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OBSTETRICS - SHORT NOTES (Exam Ready)

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1. HYPERTENSIVE DISORDERS OF PREGNANCY

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HELLP SYNDROME

• Hemolysis: Abnormal peripheral smear (schistocytes/burr cells), LDH >600 IU/L, Total bilirubin >1.2 mg/dL
• Elevated Liver Enzymes: AST/ALT >70 IU/L
• Low Platelets: <100,000/mm³

• Epigastric/RUQ pain (most common complaint)
• Nausea, vomiting, malaise
• Headache, visual disturbances
• Hypertension and proteinuria may be absent in 20% cases

• DIC (8%), Placental abruption (10%), Pulmonary edema (10%)
• Acute renal failure (5%), Eclampsia (6%)
• Hepatic hematoma/rupture (rare but life-threatening)
• Subcapsular hematoma of liver

• AFLP: elevated ammonia, coagulopathy, no severe hypertension
• TTP/HUS: more neurological signs, no hypertension, plasma exchange required

1. Stabilize mother - control BP, correct coagulopathy
2. Steroids (dexamethasone or betamethasone): may improve platelet count
3. Platelet transfusion if <20,000 or <50,000 before surgery
4. Definitive treatment: Delivery (regardless of gestational age)
5. MgSO4 for seizure prophylaxis
6. Post-delivery: most cases resolve within 48-72 hours

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MAGNESIUM SULPHATE REGIMENS IN ECLAMPSIA

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• Loading Dose:
  • 4g IV (20% solution) slowly over 5-10 minutes
  • PLUS 10g IM (50% solution) - 5g in each buttock (with 1 mL lignocaine)
• Maintenance: 5g IM (50%) every 4 hours, alternate buttocks
• Duration: 24 hours after last convulsion

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• Loading Dose: 4g IV over 5-20 minutes
• Maintenance: 1-2g/hour by IV infusion

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• Loading: 6g IV over 15-20 minutes
• Maintenance: 2-3g/hour IV

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MANAGEMENT OF ECLAMPSIA (INCLUDING PRITCHARD REGIMEN)

1. MgSO4 (Pritchard): 4g IV loading + 10g IM, then 5g IM 4-hourly
2. Antihypertensives (if diastolic BP ≥110 mmHg):
   • Hydralazine 5-10 mg IV every 20 min, OR
   • Labetalol 20 mg IV bolus (up to 300 mg total), OR
   • Nifedipine 10 mg orally

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2. DIABETES IN PREGNANCY

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GDM - DEFINITION, FETAL & NEONATAL COMPLICATIONS

• GDM criteria: Fasting ≥92 mg/dL, 1-hr ≥180 mg/dL, 2-hr ≥153 mg/dL (any one value on 75g OGTT)
• Overt DM in pregnancy: Fasting ≥126, 2-hr ≥200, or random ≥200 with symptoms

• Macrosomia (>4 kg) - most common; causes shoulder dystocia
• Congenital anomalies (more in pre-gestational DM - caudal regression syndrome is hallmark)
• Cardiomegaly, cardiac septal hypertrophy
• Polyhydramnios
• IUGR (in advanced maternal vasculopathy)
• Intrauterine death/stillbirth
• Prematurity (due to early induction)

• Hypoglycemia (most common and dangerous neonatal complication) - due to fetal hyperinsulinism
• Hypocalcemia - tremors, jitteriness
• Hyperbilirubinemia (jaundice)
• Hyaline membrane disease (RDS) - due to delayed lung maturity (insulin inhibits surfactant)
• Polycythemia → hyperviscosity
• Birth trauma (shoulder dystocia, Erb's palsy)
• Increased risk of childhood obesity and T2DM in offspring

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ORAL GLUCOSE CHALLENGE TEST (OGCT / GCT)

• Screening test for GDM (not diagnostic)
• Timing: 24-28 weeks gestation (or earlier if high risk)
• Method: 50g oral glucose load given without fasting; blood glucose checked at 1 hour
• Cut-off: ≥140 mg/dL (some use ≥130 mg/dL for higher sensitivity)
• Result: If positive → proceed to 100g 3-hour OGTT for diagnosis (Carpenter-Coustan/NDDG criteria)

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SCREENING & DIAGNOSIS OF GDM

• Universal screening at 24-28 weeks (recommended by IADPSG, ACOG)
• High-risk: screen at first visit - obesity (BMI >30), previous GDM, family history of DM, macrosomic baby (>4.5 kg), unexplained stillbirth

1. 50g GCT (non-fasting) at 24-28 weeks
2. If positive → 100g 3-hour OGTT (fasting)
   • Diagnostic if ≥2 values meet Carpenter-Coustan criteria:
     • Fasting ≥95 mg/dL, 1-hr ≥180, 2-hr ≥155, 3-hr ≥140

• 75g OGTT (fasting) at 24-28 weeks
• Diagnostic if ANY one value abnormal:
  • Fasting ≥92 mg/dL
  • 1-hour ≥180 mg/dL
  • 2-hour ≥153 mg/dL

• 75g glucose load regardless of fasting state
• 2-hour plasma glucose ≥140 mg/dL = GDM

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3. PERINATAL MORTALITY

• Asphyxia/birth trauma (major cause)
• Prematurity/RDS
• Infections (sepsis, congenital infections)
• Congenital anomalies
• IUGR
• Maternal conditions: Hypertension, diabetes, anemia, malnutrition

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MATERNAL MORTALITY RATIO (MMR)

• Delay 1: Delay in deciding to seek care (community level)
• Delay 2: Delay in reaching care facility (transport/access)
• Delay 3: Delay in receiving adequate care (healthcare quality)

• Hemorrhage (PPH - most common cause globally)
• Abortions (unsafe)
• Malaria/anemia (indirect)
• BP disorders (eclampsia, hypertension)
• Obstructed labour

