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📚 SEM 5 OBSTETRICS & GYNAECOLOGY — COMPREHENSIVE NOTES

For Essays, Viva & Easy Memorisation

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1. PRE-CONCEPTIONAL CARE

Definition

Goals (mnemonic: SAFE)

• Screen for chronic illness (diabetes, hypertension, epilepsy, thyroid)
• Assess genetics and family history
• Folic acid supplementation
• Educate on lifestyle (smoking, alcohol, weight)

Key Components

Müllerian Anomalies

• Should be corrected preconceptionally (e.g., septum resection) to reduce preterm birth risk

Previous Preterm Birth

• Recurrence risk inversely proportional to gestational age of prior preterm birth
• Prepregnancy risk factors found in 40% of preterm births - optimise DM, seizures, asthma, HTN
• Consider: progesterone therapy or cerclage in subsequent pregnancy

Viva tip: "What supplements are given preconceptionally?" → Folic acid (neural tube defect prevention), iron, iodine in deficient areas.

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2. FIGO (International Federation of Gynaecology and Obstetrics)

What is FIGO?

• International professional organisation for OB/GYN founded 1954
• Develops staging systems, clinical guidelines, and global health policies

FIGO Staging Systems (Most Tested)

Cervical Cancer (FIGO 2018)

Endometrial Cancer (FIGO 2023)

Ovarian Cancer (FIGO)

FIGO AUB Classification: PALM-COEIN

• Structural: Polyp · Adenomyosis · Leiomyoma · Malignancy/hyperplasia
• Non-structural: Coagulopathy · Ovulatory dysfunction · Endometrial · Iatrogenic · Not classified

Viva tip: FIGO = staging authority for gynaecological cancers. Always state the year of revision when giving staging.

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3. PARTOGRAM

Definition

Components (mnemonic: FILM)

• Fetal: Heart rate (every 30 min), liquor colour, moulding, station, position
• Interventions: Oxytocin, drugs, IV fluids
• Labour: Cervical dilation, uterine contractions, descent of head
• Maternal: Pulse, BP, temperature, urine (output, protein, ketones)

Alert and Action Lines

Interpretation

• Normal progress: ≥1 cm/hour cervical dilation in active labour
• Active phase: 4 cm to full dilation (10 cm)
• Latent phase: 0-4 cm (can take up to 8 hours)
• Cervix plotting to the right of action line → consider augmentation or CS

WHO Modified Partogram

• Starts at 4 cm (active phase only) - simpler, widely used in low-resource settings

Benefits

• Prevents prolonged labour
• Reduces unnecessary CS and oxytocin use
• Early identification of obstructed labour

Viva tip: "When do you start a partogram?" → At 4 cm cervical dilation (active phase). "What does crossing the action line mean?" → Augment or deliver.

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4. HYPEREMESIS GRAVIDARUM (HG)

Definition

• Weight loss >5% of pre-pregnancy body weight
• Dehydration + ketonuria/ketonaemia
• Electrolyte disturbances

Epidemiology

• Affects ~1% of pregnancies (vs. 50-90% for simple NVP)
• Peak: 8-12 weeks gestation; may persist to 20 weeks or beyond

Pathophysiology

• Rising hCG and oestradiol levels
• Association with H. pylori infection
• Maternal cytokines implicated
• Molar pregnancy / multiple pregnancy → very high hCG → severe HG

Investigations

Management (step-up)

• Small, frequent dry meals; ginger; acupressure
• Pyridoxine (vitamin B6) ± doxylamine (Diclegis = first line)

• 2 L Ringer's Lactate at 500 mL/hour
• Thiamine (B1) BEFORE any dextrose - prevents Wernicke's encephalopathy
• Then dextrose-containing fluids (D5/0.45% NaCl) once thiamine given
• Antiemetics: metoclopramide, ondansetron, promethazine

• Methylprednisolone 16 mg PO/IV every 8 hours x 3 days (last resort)
• NG enteral nutrition if unable to maintain weight

• TPN (total parenteral nutrition) in severe/refractory cases

Complications

• Maternal: Wernicke's encephalopathy (B1 deficiency), Mallory-Weiss tears, oesophageal rupture, liver failure
• Fetal: Vitamin K deficiency → bleeding diathesis; IUGR in severe cases

Viva tip: "What vitamin must be given before dextrose in HG?" → Thiamine (B1) to prevent Wernicke's. "What is first-line antiemetic?" → Pyridoxine + doxylamine.

