On Monday I have obsetretics final year mbbs exam so give me notes for imp topics which should make my exam period feel easy
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Here are your high-yield Obstetrics final year MBBS exam notes. Topics are organised the way examiners love to ask them - definition, types/classification, clinical features, management, and key mnemonics.
📚 OBSTETRICS - FINAL YEAR MBBS EXAM NOTES
1. ANTEPARTUM HAEMORRHAGE (APH)
Definition: Bleeding from the genital tract after 28 weeks of gestation (and before delivery).
Causes - mnemonic: P-P-U-R-E
- Placenta Praevia
- Placental Abruption (Abruptio placentae)
- Unexplained (marginal sinus bleed)
- Rupture of vasa praevia
- Extra-placental causes (cervical polyp, erosion, varicosities)
1A. PLACENTA PRAEVIA
Definition: Placenta implanted wholly or partly in the lower uterine segment.
Classification (Grades I-IV / Types):
| Type | Description |
|---|---|
| Type I (Low-lying) | Placenta in lower segment but does not reach os |
| Type II (Marginal) | Placenta reaches the os but does not cover it |
| Type III (Partial) | Partially covers the internal os |
| Type IV (Central/Complete) | Completely covers the internal os |
Risk factors - mnemonic: "MACS-P"
- Multiparity
- Advanced maternal age
- Caesarean section (prior) - most important
- Smoking, previous Spontaneous/induced abortion
- Prior uterine surgery
Clinical Features:
- Painless, bright red vaginal bleeding - sudden, recurrent, unprovoked
- Uterus soft, non-tender
- Abnormal fetal lie (transverse/oblique) - displaced by placenta
- High presenting part
- No FHR abnormality initially
Investigations:
- USG (TVS most accurate) - confirm diagnosis, bladder must be EMPTY before scan to avoid false positive
- DO NOT do digital/PV examination (can precipitate catastrophic bleed!)
- Coagulation profile, CBC, blood grouping and crossmatch
Management:
- Minor bleed + preterm: Bed rest, steroids for lung maturity (if <34 wks), tocolysis
- Active bleed or term: Emergency LSCS
- Delivery is ALWAYS by LSCS in Types III and IV
1B. ABRUPTIO PLACENTAE
Definition: Premature separation of a normally situated placenta.
Types:
- Revealed (80%) - blood tracks down and escapes vaginally
- Concealed (20%) - blood collects behind placenta, no external bleed
Risk factors - mnemonic: "HITS + DC"
- Hypertension/Pre-eclampsia (commonest cause ~50%)
- Intra-uterine growth restriction
- Trauma (domestic violence, road accident)
- Smoking, Substance abuse (cocaine)
- Deficiency of folate
- Chorioamnionitis / premature ROM
Clinical Features:
- Painful dark red vaginal bleeding
- Uterus: tense, rigid, "woody hard" (board-like)
- FHR changes (fetal distress)
- Couvelaire uterus (blood seeps into myometrium) - uterus bruised, purple
- DIC is a feared complication (concealed > revealed)
Comparison - exam favourite:
| Feature | Placenta Praevia | Abruption |
|---|---|---|
| Pain | Painless | Painful |
| Blood | Bright red | Dark red |
| Uterus | Soft | Hard, tender |
| Fetal lie | Abnormal | Normal |
| Coagulopathy | Rare | Common |
| PV examination | CONTRAINDICATED | May be done |
2. PRE-ECLAMPSIA & ECLAMPSIA
Definition: New-onset hypertension (BP ≥140/90 mmHg on two readings 4 hrs apart) after 20 weeks gestation + proteinuria (≥0.3 g/24 hrs or PCR ≥30) or end-organ involvement.
Severe pre-eclampsia: BP ≥160/110 or any of HELLP/eclampsia features.
