---

SARASWATI MEDICAL COLLEGE - OBG Part II

Complete Distinction-Level Answers

---

Q1. Classify and define various stages of PIH with their management (5+5=10)

PART A: Classification & Definitions (5 marks)

Classification (WHO / Standard Indian Classification):

• BP ≥140/90 mmHg on two occasions 4 hours apart after 20 weeks of gestation
• No proteinuria, no end-organ damage
• Resolves completely within 12 weeks postpartum
• Also called "transient hypertension of pregnancy"

• Gestational hypertension + proteinuria (>300 mg/24 hrs or dipstick ≥2+)
• OR gestational hypertension + signs of end-organ damage (even without proteinuria)

• SBP 140-159 mmHg / DBP 90-109 mmHg
• Proteinuria present
• No symptoms of severe disease

• SBP ≥160 mmHg or DBP ≥110 mmHg (on two occasions 4 hrs apart)
• Proteinuria ≥5 g/24 hrs
• Oliguria (<500 mL/24 hrs)
• Cerebral/visual disturbances (headache, scotoma, blurred vision)
• Pulmonary edema or cyanosis
• Epigastric/right upper quadrant pain
• Thrombocytopenia (<100,000/mL)
• Elevated liver enzymes (AST/ALT >70 U/L)
• IUGR / oligohydramnios

• Grand mal (tonic-clonic) seizures in a woman with preeclampsia
• NOT due to other causes (epilepsy, intracranial hemorrhage)
• Can occur antepartum (most common - 50%), intrapartum (25%), or postpartum (25%)

• A severe variant of preeclampsia characterized by:
  • H - Hemolysis (microangiopathic hemolytic anemia)
  • EL - Elevated Liver enzymes (AST/ALT >70 U/L)
  • LP - Low Platelets (<100,000/mL)

• Hypertension present before pregnancy OR before 20 weeks gestation OR persisting >12 weeks postpartum

• New-onset proteinuria or end-organ damage in a woman with pre-existing chronic hypertension

---

PART B: Management (5 marks)

Management of Mild Preeclampsia:

• Hospitalization (or close outpatient monitoring)
• Bed rest in left lateral position
• Monitor BP every 4-6 hours, daily urine protein, weekly LFTs, CBP, RFTs
• Fetal surveillance: NST, BPP, Doppler studies
• Antihypertensives if BP ≥150/100: Methyldopa (250-500 mg TDS) - drug of choice in pregnancy; or Nifedipine (slow-release)
• Definitive treatment = Delivery at 37 weeks if stable

Management of Severe Preeclampsia:

• Hospitalization mandatory
• IV access, Foley catheter (urine output >25 mL/hr)
• Seizure prophylaxis: Magnesium Sulfate (MgSO4)
  • Loading dose: 4-6 g IV over 15-20 minutes
  • Maintenance: 2 g/hr IV infusion
• Antihypertensive for acute severe hypertension (DBP >105):
  • Hydralazine 5-10 mg IV push, repeat q 2-4h OR
  • Labetalol 20 mg IV bolus, repeat q10 min (max 300 mg)
  • Nifedipine 10 mg oral, repeat in 30 min
• Labs: CBC, platelets, LFTs, RFTs, coagulation profile, serum Mg levels
• Corticosteroids (betamethasone) if <34 weeks for fetal lung maturity
• Deliver at 34 weeks (or earlier if maternal/fetal deterioration)

Management of Eclampsia (ABC Protocol):

1. Airway - Left lateral position, O2 by mask, prevent aspiration
2. Seizure control - MgSO4 4-6 g IV loading (slow push over 5 min), then 1-2 g/hr maintenance
3. Antihypertensive - As above
4. Monitoring - BP, urine output, serum Mg, respiratory rate, patellar reflexes
5. Delivery - Expedite delivery once mother is stabilized (within 12 hrs); LSCS if unfavorable cervix

• Loss of patellar reflexes (first sign) → Stop infusion
• Respiratory rate <16/min → Stop infusion
• UO <25 mL/hr → Reduce dose
• Antidote: Calcium gluconate 1 g IV slowly

---

Q2. Causes of Postmenopausal Bleeding, Definition and Management (5+5=10)

Definition (included in 5-mark part):

PART A: Causes (5 marks)

Mnemonic: CAVITIES

Remember: Endometrial carcinoma is the MOST IMPORTANT cause to exclude.