1. Skilled birth attendance (SBA) at every delivery
2. Emergency Obstetric Care (EmOC) - basic and comprehensive
3. Antenatal care (min 4-8 visits)
4. Family planning / spacing of births
5. Safe abortion services
6. Blood transfusion services
7. Iron/folate supplementation
8. Institutional delivery - Janani Suraksha Yojana (JSY)
9. ASHA workers, Mobile Medical Units
10. Audit of maternal deaths (MDSR)

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4. PUERPERIUM

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POST-PARTUM HAEMORRHAGE (PPH) - DEFINITION & CAUSES

• Primary PPH: Blood loss ≥500 mL after vaginal delivery (or ≥1000 mL after LSCS) within 24 hours of delivery
• Secondary PPH: Abnormal/excessive uterine bleeding from 24 hours to 12 weeks postpartum

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PROBLEMS ASSOCIATED WITH PUERPERIUM

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PUERPERAL FEVER - DEFINITION, CAUSES, FIRST LINE INVESTIGATIONS

• Wind (pulmonary - atelectasis, pneumonia) - Day 1-2
• Wound infection (episiotomy, LSCS wound) - Day 5-7
• Utrine infection (endometritis) - Day 3-5 (most common)
• Intravenous catheter thrombophlebitis
• Pelvic abscess
• Engorged breasts/mastitis - Day 7-10
• UTI - very common
• DVT/septic thrombophlebitis

1. CBC (leukocytosis)
2. Blood culture and sensitivity (before antibiotics)
3. High vaginal swab (HVS) - culture and sensitivity
4. Urine routine + culture
5. Wound swab (if wound infection)
6. CRP / ESR
7. Pelvic ultrasound (to rule out retained products, abscess)

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5. RH NEGATIVE PREGNANCY

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ROLE OF ANTI-D IN RH NEGATIVE PREGNANCY

• After any potentially sensitizing event: abortion, ectopic pregnancy, amniocentesis, CVS, APH, external cephalic version, antepartum hemorrhage, abdominal trauma
• Routine antenatal prophylaxis at 28 (and 34) weeks
• Postpartum: within 72 hours of delivery of Rh+ baby

• <20 weeks: 250 IU (50 mcg)

• 20 weeks: 500 IU (100 mcg) or 1500 IU (300 mcg) per ACOG

• Postpartum: 300 mcg (1500 IU) within 72 hrs

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ROUTINE ANTENATAL ANTI-D PROPHYLAXIS (RAADP)

• Recommended by RCOG for all non-sensitized Rh-negative women
• Timing: 28 weeks (and 34 weeks with 2-dose schedule)
• Dose (RCOG):
  • 1-dose regimen: 1500 IU at 28 weeks
  • 2-dose regimen: 500 IU at 28 weeks + 500 IU at 34 weeks
• Post-delivery: Additional anti-D within 72 hours if baby is Rh positive
• Kleihauer-Betke (KB) test / Flow cytometry: to quantify fetomaternal hemorrhage and calculate additional anti-D dose needed

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STRATEGIES FOR PREVENTION OF ISO-IMMUNIZATION IN RH NEGATIVE PREGNANCY

1. Antenatal screening of all pregnant women for Rh blood group
2. Test partner's Rh group
3. Indirect Coombs Test (ICT) for antibody screening at booking, 28, 34 weeks
4. Anti-D after every potentially sensitizing event
5. RAADP at 28 (and 34) weeks
6. Kleihauer-Betke test after delivery to assess FMH
7. Anti-D within 72 hours postpartum
8. Avoid unnecessary invasive procedures

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6. FETUS & NEWBORN

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PERINATAL HYPOXIA - DEFINITION & CAUSES

• Maternal: Hypotension, anemia, cardiorespiratory disease, hypertension, diabetes, hemorrhage
• Placental: Placental abruption, previa, infarction, IUGR
• Umbilical Cord: Cord prolapse, nuchal cord, cord compression, true knot
• Fetal: Prematurity, IUGR, congenital anomalies, hydrops, anemia
• Intrapartum: Prolonged/obstructed labor, uterine hyperstimulation, shoulder dystocia

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NEONATAL JAUNDICE

• Appears on Day 2-3, peaks Day 4-5, disappears by Day 7-10 (term) / Day 14 (preterm)
• Bilirubin <12 mg/dL (term), <15 mg/dL (preterm)
• Cause: High RBC destruction + immature conjugation (low glucuronyl transferase)

• Appears within 24 hours (Rh hemolysis, ABO incompatibility, G6PD deficiency, congenital infection)
• Bilirubin >12-15 mg/dL or rises >5 mg/dL/day
• Direct bilirubin >2 mg/dL (obstructive)
• Persists >2 weeks (hypothyroidism, galactosemia, biliary atresia)

• Phototherapy (first line): wavelength 425-475 nm, converts unconjugated bilirubin
• Exchange transfusion: if bilirubin >20 mg/dL or rapidly rising or signs of kernicterus

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RESPIRATORY DISTRESS SYNDROME (RDS) / HYALINE MEMBRANE DISEASE (HMD)

• Prematurity (most important; <32 weeks)
• Male sex, white race
• Maternal diabetes (insulin inhibits surfactant synthesis)
• Perinatal asphyxia, hypothermia, 2nd twin
• Cesarean section without labor

• Presents within 4-6 hours of birth
• Tachypnea (RR >60), nasal flaring, subcostal/intercostal retractions
• Expiratory grunting (most characteristic), cyanosis
• Ground-glass appearance on CXR, air bronchograms, bell-shaped chest

• Antenatal: Corticosteroids (betamethasone/dexamethasone) 24-34 weeks - promotes lung maturity
• Neonatal: Surfactant therapy (beractant/poractant alfa) intratracheally - MOST IMPORTANT
• CPAP, mechanical ventilation
• Warm, humidified O2, IV fluids, correction of acidosis