Mnemonic for features - "HELLP-E":
- Hemolysis
- Elevated Liver enzymes
- Low Platelets
- Proteinuria
- Eclampsia (seizures)
Pathophysiology (simplified for exam):
- Failure of normal trophoblastic invasion of spiral arteries → high-resistance vessels → placental ischaemia → endothelial dysfunction → vasospasm → systemic hypertension, proteinuria, organ damage
Risk Factors - "FHOPE":
- First pregnancy (nulliparity)
- History of pre-eclampsia, Hypertension
- Obesity, age >40
- Pre-existing renal/diabetes/autoimmune disease
- Eclampsia in previous pregnancy, Extremes of age
Management:
- Definitive treatment = DELIVERY (only cure)
- Antihypertensives: Labetalol IV (first line), Nifedipine oral, Hydralazine IV
- Seizure prophylaxis: Magnesium sulphate (Pritchard regime / Zuspan regime)
- Monitor: urine output (Foley catheter), reflexes (MgSO4 toxicity), platelet, LFT, urate
Magnesium Sulphate Toxicity - mnemonic: "L-A-R":
- Loss of DTRs (first sign) - check patellar reflex
- Arrest (respiratory depression)
- Renal failure risk
- Antidote: Calcium gluconate 1g IV
ECLAMPSIA = pre-eclampsia + grand mal seizures
- Management: ABC, left lateral position, MgSO4 (loading dose 4g IV over 15 min), deliver after stabilisation
3. POSTPARTUM HAEMORRHAGE (PPH)
Definition:
- Primary PPH: Blood loss ≥500 mL within 24 hours of delivery (≥1000 mL after caesarean)
- Secondary PPH: Abnormal bleeding between 24 hours and 12 weeks postpartum
Causes - mnemonic: "4 T's"
| T | Cause | Frequency |
|---|---|---|
| Tone | Uterine atony | >70% - COMMONEST |
| Trauma | Lacerations, rupture, inversion | ~20% |
| Tissue | Retained placenta/membranes | ~10% |
| Thrombin | Coagulopathy (DIC, etc.) | Rare |
Management - step-up approach:
- Bimanual compression + rub up uterus
- Uterotonics:
- Oxytocin 10 IU IM (or infusion) - first line
- Ergometrine 0.5 mg IM (not in hypertension)
- Misoprostol 800 mcg sublingual/rectal
- Carboprost (15-methyl PGF2α) IM - not in asthma
- Balloon tamponade (Bakri balloon) - if above fails
- Surgical: B-Lynch compression suture, uterine artery ligation
- Interventional radiology: Uterine artery embolisation
- Hysterectomy (last resort, life-saving)
B-Lynch suture = brace suture that compresses the uterus like a brace/suspender.
Shock index = HR/SBP (normal <1; PPH concern if >1)
4. ECTOPIC PREGNANCY
Definition: Implantation of the fertilised ovum outside the uterine cavity. Commonest site = ampulla of fallopian tube (75%).
Risk factors - mnemonic: "STIPE":
- Salpingitis/PID (most important - ~50% cases)
- Tubal surgery / sterilisation
- IVF / assisted reproduction
- Previous ectopic pregnancy (recurrence risk ~22%)
- Endometriosis, IUD use
Clinical features (classic triad):
- Amenorrhoea (6-8 weeks)
- Lower abdominal pain (unilateral, sharp)
- Vaginal bleeding (dark brown, scanty)
Signs:
- Cervical excitation (pain on moving cervix) = PATHOGNOMONIC of peritoneal irritation
- Adnexal mass/tenderness
- If ruptured: shoulder tip pain (diaphragmatic irritation by blood), shock
Key Investigations:
- Serum β-hCG: If >1500-2000 mIU/mL without an intrauterine pregnancy on TVS → ectopic until proven otherwise (discriminatory zone)
- TVS: First line - look for empty uterus + adnexal mass
- Culdocentesis (historical) - non-clotting blood in pouch of Douglas
Management:
| Situation | Treatment |
|---|---|
| Stable + small (<3.5 cm) + no fetal heartbeat | Methotrexate (MTX) IM - medical management |
| Stable, salpingotomy possible | Laparoscopic salpingostomy/salpingectomy |
| Ruptured / unstable | Emergency laparotomy + salpingectomy |
MTX contraindications - "BRLKH": Breastfeeding, Renal/hepatic disease, Leucopenia, Known fetal cardiac activity, Haemoperitoneum.
5. GESTATIONAL DIABETES MELLITUS (GDM)
Definition: Glucose intolerance first diagnosed during pregnancy (usually pathophysiology similar to Type 2 DM - insulin resistance).
Screening:
- All pregnant women at 24-28 weeks
- Two-step (US): 50g GCT (non-fasting) → if positive, 100g 3-hr OGTT
- One-step (IADPSG/WHO): 75g 2-hr OGTT
IADPSG Diagnostic Criteria (75g OGTT):
| Timepoint | GDM threshold |
|---|---|
| Fasting | ≥92 mg/dL (5.1 mmol/L) |
| 1-hour | ≥180 mg/dL (10.0 mmol/L) |
| 2-hour | ≥153 mg/dL (8.5 mmol/L) |
One or more values being met or exceeded = GDM.
Fetal complications - mnemonic: "MACRO":
- Macrosomia (>4 kg)
- Asymetric septal hypertrophy/cardiac defects
- Congenital anomalies (if pregestational)
- Respiratory distress syndrome
- Obesity/diabetes in offspring later
Maternal complications: Pre-eclampsia, polyhydramnios, operative delivery, future T2DM (50% within 10 years).
