Detailed Answers: Difficult Obstetrics & Gynaecology Cases

CASE No. 9 - Eclampsia in Labor with Fetal Distress

Full Clinical Picture

1. Diagnosis

2. Plan for Management of Labor

• Magnesium sulfate (MgSO4): Loading dose 4-6 g IV over 15-20 minutes, followed by maintenance infusion of 2 g/hr IV (Rosen's Emergency Medicine, Box 173.4; Williams Obstetrics). This is the drug of choice. It controls seizures and prevents recurrence while preserving uteroplacental blood flow.
• If seizures persist after MgSO4: add lorazepam 2-4 mg IV or diazepam 5-10 mg IV.

• Since diastolic BP >105 mmHg (here BP 180/100), antihypertensives are mandatory:
  • Hydralazine 5-10 mg IV push, repeat every 2-4 hours; OR
  • Labetalol 20 mg IV bolus, repeat every 10 minutes up to 300 mg total (Rosen's Emergency Medicine, Box 173.4).
  • Target: systolic <160, diastolic <105 mmHg (to prevent cerebral hemorrhage while maintaining placental perfusion).

• Since the cervix is fully dilated and the head is already in the pelvic cavity, the fastest and safest mode of delivery is obstetric forceps (outlet/low forceps).
• Cesarian section is not indicated here as vaginal delivery is imminent.
• Insert urinary catheter, monitor urine output (maintain >25 mL/hr).
• IV access - two large-bore lines; fluid balance monitoring.
• Monitor for MgSO4 toxicity: check deep tendon reflexes (loss = magnesium level ~10 mg/dL), respiratory rate (depression at ~12 mg/dL). Keep calcium gluconate 1 g IV at bedside as antidote.

• Continue MgSO4 for at least 24 hours postpartum (eclampsia can recur postpartum).
• Continue antihypertensives.

3. Sequence of Events to Help the Mother

1. Place in left lateral decubitus position (prevents aortocaval compression, reduces aspiration risk during seizure).
2. Secure airway - suction, oxygen 8-10 L/min via mask.
3. Insert IV line (x2, large bore) - draw blood for CBC, LFTs, renal function, coagulation, uric acid, electrolytes.
4. MgSO4 loading dose IV over 15-20 minutes.
5. Antihypertensive therapy.
6. Insert urinary catheter.
7. Continuous electronic fetal monitoring.
8. Vaginal delivery via outlet forceps (since head is in pelvic cavity, cervix fully dilated).
9. Active management of third stage of labor (oxytocin 10 IU IM to prevent PPH).
10. Continue MgSO4 maintenance 24 hours postpartum.
11. Observe in ICU/high-dependency unit.

4. Major Clinical Manifestations of an Eclamptic Attack - Stages

5. Conditions and Indications for Forceps

• Prolonged second stage
• Maternal exhaustion
• Fetal distress (FHR abnormalities) - as present here (FHR 160 + muffled sounds)
• Maternal conditions requiring avoidance of bearing down (eclampsia, cardiac disease, cerebral pathology)
• Head on perineum/at outlet

1. Cervix must be fully dilated (here: confirmed)
2. Membranes must be ruptured (here: must be confirmed / rupture if intact)
3. Head must be engaged (presenting part at or below the level of ischial spines)
4. Exact position of the fetal head must be known (LOA, ROA, OA, etc.)
5. No cephalopelvic disproportion
6. Bladder must be empty (catheterize)
7. Analgesia must be adequate (regional or general)
8. Operator must have sufficient skill and experience

6. Method of Applying Forceps (Simpson's/Wrigley's)

1. Check prerequisites are all met.
2. Place patient in lithotomy position. Empty bladder.
3. Identify position of head (small fontanelle left anterior = LOA most likely in this case based on Case 11 description of left womb position - assume LOA here).
4. Wandering maneuver: introduce the LEFT blade first (left hand, left side of pelvis), then the RIGHT blade.
5. Lock the handles.
6. Check application: sagittal suture runs perpendicular to shanks; posterior fontanelle equidistant from both blades; no more than one fingertip fits between the blade and head.
7. Traction: downward and outward along the pelvic curve (Pajot's maneuver / axis traction) during contraction while mother pushes.
8. Delivery of head in extension - blades removed before head is delivered over perineum if possible (to reduce perineal trauma).
9. Rest of body delivered as usual.

CASE No. 11 - Placental Abruption in Labor with Preeclampsia

Full Clinical Picture

1. Preliminary Diagnosis

2. Main Etiological Causes of Abruptio Placentae

1. Hypertension and preeclampsia (most significant; present in this case) - decidual vasculopathy leads to spontaneous hemorrhage into the decidua basalis
2. Multiparity (3+ deliveries)
3. Advanced maternal age (<20 or >35 years)
4. Prior abruptio placentae (10x recurrence risk)
5. Smoking and cocaine use (vasoconstrictive injury to decidual vessels)
6. Trauma (motor vehicle accidents, intimate partner violence - shearing of non-elastic placenta from elastic uterine wall)
7. Thrombophilia (Factor V Leiden, antiphospholipid syndrome)
8. Preterm premature rupture of membranes (PPROM)
9. Short umbilical cord
10. Uterine anomalies or fibroids
11. Cocaine/alcohol use
12. Unexplained infertility, prior miscarriage