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5. NORMAL LABOUR

Definition

Stages of Labour

Mechanisms of Normal Labour (Cardinal Movements)

1. Engagement - biparietal diameter at pelvic inlet
2. Descent - throughout labour
3. Flexion - chin to chest
4. Internal rotation - occiput rotates anterior (OA position)
5. Extension - head delivered under symphysis
6. Restitution - head realigns with shoulders
7. External rotation - shoulders rotate
8. Expulsion - anterior then posterior shoulder delivered

Active Management of 3rd Stage (AMTSL)

• Oxytocin 10 IU IM (within 1 min of delivery) - gold standard
• Controlled cord traction (Brandt-Andrews manoeuvre)
• Uterine massage after placenta delivered

Normal Findings

• Bloody show - mucus plug + blood, indicates cervical dilation
• Rupture of membranes - SROM or AROM
• Fetal heart rate 110-160 bpm between contractions
• Duration: Primipara 12-18 hrs; Multipara 6-8 hrs

Viva tip: "What is the normal duration of 2nd stage?" → Up to 2 hrs (primip), 1 hr (multip); add 1 hr each with epidural.

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6. MISCARRIAGE (Spontaneous Abortion)

Definition

Epidemiology

• 15% of clinically recognised pregnancies miscarry
• 20-40% of all pregnancies (including subclinical)
• ~75% occur before 8 weeks

Causes

Classification

Investigations

• Beta-hCG (quantitative, serial every 48 hrs - should double)
• TVS (transvaginal ultrasound) - gold standard; IUP visible at hCG ~1500 mIU/mL
• FBC, blood group, Rh factor
• Urinalysis (UTI → increased fetal wastage)

Management

Anti-D Immunoglobulin

• Give anti-D to all Rh-negative women with miscarriage ≥12 weeks (or any surgical evacuation)

Viva tip: "What is the most common cause of miscarriage?" → Chromosomal aneuploidy (~60%). "What type has a closed os with non-viable fetus?" → Missed abortion.

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7. BLEEDING IN EARLY AND LATE PREGNANCY

EARLY PREGNANCY BLEEDING (<20 weeks)

• Miscarriage (threatened, inevitable, incomplete, complete, missed)
• Ectopic pregnancy
• Implantation bleeding (normal, ~10-14 days after conception)
• Placenta praevia (rare early)
• Cervical / vaginal lesions (cervicitis, ectropion, polyp)

Ectopic Pregnancy

• Implantation outside uterus (95% fallopian tube)
• Presents: amenorrhoea + pain + bleeding (classic triad)
• Risk factors: PID, previous ectopic, IUD, surgery, ART
• Diagnosis: TVS + quantitative hCG
• If hCG >1500 and no IUP on TVS → ectopic until proven otherwise
• Treatment: Methotrexate (medical, if stable + hCG <5000) or surgical (salpingectomy/salpingostomy)

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LATE PREGNANCY BLEEDING (>20 weeks) - Antepartum Haemorrhage (APH)

Placenta Praevia

• Definition: Placenta implanted over or near internal os
• Grades:
  • I: Low-lying (edge near but not covering os)
  • II: Marginal (edge reaches os)
  • III: Partial (partially covers os)
  • IV: Complete (completely covers os)
• Golden Rule: DO NOT do vaginal examination until placenta praevia excluded by USS
• Management: Bed rest, no coitus, CS delivery (grade III/IV)

Abruptio Placentae

• Definition: Premature separation of normally situated placenta
• Associations: Pre-eclampsia/HTN (most common), cocaine, trauma, smoking, thrombophilia, age <20 or >35
• Grades:
  • I: Mild (<500 mL; no fetal distress)
  • II: Moderate (fetal distress)
  • III: Severe (fetal death, maternal shock, DIC)
• Management: Stabilise (blood, FFP, platelets), CTG monitoring, urgent delivery if fetal distress or severe

Viva tip: "What is the rule about vaginal examination in APH?" → Never do VE until placenta praevia excluded by USS.

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8. ABDOMINAL PAIN IN EARLY AND LATE PREGNANCY

Early Pregnancy (<20 weeks)

Late Pregnancy (>20 weeks)

Viva tip: "HELLP syndrome presents with what pain?" → Epigastric or RUQ pain (liver haemorrhage/distension). Always exclude in a 3rd trimester patient with epigastric pain.

