Obstetrics & Gynecology (OBGYN) Obstetrics Early Pregnancy: Signs to diagnose pregnancy Preconceptional care — supplementations & vaccinations Parity index Teratogens & associated defects Trimester-wise screenings Leopold maneuvers High-Yield Conditions: Cervical insufficiency — types of cerclage APLA (Antiphospholipid Antibody Syndrome) Ectopic pregnancy — expectant, medical & surgical management Molar pregnancy — partial vs complete Placenta & Amniotic Fluid: Placental abnormalities Amniotic fluid abnormalities Placenta previa vs placental abruption PAS (Placenta Accreta Spectrum) Multiple Pregnancy: Multiple pregnancy mechanics MCDA vs DCDA (USG evaluation) TTTS (Twin-to-Twin Transfusion Syndrome) Medical Disorders in Pregnancy: Hypertension in pregnancy Preeclampsia & eclampsia — management HELLP syndrome Diabetes in pregnancy Labor & Delivery: Modified Bishop score Active management of third stage of labor Breech presentation — management Lovset & Burns Marshall maneuvers Shoulder dystocia — HELPERR algorithm Postpartum hemorrhage — EMOTIVE protocol Gynecology Menstrual Disorders: Mullerian anomalies Primary vs Secondary amenorrhea Abnormal uterine bleeding — FIGO classification Uterine Conditions: Adenomyosis Fibroids Endometriosis — management Endometrial hyperplasia High-Yield Clinicals: Vaginal infections Ovarian cysts & tumors Cervical cancer — screening & diagnosis HPV vaccination PCOS Contraception

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OBSTETRICS & GYNECOLOGY - COMPLETE EXAM STUDY GUIDE

PART I: OBSTETRICS

1. EARLY PREGNANCY

Signs & Diagnosis of Pregnancy

Presumptive signs (felt by patient, subjective):

Amenorrhea
Nausea/vomiting (morning sickness) - peaks 8-12 weeks
Breast tenderness, pigmentation (areola darkening)
Quickening: first fetal movements felt by mother - multigravida ~16 weeks, primigravida ~18-20 weeks
Urinary frequency
Fatigue

Probable signs (found by examiner, objective but not conclusive):

Uterine enlargement
Hegar's sign: softening of the isthmus (lower uterine segment) at 6-8 weeks
Goodell's sign: softening of the cervix
Chadwick's sign: bluish-purple discoloration of cervix and vagina (congestion)
Jacquemier's sign: same as Chadwick's
Palmer's sign: regular rhythmic uterine contractions on bimanual exam
Piskacek's sign: asymmetric uterine enlargement at site of implantation
Uterine souffle (bruit)
Positive pregnancy test (hCG) - probable because hCG can be elevated in trophoblastic disease

Positive (definite) signs:

Fetal heart sounds (FHR 110-160 bpm)
Visualization of fetus on ultrasound (gestational sac visible at ~5 weeks transvaginally, ~6 weeks transabdominally)
Fetal parts palpated
Fetal movements felt by examiner

Beta-hCG timeline:

Doubles every 48 hours in normal early pregnancy
Peaks at 8-10 weeks (~100,000 mIU/mL), then falls
Discriminatory zone: 1,500-2,000 mIU/mL (transvaginal US should show gestational sac above this level)

Naegele's Rule (EDD calculation):

LMP + 7 days - 3 months + 1 year
Or: LMP + 280 days (40 weeks)

Preconceptional Care

Supplementations:

Supplement	Dose	Indication
Folic acid	0.4-0.8 mg/day (general)	Neural tube defect prevention
Folic acid (high risk)	4 mg/day	Prior NTD child, maternal epilepsy on valproate/carbamazepine, BMI >35
Iron	Not routine preconception	Start in 1st trimester
Iodine	150-220 mcg/day	Thyroid development of fetus
Vitamin D	600 IU/day	Bone health

Folic acid must start at LEAST 1 month (ideally 3 months) before conception and continue through 1st trimester
Reduces risk of NTDs (anencephaly, spina bifida, encephalocele) by 70%

Vaccinations in preconception/pregnancy:

Vaccine	Pre-pregnancy	During Pregnancy
Rubella (MMR)	Recommend if not immune; wait 1 month before conception	CONTRAINDICATED (live)
Varicella	Recommend if not immune; wait 1 month	CONTRAINDICATED (live)
Influenza (inactivated)	Yes	YES - recommended every pregnancy
Tdap	Yes	YES - 27-36 weeks every pregnancy
Hepatitis B	Complete if not immune	Safe if needed
COVID-19	Recommended	Recommended
Yellow fever (live)	Avoid	Avoid unless high risk area
Smallpox (live)	Avoid	CONTRAINDICATED

Mnemonic - Vaccines CONTRAINDICATED in pregnancy (all live attenuated):

MMR (measles, mumps, rubella)
Varicella (chickenpox)
BCG (tuberculosis)
OPV (oral polio - live, Sabin)
Yellow fever (if possible)
Smallpox (vaccinia)

Parity Index (GTPAL)

G = Gravida (total number of pregnancies, including current)
T = Term births (≥37 weeks)
P = Preterm births (20-36+6 weeks)
A = Abortions (spontaneous + induced, <20 weeks)
L = Living children

Definitions:

Nulligravida: never pregnant
Primigravida: pregnant for the first time
Multigravida: 2+ pregnancies
Nullipara: never delivered viable infant
Primipara: delivered one viable infant
Multipara: 2+ viable deliveries
Grand multipara: 5+ deliveries (increased risk: uterine atony, placenta previa, malpresentation)

Example: Woman with 3 term deliveries, 1 preterm delivery, 1 abortion, 4 living children

GTPAL = G5T3P1A1L4

Teratogens & Associated Defects

Rule: Teratogens are most damaging during organogenesis (weeks 3-8 of embryonic life = weeks 5-10 of gestational age).

