fasting) → if ≥140 mg/dL, confirm with 100g OGTT (Carpenter-Coustan criteria)

• Maternal: preeclampsia, C-section, UTI, polyhydramnios
• Fetal: macrosomia (>4 kg), shoulder dystocia, birth trauma, IUFD, respiratory distress, neonatal hypoglycemia, congenital anomalies (PGDM - sacral agenesis, VSD, TGA)

• Diet and exercise first
• If uncontrolled: Insulin (drug of choice in pregnancy; metformin/glyburide as alternatives)
• Target blood glucose: fasting <95, 1h postprandial <140 mg/dL
• Antenatal surveillance: NST, BPP
• Delivery: GDM at 39-40 weeks; PGDM at 36-38 weeks depending on control
• White classification: A1 (diet-controlled), A2 (medication-required), B-H (pregestational, by age of onset and duration)

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F. LABOR & DELIVERY

Modified Bishop Score

Score ≥8: Favorable cervix - likely successful induction Score ≤5: Unfavorable - cervical ripening agents needed (misoprostol, dinoprostone, Foley balloon)

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Stages of Labor

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Active Management of Third Stage of Labor (AMTSL)

1. Uterotonics within 1 minute of delivery - Oxytocin 10 IU IM (drug of choice); alternatives: ergometrine, carboprost, misoprostol
2. Controlled cord traction (Brandt-Andrews maneuver): counter-pressure on uterus + gentle traction on cord during contraction
3. Uterine massage after placental delivery

AMTSL reduces PPH risk by 60-70%

• Schultze mechanism: fetal (shiny) surface presents first; most common
• Duncan mechanism: maternal (rough) surface presents first; peripheral separation

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Breech Presentation - Management

• Frank breech: hips flexed, knees extended (most common, 65%)
• Complete breech: hips & knees flexed ("cannonball")
• Footling (incomplete): one or both feet presenting

• External cephalic version (ECV): Attempted at 36-37 weeks (term); success ~50-60%; tocolysis used
• Planned C-section: Preferred delivery for persistent breech at term
• Vaginal breech delivery: Only in selected cases (trained provider, frank or complete breech, adequate pelvis, flexed head, 37+ weeks)

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Lovset's Maneuver (for Extended Arms)

1. Hold baby by hips/pelvis, thumbs on sacrum
2. Rotate body 180° (turning back anteriorly) while applying downward traction
3. Posterior arm (now anterior) sweeps down and can be delivered
4. Rotate back 180° and deliver the other arm

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Burns-Marshall Maneuver (for Aftercoming Head)

1. Allow baby to hang by its own weight until nape of neck appears (spontaneous cervical extension)
2. Hold ankles and swing body in wide arc over maternal abdomen
3. Baby's mouth and nose delivered
4. Jaw and face follow over perineum

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Shoulder Dystocia - HELPERR Algorithm

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Postpartum Hemorrhage (PPH) - EMOTIVE Protocol

• Tone (70-80%): Uterine atony - most common
• Trauma: Lacerations, uterine rupture, inversion
• Tissue: Retained placenta/membranes
• Thrombin: Coagulopathy (DIC, HELLP, AFE)

1. Oxytocin (1st line)
2. Ergometrine / Syntometrine (CI: HTN)
3. Carboprost (PGF2α) - 250 mcg IM every 15 min, max 8 doses (CI: asthma)
4. Misoprostol 800-1000 mcg PR/SL
5. Tranexamic acid - recommended within 3h of diagnosis (WOMAN trial)

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PART 2: GYNECOLOGY

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G. MENSTRUAL DISORDERS

Mullerian Anomalies (ASRM Classification)

Septate uterus = most common Mullerian anomaly causing recurrent miscarriage - treatment: hysteroscopic metroplasty

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Primary vs Secondary Amenorrhea

• Age 13 with no breast development
• Age 15 with normal secondary sexual characteristics

• High FSH (>40 mIU/mL) = Ovarian failure (hypergonadotropic hypogonadism) - primary ovarian insufficiency (POI), Turner syndrome (45,X), gonadal dysgenesis
• Low/normal FSH = Hypothalamic-pituitary cause (hypogonadotropic hypogonadism) - Kallmann syndrome, functional hypothalamic amenorrhea (stress, exercise, low weight), Sheehan's syndrome
• High FSH + High LH (2:1 ratio LH:FSH) in setting of normal estrogen + anovulation = PCOS

• ↑FSH, ↓Estrogen, no uterus, 46,XY: Androgen insensitivity syndrome (complete AIS)
• ↑FSH, ↓Estrogen, uterus present, 45,X: Turner syndrome
• Normal FSH, Progesterone withdrawal bleed: Anovulation (PCOS)
• No withdrawal bleed: Outflow tract obstruction (Asherman's) or uterine/vaginal agenesis

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Abnormal Uterine Bleeding - FIGO PALM-COEIN Classification