3. Further Management Plan

1. Two large-bore IV lines - crystalloid resuscitation, blood type and crossmatch (at least 4 units pRBC)
2. Oxygen by mask
3. Continuous FHR monitoring
4. If not already given: MgSO4 for seizure prophylaxis (given preeclampsia background)
5. Immediate outlet forceps delivery (all conditions met: fully dilated, head at +3, membranes ruptured, known position)
6. Active management of third stage (oxytocin) - high risk of PPH due to Couvelaire uterus (blood infiltrates myometrium) and potential DIC
7. Check coagulation - fibrinogen, PT, PTT, platelet count (risk of DIC)
8. Neonatal resuscitation team on standby
9. If forceps fail or contraindicated - emergency CS, but in this case vaginal delivery is clearly appropriate.
10. Postpartum - ICU monitoring, correct coagulopathy with FFP/platelets if needed.

4. Can Forceps Be Used Instead of Vacuum?

• FHR is 100 bpm - severe fetal distress; forceps are faster and more reliable
• Vacuum is contraindicated in severe fetal distress (risk of cup detachment before delivery is complete)
• Vacuum requires more maternal effort (pushing) which is compromised here due to maternal hemodynamic instability
• The head is already deeply engaged (+3 station) and at the narrowest part - ideal for forceps
• DC Dutta's Obstetrics states that vacuum is contraindicated in acute fetal distress with the indication for very rapid delivery - forceps are preferred in this scenario.

CASE No. 13 - Breech Presentation with Cord Prolapse in Second Stage

Full Clinical Picture

1. Diagnosis

2. Plan for Conduction of Labor

1. Immediate manual elevation of presenting part by the examining hand to relieve cord compression - keep hand in vagina during transport.
2. Trendelenburg position (or knee-chest position) to reduce gravitational pressure on cord.
3. Oxygen to mother.
4. Keep cord moist and warm - do not attempt to replace the cord (increases trauma and vasospasm).
5. Immediate breech extraction - since buttocks and feet are in the pelvic cavity, assist delivery with the Bracht maneuver or total breech extraction.
6. Call for experienced obstetrician immediately.
7. Neonatal team standby for resuscitation.
8. If delivery is not rapidly achievable vaginally - emergency CS (but in this case, head is already in pelvic cavity - vaginal delivery should be completed immediately).

3. What Were the Mistakes?

1. Failure to diagnose and reposition the presentation earlier in labor - mixed/footling breech should have been identified antenatally and a plan for CS or controlled breech delivery made.
2. Amniotomy performed or allowed (or membranes ruptured) without the presenting part well engaged in the pelvis - the most common cause of cord prolapse is artificial rupture of membranes (ARM) with an unengaged presenting part. In footling breech, ARM should never be performed until engagement is confirmed.
3. Failure to immediately check for cord prolapse on vaginal examination at the time of membrane rupture - this is mandatory.
4. Delay in recognizing fetal distress (FHR 100 bpm) as a sign of cord compression.

4. Can a Living Fetus Be Delivered with Cord Prolapse Vaginally?

5. Aid During Second Stage with Cord Prolapse

• Manual elevation of fetal head per vagina to relieve cord compression
• Trendelenburg / knee-chest position
• Oxygen to mother, IV access
• If head at outlet: immediate outlet forceps delivery
• If head not at outlet: emergency CS with hand maintaining head elevation until uterine incision is made

• Manual elevation of buttocks/feet per vagina to relieve cord compression
• Trendelenburg / knee-chest position
• Oxygen to mother
• If buttocks at perineum: immediate total breech extraction
• Keep cord moist and warm, do NOT replace cord
• If breech is not low/delivery not possible: emergency CS

6. Breech Presentation at 34 Weeks - Management in Antenatal Clinic

1. Confirm breech presentation with ultrasound (type of breech, placental location, amount of amniotic fluid, fetal weight estimation, any fetal or uterine anomaly).
2. External cephalic version (ECV) can be offered from 36-37 weeks (NOT at 34 weeks - too early, higher risk of preterm labor and spontaneous reversion). At 34 weeks: watchful waiting - approximately 25% of fetuses presenting as breech at 34 weeks will turn spontaneously to cephalic by 36-37 weeks.
3. Advise: moxibustion (acupuncture at BL67) - evidence is limited; postural exercises (knee-chest position) - evidence limited but low risk.
4. Reassess at 36-37 weeks: if still breech, offer ECV (success rate ~50% in nulliparas, ~60% in multiparas). If ECV fails or is declined, plan for elective CS at 39 weeks (the Term Breech Trial showed that planned CS significantly reduces perinatal morbidity/mortality for term breech).
5. Document and refer to obstetric unit if any complications arise.

CASE No. 26 - Migrated IUD with Bladder Stone

Full Clinical Picture

1. Plan of Investigation and Expected Results

2. Surgical Treatment

• Open cystolithotomy: Surgical incision of the bladder (suprapubic approach) under general anesthesia; removal of the stone along with the embedded IUD; bladder repair in layers. Post-operative catheterization for 5-7 days. This is the approach described and is standard when the stone is too large for endoscopic fragmentation or the IUD is embedded in the bladder wall.
• Transurethral cystolitholapaxy (endoscopic): Newer approach - cystoscopy with mechanical/laser/pneumatic fragmentation of the stone, then removal of IUD fragments. Less invasive, shorter recovery. Preferred if stone size and IUD position allow.
• Precautions: Ensure complete removal of all IUD fragments. Check for bladder wall integrity. Prophylactic antibiotics for UTI treatment.
• The D&C (performed prior to cystolithotomy) managed the concurrent intrauterine pregnancy. The presence of an intrauterine pregnancy with a missing IUD confirmed IUD perforation/migration.