Teratogen	Defects
Thalidomide	Phocomelia (limb reduction defects - seal limbs), cardiac defects, ear anomalies
Isotretinoin (Vit A analog)	Craniofacial defects (microtia, cleft palate), CNS (hydrocephalus), cardiac (conotruncal)
Valproate	Neural tube defects (highest risk), cardiac defects, facial clefts, cognitive impairment
Phenytoin	Fetal hydantoin syndrome: cleft lip/palate, hypoplastic nails/digits, IUGR, craniofacial
Carbamazepine	NTDs (spina bifida), craniofacial, fingernail hypoplasia
Warfarin	Warfarin embryopathy: nasal hypoplasia, stippled epiphyses (weeks 6-9); CNS effects (2nd/3rd trimester); hemorrhage
ACE inhibitors / ARBs	2nd-3rd trimester: renal tubular dysplasia, oligohydramnios, skull ossification defects, pulmonary hypoplasia, limb contractures
Alcohol	Fetal Alcohol Syndrome: microcephaly, smooth philtrum, thin vermilion border, short palpebral fissures, intellectual disability, IUGR
Lithium	Ebstein's anomaly (tricuspid valve displacement)
Methotrexate	Neural tube defects, limb defects, craniofacial
Diethylstilbestrol (DES)	Vaginal clear cell adenocarcinoma in daughters, T-shaped uterus, cervical anomalies
Tetracycline	Yellow-brown teeth, bone growth inhibition
Aminoglycosides	Sensorineural hearing loss, renal damage
Misoprostol (in 1st trimester)	Moebius sequence (CN VI, VII palsy), limb defects
Cocaine	Placental abruption, IUGR, microcephaly, urogenital defects
Tobacco	IUGR, preterm birth, placental abruption/previa, SIDS
Ionizing radiation (>10 rad)	Microcephaly, intellectual disability, leukemia
Rubella virus	Cataracts, sensorineural deafness, cardiac (PDA, pulmonary stenosis), microcephaly - "blueberry muffin" rash
CMV	Most common congenital infection; periventricular calcifications, deafness, chorioretinitis, microcephaly
Toxoplasma	Classic triad: chorioretinitis, hydrocephalus, intracranial calcifications (diffuse)
Syphilis (Treponema)	Saddle nose, interstitial keratitis, Hutchinson's teeth, saber shins, CN VIII deafness
Parvovirus B19	Hydrops fetalis, aplastic crisis

Mnemonic for TORCH: Toxoplasma, Other (syphilis, VZV, HIV, parvovirus), Rubella, CMV, Herpes

Trimester-Wise Screenings

First Trimester (up to 13+6 weeks):

Dating ultrasound (7-13 weeks) - most accurate with CRL
Nuchal Translucency (NT) scan: 11-13+6 weeks
- NT >3.5 mm: risk of trisomy 21, 18, 13, Turner syndrome, cardiac defects
Combined screening (11-13+6 weeks):
- NT + serum PAPP-A + free beta-hCG
- Detection rate ~85-90% for T21
Chorionic Villus Sampling (CVS): 10-13 weeks (for karyotype/genetic testing)
Blood type, Rh, antibody screen, CBC, rubella immunity, syphilis, Hep B, HIV, gonorrhea/chlamydia, urine culture
Cell-free fetal DNA (NIPT): >10 weeks - screens for T21, T18, T13, sex chromosomal aneuploidies (sensitivity >99% for T21)

Second Trimester (14-27+6 weeks):

Quadruple screen / Quad screen (15-20 weeks, optimal 16-18 weeks):
- AFP (alpha-fetoprotein)
- beta-hCG
- Estriol (unconjugated)
- Inhibin A
- Patterns: see table below
Anatomy scan ultrasound: 18-20 weeks
Amniocentesis: 15-20 weeks (karyotype, AFP, enzyme assays)
Glucose Challenge Test (GCT/1-hr 50g): 24-28 weeks (screens for GDM)
Group B Strep (GBS) culture: 35-37 weeks

Condition	AFP	hCG	Estriol	Inhibin A
Trisomy 21 (Down)	Low	High	Low	High
Trisomy 18 (Edwards)	Low	Low	Low	Normal/Low
Open NTD / Abdominal wall defect	High	Normal	Normal	Normal
Multiple pregnancy	High	High	Normal	Normal
Smith-Lemli-Opitz	Low	Low	Very Low	Normal

Third Trimester:

Repeat CBC, syphilis, Hep B, HIV (if high risk)
GBS vaginal/rectal swab: 35-37 weeks
Fetal growth assessment
Nonstress test (NST), biophysical profile (BPP) for high-risk pregnancies
Repeat glucose tolerance if needed

Leopold Maneuvers

Performed after 28 weeks to determine fetal lie, presentation, position, and engagement.

Maneuver 1 (Fundal grip):

Both hands on fundus
Determines what is in the fundus
Soft, irregular, non-ballotable = breech (buttocks)
Hard, round, ballotable = head (cephalic)

Maneuver 2 (Lateral/Umbilical grip):

Hands on either side of abdomen
Determines fetal back and small parts
Smooth, resistant, continuous = back
Nodular, irregular, moving = limbs

Maneuver 3 (Pawlik's grip / First pelvic grip):

One hand above symphysis pubis, grasp presenting part
Determines presenting part and engagement
If ballotable = not engaged (free)
If fixed = engaged

Maneuver 4 (Second pelvic grip / Deep pelvic grip):

Face toward patient's feet, both hands on lower uterus pressing downward
Determines degree of descent/flexion
Cephalic prominence on same side as limbs = well-flexed head (sinciput felt = flexed)
Cephalic prominence on same side as back = extended/deflexed head

2. HIGH-YIELD CONDITIONS

Cervical Insufficiency (Incompetent Cervix)

Definition: Painless cervical dilation and effacement in 2nd trimester leading to repeated mid-trimester pregnancy losses (14-28 weeks) WITHOUT contractions.

Risk factors: Prior LEEP/cone biopsy, cervical trauma, Mullerian anomalies (esp. DES exposure), connective tissue disorders (Ehlers-Danlos), prior 2nd trimester losses

Diagnosis:

History (painless dilation, recurrent 2nd trimester loss)
Cervical length <25 mm on transvaginal ultrasound (TVU) is key criterion
Funneling (beaking) of internal os on ultrasound

Management - Types of Cerclage:

Type	Technique	Indication
McDonald cerclage	Purse-string suture around cervix at internal os level; simple	Most common; history-indicated or US-indicated
Shirodkar cerclage	Suture placed more proximally (buried under mucosa); more permanent appearance	Shorter cervical length; prior McDonald failure
Transabdominal cerclage (TAC)	Placed at cervicoisthmic junction via laparotomy/laparoscopy	Failed transvaginal cerclage; very short cervix; prior trachelectomy

Timing:

History-indicated cerclage: placed electively at 12-14 weeks (after 1st trimester loss risk passes)
Ultrasound-indicated cerclage: cervical length <25 mm at <24 weeks in women with prior preterm birth
Rescue/emergency cerclage: acute cervical dilation with membranes bulging

Removal: at 36-37 weeks or when labor begins

Progesterone role: 17-hydroxyprogesterone caproate (17-OHPC) IM weekly or vaginal progesterone 200 mg nightly for cervical length <20 mm without prior preterm birth history

APLA - Antiphospholipid Antibody Syndrome

Definition: Autoimmune disorder causing thrombosis (arterial + venous) and pregnancy morbidity.