Management:
- Diet + exercise first (85% controlled)
- Insulin if targets not met (oral hypoglycaemics: Metformin is safe/used in many centres)
- Targets: fasting <95, 1-hr post meal <140, 2-hr <120 mg/dL
- Deliver at 38-39 weeks (earlier if macrosomia or poor control)
6. NORMAL LABOUR
Stages of Labour:
| Stage | Duration (Primipara) | Duration (Multipara) |
|---|---|---|
| 1st Stage (cervical dilation 0→10 cm) | 8-18 hrs total | 5-12 hrs |
| - Latent phase (0-3 cm) | Up to 20 hrs | Up to 14 hrs |
| - Active phase (4-10 cm) | ≥0.5 cm/hr dilation | ≥1 cm/hr dilation |
| 2nd Stage (full dilation → delivery) | Up to 2 hrs | Up to 1 hr |
| 3rd Stage (placenta delivery) | Up to 30 min | Up to 15 min |
Cardinal movements of labour (vertex presentation) - mnemonic: "EIDFRERE":
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- Restitution
- External rotation
- Expulsion
Active Management of 3rd Stage (AMTSL):
- Oxytocin 10 IU IM within 1 min of delivery
- Controlled cord traction (Brandt-Andrews manoeuvre)
- Uterine massage after placenta delivery
7. MALPRESENTATIONS
Breech Presentation
Types:
- Frank/Extended breech (60-65%) - both hips flexed, both knees extended (feet near face)
- Complete/Flexed breech (5%) - hips and knees both flexed
- Footling/Incomplete breech (20-35%) - one/both feet present
Complications: Cord prolapse, head entrapment, birth asphyxia.
Management:
- External Cephalic Version (ECV) at 36-37 weeks (primip) / 37 weeks (multip)
- If ECV fails or contraindicated → Elective LSCS at 39 weeks
- Vaginal breech delivery: only if experienced operator + favourable criteria (flexed breech, frank breech, adequate pelvis, estimated fetal weight 2-3.8 kg, no hyperextended head)
Transverse Lie
- Always delivered by LSCS (cord prolapse risk is very high)
- If arm prolapse occurs - NEVER pull the arm, proceed to emergency LSCS
8. PRETERM LABOUR & PROM
Preterm Labour: Onset of labour before 37 completed weeks.
Management:
- Tocolysis (to delay 48 hrs for steroid effect): Nifedipine, Atosiban (oxytocin antagonist), Indomethacin (<32 wks)
- Steroids (betamethasone 12 mg IM x2 doses 24 hrs apart) for fetal lung maturity - most important if <34 weeks
- Magnesium sulphate for neuroprotection if <32 weeks
- GBS prophylaxis: Penicillin G IV during labour
PROM (Premature Rupture of Membranes): Rupture of membranes before onset of labour.
- PPROM = PROM before 37 weeks
- Diagnosis: Pooling of liquor in vagina, ferning test, nitrazine paper (turns blue - alkaline), IGFBP-1 test (AmniSure)
- Management: Antibiotics (erythromycin 250mg QID x10 days), steroids, expectant vs. induction depending on gestation
9. PUERPERAL SEPSIS
Definition: Infection of the genital tract occurring between rupture of membranes or labour and 42 days postpartum, with ≥38°C on 2 successive days.
Commonest organism: Group A Streptococcus (Streptococcus pyogenes) - most dangerous, can be rapidly fatal.
Risk factors - mnemonic: "CROM":
- Caesarean section
- Retained products of conception
- Operative vaginal delivery
- Manual removal of placenta, Multiple vaginal examinations, Mastitis
Clinical features: Fever, uterine/pelvic tenderness, offensive lochia, tachycardia, rigors.
Management:
- IV antibiotics: broad spectrum (e.g. Amoxicillin + Metronidazole + Gentamicin)
- If retained products: evacuation of uterus
- If abscess: drainage
- Septic pelvic thrombophlebitis: heparin
10. INSTRUMENTAL DELIVERY
Forceps vs. Vacuum Extractor
| Feature | Forceps | Vacuum (Ventouse) |
|---|---|---|
| Station needed | ≥+2/mid-cavity | ≥+2/outlet |
| Rotation | Can rotate (Kielland's) | Limited rotation |
| Face presentation | Possible (Wrigley's for face-to-pubis) | Contraindicated |
| GA required | Often yes | Less often |
| Maternal injury | Perineal tears | Less perineal |
| Fetal injury | Facial bruising/nerve palsy | Caput/cephalhaematoma, intracranial haemorrhage |
Prerequisites for instrumental delivery (all must be met):
- Full cervical dilation
- Membranes ruptured
- Engagement (head at/below ischial spines, i.e. ≥ station 0)
- Known position of head
- No CPD
- Bladder empty (catheterise)
- Adequate analgesia
- Informed consent
11. OBSTETRIC EMERGENCIES (Quick Reference)
Cord Prolapse
- Emergency: cord descends below presenting part after rupture of membranes
- Risk: footling breech, transverse lie, high head at ROM, polyhydramnios