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9. NORMAL AND ABNORMAL PUERPERIUM

The Puerperium

• Period from 3rd stage of labour to 6 weeks postpartum
• Anatomical, physiological, biochemical return to non-pregnant state

Normal Physiological Changes

Normal Management

• Ambulation as soon as possible (prevents DVT)
• Encourage voiding (avoid retention)
• Oxytocin 10 IU IM or drip if uterus not contracting
• Breastfeeding promotes uterine involution (oxytocin release)
• No vaginal douching; sitz baths for episiotomy
• Meperidine not preferred for breastfeeding mothers (long-acting metabolite)

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Abnormal Puerperium

1. Postpartum Haemorrhage (PPH)

1. Bimanual uterine compression
2. Oxytocin 10-40 IU IV (first-line uterotonic)
3. Ergometrine 0.5 mg IM (avoid in HTN)
4. Carboprost (15-methyl PGF2α) IM
5. Misoprostol 1000 mcg rectal (if no other oxytocics)
6. Tranexamic acid 1g IV (within 3 hrs of delivery)
7. Surgical: B-Lynch suture, uterine artery ligation, hysterectomy (last resort)

2. Puerperal Pyrexia / Sepsis

• Temp >38°C on any 2 of days 1-10 postpartum (excluding first 24 hrs)
• Most common cause: Endometritis (uterine infection)
• Organisms: Group A Streptococcus (most dangerous), E. coli, anaerobes
• Features: fever, uterine tenderness, offensive lochia, leukocytosis
• Treatment: Broad-spectrum IV antibiotics (clindamycin + gentamicin)

3. Postnatal Depression (PND)

4. Mastitis / Breast Abscess

• Mastitis: breast pain, redness, fever; continue breastfeeding; flucloxacillin
• Abscess: fluctuant swelling; surgical drainage + antibiotics

5. Thromboembolic Disease

• Highest DVT/PE risk in first 6 weeks postpartum
• Risk 5-6x higher than non-pregnant state
• Prophylaxis: early ambulation, LMWH in high-risk women

Viva tip: "What are the 4 T's of PPH?" → Tone, Trauma, Tissue, Thrombin. "First-line treatment?" → Oxytocin.

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10. HYPERTENSION IN PREGNANCY

Classification

Normal BP in pregnancy: Nadir at 18-19 wks (~113/69 mmHg); threshold 140/90 mmHg

Pathophysiology of Pre-eclampsia

• Kidney: Glomerular endotheliosis → proteinuria, AKI
• Liver: Hepatocellular necrosis → elevated transaminases, RUQ pain
• Brain: Microthrombi, oedema → headache, visual disturbance, seizures
• Blood: Thrombocytopenia, microangiopathic haemolysis
• Placenta: Infarction → IUGR, stillbirth

HELLP Syndrome

• Severe form of pre-eclampsia
• Presents with epigastric/RUQ pain, malaise, nausea
• Management: Stabilise → deliver (only cure)

Risk Factors for Pre-eclampsia

• Nulliparity, new partner (paternal antigen exposure)
• Previous PET, family history
• Multiple pregnancy, molar pregnancy
• BMI >30, age >40
• Diabetes, CKD, antiphospholipid syndrome, SLE

Management of Pre-eclampsia

• Labetalol (first-line oral) - α/β blocker
• Nifedipine (2nd line)
• Methyldopa (safe, but slow onset)
• Avoid: ACE inhibitors, ARBs (teratogenic)

• Magnesium sulphate - drug of choice for eclampsia and prevention of seizures
  • Loading: 4g IV over 5-10 min
  • Maintenance: 1-2 g/hr IV infusion
  • Monitor: urine output, reflexes, respiratory rate
  • Antidote: Calcium gluconate 10 mL of 10% IV (for toxicity)

• Only cure for pre-eclampsia
• ≥37 weeks: deliver
• <34 weeks: corticosteroids + aim to reach 34 wks if stable
• Fulminating PET/HELLP: deliver regardless of gestation

Low-dose Aspirin (75-150 mg)

• Prescribed from 12-16 weeks for women at high risk of PET
• Reduces risk of pre-eclampsia by ~15-20%

Viva tip: "What is the antidote to MgSO4 toxicity?" → Calcium gluconate. "What is the only cure for pre-eclampsia?" → Delivery.