Sapporo/Sydney Criteria (diagnosis requires ≥1 clinical + ≥1 lab criterion, confirmed on 2 occasions ≥12 weeks apart):

Clinical criteria:

Vascular thrombosis (arterial, venous, or small vessel)
Pregnancy morbidity:
- ≥3 consecutive spontaneous abortions <10 weeks (unexplained)
- ≥1 unexplained fetal death ≥10 weeks (morphologically normal)
- ≥1 premature birth <34 weeks due to preeclampsia, eclampsia, or placental insufficiency

Lab criteria (must be positive twice, ≥12 weeks apart):

Lupus anticoagulant (LA) - most strongly associated with thrombosis
Anticardiolipin antibody (aCL) IgG or IgM (medium-high titer, >40 GPL/MPL)
Anti-beta2-glycoprotein I antibody (anti-β2GPI) IgG or IgM (>99th percentile)

Pathophysiology: Antibodies activate endothelium and platelets, inhibit anticoagulant proteins → thrombosis + placental infarction

Lab curiosity: Lupus anticoagulant PROLONGS aPTT in vitro but causes THROMBOSIS in vivo (paradox)

Management in pregnancy:

Low-dose aspirin (LDA) 81 mg/day + LMWH (heparin) throughout pregnancy and 6 weeks postpartum
No warfarin in first trimester (teratogen)
Warfarin can be used postpartum/non-pregnant for long-term anticoagulation

Ectopic Pregnancy

Definition: Implantation outside the uterine cavity. Most common site: ampulla of fallopian tube (70%).

Other sites: Isthmus (most likely to rupture early due to narrow lumen), interstitial/cornual (highest mortality - ruptures late with massive hemorrhage), ovarian, abdominal, cervical, cesarean scar

Risk factors (mnemonic PEPTIDE):

Previous ectopic
PID/salpingitis (most common cause - scarring)
Previous tubal surgery
IUD (absolute rate decreases, but if pregnancy occurs, ectopic ratio increases)
DES exposure
Endometriosis

Diagnosis:

Serum hCG + TVU
If hCG >1,500-2,000 mIU/mL and no intrauterine gestational sac on TVU = ectopic until proven otherwise
Classic triad: amenorrhea + unilateral pelvic pain + vaginal bleeding
Adnexal mass, free fluid in cul-de-sac (Douglas pouch)

Management:

Approach	Criteria	Treatment
Expectant	Asymptomatic, hCG <200 mIU/mL, declining spontaneously, no rupture, small ectopic	Monitor hCG every 48h until undetectable; success ~57%
Medical (Methotrexate)	Unruptured, hemodynamically stable; hCG <5,000 mIU/mL; no fetal cardiac activity; no contraindications	MTX 50 mg/m² IM single dose (or multi-dose); hCG monitored days 4 and 7 - should drop ≥15% by day 7
Surgical	Ruptured ectopic (emergency); hemodynamic instability; hCG >5,000; contraindication to MTX; failed medical Rx	Salpingectomy (preferred) vs salpingostomy (if only tube remaining) via laparoscopy (or laparotomy if unstable)

MTX contraindications (mnemonic BLAST):

Breastfeeding
Liver/renal/hematologic disease
Absence of monitoring capability
Sac size >3.5 cm or cardiac activity
Thrombocytopenia, immunodeficiency

Post-treatment: Follow hCG to zero; RhoGAM if Rh-negative

Molar Pregnancy (Gestational Trophoblastic Disease)

Feature	Complete Mole	Partial Mole
Karyotype	46XX (most common) or 46XY - all paternal (androgenetic)	Triploid: 69XXX, 69XXY, 69XYY (one egg + two sperm OR one egg + diploid sperm)
Fetal/embryonic tissue	ABSENT	Present (abnormal fetus/parts)
Villi	All hydropic (snowstorm on US)	Some hydropic, some normal
Fetal RBCs	Absent	Present
hCG	Very high (>100,000)	Low-normal or mildly elevated
Uterine size	Large for dates	Small or equal for dates
Risk of GTN	15-20%	1-5%
Theca lutein cysts	Common (30%)	Uncommon
Hyperemesis, hyperthyroidism	More common	Rare
Preeclampsia <20 weeks	PATHOGNOMONIC finding	Rare

Classic US finding (complete mole): "Snowstorm appearance" - no fetus, heterogeneous echogenic mass

Management:

Suction curettage (evacuation) - first line regardless of uterine size
If completed childbearing: hysterectomy (eliminates risk of local GTN but not metastatic disease)
Post-evacuation: follow serum hCG weekly until 3 consecutive normal levels, then monthly for 6 months
Contraception during surveillance - avoid pregnancy for 6 months (complete mole) to allow hCG surveillance
RhoGAM if Rh-negative

GTN surveillance - gestational trophoblastic neoplasia:

Diagnose GTN if: hCG plateaus over 3 weeks, hCG rises ≥10% over 2+ weeks, persistent hCG >6 months
Chemotherapy: Methotrexate (low-risk GTN) or EMA-CO regimen (high-risk, metastatic)
GTN is highly chemosensitive - essentially curable even with metastases

3. PLACENTA & AMNIOTIC FLUID

Placental Abnormalities

Succenturiate placenta: Accessory lobe(s) connected to main placenta by vessels - risk of vasa previa and retained lobe postpartum

Bilobed placenta (bipartite): Two equal lobes - similar risks

Circumvallate placenta: Chorionic plate is smaller than basal plate; double fold of chorion/amnion at edges; associated with antepartum hemorrhage, preterm labor, IUGR

Battledore (marginal) cord insertion: Umbilical cord inserts at placental margin - usually benign

Velamentous cord insertion: Umbilical cord inserts into fetal membranes (not placenta); vessels traverse membranes unsupported - risk of vasa previa and vessel rupture

Vasa previa: Fetal blood vessels cross over internal cervical os (unsupported by placenta/cord); rupture causes sudden painless FETAL hemorrhage (not maternal) with fetal distress. TRIAD: rupture of membranes + painless vaginal bleeding + sudden fetal bradycardia/distress. Diagnosis: velamentous insertion + TVU color Doppler showing vessels over os. Management: planned C-section at 34-35 weeks. APT test (Kleihauer-Betke or alkali denaturation) on vaginal blood distinguishes fetal from maternal blood.