- Management: Call for help, DO NOT handle cord, fill bladder (300-500 mL saline), knee-chest position or Trendelenburg, emergency LSCS
Shoulder Dystocia
- Head delivered but shoulders impacted at symphysis pubis
- Mnemonic: HELPERR
- Help (call for help)
- Episiotomy if needed
- Legs (McRoberts manoeuvre - hyper-flex thighs)
- Pressure (suprapubic pressure, NOT fundal)
- Enter (internal rotational manoeuvres - Rubin II, Woods screw)
- Remove posterior arm
- Rollover (Gaskin manoeuvre - all-fours)
Uterine Rupture
- Scar dehiscence (previous CS) or spontaneous (obstructed labour, multipara)
- Warning signs: scar tenderness, poor progress, maternal/fetal distress, loss of station
- Features: sudden severe pain, fetal parts palpable abdominally, fetal distress, maternal shock
- Management: Emergency laparotomy, repair or hysterectomy
12. HYDRAMNIOS (POLYHYDRAMNIOS) & OLIGOHYDRAMNIOS
| Feature | Polyhydramnios (AFI >24 cm or deepest pool >8 cm) | Oligohydramnios (AFI <5 cm or deepest pool <2 cm) |
|---|---|---|
| Fetal causes | Oesophageal/duodenal atresia, anencephaly, NTD (can't swallow) | Renal agenesis (Potter sequence), obstructive uropathy |
| Maternal | GDM, Rh isoimmunisation | Post-dates, IUGR, PROM |
| Complication | Cord prolapse, malpresentation, PPH, preterm labour | Cord compression, MSL, fetal distress |
Potter sequence: Oligohydramnios → limb contractures + flat face + pulmonary hypoplasia (mnemonic: FLAP - Flat face, Limb contractures, Absent kidneys, Pulmonary hypoplasia)
QUICK EXAM MNEMONICS SUMMARY
| Mnemonic | Topic |
|---|---|
| 4 T's (Tone, Trauma, Tissue, Thrombin) | PPH causes |
| HELPERR | Shoulder dystocia management |
| STIPE | Ectopic risk factors |
| MACRO | GDM fetal complications |
| FLAP | Potter sequence |
| MACS-P | Placenta praevia risk factors |
| FHOPE | Pre-eclampsia risk factors |
| L-A-R | MgSO4 toxicity signs |
| CROM | Puerperal sepsis risk factors |
| HITS+DC | Abruption risk factors |
EXAM DAY TIPS
- Eclampsia management: Always start with ABC + MgSO4 before anything else. Delivery after stabilisation.
- Never do PV exam in a bleeding antepartum patient before ruling out placenta praevia by USG.
- Oxytocin is ALWAYS first-line uterotonic for PPH (not ergometrine in hypertensive patients).
- Methotrexate in ectopic: Check renal function, CBC, LFT before giving.
- GDM screen at 24-28 weeks; diagnose with 75g OGTT.
- Betamethasone (not dexamethasone preference in most guidelines) for fetal lung maturity.
- Any cord prolapse = emergency LSCS.
- Confirm instrumental delivery prerequisites before every forceps/ventouse question.
Good luck on Monday! You've got this. These topics cover the bulk of what final year examiners test. Focus especially on PPH, pre-eclampsia/eclampsia, APH (comparison table), ectopic, and the obstetric emergencies - those come up almost every year.
On Monday I have obsetretics final year mbbs exam so give me notes for imp topics which should make my exam period feel easy
Here are your high-yield Obstetrics final year MBBS exam notes - covering the topics examiners love most, with moderate depth and mnemonics throughout.
📚 OBSTETRICS - FINAL YEAR MBBS EXAM NOTES
1. ANTEPARTUM HAEMORRHAGE (APH)
Definition: Bleeding from the genital tract after 28 weeks gestation and before delivery of the baby.
Causes - mnemonic: "P-A-U-V-E"
- Placenta Praevia
- Abruption Placentae
- Unexplained (marginal sinus bleed)
- Vasa Praevia
- Extra-placental (cervical polyp, erosion, varicose veins)
1A. PLACENTA PRAEVIA
Definition: Placenta implanted wholly or partly in the lower uterine segment.
Classification:
| Type | Description |
|---|---|
| Type I (Low-lying) | Placenta in lower segment, does not reach os |
| Type II (Marginal) | Reaches but does not cover the internal os |
| Type III (Partial) | Partially covers the internal os |
| Type IV (Central/Complete) | Completely covers the internal os |
Risk factors - mnemonic: "MACS-P"
- Multiparity
- Advanced maternal age
- Caesarean section / previous uterine surgery
- Smoking, prior Spontaneous/induced abortion
- Placenta praevia in previous pregnancy
Clinical Features:
- Painless, bright red vaginal bleeding - sudden, recurrent, unprovoked
- Uterus soft and non-tender
- Abnormal lie (transverse/oblique) - fetus displaced by low placenta
- High presenting part
- FHR usually normal initially
Key rule: NEVER do a digital PV examination - can trigger catastrophic haemorrhage!