---

PART B: Management (5 marks)

Step 1 - History & Examination:

• Amount, duration, any associated symptoms (pain, discharge, weight loss)
• Drug history (HRT, tamoxifen, anticoagulants)
• Per speculum: atrophic changes, cervical lesion, polyp
• Bimanual: uterine size, mobility, adnexal mass
• Pap smear at first visit

Step 2 - Investigations:

• Transvaginal Ultrasound (TVS) - first-line investigation
  • Endometrial thickness (ET) < 4-5 mm = low risk; >5 mm = needs biopsy
  • ET <3 mm = very low risk (some authorities use this cutoff)
  • Assess for polyps, fibroids, ovarian masses
• Sonohysterography / Saline-infusion sonography - better delineates intrauterine lesions
• Endometrial biopsy (Pipelle biopsy) - office procedure, essential for histology
• Hysteroscopy + D&C - gold standard; direct visualization + directed biopsy
• Cervical biopsy if visible cervical lesion
• CBC, coagulation profile, CA-125 if ovarian mass suspected

Step 3 - Treatment (cause-specific):

• Local/topical estrogen (cream, vaginal tablet, or ring)
• Improves quality of life; systemic levels are lower with topical

• Hysteroscopic polypectomy (office or OT)

• Without atypia: Progestin therapy (Medroxyprogesterone acetate, Mirena IUS)
• With atypia / EIN: Hysterectomy (risk of concurrent endometrial cancer is 25-43%)

• Stage I/II: Total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH+BSO) + pelvic lymph node dissection
• Stage III/IV: Adjuvant radiotherapy/chemotherapy as per staging

• Avulsion polypectomy in office

• Reassess HRT regimen; optimize schedule; endometrial sampling mandatory

---

Q3. G2P1+0 at 28 Weeks - Polyhydramnios: Approach & Management (5+5=10)

Case Analysis:

• Presents at 28 weeks for ANC (first visit - high risk flag!)
• Previous delivery of large baby (4.2 kg) by LSCS = prior macrosomia
• Current USG / clinical suspicion of Polyhydramnios

Key Concerns: Suspect Gestational Diabetes Mellitus (GDM) as the underlying cause.

---

PART A: Approach / Investigations (5 marks)

Definition of Polyhydramnios:

• Mild: AFI 25-30 cm
• Moderate: AFI 30-35 cm
• Severe: AFI >35 cm

History Taking:

• Previous obstetric history (macrosomia, GDM, stillbirth)
• Symptoms of polyhydramnios: abdominal distension, breathlessness, edema
• Family history of DM, congenital anomalies
• Last review/ANC gap (this patient is at 28 weeks, first visit - very late booking)

Physical Examination:

• Fundal height (uterus large for dates)
• Difficulty in palpating fetal parts
• Fluid thrill positive
• Malpresentation common (unstable lie, transverse lie)
• Measure BP, weight, urine for glucose/protein

Investigations:

1. Ultrasound (USG) with Detailed Anomaly Scan:
   • Confirm polyhydramnios (AFI/DVP)
   • Fetal biometry (macrosomia? BPD, HC, AC, FL)
   • Fetal anomalies: Anencephaly, esophageal atresia, duodenal atresia ("double bubble"), NTDs, cardiac defects, hydrops fetalis
   • Fetal position/presentation
   • Placental location and grading
2. Oral Glucose Tolerance Test (OGTT): 75g - mandatory (fasting, 1hr, 2hr plasma glucose)
3. Fetal ECHO: To rule out cardiac anomalies
4. Karyotyping / Amniocentesis: If fetal anomalies suspected (Trisomy 18, 21)
5. TORCH screen: CMV, Toxoplasma (causes hydrops/polyhydramnios)
6. Blood group, Rh typing, ICT (Rhesus isoimmunization can cause hydrops)
7. CBC, RFTs, LFTs, HbA1c (if GDM suspected)
8. Fetal surveillance: NST, BPP, Doppler