Amniotic Fluid Abnormalities

Normal AFI: 5-24 cm (Amniotic Fluid Index) or MVP (maximum vertical pocket) 2-8 cm

Polyhydramnios (AFI >24 cm or MVP >8 cm):

Causes:

Fetal: GI obstruction (duodenal/esophageal atresia - most common structural), NMJ disorders (fetal swallowing impaired), hydrops, macrosomia
Maternal: Gestational diabetes mellitus (GDM) - most common overall cause
Anencephaly (no swallowing center), facial clefts
Idiopathic (most common overall, ~60%)

Complications: preterm labor, cord prolapse, placental abruption (after delivery), uterine atony, PPH, malpresentation

Oligohydramnios (AFI <5 cm or MVP <2 cm):

Mnemonic DRIPPS:

Drugs (ACE inhibitors, NSAIDs, indomethacin)
Renal agenesis / bilateral renal anomalies (Potter sequence)
IUGBR (IUGR - uteroplacental insufficiency)
Prolonged PROM (rupture of membranes)
Postmaturity (>42 weeks)
Synd (chromosomal/syndromic)

Potter sequence (renal agenesis + bilateral obstruction): oligohydramnios → pulmonary hypoplasia, limb contractures, flattened facies

Complications: cord compression, variable decelerations, IUGR, pulmonary hypoplasia, meconium aspiration

Placenta Previa vs Placental Abruption

Feature	Placenta Previa	Placental Abruption
Definition	Placenta implants over/near internal os	Premature separation of normally implanted placenta
Bleeding character	Painless, bright red, sudden	Painful (uterine tenderness), dark red
Uterine tone	Soft	Woody hard/rigid (couvelaire uterus)
Fetal presentation	Malpresentation common	Normal
Shock vs blood loss	Proportionate	Disproportionate (concealed)
Precipitating factors	Prior C-section (scar), multiparity, prior uterine surgery	HTN, cocaine, trauma, PROM, smoking, prior abruption, thrombophilia
DIC	Rare	Common with severe abruption
Recurrence risk	~3-5%	10% (after 1st abruption); 25% (after 2nd)
Diagnosis	TVU (most accurate; no digital exam!)	Clinical + US (retroplacental clot, though 50% false negative)
Kleihauer-Betke test	Usually not needed	YES - detects feto-maternal hemorrhage

Classification of Placenta Previa:

Complete/Total: placenta covers internal os completely
Partial: placenta partially covers os
Marginal: placental edge reaches (but does not cover) internal os
Low-lying: within 2 cm of os but not reaching it

Management of Placenta Previa:

NEVER perform digital vaginal examination (can precipitate massive hemorrhage)
Stable/no bleeding + preterm: hospitalization, corticosteroids if <34 weeks, pelvic rest, C-section at 36-37 weeks
Active bleeding/hemodynamically unstable: emergent C-section regardless of gestational age

Management of Placental Abruption:

Mild/stable + preterm (<34 weeks): conservative management, steroids
Mild/stable + term: delivery (vaginal if stable, C-section if maternal/fetal distress)
Severe/DIC/fetal distress: immediate C-section; correct coagulopathy

Placenta Accreta Spectrum (PAS)

Definition: Abnormal trophoblastic invasion of myometrium due to defective decidua basalis.

Type	Invasion Depth	Prevalence
Accreta	Adherent to myometrium (no invasion) - most common (75%)	75%
Increta	Invades into myometrium	18%
Percreta	Through myometrium into serosa or beyond (bladder, bowel) - most dangerous	7%

Risk factors: Prior C-section + anterior placenta previa = HIGHEST RISK. Each additional C-section increases risk: 1 prior C/S = 0.3%, 2 = 0.6%, 3 = 2.1%, 4 = 2.3%, 5+ = 6.7%

Diagnosis:

Ultrasound (18-20 weeks): loss of clear zone (retroplacental hypoechoic zone), placental lacunae (Swiss cheese appearance), bulging of bladder wall, bridging vessels on Doppler
MRI: supplements US, especially for posterior PAS or percreta

Management:

Planned delivery at 34-36 weeks (accreta/increta) or 34 weeks (percreta)
Cesarean hysterectomy is definitive (leave placenta in situ, remove uterus + placenta together)
Multidisciplinary team: MFM, urogynecology, urology, IR (interventional radiology for balloon occlusion), blood bank
Cell salvage, massive transfusion protocol prepared

4. MULTIPLE PREGNANCY

Mechanics

Zygosity vs Chorionicity:

Dichorionic diamniotic (DCDA): ALWAYS dizygotic (fraternal) IF two eggs; but also occurs in monozygotic twins if division occurs within 3 days of fertilization
All dizygotic twins = DCDA
Monozygotic division timing determines chorionicity:

Division Timing	Result
Days 0-3 (morula stage)	DCDA (dichorionic diamniotic)
Days 4-8 (blastocyst, inner cell mass)	MCDA (monochorionic diamniotic) - most common MZ
Days 8-12 (after amnion forms)	MCMA (monochorionic monoamniotic)
Days >13	Conjoined twins

MCDA vs DCDA - Ultrasound Evaluation

Feature	MCDA (Monochorionic Diamniotic)	DCDA (Dichorionic Diamniotic)
Chorions	1	2
Amnions	2	2
Placenta	1 shared	2 (or fused)
Inter-twin membrane	Thin (2 layers - two amnions)	Thick (4 layers - two chorions + two amnions)
Lambda sign (twin peak sign)	ABSENT	Present - triangular wedge of placental tissue insinuating between layers of inter-twin membrane at placental insertion; DCDA sign
T-sign	Present (membrane inserts perpendicular to placenta = T)	Absent
Gender	Same sex	Can be different sex
Risk of TTTS	YES (15-20%)	No
Surveillance frequency	Every 2 weeks from 16 weeks	Every 4 weeks
Delivery timing	MCDA: 36-37 weeks; MCMA: 32-34 weeks	38 weeks

Lambda/Twin Peak Sign: Triangular echogenic area of placental tissue at base of inter-twin membrane - indicates DCDA

T-sign: Thin membrane meets placenta at right angle forming "T" - indicates MCDA

TTTS (Twin-to-Twin Transfusion Syndrome)

Definition: Complication of MCDA twins due to unbalanced arteriovenous anastomoses in shared placenta → one twin (donor) transfers blood to the other (recipient).