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FETAL CIRCULATION

• First breath → lungs expand → pulmonary vascular resistance falls
• Foramen ovale closes functionally (pressure reversal); permanent closure: 3 months
• Ductus arteriosus closes: functionally (10-15 hrs), anatomically (2-3 weeks) due to O2 and bradykinin
• Ductus venosus: closes within 1 week → ligamentum venosum

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NON-STRESS TEST (NST)

• Reactive NST: 99% negative predictive value for fetal death in 1 week
• Non-reactive NST → Biophysical profile (BPP) or CST

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NEONATAL RESUSCITATION

1. Warm, dry, stimulate
2. Clear airway if needed (suction)
3. Position head in "sniffing position"
4. Assess: breathing, heart rate (HR), color

• HR >100 + breathing + pink → Routine care
• HR <100 or not breathing → Positive Pressure Ventilation (PPV) with 21% O2 (room air)
• After 30 sec PPV: If HR <60 → Chest compressions (3:1 ratio) + PPV
• If HR still <60 → Epinephrine (0.1-0.3 mL/kg of 1:10,000 IV)

• Room air (21%) for term infants; titrate O2 for preterm
• Chest compression depth: 1/3 AP diameter
• Ratio: 3 compressions : 1 breath

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APGAR SCORE

• 7-10: Normal
• 4-6: Moderately depressed; stimulate + O2
• 0-3: Severely depressed; immediate resuscitation

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7. ABRUPTIO PLACENTAE

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COMPLICATIONS OF ABRUPTION PLACENTA

• PPH (most common maternal complication)
• DIC (most serious - thromboplastins released from retroplacental clot)
• Hemorrhagic shock
• Couvelaire uterus (uteroplacental apoplexy) - blood infiltrates myometrium → woody hard uterus
• Renal cortical/tubular necrosis (acute renal failure)
• Sheehan's syndrome (pituitary necrosis)
• Recurrence in next pregnancy (10x risk)

• IUFD/Stillbirth (most serious)
• Prematurity
• IUGR
• Perinatal asphyxia
• Fetal anemia

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COMPARISON: PLACENTA PREVIA vs ABRUPTION PLACENTA

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8. MATERNAL ADAPTATIONS IN PREGNANCY

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PHYSIOLOGICAL CHANGES DURING PREGNANCY

• Blood volume increases 40-50% (1200-1600 mL) - begins 6 weeks, peaks 28-32 weeks
• Plasma volume increases 50%; RBC mass increases 25% → Physiological anemia of pregnancy
• Cardiac output increases 30-50% (due to increased HR + stroke volume)
• Heart rate increases 10-15 bpm
• Blood pressure: decreases slightly in 1st/2nd trimester (progesterone-mediated vasodilation); returns to normal in 3rd trimester
• Supine hypotension syndrome: IVC compression by gravid uterus

• Hemoglobin: falls to 10.5-11 g/dL (physiological)
• WBC: increases to 10,000-16,000/mm³ (neutrophilia)
• Platelets: slightly decrease
• Hypercoagulable state: increased fibrinogen (most dramatic), Factors VII, VIII, IX, X; decreased Protein S → DVT risk

• Tidal volume increases 40%
• Residual volume decreases 20%
• Functional residual capacity (FRC) decreases
• Minute ventilation increases → physiological hyperventilation → respiratory alkalosis (PaCO2 falls to 30 mmHg)
• Compensated by renal bicarbonate excretion

• Kidneys enlarge by 1 cm
• GFR increases 50%, renal plasma flow increases 60-80%
• Glucosuria possible at normal blood sugar
• Glycosuria, proteinuria (up to 300 mg/day) may be normal
• Ureteral dilatation (progesterone effect + uterine compression)

• Morning sickness (hCG effect), constipation, hemorrhoids
• Delayed gastric emptying, decreased LES tone → heartburn
• Splaying of rectum and sigmoid

• Skin: Linea nigra, melasma/chloasma, striae gravidarum, spider angiomas
• Thyroid: Enlarges; TBG increases; Total T4/T3 increases; but free T4/T3 normal

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CARDIOVASCULAR & HEMATOLOGICAL CHANGES IN PREGNANCY

• Apex beat displaced upward and laterally
• Soft systolic murmur (physiological - due to hyperdynamic state)
• Split S1, S3 may be heard (normal in pregnancy)
• ECG changes: left axis deviation, T-wave inversion in V1-V3
• Varicose veins, edema (due to venous stasis + reduced colloid osmotic pressure)

• Total additional iron: ~1000 mg
• Supplementation: 60 mg elemental iron daily (WHO); India recommends IFA tablets

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9. MULTIPLE / TWIN PREGNANCY

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COMPARISON: MONOZYGOTIC vs DIZYGOTIC TWINS

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COMPLICATIONS IN MONOCHORIONIC DIAMNIOTIC (MCDA) TWIN PREGNANCY

1. Twin-Twin Transfusion Syndrome (TTTS) - 10-15% of MCDA
2. Twin Anemia-Polycythemia Sequence (TAPS)
3. Selective IUGR (due to unequal placental sharing)
4. Single Intrauterine Fetal Demise - risk of co-twin death/neurological damage
5. Preterm labor (higher than DCDA)

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MATERNAL COMPLICATIONS OF MULTIFETAL GESTATION

1. Anemia, nutritional deficiency
2. Hyperemesis gravidarum
3. Preeclampsia/Hypertension (3x increased risk)
4. Gestational diabetes
5. Polyhydramnios
6. Preterm labor and delivery (most common complication)
7. Placental abruption, placenta previa
8. Malpresentation, cord prolapse
9. PPH (uterine atony)
10. Operative delivery / LSCS
11. Postpartum depression

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TWIN-TWIN TRANSFUSION SYNDROME (TTTS) - DIAGNOSIS & MANAGEMENT

• USG: Polyhydramnios in recipient (DVP ≥8 cm), oligohydramnios in donor (DVP ≤2 cm)
• Same-sex twins, single placenta
• Weight discordance >20%, inter-twin membrane present