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11. GESTATIONAL DIABETES MELLITUS (GDM)

Definition

Epidemiology & Pathophysiology

• Affects 5-9% of pregnant women
• Pregnancy = state of progressive insulin resistance (due to HPL, oestrogen, progesterone, cortisol)
• GDM = inability to compensate for this resistance
• Small subset (~6%) may have pre-type 1 DM

Risk Factors

• Obesity (BMI >30), age >25
• Previous GDM, previous macrosomic baby (>4 kg)
• Family history of T2DM
• Ethnic groups: Hispanic, Native American, Asian, African American
• Polycystic ovary syndrome
• Glucosuria

Complications

• Pre-eclampsia, UTI, polyhydramnios
• Operative delivery
• Progression to T2DM (50% within 10 years)

• Macrosomia (LGA >4 kg) → shoulder dystocia risk
• Neonatal hypoglycaemia (most common neonatal complication)
• Respiratory distress syndrome
• Hyperbilirubinaemia, polycythaemia
• Congenital anomalies (if pre-existing DM at conception)
• Stillbirth (if poorly controlled)
• IUGR (with vascular complications)

Screening

1. 50g Glucose Challenge Test (GCT) - non-fasting, 1 hour
   • If ≥140 mg/dL → proceed to diagnostic OGTT
2. 100g 3-hour OGTT (fasting)

Management

1. Diet and lifestyle - first 1-2 weeks; 30-33 kcal/kg/day; carb restriction
2. Blood glucose monitoring - fasting <95 mg/dL; 1 hr post-meal <140 mg/dL; 2 hr <120 mg/dL
3. Insulin - if targets not met within 1-2 weeks (safest; doesn't cross placenta in significant amounts)
4. Metformin or glyburide - oral agents (controversial; cross placenta)
5. Fetal surveillance: growth scans, kick counts, NST in 3rd trimester
6. Timing of delivery: 38-40 weeks if well-controlled; earlier if poor control/complications
7. Postpartum: 75g OGTT at 6-12 weeks postpartum to exclude persistent DM

Viva tip: "When is GDM screening done?" → 24-28 weeks. "Most common neonatal complication?" → Hypoglycaemia. "What resolves GDM?" → Delivery, but 50% get T2DM within 10 years.

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12. NORMAL AND ABNORMAL MENSTRUATION

Normal Menstruation

Definitions

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Amenorrhoea

Primary Amenorrhoea

• No period by age 16 with secondary sexual characteristics
• No period by age 14 without secondary sexual characteristics
• Evaluate by age 15 if normal growth + secondary sex characteristics

Secondary Amenorrhoea

• Absence ≥3 months (≥6 months in women with previously irregular cycles)
• First exclude pregnancy!

• Pregnancy (most common)
• Ovarian - PCOS, premature ovarian insufficiency
• Situational - weight loss, excessive exercise, stress (hypothalamic)
• Hyperprolactinaemia (pituitary adenoma, drugs)
• Chronic illness (thyroid, adrenal, DM)

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Abnormal Uterine Bleeding (AUB) - PALM-COEIN

• Polyp
• Adenomyosis
• Leiomyoma (fibroid) - submucosal most likely to cause bleeding
• Malignancy / hyperplasia

• Coagulopathy (von Willebrand disease, ITP, anticoagulants)
• Ovulatory dysfunction (most common = PCOS, hypothyroidism)
• Endometrial (endometritis, endometrial dysfunction)
• Iatrogenic (IUD, hormones, anticoagulants)
• Not yet classified

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Dysmenorrhoea

• NSAIDs (ibuprofen, mefenamic acid) - inhibit prostaglandin synthesis - first line
• Combined oral contraceptive pill
• Heat, exercise

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Polycystic Ovary Syndrome (PCOS) - Key Cause of AUB

1. Oligo/anovulation
2. Clinical/biochemical hyperandrogenism
3. Polycystic ovaries on USS (≥12 follicles per ovary, or ovarian volume >10 mL)

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Menopause

• Natural menopause: 12 consecutive months amenorrhoea at age 45-55
• Premature ovarian insufficiency (POI): before age 40
• Symptoms: hot flushes, night sweats, vaginal atrophy, mood changes
• FSH >40 IU/L; oestradiol <100 pmol/L confirms menopause

Viva tip: "What is the first investigation in secondary amenorrhoea?" → Urine/serum beta-hCG (exclude pregnancy). "PALM-COEIN was developed by whom?" → FIGO. "Primary dysmenorrhoea mechanism?" → Excess PGF2α.

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🗂️ QUICK VIVA RECALL SHEET

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