CASE No. 34 - Eclampsia with Fetal Death

Full Clinical Picture

1. Diagnosis

2. Plan for Management and Sequence of Events

1. Airway, Breathing, Circulation - lateral position, oxygen, two IV lines.
2. MgSO4 - 4-6 g loading dose IV over 15-20 minutes → 2 g/hr maintenance (seizure control and prevention).
3. Antihypertensives: Hydralazine 5-10 mg IV or Labetalol 20 mg IV bolus (target systolic <160 mmHg).
4. Urinary catheter - monitor urine output (>25 mL/hr).
5. Laboratories: CBC, platelets, LFTs, renal function, coagulation (DIC screen) - especially given she may have been in labor some time.
6. Continue labor (oxytocin augmentation if contractions are insufficient) - vaginal delivery is the goal with IUFD.
7. When head descends to outlet - conduct delivery normally or with episiotomy to protect perineum.
8. Active management of 3rd stage - oxytocin 10 IU IM or IV to prevent PPH.
9. Continue MgSO4 24 hours postpartum.
10. Psychological support - discuss fetal death sensitively.

3. What Were the Mistakes?

1. Using hydrochlorothiazide (a diuretic) to treat preeclampsia. This is absolutely contraindicated. Preeclampsia is associated with hypovolemia (reduced plasma volume). Diuretics further deplete intravascular volume, worsen placental perfusion, and promote fetal hypoxia and IUFD. DC Dutta's Obstetrics explicitly states diuretics are contraindicated in preeclampsia. (Williams Obstetrics, Ch. 40: "Diuretics have no role in the treatment of preeclampsia and may be harmful by depleting the already reduced plasma volume.")
2. Refusing hospitalization - a woman with preeclampsia (BP 150/100, proteinuria 0.6 g/L) must be hospitalized for monitoring and treatment. Outpatient management of this severity is inappropriate and dangerous.
3. No MgSO4 for seizure prophylaxis was given despite severe features (BP 150/100, proteinuria) - this likely contributed to the subsequent eclamptic fits.
4. No antihypertensive treatment was initiated despite severe-range BP.
5. Delayed presentation to hospital (from March to August despite onset of symptoms) contributed to IUFD.

4. Possible Indications for CS from This Task

1. Eclampsia with unfavorable cervix (unripe cervix, failure of induction) - if induction fails with alive fetus
2. Fetal distress not responding to resuscitation (if fetus were alive)
3. Failed induction with alive fetus and maternal deterioration
4. Cephalopelvic disproportion (head not engaging despite complete dilation - as seen here with head "pressed against pelvic inlet")
5. Persistent severe hypertension not controlled by medications
6. Eclampsia postpartum with ongoing seizures

5. Conditions and Contraindications for Forceps

1. Cervix fully dilated
2. Membranes ruptured
3. Head engaged (at or below level of ischial spines)
4. Exact position of head known
5. No cephalopelvic disproportion
6. Bladder empty (catheterized)
7. Adequate analgesia
8. Skilled operator
9. Informed consent
10. Facilities for emergency CS available (in case of failure)

1. Absolute:
   • Unengaged head (presenting part above ischial spines)
   • Incompletely dilated cervix
   • Unknown position of head
   • Proved or suspected CPD
   • Fetal coagulation disorder (e.g., hemophilia - forceps blades may cause intracranial hemorrhage)
   • Live fetus with conditions where increased intracranial pressure is dangerous
2. Relative:
   • Premature fetus (vacuum preferred or CS)
   • Face presentation (mento-posterior - delivery impossible)
   • Failed vacuum (if forceps attempted after failed vacuum, risk of fetal injury is significant - requires experienced operator)

CASE No. 35 - Twin Pregnancy, Second Twin in Transverse Lie

Full Clinical Picture

1. Diagnosis

2. Plan for Management of Labor (Second Twin)

1. Confirm presentation and position of second twin by vaginal examination and/or ultrasound.
2. Check FHR continuously (132 bpm = normal, good sign).
3. Two options:
   • External cephalic version (ECV): Under tocolysis (terbutaline 0.25 mg SC or IV), attempt to turn the fetus externally to a cephalic or breech presentation, then rupture membranes and allow vaginal delivery.
   • Internal podalic version (IPV) + total breech extraction: The operator inserts a hand into the uterus (membranes intact or just ruptured), grasps both fetal feet, and converts the transverse lie to a breech by rotating the fetal body (internal version), then delivers by breech extraction. This is a classical obstetric maneuver particularly suitable for the second twin (Williams Obstetrics, Ch. 45 "Multiple Gestations").
4. If neither maneuver succeeds or fetal distress develops: emergency CS for second twin.
5. Oxytocin infusion is continued to maintain uterine contractions.
6. Do NOT wait - if no contractions after delivery of first twin, start oxytocin.