Investigations:
- TVS (transvaginal USG) - safest and most accurate; empty bladder before scan (full bladder gives false positive)
- CBC, coagulation profile, blood group and crossmatch
Management:
- Preterm, minor bleed: bed rest, steroids (<34 wks), tocolysis
- Term or major bleed: LSCS
- Types III and IV - always deliver by LSCS
1B. ABRUPTIO PLACENTAE
Definition: Premature separation of a normally situated placenta.
Types:
- Revealed (80%) - blood escapes vaginally
- Concealed (20%) - blood collects behind placenta, no external bleed (more dangerous - DIC risk)
Risk factors - mnemonic: "HITS-DC"
- Hypertension/Pre-eclampsia (commonest ~50%)
- IUGFR / intrauterine growth restriction
- Trauma (domestic violence, RTA)
- Smoking, cocaine use
- Deficiency of folate
- Chorioamnionitis / PROM
Clinical Features:
- Painful, dark red bleeding
- Uterus: tense, rigid, "woody hard" / board-like
- Uterus may be larger than dates (concealed blood)
- FHR abnormality / fetal distress
- Couvelaire uterus (blood seeps into myometrium - bruised, purple)
- DIC - feared complication
APH COMPARISON TABLE (Exam Favourite!)
| Feature | Placenta Praevia | Abruptio Placentae |
|---|---|---|
| Pain | Painless | Painful |
| Blood colour | Bright red | Dark red |
| Uterus | Soft, non-tender | Hard, tender |
| Fetal lie | Often abnormal | Normal |
| Coagulopathy | Rare | Common |
| PV exam | CONTRAINDICATED | May be done cautiously |
| Fetal distress | Late/absent | Early and severe |
2. PRE-ECLAMPSIA & ECLAMPSIA
Definition: New-onset hypertension (BP ≥140/90 mmHg on two readings ≥4 hrs apart) after 20 weeks gestation, with proteinuria (≥0.3 g/24 hrs) or end-organ involvement (no proteinuria needed if severe features present).
Severe PET: BP ≥160/110 OR any of the features below.
HELLP Syndrome - mnemonic: "HELLP"
- Hemolysis (microangiopathic)
- Elevated Liver enzymes (AST/ALT >70 IU/L)
- Low Platelets (<100,000)
- Proteinuria (associated)
Pathophysiology (simplified):
Failure of trophoblastic invasion of spiral arteries → high-resistance uteroplacental circulation → placental ischaemia → endothelial dysfunction → vasospasm → hypertension + proteinuria + multi-organ damage.
Risk factors - mnemonic: "FHOPE"
- First pregnancy (nulliparity - strongest risk factor)
- History of PET, Hypertension
- Obesity, age >40
- Pre-existing renal/diabetes/autoimmune disease
- Eclampsia / PET in previous pregnancy
Management:
- Definitive treatment = DELIVERY (the only cure)
- Antihypertensives: Labetalol IV (first choice), Nifedipine oral, Hydralazine IV
- Seizure prophylaxis: Magnesium Sulphate (MgSO4)
MgSO4 Regimens:
- Pritchard: Loading 4g IV + 10g IM (5g each buttock); Maintenance 5g IM every 4 hrs
- Zuspan: Loading 4g IV over 20 min; Maintenance 1-2g/hr IV infusion
MgSO4 Toxicity - watch for "R-A-D":
- Respiratory depression (RR <12/min)
- Absent patellar/deep tendon reflexes (first sign)
- Decreased urine output (<30 mL/hr)
- Antidote: Calcium gluconate 1g IV slowly
ECLAMPSIA = pre-eclampsia + grand mal seizures
- Management: ABC + Left lateral position + MgSO4 4g IV over 15 min + deliver after stabilisation
3. POSTPARTUM HAEMORRHAGE (PPH)
Definition:
- Primary PPH: Blood loss ≥500 mL within 24 hours of delivery (≥1000 mL after LSCS)
- Secondary PPH: Abnormal bleeding from 24 hours to 12 weeks postpartum
Causes - mnemonic: "4 T's"
| T | Cause | Frequency |
|---|---|---|
| Tone | Uterine atony | >70% - COMMONEST |
| Trauma | Lacerations, uterine rupture, inversion | ~20% |
| Tissue | Retained placenta/membranes | ~10% |
| Thrombin | Coagulopathy (DIC, von Willebrand) | Rare |
Management - step-up ladder:
- Massage the uterus, bimanual compression
- Uterotonics:
- Oxytocin 10 IU IM/IV - first line always
- Ergometrine 0.5 mg IM - avoid in hypertension
- Misoprostol 800 mcg sublingual/rectal
- Carboprost (15-methyl PGF2α) IM - avoid in asthma
- Balloon tamponade (Bakri balloon) - success rate up to 91%
- Surgery: B-Lynch compression suture, uterine artery ligation, internal iliac ligation
- Interventional radiology: Uterine artery embolisation
- Hysterectomy - last resort, life-saving
Key fact: Ergometrine is contraindicated in hypertensive patients; oxytocin is ALWAYS the first uterotonic.