Causes of Polyhydramnios (for completeness):

• Maternal: GDM (most common in this case), Rh incompatibility
• Fetal: Fetal anomalies impairing swallowing (anencephaly, esophageal atresia, duodenal atresia), NTDs, cardiac defects, fetal hydrops
• Placental: Chorioangioma
• Idiopathic: ~50% of mild cases

---

PART B: Management (5 marks)

Based on severity and gestational age (28 weeks = preterm):

• If GDM confirmed: Dietary control, insulin therapy (insulin preferred in pregnancy), tight glycemic control (fasting <95 mg/dL, 2hr postprandial <120 mg/dL)
• If fetal anomaly incompatible with life: Counselling + termination options (per MTP Act)
• If Rh isoimmunization: Fetal surveillance, intrauterine transfusion if needed

• Conservative (mild/moderate, no maternal distress):
  • Hospitalization
  • Bed rest in left lateral position
  • Monitor for PPROM, preterm labour
  • Serial AFI every 2-3 weeks
• Therapeutic Amniocentesis (Amnioreduction):
  • For severe symptomatic polyhydramnios causing respiratory embarrassment
  • Remove 1-1.5 L under ultrasound guidance (slow removal to prevent abruption)
  • May need to be repeated
• Indomethacin (COX inhibitor):
  • Reduces fetal urine production
  • Used <32 weeks only (risk of premature closure of ductus arteriosus after 32 wks)
  • Monitor for ductal constriction with fetal ECHO
  • Dose: 25-50 mg TDS

• Hospitalization recommended given unstable lie risk
• Corticosteroids (Betamethasone 12 mg IM x2 doses, 24 hrs apart) for fetal lung maturity given preterm status
• Tocolytics if preterm contractions develop
• Plan delivery at 37-38 weeks (or earlier if deterioration)
• Mode: Repeat LSCS preferred (previous LSCS + malpresentation risk)
• During delivery/LSCS: Controlled amniotomy to prevent cord prolapse and placental abruption
• Pediatrician should be present at delivery (risk of birth asphyxia, macrosomia complications)

• Weekly NST, BPP
• Growth scan every 3-4 weeks
• Doppler if IUGR/distress

---

Q4. Short Notes (8 × 5 = 40 marks)

---

(a) Supports of the Uterus

Primary Supports (most important):

• Forms the floor of the pelvic cavity
• Components: Pubococcygeus, puborectalis, iliococcygeus
• Acts as the "hammock" supporting all pelvic organs
• Damage during childbirth leads to prolapse

• Thickened condensations of parametrium at the base of the broad ligament
• Run from cervix/upper vagina to lateral pelvic wall
• Most important ligamentous supports against prolapse
• Contain uterine vessels

• Run from cervix posterolaterally to sacrum (S2-S4)
• Maintain uterine anteversion
• Important in uterovaginal prolapse (plication used in repair)

• Run from cervix anteriorly to pubic symphysis
• Contribute to bladder support

Secondary Supports:

• Double peritoneal folds enclosing uterine tubes, ovarian and round ligaments
• Provide minimal mechanical support; contain structures

• From uterine cornua through inguinal canal to labia majora
• Maintain anteversion (weak; stretched in pregnancy)

• From ovary to uterine cornua; medial attachment of ovary

• Lateral attachment of ovary to pelvic wall; contains ovarian vessels

Clinical significance:

---

(b) Maternal Mortality Rate (MMR) and Its Causes

Definition:

Causes of Maternal Mortality:

• Hemorrhage (25-30%) - Leading cause globally and in India
  • PPH (most common direct obstetric death cause): uterine atony (80%), retained placenta, trauma
  • Antepartum: Placenta previa, abruptio placentae
• Hypertensive disorders (14%) - Eclampsia, HELLP syndrome
• Sepsis/Infection (11%) - Post-delivery, post-abortion sepsis
• Unsafe abortion (8%) - Sepsis, hemorrhage, injury
• Obstructed labour (8%) - Uterine rupture, birth asphyxia
• Embolism (3%) - Pulmonary thromboembolism, AFE

• Anemia (major contributor in India)
• Malaria, tuberculosis, hepatitis
• Heart disease, diabetes
• Autoimmune disorders
• COVID-19 (recent addition)

Reduction Strategies (3 Delays Model):

• Delay 1: Delay in seeking care (community education, empowerment)
• Delay 2: Delay in reaching facility (transport, roads)
• Delay 3: Delay in receiving care (skilled providers, blood banks, OT readiness)

---

(c) Causes of Female Infertility

Causes by Anatomical Site:

• PCOS (most common ovulatory disorder)
• Premature ovarian insufficiency/failure (POI/POF)
• Hypothalamic-pituitary dysfunction (Kallmann syndrome, hyperprolactinemia)
• Age-related decline in ovarian reserve
• Ovarian cysts, endometriosis

• Tubal occlusion (bilateral) - most common: post-PID (Chlamydia, gonorrhea)
• Hydrosalpinx, pyosalpinx
• Endometriosis (pelvic adhesions, tubal damage, impaired implantation)
• Pelvic adhesions post-surgery/infection
• Peritoneal fistulas

• Congenital anomalies: septate uterus (most common), bicornuate, unicornuate
• Asherman's syndrome (intrauterine adhesions - post D&C/endometritis)
• Fibroids (submucous type most relevant)
• Endometrial polyps
• Thin endometrium (poor receptivity)

• Cervical stenosis (post-LEEP, cone biopsy)
• Hostile cervical mucus (anti-sperm antibodies)
• Cervical infection

• Vaginismus (non-consummation)
• Vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)

• Thyroid disorders (hypo/hyperthyroidism)
• Hyperprolactinemia
• Cushing's syndrome, Congenital adrenal hyperplasia
• Severe systemic illness (anemia, TB, renal failure)

Investigations:

• Day 2-3 FSH, LH, AMH (ovarian reserve), AFC (antral follicle count)
• Prolactin, TSH, testosterone
• HSG (hysterosalpingography) - tubal patency + uterine cavity
• Diagnostic hysteroscopy - uterine cavity assessment
• Diagnostic laparoscopy - endometriosis, adhesions, tubal factors (gold standard for peritoneal factors)
• Transvaginal USG - folliculometry, PCOS, fibroids
• Husband's semen analysis (always evaluate both partners!)

---

(d) Choriocarcinoma - Management

Definition:

Features:

• Precedes 50% of cases: hydatidiform mole; 25% normal pregnancy; 25% ectopic/miscarriage
• Extremely vascular - spreads hematogenously (lungs first, then brain, liver, kidneys)
• Produces very high levels of beta-hCG (tumor marker and monitoring tool)
• Very chemosensitive - one of the most curable malignancies

Staging (FIGO):

• Stage I: Confined to uterus
• Stage II: Outside uterus but within genital structures
• Stage III: Pulmonary metastases
• Stage IV: Other distant metastases (brain, liver = worst prognosis)

FIGO/WHO Prognostic Scoring:

Management:

• Single-agent chemotherapy: Methotrexate (MTX) with leucovorin rescue (first-line)
• Alternative: Actinomycin-D (if MTX contraindicated, e.g., liver/renal impairment)
• Cure rate: >95%

• Multi-agent chemotherapy: EMA-CO regimen
  • E = Etoposide
  • M = Methotrexate
  • A = Actinomycin-D
  • CO = Cyclophosphamide + Oncovin (vincristine)
• Cure rate: 70-90%