• Stage I: Conservative management, close surveillance
• Stages II-IV: Fetoscopic Laser Photocoagulation (FLP) of anastomotic vessels on placental surface - treatment of choice
• Amnioreduction (reduces symptoms, less effective than laser)
• Selective feticide (extreme cases)
• Delivery at 32-34 weeks (or earlier if deterioration)

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10. DELIVERY OF AFTERCOMING HEAD IN BREECH

• Grasp ankles and swing body upward (180° arc) over mother's abdomen
• Gradually lower the head while assistant applies suprapubic pressure
• Head delivers by flexion

• Index and middle fingers of one hand placed on maxilla (or cheekbones) → flexes head
• Body rests on forearm
• Other hand: two fingers on shoulders, middle finger on occiput → flexes and guides
• Head delivered by gentle traction downward then upward (J-shaped motion)

• Most controlled method
• Specially designed forceps with long shank and downward pelvic curve
• Applied from below while assistant holds the body elevated
• Used when MSV fails or for added safety

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11. PARTOGRAPH / PARTOGRAM

• Fetal heart rate (every 30 minutes)
• Membranes and liquor: I = intact, C = clear, M = meconium, A = absent/dry
• Moulding: 0, 1+, 2+, 3+

• Cervical dilatation (cm) - plotted on graph
• Descent of head (fifths palpable abdominally)
• Alert line: Starts at 4 cm dilatation, rate of 1 cm/hour (expected normal progress)
• Action line: 4 hours to the right of alert line
• If progress crosses action line → reassess and consider intervention

• Contractions (frequency, duration per 10 min)
• Oxytocin administration
• Drugs, IV fluids
• BP, pulse, temperature (hourly)
• Urine: volume, protein, acetone

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12. ANTENATAL CARE

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FIRST TRIMESTER SCREENING FOR ANEUPLOIDIES

• Free β-hCG: elevated in Down syndrome
• PAPP-A (Pregnancy Associated Plasma Protein-A): reduced in Down syndrome

• Nuchal Translucency (NT): >3.5 mm abnormal (measures fluid at back of neck)
• Nasal bone absence: present in 60-70% Down syndrome
• Tricuspid regurgitation, ductus venosus PI: additional markers

• AFP (low in Down's, high in NTD)
• β-hCG (high in Down's)
• Unconjugated estriol (low in Down's)
• Inhibin A (high in Down's) - Quad screen

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ANTENATAL CARE

• Nutritional supplementation (IFA, calcium, folic acid 5 mg in high-risk)
• Tetanus toxoid: TT1 + TT2 (1 month apart) or Td booster
• USG at 11-13 weeks (dating/NT) and 18-20 weeks (anatomy)
• Screening for anemia, infections (VDRL, HIV, hepatitis B, rubella)
• Counseling: diet, rest, signs of danger

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FIRST TRIMESTER ULTRASOUND

• 6-7 weeks: Confirmation of intrauterine pregnancy, fetal heartbeat (FHR 90-110 bpm)
• 7-10 weeks: Dating by CRL (Crown-Rump Length); accurate to ±5 days
• 11-13+6 weeks: NT measurement, nasal bone, nuchal fold, chorionicity (twin)
  • CRL 45-84 mm for NT measurement
  • Diagnose: anencephaly, major structural defects

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HYPEREMESIS GRAVIDARUM

• Wernicke's encephalopathy (thiamine deficiency - MUST give thiamine before glucose)
• Mallory-Weiss tear, esophageal rupture
• Hyponatremia, hypokalemia, metabolic alkalosis
• Peripheral neuropathy, IUGR

1. IV rehydration (Normal saline / Hartmann's)
2. Thiamine 100 mg IV before dextrose
3. Antiemetics: Ondansetron, Metoclopramide, Promethazine, Cyclizine
4. Pyridoxine (Vitamin B6) + Doxylamine
5. Correct electrolytes (especially K+)
6. Nutritional support (enteral or TPN if severe)
7. Avoid triggers; small frequent meals
8. Helicobacter pylori eradication if positive

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ROLE OF ANTENATAL CORTICOSTEROIDS

• Betamethasone 12 mg IM x2 doses, 24 hours apart (preferred)
• Dexamethasone 6 mg IM x4 doses, 12 hours apart

1. Reduces RDS by 50% (most important)
2. Reduces intraventricular hemorrhage (IVH) by 40%
3. Reduces necrotizing enterocolitis (NEC)
4. Reduces neonatal mortality
5. Reduces need for surfactant therapy

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13. LABOUR & DELIVERY

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BISHOP SCORE & ITS INTERPRETATION

• Score ≥8: Favorable cervix; induction likely to succeed (similar to spontaneous labor)
• Score 6-7: Borderline; cervical ripening may be needed
• Score <6: Unfavorable; cervical ripening required before induction (Prostaglandins, Foley catheter)

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METHODS OF INDUCTION OF LABOUR

• Sweeping/Stripping membranes: Separates chorioamniotic membrane from lower segment
• Foley catheter/Balloon catheter: Placed in cervical os; mechanical pressure stimulates prostaglandins
• Laminaria tents/Hygroscopic dilators
• AROM (Amniotomy/ARM): Surgical rupture of membranes; only when cervix is favorable

• Prostaglandins (most effective for cervical ripening):
  • Dinoprostone (PGE2): vaginal gel/tablet/pessary (Cervigel, Cervidil)
  • Misoprostol (PGE1): 25 mcg vaginally every 4-6 hours (cervical ripening)
• Oxytocin IV infusion: Most common method; start low dose (0.5-1 mU/min), titrate
• Mifepristone: Antiprogestin; sensitizes myometrium to prostaglandins

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ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR (AMTSL)