Donor twin: hypovolemic, oligo/anhydramnios, growth restricted, "stuck twin" (appears fixed against uterine wall, bladder not visible)

Recipient twin: hypervolemic, polyhydramnios, hydrops, cardiomegaly, polycythemia, risk of cardiac failure

Quintero Staging System:

Stage	Features
I	Discordant AFV (polyhydramnios in recipient MVP >8 cm; oligohydramnios in donor MVP <2 cm); bladder visible in both
II	Bladder NOT visible in donor (critically ill)
III	Abnormal Doppler (absent/reversed end-diastolic flow in umbilical artery, ductus venosus or reversed flow in umbilical vein)
IV	Hydrops in either twin
V	Fetal demise of one or both twins

Management:

Stage I: close surveillance (may regress spontaneously)
Stages II-IV: Fetoscopic laser photocoagulation (FLP) of anastomotic vessels - TREATMENT OF CHOICE before 26 weeks
Amnioreduction: temporizing measure only
Selective feticide: for stage V/discordant anomalies

TAPS (Twin Anemia-Polycythemia Sequence): Chronic small AV anastomoses → anemia in donor, polycythemia in recipient WITHOUT amniotic fluid discordance

TRAP (Twin Reversed Arterial Perfusion) sequence: Acardiac twin - one twin has absent/rudimentary heart, parasitically perfused by pump twin via reversed arterial flow. Rx: radiofrequency ablation of cord of acardiac twin.

5. MEDICAL DISORDERS IN PREGNANCY

Hypertension Classification in Pregnancy

Category	Definition
Chronic HTN	Pre-existing or diagnosed <20 weeks; persists >12 weeks postpartum
Gestational HTN	New onset HTN ≥20 weeks WITHOUT proteinuria or severe features; resolves <12 weeks postpartum
Preeclampsia	New onset HTN ≥20 weeks WITH proteinuria OR severe features
Eclampsia	Preeclampsia + new-onset grand mal seizures
Chronic HTN with superimposed preeclampsia	Chronic HTN + new/worsening proteinuria or severe features ≥20 weeks

HTN in pregnancy defined as: SBP ≥140 OR DBP ≥90 mmHg on 2 occasions ≥4 hours apart

Preeclampsia & Eclampsia

Preeclampsia diagnostic criteria:

HTN (≥140/90) at ≥20 weeks + ANY of:
- Proteinuria ≥300 mg/24h OR P:Cr ratio ≥0.3 OR dipstick ≥2+
- OR (WITHOUT proteinuria) - severe features: thrombocytopenia <100K, renal insufficiency Cr >1.1 mg/dL, impaired liver function (LFTs x2 normal), pulmonary edema, new-onset headache unresponsive to medication, visual symptoms

Severe features (ACOG 2022):

SBP ≥160 or DBP ≥110 (confirmed within 15 minutes)
Thrombocytopenia <100,000/µL
Impaired liver function (LFTs ≥2x normal, severe RUQ/epigastric pain)
Progressive renal insufficiency (Cr >1.1 or doubling of Cr)
Pulmonary edema
New-onset headache unresponsive to medication / visual disturbances

Pathophysiology: Abnormal placentation → poor trophoblast invasion of spiral arteries → uteroplacental ischemia → release of antiangiogenic factors (sFlt-1, sEng) → widespread endothelial dysfunction → HTN, proteinuria, end-organ damage

sFlt-1:PlGF ratio: Elevated ratio is predictive of preeclampsia onset (sFlt-1 = soluble FMS-like tyrosine kinase 1 antagonizes VEGF/PlGF)

Management of Preeclampsia:

Antihypertensives (acute severe HTN - SBP ≥160 or DBP ≥110):

IV Labetalol (first line) - 20 mg IV bolus, repeat 40-80 mg q10-20 min, max 300 mg
IV Hydralazine - 5-10 mg IV q20 min
PO Nifedipine (immediate release) 10-20 mg PO
Goal: reduce BP to 140-150/90-100 (do not reduce too rapidly)

Chronic antihypertensives (maintain BP <160/110):

Labetalol, Nifedipine (extended release), Methyldopa
AVOID: ACE inhibitors, ARBs (teratogenic), atenolol (IUGR)

Seizure prophylaxis - Magnesium Sulfate:

4-6 g IV loading dose over 20 minutes, then 1-2 g/hr maintenance
Used for: preeclampsia with severe features, eclampsia (also treats/prevents recurrent seizures)
Therapeutic level: 4-7 mEq/L
Monitor: urine output, respiratory rate (>12/min), patellar reflexes (must be present)
Toxicity signs (as Mg rises):
- 5-8 mEq/L: Loss of patellar reflexes
- 10-13 mEq/L: Respiratory depression
- 15 mEq/L: Cardiac arrest
Antidote: Calcium gluconate 1g IV

Definitive treatment: DELIVERY

Severe preeclampsia with severe features: deliver at 34 weeks
Without severe features: deliver at 37 weeks
Eclampsia: immediate stabilization (MgSO4, airway, BP control), then delivery (not necessarily C-section - vaginal delivery preferred if feasible)

Postpartum: BP management for 6 weeks postpartum; can develop preeclampsia UP TO 6 weeks postpartum (postpartum preeclampsia)

HELLP Syndrome

Hemolysis, Elevated Liver enzymes, Low Platelets - severe variant of preeclampsia (occurs in ~20% of severe cases)

Diagnostic criteria (Mississippi classification):

Class I (severe): platelets <50K + AST/ALT ≥70 + LDH ≥600
Class II (moderate): platelets 50-100K
Class III (mild): platelets 100-150K

Tennessee criteria (simpler):

Microangiopathic hemolytic anemia (LDH >600, abnormal peripheral smear - schistocytes)
AST >70 IU/L
Platelets <100,000/µL

Symptoms: Epigastric/RUQ pain, nausea/vomiting, malaise, headache; hypertension may be absent/mild in 20%

Complications: DIC, hepatic rupture/hematoma, acute renal failure, placental abruption, pulmonary edema

Management:

Stabilize: IV MgSO4 (seizure prophylaxis), antihypertensives
Steroids: Dexamethasone (increases platelet count temporarily - controversial for maternal benefit)
Delivery: ≥34 weeks → deliver promptly. <34 weeks → steroids for fetal lung maturity, deliver within 48h
Platelets <50K and C-section: transfuse platelets preoperatively
Watch for subcapsular hepatic hematoma (avoid vigorous palpation of right upper quadrant)