• Hysterectomy: For uterine perforation, uncontrolled bleeding, chemoresistance, desire to complete family
• Resection of solitary metastases (lung, brain) in chemoresistant disease

• Whole-brain radiation + EMA-CO
• Intrathecal MTX

• Weekly hCG until normal x3, then monthly x12 months
• Contraception mandatory during treatment and for 12 months after (hCG must be interpretable)
• Normal hCG = complete remission
• Plateauing/rising hCG = treatment failure, change regimen

---

(e) AMTSL - Active Management of the Third Stage of Labour

Components of AMTSL (Standard WHO Protocol):

• Oxytocin 10 IU IM (drug of choice) - given within 1 minute of baby's birth
• Alternatives (if oxytocin unavailable): Misoprostol 600 mcg orally OR Ergometrine 0.2 mg IM (not in hypertension)
• Carbetocin (long-acting oxytocin) - single 100 mcg IM dose, superior to oxytocin in some settings

• Wait for strong uterine contraction (2-3 min after oxytocin)
• Counterpressure on suprapubic area (guard the uterus against inversion)
• Steady, continuous, downward traction on cord
• Never apply before uterotonic effect + contraction

• Sustained uterine massage after placenta delivery
• Ensure uterus remains well-contracted (feel for "woody" feel)
• Check for complete placenta and membranes

Why AMTSL?

• Reduces PPH risk by ~60%
• Reduces blood loss and need for blood transfusion
• Reduces incidence of severe PPH requiring intervention
• WHO recommends for all deliveries (home and hospital)

Previous (Abandoned) Components:

• Oxytocin in the anterior shoulder (now replaced with IM after baby born)
• Early cord clamping (now deferred cord clamping at 1-3 mins is recommended for term infants)

---

(f) PALM-COEIN Classification

PALM - Structural Causes (Identifiable on Imaging/Histology):

COEIN - Non-Structural Causes:

Clinical Application:

• A patient can have more than one cause (e.g., AUB-L + AUB-O)
• Each cause is denoted with a superscript: Present (1) or Absent (0)
• Example: AUB-L(SM)¹ O¹ = Submucosal fibroid + ovulatory dysfunction

Investigations:

• TVS (transvaginal ultrasound) - first line
• Hysteroscopy - for intracavitary lesions (P, A, L)
• MRI - for adenomyosis, fibroids (mapping)
• CBC, TSH, prolactin, coagulation screen (for COEIN causes)
• Endometrial biopsy - for M (malignancy/hyperplasia)

---

(g) Difference between Abruptio Placentae and Placenta Previa

---

(h) Stages of Labour

First Stage of Labour (Cervical Stage):

• Cervical effacement and early dilatation (0-3 cm)
• Irregular, mild contractions becoming stronger
• Duration: Primigravida up to 20 hours; Multigravida up to 14 hours
• Prolonged latent phase >20 hrs primigravida, >14 hrs multigravida

• Cervical dilatation 4-10 cm
• Regular, stronger contractions (3-4 in 10 min, lasting 45-60 sec)
• Rate of dilatation: Primigravida 1 cm/hr; Multigravida 1.5-2 cm/hr
• Monitored on Partogram (Friedman's curve)
• Arrest: No change in 4+ hours in active phase = prolonged active phase

Second Stage of Labour (Expulsive Stage):

• Passive phase: Full dilatation but no urge to push
• Active phase: Pushing with contractions
• Duration: Primigravida up to 2 hours (3 hours with epidural); Multigravida up to 1 hour (2 hours with epidural)
• Cardinal movements: Engagement → Descent → Flexion → Internal rotation → Extension → External rotation (restitution) → Expulsion

Third Stage of Labour (Placental Stage):

• Duration: Up to 30 minutes (normal); if >30 min = retained placenta
• Managed by AMTSL
• Signs of placental separation: Lengthening of cord, gush of blood, uterus rises and becomes globular (Calkin's sign), bearing down sensation
• Schultz mechanism: Central separation, shiny (fetal) surface first
• Duncan mechanism: Lateral separation, maternal surface first