4. ECTOPIC PREGNANCY
Definition: Implantation of the fertilised ovum outside the uterine cavity.
Sites - mnemonic: "Ampulla is 75%"
- Ampulla (75%) > Isthmus (12%) > Fimbria (11%) > Interstitial (2-3%) > Ovary, Cervix, Abdominal (rare)
Risk factors - mnemonic: "STIPE"
- Salpingitis/PID (most important - causes ~50% of cases)
- Tubal surgery or previous sterilisation
- IVF/assisted reproduction
- Previous ectopic pregnancy (recurrence ~22%)
- Endometriosis, IUD use
Classic Triad:
- Amenorrhoea (6-8 weeks)
- Lower abdominal pain (unilateral, colicky/sharp)
- Vaginal bleeding (dark brown, scanty - "prune juice")
Signs:
- Cervical excitation (pain on moving cervix) = pathognomonic of peritoneal irritation
- Adnexal tenderness/mass
- If ruptured: shoulder-tip pain (diaphragm irritated by blood), collapse and shock
Investigations:
- Serum β-hCG + TVS (the two pillars of diagnosis)
- Discriminatory zone: if β-hCG >1500-2000 mIU/mL with no IUP on TVS → ectopic until proven otherwise
- In ruptured ectopic: free fluid/blood in pouch of Douglas on USG
Management:
| Situation | Treatment |
|---|---|
| Stable, small (<3.5 cm), unruptured, no fetal heartbeat | Methotrexate (MTX) IM - medical management |
| Stable, surgical candidate | Laparoscopic salpingostomy (tube-sparing) or salpingectomy |
| Ruptured / haemodynamically unstable | Emergency laparotomy + salpingectomy |
MTX contraindications - "BRLKH":
Breastfeeding, Renal/hepatic disease, Leucopenia, Known fetal cardiac activity, Haemoperitoneum
5. GESTATIONAL DIABETES MELLITUS (GDM)
Definition: Glucose intolerance first recognised in pregnancy (not pre-existing diabetes).
Screening: All pregnant women at 24-28 weeks
- Two-step (USA): 50g GCT (non-fasting) → if ≥140 mg/dL, proceed to 100g 3-hr OGTT
- One-step (IADPSG/WHO - widely used): 75g 2-hr OGTT
IADPSG Diagnostic Criteria (75g OGTT - any ONE value met = GDM):
| Timepoint | Threshold |
|---|---|
| Fasting | ≥92 mg/dL (5.1 mmol/L) |
| 1-hour | ≥180 mg/dL (10.0 mmol/L) |
| 2-hour | ≥153 mg/dL (8.5 mmol/L) |
Fetal complications - mnemonic: "MACRO"
- Macrosomia (>4 kg) - leads to shoulder dystocia
- Asymmetric septal hypertrophy
- Congenital anomalies (neural tube, cardiac)
- Respiratory distress syndrome (delayed lung maturity)
- Obesity/T2DM in offspring later in life
Maternal complications: Pre-eclampsia, polyhydramnios, operative delivery, UTI, future T2DM (50% within 10 years).
Management:
- Step 1: Diet + exercise (controls ~85%)
- Step 2: Insulin if targets not met (safest; metformin used in many centres)
- Glycaemic targets: fasting <95, 1-hr post meal <140, 2-hr <120 mg/dL
- Deliver at 38-39 weeks (or earlier if macrosomia/poor control)
- Screen for T2DM at 6-12 weeks postpartum with 75g OGTT
6. NORMAL LABOUR
Stages of Labour:
| Stage | Events | Duration (Primip) | Duration (Multip) |
|---|---|---|---|
| 1st Stage | 0 → 10 cm dilation | 8-18 hrs | 5-12 hrs |
| Latent phase | 0-3 cm | Up to 20 hrs | Up to 14 hrs |
| Active phase | 4-10 cm | ≥0.5 cm/hr | ≥1 cm/hr |
| 2nd Stage | Full dilation → delivery | Up to 2 hrs | Up to 1 hr |
| 3rd Stage | Placenta delivery | Up to 30 min | Up to 15 min |
Cardinal Movements (vertex presentation) - mnemonic: "ED-FI-ERRE"
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- Restitution
- External rotation
- Expulsion
Active Management of 3rd Stage (AMTSL):
- Oxytocin 10 IU IM within 1 minute of baby delivery
- Controlled cord traction (Brandt-Andrews manoeuvre)
- Uterine massage after placenta is delivered
7. MALPRESENTATIONS
Breech Presentation
Types:
- Frank/Extended (65%): hips flexed, knees extended - feet near face
- Complete/Flexed (5%): hips + knees both flexed
- Footling/Incomplete (25-30%): one or both feet presenting first
Complications: Cord prolapse (highest in footling), head entrapment, birth asphyxia.