Diabetes in Pregnancy

Classification:

Pre-gestational diabetes (PGDM): Type 1 or Type 2 DM diagnosed before pregnancy
Gestational diabetes mellitus (GDM): Diagnosed during pregnancy (usually 24-28 weeks)

Screening for GDM:

Two-step approach (ACOG - US):
- Step 1: 1-hr 50g GCT (glucose challenge test) - no fasting needed; threshold ≥140 mg/dL (some use ≥130)
- Step 2: If abnormal, 3-hr 100g OGTT (fasting): Carpenter-Coustan or NDDG criteria
  - GDM if ≥2 values meet/exceed thresholds

One-step approach (IADPSG/WHO): 2-hr 75g OGTT fasting; GDM if ANY single value exceeds: fasting ≥92, 1-hr ≥180, 2-hr ≥153 mg/dL

Maternal complications of diabetes in pregnancy:

Preeclampsia (risk 4x)
Worsening of pre-existing diabetes complications (retinopathy, nephropathy)
Polyhydramnios
UTI, candidiasis
Preterm labor
Increased C-section rate

Fetal/Neonatal complications (White's "too big, too sick" mnemonic):

Macrosomia (>4000g) - most common; shoulder dystocia risk
IUGR (with severe vasculopathy in type 1)
Congenital anomalies (mainly cardiac - VSD, TGA, conotruncal; NTDs) - PRE-GESTATIONAL DM risk
Sacral agenesis/caudal regression - PATHOGNOMONIC for maternal diabetes
Neonatal hypoglycemia (beta cell hyperplasia → insulin surge after delivery)
Polycythemia, hyperbilirubinemia
RDS (delayed lung maturity due to high insulin)
Stillbirth risk increased

Management of GDM:

Dietary modification (carbohydrate restriction) + exercise - first line
Blood glucose monitoring: fasting <95 mg/dL, 1-hr postprandial <140 mg/dL, 2-hr <120 mg/dL
If targets not met in 1-2 weeks: Insulin (first-line pharmacologic in US); Metformin and Glyburide are alternatives but cross placenta
Delivery: GDM on diet alone → 40-41 weeks; GDM on insulin → 39-40 weeks; PGDM → 39 weeks (or earlier with complications)

Post-delivery: GDM resolves in most (90%+); test with 75g OGTT at 4-12 weeks postpartum; lifetime risk of type 2 DM is 50%

6. LABOR & DELIVERY

Modified Bishop Score

Used to assess cervical favorability for induction. Score ≥8 = favorable (induction likely to succeed); <6 = unfavorable (consider cervical ripening).

Parameter	0	1	2	3
Dilation (cm)	Closed	1-2	3-4	5+
Effacement (%)	0-30	40-50	60-70	80+
Station	-3	-2	-1/0	+1/+2
Consistency	Firm	Medium	Soft	-
Position	Posterior	Mid	Anterior	-

Maximum score: 13

Cervical ripening agents (unfavorable cervix):

Prostaglandins: Dinoprostone (PGE2) gel/insert, Misoprostol (PGE1) - most potent
Mechanical: Foley catheter balloon, osmotic dilators (laminaria)

Active Management of Third Stage of Labor

Third stage = from delivery of baby to delivery of placenta (normally ≤30 minutes)

Active management reduces PPH risk by 60-70% compared to expectant management.

Components (AMTSL):

Uterotonic administration within 1 minute of birth (even before cord clamping in some protocols)
- Oxytocin 10 IU IM (first choice) or IV infusion - standard
- Ergometrine 0.5 mg IM/IV (not in HTN or cardiac disease)
- Misoprostol 600 mcg sublingual (if oxytocin unavailable - resource-limited settings)
- Carbetocin (oxytocin analog) - single dose, longer acting
Controlled cord traction (CCT): Brandt-Andrews method - apply gentle traction on cord while supporting uterus suprapubically; avoids uterine inversion
Uterine massage after placental delivery

Signs of placental separation:

Calkin's sign: uterus becomes globular, firm, and rises in abdomen
Cord lengthens
Gush of blood
Uterus becomes freely mobile

Normal blood loss at delivery: <500 mL (vaginal), <1000 mL (C-section)

Breech Presentation - Management

Types of breech:

Frank breech (50-70%): hips flexed, knees extended (pike position)
Complete breech (5-10%): hips and knees flexed (cross-legged)
Footling/incomplete breech (20-25%): one or both feet present below buttocks (highest risk of cord prolapse)

External Cephalic Version (ECV):

Performed at ≥36-37 weeks
Success rate ~50-60%
Contraindications: PROM, placenta previa, multiple gestation, previous uterine scar with complications, nonreassuring FHR, oligohydramnios

Planned vaginal breech delivery criteria (selected cases):

Frank or complete breech (not footling)
Adequate pelvis (clinical pelvimetry)
No fetal macrosomia (<3500g)
Flexed fetal head (no hyperextension on US)
Experienced operator
Term gestation (37-42 weeks)

Assisted breech delivery maneuvers:

Lovset's Maneuver (for delivery of arms):

Used when arms are extended alongside the head (nuchal arms)
Rotate fetal trunk 180° while applying downward traction, keeping back uppermost
Rotation causes arms to sweep across face and deliver under pubic arch
Complete rotation back 180° to deliver other arm

Burns-Marshall Maneuver (for delivery of aftercoming head):

After trunk delivered, fetus hangs by its own weight (downward traction) to flex head into pelvis
Grasp baby by ankles; swing feet upward in wide arc over maternal abdomen
Head delivers over perineum
Alternative: Mauriceau-Smellie-Veit (MSV) maneuver - two fingers on fetal maxilla (jaw), index and middle finger on shoulders → traction + flexion of head

Shoulder Dystocia - HELPERR Algorithm

Definition: Failure of delivery of fetal shoulders with normal gentle downward traction after delivery of the head; anterior shoulder is impacted behind maternal pubic symphysis.