3. Methods for Determining Breech Presentation of Twins

1. Abdominal palpation (Leopold's maneuvers): Hard, smooth, round, ballotable head felt in fundus; soft, irregular, non-ballotable breech at the lower pole. However this is less reliable in twin pregnancy due to overcrowding.
2. Vaginal examination: Soft, irregular presenting part; soft cleft (intergluteal) between two bony prominences (ischial tuberosities) can be felt; may feel the sacrum, feet, or genitalia.
3. Ultrasound (most reliable): Direct visualization of fetal head, spine, and presenting part for each twin separately. Also evaluates chorionicity, amniotic fluid, and placental position.
4. Auscultation: FHR heard at or above umbilicus on both sides simultaneously in twins.
5. X-ray (rarely used today): Would show skeletal positions but radiation exposure makes it obsolete.

4. Possible Complications During Labor for Mother and Fetus

• Postpartum hemorrhage (PPH) - overdistended uterus = uterine atony (most common cause of PPH in twins)
• Perineal lacerations (multiple deliveries)
• Retained placenta
• Placental abruption (between delivery of first and second twin)
• Cord entanglement (monochorionic twins)
• Operative delivery complications (forceps, ventouse, breech extraction)
• Increased rate of CS
• Amniotic fluid embolism

• Prematurity (most important - twins deliver earlier)
• Low birth weight, IUGR
• Fetal distress (cord prolapse more common in second twin, especially after first delivery)
• Birth asphyxia (especially second twin)
• Cord prolapse
• Trauma from operative delivery
• Twin-to-twin transfusion syndrome (monochorionic)
• Locked twins (rare, first breech + second vertex = locking of chins)

5. If First Twin Were in Breech Position - Complications in Conservative Management

1. Locked twins - if second twin is vertex and its head descends into the pelvis before the first twin's breech body is fully delivered, the two fetal heads may lock (chin-to-chin interlocking). This is a life-threatening obstetric emergency.
2. Cord prolapse - breech presentation with incompletely occlusive presenting part.
3. Head entrapment - the unmolded aftercoming head of the breech may be entrapped in a partially dilated cervix (especially premature fetus - Mauriceau-Smellie-Veit maneuver needed).
4. Birth asphyxia - delayed delivery of the aftercoming head in a breech increases asphyxia risk.
5. Fetal injury - extended arm, broken clavicle, brachial plexus injury.
6. Increased perinatal mortality compared to CS for first breech twin.

CASE No. 39 - Twin Pregnancy Complications: PPH After Delivery

Case Part 1 (35-year-old G3P2, dizygotic twins, 13 weeks)

1. Which is NOT an Issue She Should Be Concerned About?

• Preterm labor/delivery
• Preeclampsia (higher risk in twins)
• Gestational diabetes
• IUGR/discordant growth
• PPH
• Chromosomal abnormalities (advanced maternal age)

Case Part 2 (38 weeks, chorioamnionitis, large hemorrhage after delivery)

2. Most Likely Cause of Postpartum Hemorrhage

1. Twin pregnancy (uterine overdistension)
2. Prolonged labor (16 hours to 5 cm + additional 6 hours)
3. Chorioamnionitis (myometrial inflammation)
4. Oxytocin use (can cause uterine fatigue/tachysystole)

• Uterine massage/bimanual compression
• Oxytocin 10-20 IU IM/IV infusion
• Ergometrine 0.5 mg IM (if not hypertensive)
• Misoprostol 800-1000 mcg PR
• Carboprost (Hemabate) 0.25 mg IM every 15 min (if above fail)
• Intrauterine balloon tamponade (Bakri balloon)
• Surgical: B-Lynch suture, uterine artery ligation, hysterectomy (last resort)

CASE No. 40 - Placenta Accreta

Full Clinical Picture

1. Most Likely Diagnosis

• Placenta accreta: Chorionic villi attach directly to myometrium (no decidua basalis). Most common (75-78%). No plane of cleavage but the invasion does not go deeply.
• Placenta increta: Villi invade into myometrium.
• Placenta percreta: Villi penetrate through entire myometrium to serosa (or beyond into bladder/bowel). Most severe.

• Previous CS (especially with anterior low-lying placenta)
• Uterine surgery (myomectomy, curettage)
• Multiparity (as in this case)
• Previous uterine infection
• Placenta previa

2. Next Step in Management

1. Stop attempting manual removal if firm resistance is met - forced removal will cause massive hemorrhage.
2. IV access x2 large-bore, blood type and crossmatch (6-8 units pRBC), IV fluids.
3. Call for senior obstetrician/team.
4. Oxytocin infusion 20-40 IU in 500 mL NS - maintains uterine tone to reduce bleeding.
5. Examine under anesthesia - attempt manual removal under GA after oxytocin uterine softening, only if not already done.
6. If placenta still cannot be removed: conservative management (leaving placenta in situ) OR surgical management:
   • Conservative: Leave placenta completely in situ, give methotrexate (controversial), monitor for infection and delayed hemorrhage, allow placenta to resorb. Used to preserve fertility.
   • Hysterectomy (cesarean hysterectomy): Definitive treatment, especially if there is massive hemorrhage or if percreta suspected. This is the gold standard management for placenta accreta with hemorrhage.
7. Interventional radiology (balloon occlusion of internal iliac arteries) can be used adjunctively to reduce blood loss if available and if planned CS for known accreta.
8. Transfuse as needed.