Management:
- ECV (External Cephalic Version) at 36-37 weeks (offered to all breech presentations)
- If ECV fails/contraindicated: Elective LSCS at 39 weeks
- Vaginal breech only if: experienced operator + flexed breech + adequate pelvis + EFW 2-3.8 kg + no hyperextended head
Face Presentation
- Commonest mento-anterior position delivers vaginally
- Mento-posterior = LSCS (cannot flex to deliver)
Brow Presentation
- Most unfavourable (largest diameter presents)
- Usually requires LSCS
Transverse/Oblique Lie
- Always LSCS - cord prolapse risk very high
- If arm prolapses: NEVER pull it; proceed to immediate LSCS
8. PRETERM LABOUR & PROM
Preterm Labour: Onset of regular uterine contractions with cervical change before 37 completed weeks.
Management of preterm labour:
- Tocolysis (buys 48 hrs for steroids): Nifedipine (first choice), Atosiban (oxytocin antagonist), Indomethacin (<32 wks)
- Corticosteroids: Betamethasone 12 mg IM x2 doses, 24 hrs apart - given if <34 weeks (fetal lung maturity)
- MgSO4 for fetal neuroprotection if <32 weeks
- GBS prophylaxis: Penicillin G IV in labour
PROM (Premature Rupture of Membranes): Rupture before onset of labour at any gestation.
- PPROM = PROM before 37 weeks
Diagnosis:
- Pooling of liquor on speculum exam
- Ferning test (amniotic fluid crystallises like ferns on a glass slide)
- Nitrazine paper test: turns blue (amniotic fluid is alkaline, pH 7.0-7.5 vs vaginal pH 3.5-4.5)
- AmniSure (IGFBP-1 test) - most specific
Management of PPROM:
- Antibiotics: Erythromycin 250 mg QID x10 days (reduces infection, prolongs latency)
- Steroids if <34 weeks
- Expectant management vs. induction based on gestation and clinical picture
9. PUERPERAL SEPSIS
Definition: Infection of the genital tract between rupture of membranes/labour and 42 days postpartum, with fever ≥38°C on 2 successive days.
Commonest organism: Streptococcus pyogenes (Group A Strep) - most virulent, can cause rapid maternal death. Other organisms: E. coli, Staphylococcus, anaerobes.
Risk factors - mnemonic: "CROM"
- Caesarean section (single biggest risk factor)
- Retained products of conception
- Operative vaginal delivery
- Multiple vaginal examinations, Manual removal of placenta, Mastitis
Features: Fever, uterine/pelvic tenderness, offensive/purulent lochia, tachycardia, rigors.
Management:
- IV broad-spectrum antibiotics (e.g. Amoxicillin + Metronidazole + Gentamicin)
- Remove source: evacuation of retained products
- If abscess: drainage
- Septic pelvic thrombophlebitis: therapeutic heparin
10. INSTRUMENTAL DELIVERY
Forceps vs. Vacuum (Ventouse) - Comparison Table
| Feature | Forceps | Vacuum/Ventouse |
|---|---|---|
| Rotation | Yes (Kielland's) | Limited |
| Face presentation | Yes (Wrigley's) | Contraindicated |
| Prematurity (<34 wks) | Preferred | Avoid |
| Maternal injury | More perineal tears | Less |
| Fetal scalp injury | Facial bruising, nerve palsy | Chignon, cephalhaematoma, ICH |
| Failed attempt | Can proceed to forceps | - |
Prerequisites for Instrumental Delivery (ALL must be present):
Mnemonic: "6 C's + PPP"
- Cervix fully dilated
- Consent obtained
- Cephalic presentation (known position)
- Cephalo-pelvic disproportion absent
- Contraction present (pushing effort)
- Catheter (bladder empty)
- Pain relief adequate
- Paediatrician informed
- Presenting part at/below ischial spines (engaged)
11. OBSTETRIC EMERGENCIES
Cord Prolapse
- Umbilical cord descends below presenting part after ROM
- Risk factors: footling breech, transverse lie, high head at ARM, polyhydramnios, multiparity
Management - "FILL the bladder, CALL for help":
- Call for help
- Do NOT handle or compress the cord
- Relieve pressure: knee-chest/Trendelenburg position, fill bladder with 300-500 mL saline
- Emergency LSCS (or ventouse/forceps if fully dilated + head at perineum)
Shoulder Dystocia
- Head delivers but anterior shoulder impacted behind symphysis pubis
- Turtle-neck sign / retraction of head after delivery
Management - mnemonic: "HELPERR"
| Step | Action |
|---|---|
| H | Help - call for help immediately |
| E | Episiotomy (if needed for manoeuvres) |
| L | Legs - McRoberts manoeuvre (hyperflex thighs onto abdomen) |
| P | Pressure - suprapubic (NOT fundal) pressure |
| E | Enter - internal rotational manoeuvres (Rubin II, Woods screw, Barnum manoeuvre) |
| R | Remove posterior arm |
| R | Roll over (Gaskin all-fours manoeuvre) |
Uterine Rupture
Warning signs: Scar tenderness, prolonged labour, maternal tachycardia, fetal distress, loss of fetal station.