1. Uterotonic within 1 minute of birth: Oxytocin 10 IU IM (drug of choice)
   • Alternatives: Misoprostol 600 mcg oral/SL (if oxytocin unavailable)
   • Carboprost, Ergometrine (if oxytocin fails)
2. Controlled Cord Traction (CCT): After signs of placental separation; gentle traction with counter-pressure (Brandt-Andrews maneuver)
3. Uterine massage: After placental delivery

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EPISIOTOMY

• Mediolateral: 45° to midline (common in UK/India); less risk of extension to rectum
• Median/Midline: Along midline (common in USA); less painful, heals better but higher risk of 3rd/4th degree tear

• Fetal distress (to expedite delivery)
• Instrumental delivery (forceps/vacuum)
• Preterm delivery (to protect fetal head)
• Shoulder dystocia
• Breech delivery
• Previous 3rd/4th degree tear (relative)

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CORD PROLAPSE

1. Do NOT push cord back (risk of spasm)
2. Relieve compression: Manually elevate presenting part off cord; knee-chest position or Trendelenburg position
3. Wrap cord in warm, moist towel if outside vulva
4. Call for help; IV access; O2
5. Emergency LSCS - most common management if baby alive
6. Maintain manual elevation of presenting part until delivery
7. If fully dilated + vertex → forceps or vacuum; if breech → extract

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COMPLICATIONS OF CESAREAN SECTION

• Hemorrhage, bladder injury, ureter injury, bowel injury
• Anesthetic complications (spinal headache, hypotension)
• Difficulty extracting baby (especially extended head in breech)

• PPH (uterine atony, wound bleeding)
• Wound dehiscence, hematoma
• Pulmonary embolism, DVT
• Ileus, infection

• Scar dehiscence/rupture in subsequent pregnancy
• Placenta previa/accreta in subsequent pregnancy (major risk)
• Adhesions → pelvic pain, bowel obstruction
• Infertility, ectopic pregnancy
• "Too posh to push" - psychological preference for LSCS
• Neonatal respiratory morbidity (TTN - transient tachypnea of newborn)

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POLYHYDRAMNIOS - CAUSES & COMPLICATIONS

• Fetal causes:
  • GI obstruction: Esophageal/duodenal atresia, tracheoesophageal fistula (impaired swallowing)
  • Neural tube defects: Anencephaly (reduced swallowing)
  • Fetal tumors: sacrococcygeal teratoma
  • Hydrops fetalis
  • Multiple pregnancy (TTTS)
  • Chromosomal abnormalities (Trisomy 18, 21)
• Maternal causes:
  • Diabetes mellitus (most common in India)
  • Rh isoimmunization

• Maternal: Respiratory embarrassment, preterm labor, malpresentation, cord prolapse, PPH (uterine atony due to overdistension), placental abruption
• Fetal: Preterm birth, perinatal asphyxia, cord prolapse, congenital anomalies

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14. MEDICAL TERMINATION OF PREGNANCY (MTP)

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MTP ACT (INDIA) - 1971, Amended 2021

• Survivors of rape/sexual assault
• Minors
• Change in marital status (divorce, widowhood)
• Women with disabilities/mental illness
• Fetal malformation
• Humanitarian setting (emergency)

• Continuation would endanger maternal life or physical/mental health
• Risk of fetal abnormality
• Rape/incest
• Contraceptive failure (now extended to any woman, not just married)

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MISOPROSTOL

1. Cervical ripening before MTP/ERPC
2. MTP (with Mifepristone) up to 10 weeks: Mifepristone 200 mg + Misoprostol 800 mcg vaginally 48 hrs later
3. Induction of labour (25 mcg vaginally q4-6h for living fetus; higher doses for missed abortion)
4. PPH treatment: 800-1000 mcg rectally/SL (if oxytocin unavailable)
5. Treatment of missed/incomplete abortion

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15. SHEEHAN SYNDROME

• Failure of lactation (1st sign) - prolactin deficiency
• Amenorrhea (LH/FSH deficiency)
• Loss of axillary and pubic hair (LH/FSH, TSH)
• Features of hypothyroidism (TSH deficiency)
• Features of hypoadrenalism (ACTH deficiency) - weakness, hypotension, hypoglycemia
• GH deficiency - most common long-term deficiency

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16. PREIMPLANTATION GENETIC DIAGNOSIS (PGD)

• Couples with known chromosomal abnormalities (translocations)
• X-linked disorders (hemophilia, DMD)
• Single gene disorders (CF, SCA, Thalassemia, Huntington's)
• Advanced maternal age (PGT-A for aneuploidy)
• Recurrent miscarriage
• HLA matching (savior sibling)

1. IVF → embryo to blastocyst stage (Day 5)
2. Trophectoderm biopsy (5-10 cells) from blastocyst
3. Genetic analysis: PCR, NGS (Next Generation Sequencing), FISH, CGH
4. Transfer of unaffected embryos

• PGT-A (Aneuploidy): Screen for chromosome number abnormalities
• PGT-M (Monogenic): Test for single gene disorders
• PGT-SR (Structural rearrangements): Chromosomal translocations

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17. MEASURES TO REDUCE PERINATAL TRANSMISSION OF HIV

1. Early antenatal HIV testing (PPTCT program - Prevention of Parent to Child Transmission)
2. Start ART (Antiretroviral therapy) for all HIV+ pregnant women regardless of CD4 count (Option B+)
3. WHO preferred regimen: TDF + 3TC (or FTC) + EFV from first trimester
4. Monitor viral load - aim for undetectable VL at delivery
5. Prophylactic co-trimoxazole (if CD4 <350)

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18. HYDATIDIFORM MOLE

• Abnormal uterine bleeding (most common) - brownish discharge
• Uterus large for dates (complete mole)
• Hyperemesis gravidarum (due to very high β-hCG)
• Theca lutein cysts (bilateral ovarian enlargement)
• Early-onset preeclampsia (<20 weeks - pathognomonic)
• No fetal heart sounds
• Hyperthyroidism (hCG has TSH-like activity)

