I am going to give you some complex tasks of obstetrics and gynaecology. Read all the books like williams and dcdutta and others to give me the most detailed and correct answers along with diagnosis of each task . Give an explanatory answer. Below are the most difficult and complicated clinical cases from the file, based on complexity of diagnosis, management decisions, rare pathology, or multiple simultaneous issues. Each case is reproduced exactly as in the English portions of the document. --- CASE № 9 Primipara woman 20 years old was send to the labor room with a full-term pregnancy in a state of sopor. At home and on the road was three attack of eclampsia. BP 180/100. Labor after 2-3 minutes. The opening of the cervix is complete, head into the pelvic cavity. Fetus is medium size. Fetal heartbeat muffled, 160 bpm. 1. Diagnosis. 2. Plan for the management of labor. 3. List the sequence of events to help the mother in this case. 4. List the major clinical manifestations of an attack of eclampsia according to stages. 5. Condition and indications for forceps. 6. Show on the phantom method to operate forceps. CASE № 11 In primigravida women, whose pregnancy proceeded with moderate preeclampsia, during labor arise stomach pain, weakness, dizziness, bleeding from the genital tract. Pulse increased to 100 bpm, blood pressure 100/60 mmHg. The uterus is tense, painful on palpation, more on the right, between labor attempts not relaxed. The fetal head in the pelvic cavity. Fetal heart rate - about 100 bpm. Vaginal examination: a complete opening of the cervix, the amniotic sac is not present, the fetal head in the narrowest part of the pelvis, a small fontanelle at the left womb, located below the big one. 1. Make a preliminary diagnosis. 2. What are the main etiological cause of this disease? 3. Further management plan. 4. Is it possible in this case, the use of forceps instead of vacuum? CASE № 13 Multipara woman in the second stage of labor with mixed breech presentation of fetus, marked decrease in the fetal heart rate up to 100 beats / min and decrease of the heart sounds. At vaginal examination, cervix is not noted, buttocks and feet of the fetus are in the pelvic cavity, prolapse of umbilical cord found. 1. Diagnosis. 2. Plan for the conduction of labor. 3. What are the mistakes? 4. Is it possible to give birth to a living fetus with umbilical cord prolapsed by vaginal delivery: a) in the cephalic presentation, and b) for breech presentation? 5. What kind of aid should be provided to women in the II stage of labor when there is prolapse of umbilical cord: a) cephalic presentation, and b) in breech presentation? 6. At 34 weeks revealed breech presentation of fetus, further tactics of doctor of women consultation clinic. CASE № 26 We report a 35 year old lady presenting with a bladder stone formed over a migrated intrauterine device. The lady presented to her gynecologist with amenorrhea for 3 months, irritative lower urinary tract symptoms and hematuria. The lady had an 8 week gestation pregnancy. History was suggestive of intrauterine contraceptive device placement 10 years back. The patient underwent dilatation and curettage as she was not keen on continuing the pregnancy. Investigations included hematocrit, plain X-ray of abdomen, ultrasound of abdomen, urinalysis, and urine culture and sensitivity. Plain X-ray and ultrasound of the abdomen confirmed a bladder stone. Open cystolithotomy was performed under general anesthesia. The stone formed over a copper-T intrauterine contraceptive device. Post operative course was uneventful and the patient is currently asymptomatic. The importance of post-insertion follow up and the need for awareness of migration of intrauterine contraceptive device including intravesical migration cannot be overemphasized. 1. What is the plan of investigation? Write the expected results. 2. What is the surgical treatment for this pathology? CASE № 34 Multipara woman, 28 years old. The first fetal kicking felt on the 8.03.2012. Two weeks ago, increased blood pressure to 150/100 mmHg. Appeared edema, proteinuria 0.6 g / l. Refused hospitalization, was treated at home with hydrochlorothiazide. Taken to the hospital on the 3.08.2012 with complaints of headache, blurred vision. The contractions every 2-3 minutes for 30 seconds. Green amniotic fluid poured out on admission. Fetal heartbeat can not be heard. The opening of the cervix is complete, head pressed against the entrance to the pelvis. Blood pressure 160/100 mmHg. 1. Diagnosis. 2. Plan for the management of labor and the sequence of events to help the mother in this case. 3. What are the mistakes? 4. List the possible indications for CS from the task. 5. List the conditions and contraindications for forceps. CASE № 35 The second stage of delivery of twins. After the birth of the first fetus weighing 2900 g, carried out vaginal examination, at which revealed that the second fetus is in a transverse lie, the head of the fetus on the right, rhythmic heartbeat of the fetus, 132 beats per minute, at the level of the umbilicus. 1. Diagnosis. 2. Plan for the management of labor. 3. What are the methods for the determination of breech presentation of twins? 4. List the possible complications during labor for the mother and the fetus. 5. If the first fetus of the twins would be in the breech position , what complications could arise in conservative management of labor ? CASE № 39 A 35-year-old Gravida 3 Para 2 patient with a dizygotic twin pregnancy presents for a routine prenatal visit at 13 weeks gestation. She is nervous about being a "high-risk" obstetric patient and wonders about the possibility of complications. 1. Which of the following is not an issue about which she should be concerned? She is at 38 weeks gestation with vertex/vertex twin presents for induction of labor. She is begun on oxytocin and begins having contractions after several hours. She progresses slowly over the next 16 hours until she is 5 cm and at this point develops a fever and fetal tachycardia. She is diagnosed with chorioamnionitis and antibiotic therapy is started. She delivers the babies vaginally 6 hours later. Right after delivery of the second infant, there is a large, continuous hemorrhage from the vagina. 