Risk factors: Macrosomia (most common), maternal diabetes, obesity, prolonged 2nd stage, operative vaginal delivery, prior shoulder dystocia

Complications: Brachial plexus injury (Erb's palsy - C5-C6; Klumpke's - C8-T1), clavicle fracture, humerus fracture, fetal hypoxia/death

HELPERR Algorithm:

Letter	Action
H	Call for Help (additional obstetric, neonatal, anesthesia team)
E	Evaluate for episiotomy (makes room for maneuvers, not shoulder itself)
L	Legs (McRoberts maneuver) - hyperflexion of maternal thighs onto abdomen; flattens lumbar lordosis, rotates pubic symphysis superiorly; single most effective first maneuver
P	Suprapubic Pressure (Rubin I) - applied downward and laterally to dislodge anterior shoulder; DO NOT apply fundal pressure
E	Enter (internal rotational maneuvers): Rubin II (pressure on posterior aspect of anterior shoulder) or Woods' screw (pressure on anterior aspect of posterior shoulder) or Rubin II + Woods = Rubin-Woods screw maneuver
R	Remove posterior arm - sweep posterior arm across chest to deliver it
R	Roll patient to all-fours (Gaskin maneuver)

Last resort maneuvers: Zavanelli (cephalic replacement then C-section), deliberate clavicle fracture, symphysiotomy

Postpartum Hemorrhage - EMOTIVE Protocol

Definition: Blood loss ≥500 mL after vaginal delivery or ≥1000 mL after C-section within 24 hours (primary PPH); OR any blood loss causing hemodynamic instability.

Causes - 4 T's:

Tone (70-80%) - uterine atony (most common)
Trauma (20%) - lacerations, hematoma, uterine rupture/inversion
Tissue (5-10%) - retained placenta/products
Thrombin (1%) - coagulopathy (DIC, HELLP, AFE)

EMOTIVE Protocol (mnemonic for step-by-step management):

Letter	Action
E	Establish IV access, fluids, blood products; call for help; measure blood loss
M	Massage uterus (bimanual uterine compression and massage)
O	Oxytocin first-line uterotonic: 10-40 IU IV infusion
T	Tranexamic acid: 1g IV within 3 hours of delivery (reduces mortality)
I	Inspect for lacerations (vagina, cervix, uterus); repair
V	Vacuum out uterus (explore uterine cavity for retained products; manual removal)
E	Embolize (interventional radiology - uterine artery embolization) OR surgical intervention

Uterotonics stepwise:

Oxytocin 20-40 IU/L IV infusion
Ergometrine (Methylergonovine) 0.25 mg IM (CI: HTN, cardiac)
Carboprost (PGF2α) 0.25 mg IM q15-90 min, max 8 doses (CI: asthma)
Misoprostol 600-1000 mcg rectal/sublingual
Carbetocin

Surgical options (step-up approach):

B-Lynch suture (compression suture)
Uterine artery ligation (O'Leary stitch)
Internal iliac (hypogastric) artery ligation
Uterine artery embolization (IR)
Hysterectomy (definitive/last resort)

Balloon tamponade: Bakri balloon, SOS tamponade balloon (pack uterine cavity)

PART II: GYNECOLOGY

7. MENSTRUAL DISORDERS

Mullerian Anomalies

Embryology: Mullerian (paramesonephric) ducts form uterus, fallopian tubes, and upper vagina. Failure of development, fusion, or resorption → anomalies.

American Fertility Society (AFS/ASRM) Classification:

Class	Type	Description
I	Hypoplasia/Agenesis	Uterovaginal agenesis (Mayer-Rokitansky-Kuster-Hauser - MRKH syndrome): absent uterus + upper vagina; normal 46XX female; normal ovaries; primary amenorrhea with normal secondary sexual characteristics
II	Unicornuate uterus	One Mullerian duct develops; banana-shaped uterus; may have rudimentary horn (communicating or non-communicating); risk of ectopic if rudimentary horn has endometrial cavity
III	Didelphys	Complete failure of Mullerian duct fusion; two separate uterine horns, two cervices, often duplicated vagina; relatively good reproductive outcomes
IV	Bicornuate uterus	Partial non-fusion of upper horns; heart-shaped uterus; partial or complete (to internal os); more common; associated with recurrent pregnancy loss
V	Septate uterus	MOST COMMON Mullerian anomaly; partial or complete midline septum (failure of resorption); external contour normal; HIGHEST rate of pregnancy loss; treated by hysteroscopic metroplasty
VI	Arcuate uterus	Mild indentation of fundus; generally considered normal variant
VII	DES-related	T-shaped uterus, cervical/vaginal anomalies

Key distinction: Bicornuate vs Septate:

Bicornuate: abnormal external contour (notch >1 cm), two horns; MRI diagnostic
Septate: normal external contour, internal septum; treated hysteroscopically

Primary vs Secondary Amenorrhea

Primary amenorrhea:

No menses by age 15 (with normal secondary sexual characteristics)
No menses by age 13 (without secondary sexual characteristics)

Approach - FSH level first:

FSH	Diagnosis	Features
High FSH (hypergonadotropic)	Gonadal dysgenesis	Turner syndrome (45X0): short stature, webbed neck, shield chest, coarctation of aorta, primary amenorrhea; streak ovaries; Swyer syndrome (46XY): complete gonadal dysgenesis, phenotypic female, testes (gonadectomy needed - gonadoblastoma risk)
Low/Normal FSH (hypogonadotropic)	Hypothalamic/pituitary failure	Kallmann syndrome: GnRH deficiency + anosmia; constitutional delay; hypothalamic amenorrhea (weight loss, exercise, stress)
Normal FSH with absent uterus	Mullerian agenesis (MRKH) vs androgen insensitivity	MRKH: 46XX, absent uterus/upper vagina, normal ovaries; AIS (testicular feminization): 46XY, absent uterus, inguinal or abdominal testes, blind vaginal pouch, absent/sparse pubic/axillary hair, normal female phenotype

Secondary amenorrhea:

Absence of menses for ≥3 months (previously regular cycles) or ≥6 months (previously irregular)

Most common cause: PREGNANCY (rule out first)

Approach by hCG → FSH/LH/PRL:

Category	Examples
Uterine (outflow tract)	Asherman's syndrome (intrauterine adhesions from D&C/endometritis); cervical stenosis; Progestin challenge test: no bleed = outflow problem or low estrogen
Ovarian	Premature ovarian insufficiency/failure (POI/POF): <40 years; high FSH; low estrogen; can be autoimmune, Turner mosaic, iatrogenic
Pituitary	Hyperprolactinemia (prolactinoma - most common pituitary cause); Sheehan's syndrome (postpartum pituitary necrosis - difficulty breastfeeding, loss of pubic/axillary hair, failure to lactate); empty sella
Hypothalamic	Functional hypothalamic amenorrhea (FHA): stress, underweight, excessive exercise; low GnRH → low FSH/LH → low estrogen; diagnosis of exclusion
Thyroid/Adrenal	Hypothyroidism (↑TSH → ↑TRH → ↑prolactin); CAH; Cushing's