CASE No. 46 - Cord Prolapse with Footling Breech, Full Dilation

Full Clinical Picture

1. Diagnosis

2. Plan of Management

1. Do NOT replace the cord - keep it warm and moist with a sterile, wet, warm towel.
2. Manual elevation of buttocks to relieve cord compression (hand in vagina, lift presenting part away from cord).
3. Trendelenburg position (head down) or knee-chest position.
4. Oxygen to mother.
5. IV access, draw blood.
6. Immediate total breech extraction by an experienced obstetrician:
   • Grasp both ankles/feet
   • Apply gentle traction to deliver legs, then buttocks
   • Deliver trunk and arms (Lovset's maneuver for arms if needed)
   • Deliver aftercoming head (Mauriceau-Smellie-Veit maneuver or Bracht maneuver)
7. Neonatal resuscitation team on standby (FHR 100 = fetal distress, expect depressed newborn).
8. Active management of 3rd stage - oxytocin after delivery.
9. If breech extraction fails or FHR drops further - emergency CS (but this should be last resort as buttocks are already at mid-pelvis).

3. What Mistakes Did the Doctor Make?

1. Failure to plan delivery in hospital for a multipara with breech presentation - should have been admitted antenatally and planned for CS or controlled breech delivery.
2. Amniotomy (or allowing spontaneous rupture) was not managed correctly - the patient ruptured membranes "en route to hospital" - the critical error is that the woman with a breech presentation was not admitted to hospital before membrane rupture. Cord prolapse is a known complication of breech + membrane rupture.
3. No immediate vaginal examination at the time of membrane rupture - cord prolapse must be excluded immediately when membranes rupture in any abnormal presentation.
4. Transport delay - a multipara with breech presentation who is in labor should be transported immediately; the fact that the amniotic sac ruptured en route suggests she was in active labor at home.
5. Failure to offer ECV at 36-37 weeks (or CS planning) once breech was confirmed.

CASE No. 62 - HELLP Syndrome at 36 Weeks

Full Clinical Picture

• Hemoglobin 74 g/L (severely low - hemolysis)
• Leucocytes 8.6 x10^9/L (normal)
• Platelets 92,000/mL (thrombocytopenia - <100,000)
• Liver enzymes: very high (elevated LFTs)
• Proteinuria 0.09 mg/L (low - but note: in context of BP 160/110 with other features, criteria for severe preeclampsia met)

1. Primary Diagnosis

• H = Hemolysis (Hb 74 g/L - severe anemia; peripheral blood smear would show microangiopathic hemolytic anemia with schistocytes/burr cells)
• EL = Elevated Liver enzymes (very high transaminases - AST, ALT, LDH)
• LP = Low Platelets (92,000/mL - <100,000 = severe thrombocytopenia)

• Class 1: Platelets ≤50,000 (most severe)
• Class 2: Platelets 50,000-100,000 (this patient's platelet count of 92,000 = Class 2 HELLP)
• Class 3: Platelets 100,000-150,000

2. Mode of Delivery

1. Stabilize the mother first:
   • MgSO4: 4-6 g IV loading dose → 2 g/hr maintenance (seizure prophylaxis and treatment)
   • Antihypertensives: Labetalol or Hydralazine IV (target BP <160/110)
   • Corticosteroids (dexamethasone 10 mg IV q12h): may temporarily improve platelet count and liver enzyme levels; also fetal lung maturation at 36 weeks (marginal benefit but often given)
   • Transfuse platelets if <20,000 or bleeding/before surgery; transfuse pRBC for hemoglobin correction
   • Correct coagulopathy with FFP if needed
2. Mode of delivery:
   • Cesarean section is preferred given: platelet count 92,000 (moderate thrombocytopenia - regional anesthesia may be risky), severe hypertension, risk of maternal deterioration and intracranial hemorrhage with Valsalva
   • If cervix is favorable (Bishop score >6) and the patient is hemodynamically stable with no ongoing seizures: induction of labor and vaginal delivery can be attempted (avoids surgical risks of CS)
   • Final decision must be individualized - most authorities recommend CS for HELLP at <34 weeks or with maternal instability; at 36 weeks with stable vitals, vaginal delivery after induction is acceptable if cervix is favorable.
3. Postpartum: HELLP can worsen for 24-48 hours after delivery before improving. Continue MgSO4 for 24-48 hours. Monitor platelets daily.

CASE No. 65 - Hydatidiform Mole

Full Clinical Picture

1. Primary Diagnosis

1. Uterus large for dates (22 weeks size at 10 weeks gestation)
2. Markedly elevated beta-hCG (110,000 mIU/mL at 10 weeks - exceeds expected level for gestational age)
3. Ultrasound "snowstorm pattern" - heterogeneous echogenic mass filling the uterine cavity with multiple small cystic spaces (hydropic villi), no identifiable fetal parts = classic of complete mole
4. Vaginal bleeding in first trimester
5. Hypertension at 10 weeks (preeclampsia before 20 weeks is pathognomonic of molar pregnancy)
6. Age 41 - advanced maternal age is a risk factor for GTD (risk increases after age 40)
7. Filipino background - higher incidence of GTD in Southeast Asian populations (5-10x higher than Western populations)
8. Hyperemesis (headache/vertigo may suggest excessive hCG stimulation)