• β-hCG: markedly elevated (>100,000 IU/L)
• USG: "Snowstorm" appearance (complete mole), no fetus
• CXR, CT chest (to rule out metastases)
• Histopathology after evacuation (gold standard)

1. Surgical evacuation by suction curettage (method of choice)
2. Oxytocin after cervical dilatation (reduces hemorrhage)
3. Blood group and cross match; IV access
4. Anti-D if Rh negative
5. Histological confirmation
6. Serial β-hCG monitoring (weekly until undetectable, then monthly for 6 months-1 year)
7. Contraception for 6-12 months (avoid pregnancy until β-hCG normal)
8. If β-hCG plateaus or rises → Gestational Trophoblastic Neoplasia (GTN) → chemotherapy (Methotrexate first line)

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19. PREVENTION OF ANEMIA IN PREGNANCY

• Iron-Folic Acid (IFA) tablets: 100 mg elemental iron + 500 mcg folic acid daily for all pregnant women
• Start from 2nd trimester (India: from first contact)
• Calcium should NOT be taken simultaneously (reduces iron absorption)
• Take on empty stomach with Vitamin C (enhances absorption)

• Green leafy vegetables, jaggery, dried fruits, meat/fish
• Avoid tea/coffee with meals (tannins inhibit iron absorption)

1. Daily iron/folic acid supplementation
2. Malaria prevention (endemic areas)
3. Deworming (albendazole 400 mg once after 1st trimester)
4. Treat infections

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20. ABORTION

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SEPTIC ABORTION

1. Resuscitation: IV fluids, O2
2. Blood cultures before antibiotics
3. Broad-spectrum IV antibiotics: Ampicillin + Gentamicin + Metronidazole
4. Evacuation of uterus (AFTER antibiotic cover for 4-6 hours) - Gentle suction curettage
5. Anti-D if Rh negative
6. ICU care if septic shock

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MISSED ABORTION

• No fetal heartbeat with CRL >7 mm (missed abortion/embryonic demise)
• No embryo with gestational sac >25 mm (anembryonic pregnancy/blighted ovum)

1. Expectant: Wait 1-2 weeks; 50-80% will expel spontaneously
2. Medical: Misoprostol (800 mcg vaginally; repeat in 3 hours if needed)
3. Surgical: Manual Vacuum Aspiration (MVA) up to 12 weeks; D&C

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CAUSES OF FIRST & SECOND TRIMESTER ABORTION + INEVITABLE ABORTION

• Chromosomal abnormalities (most common - 50-60%): Trisomies, monosomy X
• Implantation defects
• Luteal phase defect (low progesterone)
• Infection: TORCH, Mycoplasma
• Uterine anomalies (arcuate, bicornuate)

• Cervical incompetence (most important cause)
• Uterine anomalies (septate uterus)
• Antiphospholipid syndrome (APS)
• Infections: Listeria, Syphilis
• Thrombophilias: Factor V Leiden, Protein C/S deficiency
• Poorly controlled DM/thyroid disease

• Definition: Abortion in progress; cannot be prevented
• Signs: Dilated cervix, heavy bleeding, passage of clots/products
• USG: Products in cervical canal

• Hospitalize; IV access
• < 12 weeks: Medical (Misoprostol) or surgical (MVA/suction curettage)

• 12 weeks: Oxytocin infusion to complete the process; ERPC if retained

• Anti-D prophylaxis (if Rh negative)
• Anti-infective cover

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21. PRETERM LABOUR

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MANAGEMENT AT 33 WEEKS WITH PRETERM LABOUR

1. Assess: Confirm gestational age, fetal presentation, fetal well-being (CTG), cervical dilatation
2. Investigations: HVS/urine culture, GBS swab, FBC, CRP, fFN (fetal fibronectin) if diagnosis uncertain
3. Corticosteroids (antenatal): Betamethasone 12 mg IM x2 (24 hours apart) → lung maturity
4. Tocolysis (to gain 48 hours for steroid effect):
   • Nifedipine 10-20 mg orally (1st line - Ca channel blocker)
   • Atosiban (Oxytocin receptor antagonist) IV - preferred in Europe
   • Indomethacin (COX inhibitor) - <32 weeks only (risk of PDA closure)
5. MgSO4 neuroprotection: <32 weeks - reduces cerebral palsy
6. GBS prophylaxis: Benzyl Penicillin IV if GBS positive or unknown
7. Monitor: CTG, maternal vitals, urine output
8. At 33 weeks: Aim to delay delivery if safe; deliver if signs of infection, fetal compromise

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COMPLICATIONS IN PRETERM NEONATE

• RDS/Hyaline Membrane Disease (most common)
• Apnea of prematurity
• Bronchopulmonary dysplasia (BPD) - with prolonged O2/ventilation
• Transient Tachypnea of Newborn (TTN)

• Intraventricular hemorrhage (IVH)
• Periventricular leukomalacia (PVL) → cerebral palsy

• Necrotizing Enterocolitis (NEC) - ischemia/infection of bowel
• Poor feeding, feeding intolerance

• Hypoglycemia, hypothermia, hypocalcemia

• Neonatal sepsis (early and late onset)

• Retinopathy of Prematurity (ROP) - especially <32 weeks or <1500 g

• Jaundice (prolonged), patent ductus arteriosus (PDA), anemia

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DRUGS USED AS TOCOLYTICS

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22. COUVELAIRE UTERUS

• Uterus fails to contract (atony) → severe PPH
• Cannot palpate fetal parts
• Hard, woody, board-like uterus

• Usually does not require hysterectomy; uterus contracts after delivery and clot removal
• Hysterectomy only if uncontrollable hemorrhage/PPH despite all measures

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23. SICKLE CELL DISEASE IN PREGNANCY