Fourth Stage of Labour:

• First 1-2 hours after delivery
• Period of maximum risk for PPH
• Close monitoring of BP, pulse, uterine tone, bleeding

---

Q5. MTP Act - Definition, Amendments, and Counselling (2+3+5=10)

PART A: What is the MTP Act? (2 marks)

---

PART B: Amendments to the MTP Act (3 marks)

MTP (Amendment) Act 2002:

• Allowed registered medical practitioners to perform MTP in government-approved private facilities
• Expanded the list of approved facilities

MTP Amendment Rules 2003:

• Allowed nurses/ANMs to administer medical abortion drugs (Mifepristone + Misoprostol) in rural settings

MTP (Amendment) Act 2021 (Most Important):

• Survivors of sexual assault/rape/incest
• Minors (<18 years)
• Change of marital status (widowhood, divorce during pregnancy)
• Women with physical disabilities (≥40% as per applicable legislation)
• Mentally ill women
• Fetal anomalies diagnosed during pregnancy
• Humanitarian settings/disasters/emergencies

• Up to 20 weeks: 1 RMP opinion
• 20-24 weeks (special categories): 2 RMP opinions
• Beyond 24 weeks: Only for substantial fetal anomalies incompatible with life; requires State-level Medical Board

---

PART C: Role of Gynaecologist in Counselling a 20-Year-Old Primigravida at 12 Weeks Wanting MTP (5 marks)

Setting:

Pre-MTP Counselling Framework:

• Ensure privacy and confidentiality (per MTP Act 2021 Section 5A)
• No husband/family consent needed (she is ≥18 years)
• Speak without bias or coercion

• Confirm pregnancy (urine/blood hCG, USG)
• Confirm intrauterine location (rule out ectopic)
• USG for gestational age (12 weeks confirmed)
• Rule out fetal anomalies (if relevant)

• Option 1 - Continuing the Pregnancy: Support available, adoption options, social support
• Option 2 - Medical MTP: (For 12 weeks: MVA preferred, medical abortion possible up to 9 weeks)
• Respect her autonomous decision; do not impose

• Method of choice at 12 weeks: Surgical - Manual Vacuum Aspiration (MVA) or Electric Vacuum Aspiration (EVA)
• Medical method (Mifepristone + Misoprostol) alone is less effective at 12 weeks; may need surgical completion
• Procedure: cervical priming (Misoprostol) → MVA under local anesthesia → outpatient/day care

• Failure/incomplete abortion (need repeat procedure)
• Infection/sepsis (pelvic inflammatory disease)
• Uterine perforation (rare: 0.1%)
• Hemorrhage
• Cervical injury
• Asherman's syndrome (intrauterine adhesions - rare, affects future fertility)
• Anesthesia risks
• Future fertility is generally NOT affected by properly performed MTP

• Counsel regarding all contraceptive options (LARC preferred)
• Copper IUD - can be inserted immediately post-MTP (highly effective, long-term)
• Hormonal methods - Pills, injectable, implant
• Barrier methods - Condoms (also STI protection)
• Emphasize that abortion is NOT a method of contraception

• Acknowledge emotional distress, ambivalence, guilt, or relief - all are normal responses
• Provide psychological first aid; refer to counselor/social worker if needed
• Arrange follow-up appointment (2 weeks post-MTP)

• Written consent of the woman only (≥18 years - she consents herself)
• Explain procedure, risks, alternatives in her language
• She has the right to withdraw consent at any time before the procedure

• MTP can only be performed at approved facilities
• Record keeping is mandatory (confidential, not to be disclosed)
• One RMP opinion is sufficient at 12 weeks (within 20-week limit)

• Routine antibiotics prophylaxis (Doxycycline)
• Confirm complete evacuation (clinical + USG at 2 weeks)
• Monitor for complications
• Repeat hCG if needed to confirm completion
• Start contraception immediately (if not IUCD inserted same day)

---

Summary Table for Quick Revision