• HMB (Heavy Menstrual Bleeding): >80 mL or subjectively heavy interfering with quality of life
• Oligomenorrhea: Cycles >35 days
• Polymenorrhea: Cycles <21 days

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H. UTERINE CONDITIONS

Adenomyosis

• USG: thickened posterior wall, asymmetric myometrium, heterogeneous myometrium, myometrial cysts (Swiss cheese pattern), "question mark" uterus sign
• MRI (gold standard): junctional zone thickness ≥12 mm

• Medical: Levonorgestrel IUD (LNG-IUD/Mirena) - first-line; combined OCP; progestogens; GnRH agonists
• Surgical: Hysterectomy (definitive)

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Fibroids (Leiomyomas)

• Submucosal (types 0-2): Most symptomatic; cause HMB, recurrent miscarriage
• Intramural (types 3-5): Most common overall; bulk symptoms
• Subserosal (types 5-7): Pelvic pressure, urinary/bowel symptoms; pedunculated can tort

• Medical: Tranexamic acid, NSAIDs, OCP, progestogens, LNG-IUD; GnRH agonists (shrink fibroids 30-50%, used pre-op); Ulipristal acetate (selective progesterone receptor modulator)
• Surgical: Myomectomy (fertility-preserving), hysterectomy (definitive)
• Procedural: Uterine artery embolization (UAE), MRI-guided focused ultrasound (MRgFUS)

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Endometriosis

• Stage I (Minimal): Isolated implants
• Stage II (Mild): Implants + mild adhesions
• Stage III (Moderate): Endometriomas, moderate adhesions
• Stage IV (Severe): Large endometriomas, dense adhesions, cul-de-sac obliteration

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Endometrial Hyperplasia

• Endometrial hyperplasia without atypia (simple or complex): Low risk of malignancy (<5%); responds to progesterone
• Endometrial intraepithelial neoplasia (EIN) / Atypical hyperplasia: 30-40% risk of coexisting/progression to endometrial cancer

• Without atypia: Continuous progestogens (LNG-IUD preferred), repeat endometrial sampling
• With atypia (EIN): Hysterectomy (standard); progestogen therapy if fertility desired or surgical risk high
• Rule out concurrent endometrial carcinoma before conservative management

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I. HIGH-YIELD CLINICALS (GYNECOLOGY)

Vaginal Infections

1. Homogeneous grey-white discharge
2. Vaginal pH >4.5
3. Positive whiff/amine test
4. Clue cells on microscopy (≥20%)

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Ovarian Cysts and Tumors

• Follicular cyst: Failed ovulation, resolves spontaneously; thin-walled, unilocular, <10 cm
• Corpus luteum cyst: Post-ovulation, may cause delayed menses, pain; can hemorrhage (hemoperitoneum)
• Theca lutein cysts: Bilateral, associated with ↑hCG (molar pregnancy, ovarian hyperstimulation)

• Most common ovarian tumor in young women/girls
• Contains hair, teeth, sebaceous material
• USG: Rokitansky protuberance (dermoid plug), shadowing teeth
• Complication: Ovarian torsion, rupture (chemical peritonitis)
• Management: Cystectomy (preserve ovarian tissue)

• Risk factors: Large cysts >5 cm, dermoids, ovarian hyperstimulation
• Symptoms: Sudden-onset unilateral pelvic pain, N/V, adnexal mass
• USG + Doppler: May show absent flow (not always)
• Management: Surgical (laparoscopic detorsion); salpingo-oophorectomy if necrotic

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Cervical Cancer - Screening and Diagnosis

• CIN I = Mild dysplasia (lower third of epithelium)
• CIN II = Moderate (lower two-thirds)
• CIN III = Severe dysplasia/carcinoma in situ (full thickness)

• CIN I: Observation (most regress spontaneously)
• CIN II-III: LEEP (Loop Electrosurgical Excision Procedure) or cryotherapy or cold knife cone (CKC)
• Microinvasive (Stage IA1): LEEP or cone or simple hysterectomy
• Stage IA2-IIA: Radical hysterectomy + lymph node dissection (Wertheim's hysterectomy)
• Stage IIB+: Concurrent chemoradiation (cisplatin + external beam RT + brachytherapy)

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HPV Vaccination

• 2-dose series: Given at 0, 6-12 months (if first dose <15 years)
• 3-dose series: 0, 1-2, 6 months (if ≥15 years or immunocompromised)

• Routine vaccination: 9-12 years (boys and girls)
• Catch-up: 13-26 years
• Shared decision-making: 27-45 years

Vaccination does NOT eliminate need for cervical screening

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PCOS (Polycystic Ovary Syndrome)

1. Oligo/anovulation (irregular cycles >35 days or <8 cycles/year)
2. Clinical or biochemical hyperandrogenism (acne, hirsutism, elevated testosterone/free androgen index)
3. Polycystic ovaries on USG (≥20 follicles/ovary in 8 MHz probe OR ovarian volume >10 mL)