• Preconceptional: Genetic counseling, partner testing, folic acid 5 mg/day
• Antenatal: Hydroxyurea (teratogenic - STOP in pregnancy), folic acid, iron if deficient (not routine), hydroxyzine for pain
• Regular transfusions if Hb <6 g/dL or recurrent crises
• Screen for complications: Doppler, USS, echo
• Antibiotics prophylaxis (penicillin V), pneumococcal/meningococcal vaccines
• Avoid dehydration, hypoxia, infections, cold, stress
• Intrapartum: Continuous CTG, avoid prolonged labor, O2, hydration

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24. INSTRUMENTAL DELIVERY

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KIELLAND FORCEPS

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FORCEPS APPLICATION - AFTERCOMING HEAD OF BREECH

• Long shank; no pelvic curve; downward perineal curve
• Applied from below while assistant holds the body elevated
• Prevents uncontrolled rapid descent and intracranial injury

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PREREQUISITES & COMPLICATIONS OF VACUUM DELIVERY

• Ruptured membranes
• Sufficient cervical dilatation (fully dilated)
• Vertex presentation (OP, OT positions possible)
• Presentation engaged
• Also: Known fetal position, adequate pelvic size, empty bladder, no fetal coagulopathy

• Fetal: Cephalhematoma (most common), subgaleal (subaponeurotic) hemorrhage (most dangerous), scalp lacerations, retinal hemorrhage, jaundice, IVH
• Maternal: Vaginal/perineal lacerations, anal sphincter injury

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25. BIOPHYSICAL PROFILE (BPP)

• 8-10: Normal; repeat in 1 week
• 6: Equivocal; repeat in 24 hours
• 4: Abnormal; consider delivery
• 0-2: Serious fetal compromise; deliver

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26. POST-MATURITY SYNDROME (Clifford's Syndrome)

• Macrosomia (if placenta still functional) OR IUGR (if placental insufficiency)
• Meconium aspiration syndrome (MAS)
• Oligohydramnios, cord compression
• Birth asphyxia, stillbirth
• Neonatal hypoglycemia

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27. ADVANTAGES & DISADVANTAGES OF ORAL CONTRACEPTIVE PILLS (OCPs)

• Highly effective (>99% with perfect use)
• Regulates menstrual cycle; reduces dysmenorrhea
• Reduces risk of ovarian cancer (40-80%) and endometrial cancer
• Improves acne, hirsutism (anti-androgenic pills)
• Reduces PID, ectopic pregnancy
• Treats endometriosis, PCOS
• Reduces benign breast disease
• Decreases iron-deficiency anemia (lighter periods)

• No STI protection
• Requires daily compliance
• Cardiovascular risks: DVT, PE, stroke (estrogen-mediated), myocardial infarction (smokers)
• Hypertension
• Nausea, breast tenderness, breakthrough bleeding
• Mood changes, reduced libido
• Slight increased risk of cervical cancer and breast cancer (controversial)
• Contraindicated: Migraines with aura, breastfeeding <6 weeks, known thrombophilia, smoking >35 years, liver disease

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28. ASYMPTOMATIC BACTERIURIA (ASB)

• Nitrofurantoin (avoid at term - risk of neonatal hemolysis)
• Amoxicillin / Augmentin
• Cephalexin
• Fosfomycin

• Pyelonephritis (most serious; 20-30x risk)
• Preterm labour, PROM
• Low birthweight, IUGR
• Anemia

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29. PLATYPELLOID PELVIS

• Engagement usually in transverse position
• Deep transverse arrest common
• Difficult/prolonged labor
• Increased LSCS rate

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30. DETECTION OF FETOMATERNAL HAEMORRHAGE (FMH)

• Gold standard
• Principle: Adult Hb (HbA) elutes in acid buffer; Fetal Hb (HbF) is resistant → fetal cells stain pink; maternal cells are ghost cells
• Volume of FMH = (% fetal cells / 50) × maternal blood volume (assumed 5000 mL)
• If FMH >4 mL → additional anti-D needed

• 1 mL (packed fetal cells) → 125 IU anti-D
• 500 IU anti-D covers ~4 mL FMH

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31. ANEUPLOIDY SCREENING

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SCREENING FOR DOWN'S SYNDROME (TRISOMY 21)

• NT + PAPP-A + free β-hCG = Combined screening (85% detection, 5% FPR)
• NIPT: >99% sensitivity (gold standard screening - NOT diagnostic)

• Triple test: AFP (low) + hCG (high) + uE3 (low) - 70% detection
• Quad test: Above + Inhibin A (high) - 81% detection

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PRENATAL DIAGNOSIS

• Chorionic Villus Sampling (CVS): 10-13 weeks; karyotype/DNA analysis
• Amniocentesis: 15-20 weeks; karyotype, FISH, microarray
• Fetal blood sampling (Cordocentesis): >18 weeks
• Fetoscopy: Direct visualization

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CHORIONIC VILLUS SAMPLING (CVS)

• Miscarriage rate: 0.5-1%
• Limb reduction defects (if done before 9 weeks - avoid)
• FMH (give anti-D to Rh negative women)
• Confined placental mosaicism (2-3%) - may require amniocentesis to confirm

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AMNIOCENTESIS

• Karyotyping, FISH, chromosomal microarray
• PCR for single gene disorders
• AFP (NTD), Acetylcholinesterase (NTD)
• Lung maturity assessment (L/S ratio, PG)
• Assessment of Rh isoimmunization (ΔOD450)

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32. EXTERNAL CEPHALIC VERSION (ECV)

• Uncomplicated singleton pregnancy
• Non-cephalic presentation
• Adequate amniotic fluid
• Reactive NST / normal CTG
• Informed consent

• Placenta previa, abruption
• Ruptured membranes
• Multiple pregnancy
• Uterine scar (relative)
• Oligohydramnios
• Cord round neck (significant nuchal cord)
• Previous LSCS (relative)