2. Medical Management

1. Investigations first: Chest X-ray (pulmonary metastases), CBC (anemia from bleeding), LFTs/renal function, thyroid function (hCG has TSH-like activity - hyperthyroidism in 7% of moles), coagulation panel.
2. Correct anemia if present - transfuse pRBC if hemoglobin <8 g/dL.
3. Anti-thyroid treatment if clinically hyperthyroid (propranolol for symptoms; methimazole/PTU for severe cases).
4. Rh typing - give Rh immune globulin to Rh-negative patients before uterine evacuation.
5. Oxytocin is NOT given before evacuation (may cause trophoblastic embolism by pushing molar tissue into venous sinuses).
6. Anti-emetics for hyperemesis gravidarum if present.
7. Post-evacuation hCG monitoring: Weekly serum beta-hCG until 3 consecutive normal values, then monthly for 6-12 months. This is critical for detecting persistent GTD (invasive mole) or choriocarcinoma.
8. Contraception: Oral contraceptives or barrier methods for 12 months after a complete mole (to ensure hCG normalization is not confused with a new pregnancy).
9. Chemotherapy (prophylactic): Methotrexate or actinomycin-D given prophylactically in high-risk moles (hCG >100,000, uterus large for dates, age >40) in some centers - though not universally recommended; reduces rate of malignant transformation.

3. Surgical Management

1. Suction curettage (vacuum aspiration):
   • Performed in operating theater under general or regional anesthesia
   • Cervical dilation with laminaria or dilators
   • Suction curette (10-12 mm) used to evacuate the molar tissue
   • Oxytocin infusion started AFTER evacuation begins (not before) to reduce bleeding
   • Gentle sharp curettage after suction to ensure completeness
   • Blood should be readily available (risk of significant hemorrhage)
   • All evacuated tissue sent for histopathology (confirms diagnosis, rules out choriocarcinoma)
   • Prophylactic anti-D immunoglobulin if Rh-negative
2. Hysterectomy:
   • Preferred if patient is >40 years old, desires permanent sterilization, or has significant uterine bleeding not controlled by suction
   • Does NOT eliminate need for hCG follow-up (malignant transformation can still occur from metastatic sites)
   • In this 41-year-old patient with a large uterus (22-week size): hysterectomy may be considered, especially since she is of advanced age and the uterus is significantly enlarged
3. Post-operative:
   • Chest X-ray post-evacuation (pulmonary trophoblastic embolization)
   • Weekly hCG titres until undetectable
   • Pelvic ultrasound to confirm uterine evacuation

CASE No. 66 - Preterm Labor with Chorioamnionitis and Neonatal Infection

Full Clinical Picture

1. Preliminary Diagnosis on Admission

2. Tactic of Conduction of Labor

1. Broad-spectrum antibiotics immediately:
   • Ampicillin 2 g IV q6h + Gentamicin 5 mg/kg IV q24h ± Metronidazole 500 mg IV q8h (anaerobe coverage)
   • Continue antibiotics intrapartum and for 24 hours postpartum
2. Do NOT give tocolytics (magnesium, nifedipine, indomethacin) - chorioamnionitis is an absolute contraindication to tocolysis.
3. Corticosteroids (betamethasone/dexamethasone): If time permits at 34-35 weeks (borderline benefit; some guidelines recommend up to 34+6 weeks). However, with active chorioamnionitis, corticosteroids are relatively contraindicated.
4. Continuous fetal monitoring: FHR 156 = tachycardia (normal upper limit is 160); monitor for further deterioration.
5. Allow labor to progress - at 6 cm dilation and 34-35 weeks with PPROM + chorioamnionitis, allow vaginal delivery. Oxytocin augmentation if contractions inadequate.
6. Cesarean section if: fetal distress develops, failure to progress, malpresentation preventing vaginal delivery.
7. Neonatal team must be present at delivery - preterm + suspected infection.
8. Cord blood sent for culture.

3. Final Diagnosis

• Congenital/neonatal herpes simplex (HSV): vesicular lesions - must exclude given the history
• Group B Streptococcus (GBS) or Staphylococcus aureus neonatal skin infection
• Listeria monocytogenes: granulomatosis infantiseptica
• Congenital varicella (less likely, no history)

4. Risk Factors for the Identified Obstetric Pathology (PPROM + Chorioamnionitis)

1. Previous chlamydial cervicitis - genital tract infection disrupts cervical mucus plug and ascending resistance; Chlamydia trachomatis is directly associated with PPROM and chorioamnionitis
2. Previous medical abortion - uterine instrumentation increases risk of endometritis and ascending infection
3. PPROM itself - once membranes are ruptured, the barrier to ascending infection is removed; the longer the time from rupture to delivery, the higher the infection risk (6 hours in this case)
4. Preterm gestation (34-35 weeks) - preterm PPROM is associated with subclinical infection in up to 40% of cases
5. Bacterial vaginosis (likely given history of STI and gynecological history)
6. Cervikal insufficiency (possible given 6 cm dilation at 34 weeks with relatively fast progression)
7. Green malodorous liquor - indicates pre-existing infection already present before full labor

CASE No. 69 - Polyhydramnios with Suspected Intrauterine Infection

Full Clinical Picture

1. Preliminary Diagnosis

2. Possible Risk Factors

1. Chronic salpingo-oophoritis - history of upper genital tract infection (ascending bacteria/Chlamydia/Gonorrhea) - risk for intrauterine infection
2. Previous miscarriage (may have been related to undetected infection)
3. Multiparity - multiple pregnancies reduce protection against ascending infection
4. Possible undiagnosed TORCH infection (CMV, toxoplasmosis - often subclinical in mother)
5. Possible syphilis - syphilitic placentitis causes thick placenta + hydrops features + polyhydramnios