2. What is the most likely cause of this? CASE № 40 A 30-year-old multiparous patient is in the III stage of labor. After 30 min after delivery of the fetus there are no signs of placental separation, no vaginal bleeding. A manual extraction of the placenta is undertaken. The placenta seems to be firmly adherent to the uterus. 1. What is the most likely diagnosis? 2. What is your next step in management for this patient? CASE № 46 Multigravida, 25 years old, admitted in the hospital with the prolapse of umbilical cord. Rupture of amniotic sac occur when patient was on the way to the hospital, contractions begun 5 hours ago. The third pregnancy proceeded without complication to full term. The first pregnancy 3 years ago was finished by normal urgent sorts, the child was healthy, second pregnancy - spontaneous abortion on the second month of pregnancy one year ago. The size of a pelvis: 26- 29-33-20. Longitudinal lie of fetus, left lateral position, breech presentation. Estimated weight of fetus - 3100,0±200,0. Auscultation of the fetal heart beat: 100 beats/minute, rhythmical. Vaginal examination: cervical dilatation full, without amniotic sac, in vagina can feel prolapsed pulsation of umbilical cord. Buttocks in the narrow part of pelvic cavity. 1. The Diagnosis. 2. The Plan of management. 3. What mistakes did the doctor do? CASE № 62 White woman, 37 years old at 36 weeks of pregnancy was admitted to the maternity hospital due to high BP 160/110 mmHg, severe headache, visual disturbance and epigastric pain. On laboratory investigation: Hemoglobin – 74 /1 Leucocytes – 8.6 х 10^ Platlets counts – 92000/ml and very high of liver enzymes. Proitenuria – 0.09 mg/l 1. What is the primary diagnosis? 2. Suggestion of way of the delivery? CASE № 65 White Philipinian woman, 41 years old at 10 weeks of pregnancy suffering from mild vaginal bleeding with headache and vertigo. On laboratory investigation: BP – 150/90mmHg, Pls – 86/min Tº – 36.7ºC, β-hCG serum titer - 110,000 miu/ml External examination, we found that the size of uterus is going to 22weeks of pregnancy. During ultrasound examination we had a picture of “snow storm” pattern covering the atropic figure. 1. What is the primary diagnosis? 2. Medical appropriate management of the disease? 3. Surgical appropriate management of the disease? CASE № 66 Patient S, 23 years old, was admitted to the labor room at 34-35 weeks of gestation with complaints of rupture of membranes 6 hours ago, regular contractional abdominal pain for 4 hours. In the history of the patient, one medical abortion and chlamydial cervicitis. This second pregnancy, desirable, inspection and pre-pregnancy preparation was carried out. The general condition is satisfactory. Pulse - 92 beats per minute, blood pressure - 110/70 mm Hg. The body temperature - 38,1 ° C, with chills . The uterus is enlarge in accordance to 34 weeks of pregnancy felt during palpation. Longitudinal lie of the fetus, cephalic presentation, small segment of head at the pelvic inlet. Fetal heartbeat is muted, rhythmic, 156 beats per minute. Leaking of green murky amniotic fluid with an unpleasant odor. At vaginal examination revealed that the cervix is flattened, thin, cervical dilation 6 cm. Amniotic sac is not defined. Small segment of the fetal head at the entrance to the pelvis, sagittal suture in the left oblique size, small fontanelle at the right of the womb. After 3 hours from admission, a live birth of preterm male fetus weighing 2350 g , length 44 cm, with Apgar scores of 6-7 points. On the skin newborn presence many vesiculo-pustular eruptions. 1. Make a preliminary diagnosis on admission. 2. What was the tactic of conduction of labor? 3. Formulate the final diagnosis. 4. From the problem of the task, select possible risk factors of the identified obstetrical pathology. CASE № 69 The doctor of women consultation clinic to ultrasound examination directed multigravida, multipara pregnant women M, 26 years old, at 24 weeks of gestation. In the medical history of the patient, one normal delivery 3 years ago, one miscarriage 2 years ago, chronic salpingo- oophoritis. An ultrasound examination revealed polyhydramnios, hyperechoic suspension in the amniotic fluid, increased of placenta thickness up to 33 mm. Anatomy of fetus is not disturbed; fetometrical figures correspond to gestational normally. Pregnant women transferred to hospital for further treatment. 1. Make a preliminary diagnosis. 2. Specify the possible risk factors of the identified obstetrical pathology. 3. Make a plan of investigation for this pregnant woman. 4. Specify the groups of drug necessarily for treatment of the identified obstetrical pathology. CASE № 85 Patient B, 32 years old, complained of a nagging pain in the lower abdomen and back. Directed to hospitalization by women consultation clinic, for observation of prenancy. From history, she had 4 pregnancies. The first pregnancy ended in urgent delivery, large fetus 8 years ago. Second birth - premature at 32 weeks. Two subsequent pregnancies ended in miscarriage at time 16 and 20 weeks. In the mirror: hyperemia and swelling of the vaginal mucosa, the cervix is short, the external os gapes in the transverse diameter. With bimanual examination: short cervix 2.5 cm, soft in consistency, letting pass one transverse finger. The uterus is enlarge to 13-14 weeks of pregnancy, painless, excitable during investigation. 1. Formulate the diagnosis. 2. What is the approach for the management of the pregnant woman? 3. What are the indications and contraindications for the correction of cervical insufficiency? 4. List the criteria for diagnosis of cervical insufficiency. CASE № 94 A 40-year-old woman was delivered by ambulance to a maternity home with complaints of bleeding of a significant amount, beginning today for the first time. Simultaneously with bleeding 4 hours ago, it had begun regular pain of average intensity. Pregnancy 7-th, term.