1. CTG before and after
2. Tocolysis (Terbutaline/Salbutamol SC or IV) to relax uterus
3. Ultrasound guidance
4. Forward roll or back flip maneuver
5. CTG monitoring for 30-60 minutes after

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33. NYHA CLASSIFICATION OF HEART DISEASE IN PREGNANCY

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34. MUTHULAKSHMI REDDY SCHEME (MMRSY - Tamil Nadu)

• Financial assistance: Rs. 18,000 (currently updated) paid in installments
• Nutritional support
• Free ANC, delivery, and postnatal care

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35. RETAINED PLACENTA

• Placenta trapped: Cervix contracts before placenta descends; separated but not expelled
• Placenta adherens: Poorly contracted uterus; placenta attached to flaccid uterus
• Morbidly adherent placenta (MAP): Placenta accreta/increta/percreta

1. IV access; crossmatch blood
2. Catheterize bladder (full bladder prevents placental descent)
3. Oxytocin 10 IU IV
4. Brandt-Andrews maneuver (controlled cord traction)
5. Manual removal of placenta (MROP) under anesthesia/analgesia (if above fails)
   • Spinal or general anesthesia
   • Insert hand into uterus, find cleavage plane, shear off placenta
6. Antibiotics (ampicillin + metronidazole)
7. Bimanual compression if PPH after MROP
8. For accreta: Hysterectomy may be required

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36. PHYSIOLOGY OF LACTATION

• Non-suckling → prolactin levels fall
• Estrogen (high-dose): inhibits milk production (used in lactation suppression)
• Bromocriptine/Cabergoline (dopamine agonists): suppress prolactin

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37. DIAGNOSIS OF PREGNANCY

• Amenorrhea (most important)
• Morning sickness, nausea/vomiting
• Breast tenderness, breast enlargement, Montgomery's tubercles
• Urinary frequency
• Quickening (first perception of fetal movement): 16-20 weeks (primi 20 wks, multi 16-18 wks)
• Skin changes: linea nigra, chloasma

• Uterine enlargement
• Hegar's sign: Softening of lower uterine isthmus (6-8 weeks)
• Goodell's sign: Softening of cervix
• Chadwick's sign: Bluish-violet discoloration of cervix/vagina
• Palmer's sign: Rhythmic uterine contractions (Braxton Hicks)
• Piskacek's sign: Asymmetrical uterine enlargement at implantation site
• Positive pregnancy test (urine/serum hCG)

• Fetal heart sounds (auscultation ≥12 weeks Doppler; ≥18-20 weeks Pinard)
• Fetal parts felt (ballottement, palpation ≥20 weeks)
• Fetal movements felt by examiner
• Ultrasound: gestational sac (≥4.5 weeks), fetal heartbeat (≥6 weeks), fetal parts

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38. VULVAL HEMATOMA

• Spontaneous delivery (perineal laceration, venous rupture)
• Instrumental delivery (forceps/vacuum)
• Post-episiotomy/repair
• Trauma, sexual assault

• Intense, severe unilateral vulval pain and pressure (hallmark)
• Rapidly enlarging vulval swelling
• Bluish/dark discoloration
• Urinary retention (common)
• Signs of shock if large

• Vulvovaginal hematoma: limited to vulva + vagina
• Broad ligament hematoma: blood tracks into parametrium (larger, more dangerous)

• Small (<5 cm, stable): Conservative - ice pack, analgesia, pressure, observe
• Large/expanding/patient in pain:
  • Incision and drainage under anesthesia
  • Evacuate clot, ligate bleeding vessels (if identifiable)
  • Leave drain or pack
  • Antibiotics to prevent infection
• Blood transfusion if needed
• Foley catheter for urinary retention

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39. ANENCEPHALY

• Neural tube defect (NTD)
• Associated with polyhydramnios (fetus cannot swallow normally)
• Elevated maternal serum AFP
• Ultrasound: absent cranial vault, "frog-eye" appearance, no brain tissue above eyes

• Detected antenatally: Offer termination of pregnancy
• If continuing: Comfort care only at delivery
• Serial USG for polyhydramnios (amnioreduction if respiratory compromise)

• Folic acid 0.4 mg/day preconceptionally and in first trimester (reduces NTD by 70%)
• High-risk (previous NTD): 5 mg/day

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40. ANTEPARTUM FETAL SURVEILLANCE

• Normal S/D ratio: <3 after 30 weeks
• Absent End Diastolic Flow (AEDF): Increased fetal risk
• Reversed EDF: Urgent delivery

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41. INVERSION OF UTERUS

• Fundal pressure (Credé's maneuver) before placental separation
• Excessive cord traction
• Short cord
• Sudden raised IAP
• Morbidly adherent placenta
• Relaxed uterus/atony
• Primigravida

• Sudden severe lower abdominal pain (tearing sensation)
• Massive PPH → haemorrhagic shock
• Neurogenic shock (parasympathetic - bradycardia, hypotension) - out of proportion
• Absence of uterine fundus on abdominal palpation
• Mass visible/palpable at introitus (2nd/3rd degree)

1. Call for help; IV access x2; O2; resuscitate
2. Do NOT remove placenta if still attached (may precipitate massive hemorrhage)
3. MANUAL REPLACEMENT (Johnson's maneuver - immediate, within minutes):
   • Push uterus back in reverse order of inversion (last part to invert = first to replace)
   • Start with nearest part of fundus
   • Use fist to push fundus through cervix
   • Hydrostatic method (Sullivan's): warm saline into posterior fornix
4. Tocolysis (Terbutaline/MgSO4/GTN) to relax cervical ring before replacement
5. Oxytocin AFTER replacement to contract uterus
6. Blood transfusion
7. Surgical replacement (Huntington's/Haultain's) if manual fails
8. Antibiotic cover

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Note: These notes are compiled for exam preparation. Clinical practice must follow institutional protocols and current national/international guidelines. Drug doses should be confirmed with current pharmacopeia before clinical use.