3. Plan of Investigation

4. Drug Groups for Treatment

1. Syphilis (most treatable with best outcomes):
   • Benzathine penicillin G 2.4 million IU IM in 3 doses, 1 week apart (Treponema pallidum is exquisitely penicillin-sensitive)
2. Toxoplasmosis:
   • Spiramycin 1 g PO q8h (reduces vertical transmission if fetus not yet infected)
   • If fetal infection confirmed: Pyrimethamine + Sulfadiazine + Folinic acid
3. CMV: No proven effective antiviral for congenital CMV prevention in pregnancy; hyperimmune CMV globulin (controversial); Valacyclovir under investigation.
4. Rubella: No treatment; if susceptible and exposed, rubella-specific immunoglobulin may reduce severity. Future prevention by vaccination (post-pregnancy MMR).
5. Listeriosis:
   • Ampicillin IV (drug of choice, crosses placenta)
   • Add Gentamicin for synergy in severe cases
6. General supportive drugs:
   • Amnioreduction (therapeutic amniocentesis) for severe polyhydramnios causing maternal discomfort, preterm labor risk, or respiratory compromise
   • Indomethacin (COX inhibitor) can reduce amniotic fluid production (used for polyhydramnios; caution: close ductus arteriosus - only before 32 weeks; short-term use)

CASE No. 85 - Cervical Insufficiency (Incompetence)

Full Clinical Picture

1. Diagnosis

2. Management Approach

1. McDonald cerclage (most common): High purse-string suture (non-absorbable, e.g., Ethibond or Mersilene tape) placed around the cervix at the junction of the cervix and lower uterine segment, via the vaginal approach. Suture removed at 36-37 weeks or at onset of labor.
2. Shirodkar cerclage: Technically more demanding; suture placed higher at the level of the internal os after pushing bladder and rectum aside. Stronger support.
3. Transabdominal cerclage (TAC): Reserved for failed vaginal cerclage, very short cervix, or previous cervical amputation. Placed laparoscopically or via laparotomy.

• Bed rest/pelvic rest (avoid intercourse, heavy lifting)
• Progesterone supplementation (17-OHPC 250 mg IM weekly OR vaginal progesterone 200-400 mg nightly from 16-36 weeks) - reduces preterm delivery risk
• Cervical length monitoring by transvaginal ultrasound every 2 weeks
• Treat any vaginal infection found

3. Indications and Contraindications for Cervical Cerclage

1. History-indicated (elective): 3 or more unexplained mid-trimester losses or preterm deliveries (<34 weeks) attributable to cervical insufficiency
2. Ultrasound-indicated (rescue/emergency): Cervical length <25 mm (by TVU) at 16-24 weeks in a woman with previous preterm birth <34 weeks
3. Physical exam-indicated (emergency cerclage): Dilated cervix (≥2 cm) with visible membranes on speculum examination in the second trimester before 24 weeks, in the absence of labor or infection

1. Active intrauterine infection/chorioamnionitis (infection around suture causes catastrophic sepsis)
2. Active labor (contractions present)
3. Ruptured membranes (PPROM - placing suture through infected field)
4. Evidence of fetal anomaly incompatible with life (futile intervention)
5. Cervical dilation >4-5 cm with advanced effacement (technical impossibility / high risk)
6. Vaginal bleeding of unknown origin (possible abruption or other pathology)
7. Intrauterine fetal death
8. Gestational age >24-26 weeks (rescue cerclage may still be attempted in select cases)

4. Criteria for Diagnosis of Cervical Insufficiency

1. History of 2 or more painless mid-trimester pregnancy losses (without labor)
2. History of preterm deliveries at progressive earlier gestations
3. History of cervical trauma: previous large baby delivery, forceps, cervical lacerations, LLETZ/LEEP, cone biopsy, deep diathermy

1. Short cervix on speculum/bimanual (<2.5 cm)
2. Open external or internal os without contractions
3. Admitting a Hegar dilator size 8 without resistance between pregnancies (non-pregnant state)

1. Cervical length <25 mm at 16-24 weeks
2. Funneling (beaking/wedging) of the internal os - amniotic membranes prolapse into the internal os taking on a U, V, or W shape
3. Progressive cervical shortening on serial TVU measurements
4. Absence of uterine contractions during shortening

CASE No. 94 - Placenta Previa with Hemorrhage

Full Clinical Picture

1. Diagnosis

2. Plan for Conducting Delivery

• Heavy active bleeding
• Plentiful hemorrhage causing hemodynamic instability (pulse 100, BP 110/60)
• Term pregnancy (40 weeks)
• 2-finger cervical dilation (labor has started)
• Placenta covering/marginal to cervical os