Must exclude other causes: thyroid disease, hyperprolactinemia, non-classical CAH (21-hydroxylase deficiency - check 17-OHP)

• Menstrual irregularity (oligomenorrhea, anovulation, secondary amenorrhea)
• Hirsutism (Ferriman-Gallwey score ≥8), acne, androgenic alopecia
• Obesity (central), acanthosis nigricans (insulin resistance)
• Infertility (anovulation)
• Long-term risks: Type 2 DM, metabolic syndrome, endometrial cancer (unopposed estrogen from anovulation), cardiovascular disease

• LH:FSH ratio >2:1 (or >3:1)
• Elevated LH, normal or low FSH
• Elevated androgens (testosterone, DHEAS)
• Elevated AMH
• Low SHBG

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Contraception

• Mechanism: Inhibit ovulation (primary), cervical mucus thickening, endometrial atrophy
• Absolute contraindications (UKMEC 4): Migraine with aura, DVT/PE history, breast cancer, liver disease, current smoker >35 yrs, hypertension ≥160/100, SLE with antiphospholipid antibodies
• Non-contraceptive benefits: Reduced dysmenorrhea, HMB, acne, ovarian/endometrial cancer risk

• Safe in breastfeeding, HTN, migraine
• Mechanism: Primarily cervical mucus; norethisterone (traditional); desogestrel (inhibits ovulation too)
• Must be taken within 3h window (traditional) or 12h (desogestrel)

• Levonorgestrel (Plan B): 1.5 mg single dose within 72 hours (best within 12h); does not affect established pregnancy
• Ulipristal acetate (ella): 30 mg within 120 hours; more effective than LNG; avoid with progestogens
• Copper IUD: Most effective EC; within 5 days of unprotected sex; can be kept for ongoing contraception

• Mechanism: toxic to sperm (copper ions), impairs fertilization, prevents implantation
• CI: Pregnancy, unexplained uterine bleeding, pelvic infection, uterine anomaly, copper allergy
• Side effects: Heavier, more painful periods
• Duration: 5-10 years (depending on device)

• Mechanism: Progestogen locally - cervical mucus, endometrial atrophy, partial ovulation suppression
• Benefits: Reduces HMB by 90%, treats endometriosis/adenomyosis, amenorrhea
• Duration: 5-8 years

• 150 mg IM every 12 weeks (or 104 mg SC every 13 weeks)
• Return to fertility may be delayed 6-18 months
• Side effect: Irregular bleeding, bone density loss (reversible), amenorrhea

• Single subdermal rod, left upper arm
• Contains etonogestrel, works for 3 years
• Most effective reversible contraception

• Female: Laparoscopic salpingectomy (now preferred over tubal ligation - also reduces ovarian cancer risk); Essure (discontinued)
• Male: Vasectomy - cheaper, safer, more effective; takes 12-20 weeks to confirm azoospermia

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QUICK-REFERENCE MNEMONICS SUMMARY

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• Early Pregnancy - All 3 categories of pregnancy signs (presumptive/probable/positive), preconceptional supplements + safe/unsafe vaccines, GTPAL parity index, teratogens table with specific defects, trimester-wise screening protocols, and all 4 Leopold maneuvers with what each determines
• High-Yield Conditions - Cervical insufficiency with McDonald's/Shirodkar/transabdominal cerclage comparison; APLA Sapporo criteria + pregnancy management; Ectopic pregnancy (expectant/MTX/surgical criteria); Complete vs partial mole (karyotype, USG, hCG, malignant potential)
• Placenta & Amniotic Fluid - Vasa previa, Battledore/velamentous insertion; polyhydramnios vs oligohydramnios with causes and mnemonics; Previa vs abruption comparison table; PAS accreta/increta/percreta + management
• Multiple Pregnancy - Chorionicity by day of division; DCDA vs MCDA USG features (Lambda sign vs T-sign); TTTS Quintero staging + FLP
• Medical Disorders - HTN classification; preeclampsia diagnosis + severe features + MgSO4; eclampsia MARVELS; HELLP Tennessee criteria + Mississippi classification; GDM screening (one-step/two-step) + management

• Modified Bishop score table (all 5 parameters); stages of labor; AMTSL 3 components; breech types + ECV; Lovset's + Burns-Marshall maneuvers; HELPERR shoulder dystocia algorithm; PPH EMOTIVE protocol + 4 T's

• Mullerian anomalies (ASRM Classes I-VII including MRKH); primary vs secondary amenorrhea workup with FSH interpretation; PALM-COEIN AUB classification; Adenomyosis/Fibroids/Endometriosis/Endometrial hyperplasia (diagnosis + management); Vaginal infections comparison (BV/VVC/Trichomonas) with Amsel's criteria; Ovarian cysts + tumor markers + cancer histology types; Cervical cancer screening (ACOG 2021) + CIN management; HPV vaccination schedules; PCOS Rotterdam criteria + full management; Contraception efficacy table + mechanism/CI for each method