Features of complete rupture:
- Sudden severe abdominal pain, then pain relief (tension releases)
- Fetal parts palpable abdominally (fetus extruded)
- Fetal distress → fetal death
- Maternal shock
Management: Emergency laparotomy → repair (if feasible) or hysterectomy.
12. POLYHYDRAMNIOS & OLIGOHYDRAMNIOS
| Feature | Polyhydramnios (AFI >24 cm) | Oligohydramnios (AFI <5 cm) |
|---|---|---|
| Fetal causes | Oesophageal/duodenal atresia, anencephaly, NTD (can't swallow) | Renal agenesis, obstructive uropathy |
| Maternal causes | GDM, Rh isoimmunisation | Post-dates, IUGR, PROM |
| Complications | Cord prolapse, malpresentation, PPH, preterm labour | Cord compression, MSL, fetal distress |
Potter Sequence (bilateral renal agenesis + severe oligohydramnios):
Mnemonic: FLAP - Flat face, Limb contractures, Absent kidneys, Pulmonary hypoplasia
13. ISOIMMUNISATION (Rh INCOMPATIBILITY)
Mechanism: Rh-negative mother sensitised by Rh-positive fetal RBCs → maternal anti-D IgG crosses placenta → haemolysis of fetal RBCs → Hydrops fetalis.
Prevention:
- Anti-D immunoglobulin 300 mcg IM to Rh-negative mothers:
- At 28 weeks (routine)
- Within 72 hours of any sensitising event (delivery, miscarriage, APH, amniocentesis, ECV, trauma)
Diagnosis in fetus: Middle cerebral artery peak systolic velocity (MCA-PSV) on Doppler (>1.5 MoM = fetal anaemia).
Treatment: Intrauterine blood transfusion (if severe fetal anaemia preterm).
Hydrops fetalis: Generalised oedema + ascites + pleural/pericardial effusion (>2 body cavities).
14. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Types:
- Complete Hydatidiform Mole (46XX, all paternal)
- Partial Hydatidiform Mole (69XXX or 69XXY, triploid)
- Invasive Mole, Choriocarcinoma, PSTT
Complete vs Partial Mole:
| Feature | Complete Mole | Partial Mole |
|---|---|---|
| Karyotype | 46XX (diploid, all paternal) | 69XXX/69XXY (triploid) |
| Fetus | Absent | Present (abnormal) |
| β-hCG | Very high | Moderately elevated |
| USG | "Snowstorm" pattern | Swiss cheese placenta |
| Malignant potential | 15-20% | 0.5-3% |
Clinical features: Exaggerated morning sickness, uterus large for dates, absent FH, vaginal bleeding (may pass grape-like vesicles), no fetal parts, very high β-hCG, theca lutein cysts.
Management:
- Suction evacuation + histopathology
- Serial β-hCG monitoring (every 2 weeks until normal, then monthly)
- Contraception for at least 6 months after normalisation
- If β-hCG rises or plateaus: gestational trophoblastic neoplasia → chemotherapy (Methotrexate or Actinomycin-D)
QUICK-FIRE MNEMONICS SUMMARY
| Mnemonic | For |
|---|---|
| 4 T's (Tone, Trauma, Tissue, Thrombin) | PPH causes |
| HELPERR | Shoulder dystocia steps |
| STIPE | Ectopic risk factors |
| MACRO | GDM fetal complications |
| FLAP | Potter sequence |
| MACS-P | Placenta praevia risk factors |
| FHOPE | Pre-eclampsia risk factors |
| R-A-D | MgSO4 toxicity signs |
| CROM | Puerperal sepsis risk factors |
| HITS-DC | Abruption risk factors |
| BRLKH | MTX contraindications |
| ED-FI-ERRE | Cardinal movements of labour |
EXAM DAY RULES - NEVER FORGET
- Never do a digital PV in antepartum bleeding until placenta praevia is excluded by USG.
- Eclampsia: ABC → MgSO4 4g IV → stabilise → deliver. Do not rush straight to theatre.
- PPH: Oxytocin is ALWAYS first uterotonic. Ergometrine is avoided in hypertension.
- Ectopic: β-hCG >2000 + empty uterus on TVS = ectopic until proven otherwise.
- Cord prolapse: Never handle cord, fill the bladder, knee-chest, emergency LSCS.
- Shoulder dystocia: McRoberts + suprapubic pressure first. NEVER fundal pressure.
- Mole: Suction evacuation + serial β-hCG. No pregnancy for 6 months.
- Betamethasone for lung maturity before 34 weeks, MgSO4 for neuroprotection before 32 weeks.
All the best on Monday - you've covered everything that examiners consistently target across finals. The APH comparison table, HELPERR, the 4 T's of PPH, and eclampsia management tend to appear in almost every sitting. Focus on those first if you're short on time!
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