1. Two large-bore IV lines - aggressive fluid resuscitation
2. Blood type and crossmatch - at least 4-6 units pRBC
3. CBC, coagulation panel, renal/liver function
4. Urinary catheter
5. Oxygen by mask
6. Continuous FHR monitoring while preparing for CS
7. Emergency Lower Segment Cesarean Section (LSCS) under regional or general anesthesia
   • Note: Anterior placenta previa (as here) - surgeon must plan incision to avoid cutting through placenta; may require classical (vertical) uterine incision if placenta is completely anterior
   • Neonatal team standby
8. Active management of 3rd stage - oxytocin; be prepared for massive PPH (grand multipara + placenta previa = very high PPH risk)
9. Blood products ready (FFP, platelets, cryoprecipitate)
10. If placenta accreta is found: prepare for possible hysterectomy

3. Absolute Indications for CS, Contraindications, Conditions

1. Placenta previa (central/complete) - cannot deliver vaginally without catastrophic hemorrhage
2. Previous CS with placenta previa (risk of scar rupture + accreta)
3. Transverse lie that cannot be corrected
4. Umbilical cord prolapse with unengaged head
5. Cephalopelvic disproportion (absolute)
6. Severe abruptio placentae with alive fetus
7. Active genital herpes at time of delivery
8. Obstructing pelvic mass (fibroids, ovarian cyst)
9. Fetal distress with contraindication to vaginal delivery

1. Signed informed consent
2. Anesthesia team available (regional preferred; general if emergency)
3. Blood available (cross-matched)
4. Neonatal team ready
5. Operating theater ready

1. Patient refusal (informed consent required)
2. Dead fetus with no maternal indication (vaginal delivery preferred)
3. Severe clotting disorder (correct first)

CASE No. 95 - Eclampsia at 35 Weeks

Full Clinical Picture

1. Diagnosis

• BP 180/100: Severe preeclampsia range (≥160/110 systolic or ≥110 diastolic)
• Proteinuria 3+: Severe proteinuria
• 3 convulsive attacks + blackout: Classic eclampsia
• Headache + visual disturbance: CNS involvement (hypertensive encephalopathy)
• Ascites: Massive proteinuria causing hypoproteinemia and fluid third-spacing
• Antepartum: 35 weeks, no labor contractions

2. Steps of Emergency Care

1. A - Airway: Lateral decubitus position (left), jaw thrust if unconscious, suction secretions, oxygen 8-10 L/min via mask (prevent maternal hypoxia).
2. B - Breathing: Assess respiratory rate, SpO2 monitoring. Avoid respiratory depression.
3. C - Circulation: Two large-bore IV lines. IV fluid resuscitation (but restrict fluids - risk of pulmonary edema in eclampsia). Blood draw: CBC, LFTs, renal function, uric acid, coagulation, electrolytes, group and screen.
4. D - anticonvulsant (Drugs):
   • Magnesium sulfate: Loading dose 4-6 g IV over 15-20 minutes → maintenance 2 g/hr (Rosen's EM, Box 173.4).
   • Monitor: deep tendon reflexes (loss = toxicity), respiratory rate, urine output. Keep calcium gluconate 1 g IV at bedside.
   • If seizures persist after MgSO4: lorazepam 2-4 mg IV or diazepam 10 mg IV.
5. E - Antihypertensives:
   • Hydralazine 5-10 mg IV q2-4h, OR
   • Labetalol 20 mg IV bolus (repeat up to 300 mg total), OR
   • Nifedipine 10-20 mg PO (immediate release) - effective but slower onset.
   • Target: systolic 140-155 mmHg, diastolic 90-100 mmHg (avoid precipitous drops).
6. Urinary catheter - urine output monitoring (>25 mL/hr target).
7. Fetal monitoring - continuous CTG; muffled heart sounds with 132 bpm - reassuring rate but quality suggests fetal compromise.
8. Corticosteroids: Betamethasone 12 mg IM q24h x2 doses (fetal lung maturity at 35 weeks - marginal benefit but given).
9. Plan for delivery: After stabilization, delivery must proceed - at 35 weeks with eclampsia, the risk of keeping the fetus in utero outweighs prematurity risk. Decision: CS (if head not engaged, cervix unfavorable) vs. induction of labor.
10. CT head if: decreased consciousness persists, lateralizing neurological signs, or to exclude intracranial hemorrhage (a catastrophic complication of eclampsia).

3. Complications for Mother and Fetus

1. Intracranial hemorrhage (leading cause of maternal death in eclampsia)
2. HELLP syndrome (complicates 10-20% of severe preeclampsia/eclampsia)
3. Pulmonary edema / ARDS (from capillary leak, fluid overload, decreased oncotic pressure from proteinuria)
4. Acute kidney injury / Acute tubular necrosis (from renal vasospasm and hypoperfusion)
5. Abruptio placentae (20% of cases)
6. Disseminated intravascular coagulation (DIC)
7. Liver rupture / subcapsular hematoma (rare but life-threatening)
8. Cortical blindness (reversible, from cerebral vasospasm in occipital cortex)
9. Aspiration pneumonia (during seizure)
10. Maternal death (<2% in well-managed cases, much higher in resource-limited settings)

1. Intrauterine growth restriction (IUGR) from chronic uteroplacental insufficiency
2. Fetal distress / birth asphyxia
3. Premature birth (at 35 weeks - neonatal complications of prematurity)
4. Stillbirth/Intrauterine fetal death (from severe placental insufficiency, especially if untreated)
5. Neonatal thrombocytopenia (if HELLP component - maternal antibodies cross placenta)
6. Perinatal death (2-8.6% in eclampsia - Sibai et al., 1981; cited in Family Medicine Textbook 9e)

Summary Reference Table