Abnormal Uterine Bleeding - FIGO Classification (PALM-COEIN)

Normal cycle parameters:

Frequency: 24-38 days
Duration: 4-8 days
Volume: 5-80 mL (>80 mL = heavy menstrual bleeding)

PALM-COEIN classification (FIGO 2011, updated 2018):

PALM (structural causes - detectable on imaging):

Acronym	Condition
P	Polyp (endometrial, cervical)
A	Adenomyosis
L	Leiomyoma (fibroid) - submucosal most symptomatic
M	Malignancy and hyperplasia

COEIN (non-structural causes):

Acronym	Condition
C	Coagulopathy (von Willebrand disease - most common bleeding disorder in women; also ITP, hemophilias)
O	Ovulatory dysfunction (PCOS, hypothyroidism, hyperprolactinemia, perimenopause)
E	Endometrial (primary endometrial hemostatic disorders - prostaglandin imbalance)
I	Iatrogenic (IUDs, anticoagulants, antipsychotics, antidepressants)
N	Not classified (AV malformations, isthmocele)

8. UTERINE CONDITIONS

Adenomyosis

Definition: Presence of endometrial glands AND stroma within the myometrium (at least 2.5 mm below basal endometrium), causing myometrial hypertrophy.

Demographics: Typically multiparous women, 40-50s; often coexists with fibroids and endometriosis

Symptoms:

Menorrhagia (heavy menstrual bleeding) - most common
Dysmenorrhea (secondary; progressively worsening)
Dyspareunia
Symmetric uterine enlargement ("boggy uterus")

Diagnosis:

MRI: most accurate - diffuse thickening of junctional zone >12 mm; "venetian blind" striations; poorly defined endometrial-myometrial interface
TVU: asymmetric myometrial thickness, subendometrial echogenic nodules, fan-shaped shadowing, myometrial cysts
Definitive: histopathology of hysterectomy specimen

Management:

Medical: NSAIDs (dysmenorrhea), hormonal suppression (OCPs, LNG-IUS/Mirena - MOST effective; GnRH agonists)
Levonorgestrel IUS (Mirena): first-line medical treatment; significantly reduces menorrhagia and dysmenorrhea
Surgical: Hysterectomy is definitive (only cure)

Uterine Fibroids (Leiomyomas)

Most common benign tumor of uterus (and most common tumor in women of reproductive age). Composed of smooth muscle + fibrous tissue. Estrogen-dependent.

Classification by location:

Type	Location	Symptoms
Submucosal (Type 0-2)	Project into uterine cavity	Most symptomatic - HMB, infertility, pregnancy loss
Intramural (Type 3-4)	Within myometrium	Bulk symptoms, HMB
Subserosal (Type 5-7)	Project outside uterus	Pressure symptoms, urinary frequency
Pedunculated	Attached by stalk (submucosal or subserosal)	Torsion risk if pedunculated subserosal

Symptoms ("PUMP"):

Pressure/bulk symptoms (urinary frequency, constipation)
Uterine enlargement
Menorrhagia (HMB)
Pain/dysmenorrhea

Red degeneration (carneous degeneration): acute complication in pregnancy; fibroid outgrows blood supply → central hemorrhagic infarction; presents with acute abdominal pain, fever, localized uterine tenderness; management: analgesics (NSAIDs), conservative

Investigations:

TVU: hypoechoic whorled masses (shadowing); first line
Saline infusion sonohysterography (SIS): best for submucosal fibroids
Hysteroscopy: direct visualization + treatment of submucosal
MRI: most accurate for mapping and preoperative planning

Management:

Option	Notes
Watchful waiting	Asymptomatic; approaching menopause
LNG-IUS (Mirena)	HMB; does not shrink fibroids
GnRH agonists (Leuprolide)	Shrink fibroids 35-65%; preoperative use; max 6 months (bone loss); add-back therapy if >3 months
GnRH antagonists (Elagolix, Relugolix)	Newer oral agents; approved for fibroid-associated HMB
Tranexamic acid / NSAIDs	Symptomatic HMB relief
Myomectomy	Fertility-preserving surgical option; laparoscopic/hysteroscopic/open
UAE (Uterine artery embolization)	Minimally invasive; not for women desiring future fertility
Hysterectomy	Definitive cure
MR-guided focused ultrasound	Non-invasive; selected fibroids

Endometriosis

Definition: Presence of endometrial-like glands and stroma OUTSIDE the uterine cavity. Retrograde menstruation theory (Sampson) most accepted.

Common sites: Ovaries (chocolate cysts/endometriomas - most common), uterosacral ligaments, posterior cul-de-sac (Douglas pouch), rectovaginal septum, bladder, bowel, umbilicus (Villar's nodule), lung (catamenial pneumothorax)

Symptoms - 3 D's: Dysmenorrhea (progressive, secondary), Dyspareunia (deep), Dyschezia (painful defecation)

Also: infertility, chronic pelvic pain, menorrhagia, subfertility

Classic finding: Fixed, retroverted uterus; uterosacral nodularity; adnexal masses (endometriomas)

Diagnosis:

Definitive: Laparoscopy with biopsy - gold standard
Powder burn/gunshot lesions, blue-black lesions
Endometrioma: ground-glass appearance on TVU; "chocolate cyst" (old blood)
CA-125: elevated but non-specific; useful for monitoring treatment

rASRM staging (1-4):

Stage 1 (Minimal), Stage 2 (Mild), Stage 3 (Moderate), Stage 4 (Severe - extensive adhesions, bilateral endometriomas)

Management:

Indication	Treatment
Pain (no fertility desired)	NSAIDs → Combined OCP (first-line) → Progestins (norethindrone, DMPA) → LNG-IUS → GnRH agonists (add-back therapy) → Danazol (androgenic - last resort due to side effects)
Fertility desired	Laparoscopic excision/ablation of lesions; ovarian endometrioma >4 cm → cystectomy (not drainage - recurs)
Severe/refractory	Hysterectomy + bilateral salpingo-oophorectomy (BSO)

Key drug side effects:

GnRH agonists: menopausal symptoms, bone loss (add back estrogen/progesterone)
Danazol: androgenic effects (acne, hirsutism, deepening voice, weight gain), lipid changes, hepatotoxicity

Endometrial Hyperplasia

Risk factors: Unopposed estrogen exposure (obesity, PCOS, anovulation, estrogen-secreting tumors, tamoxifen use, exogenous estrogen without progesterone)

WHO Classification:

Type	Atypia	Cancer Risk
Hyperplasia without atypia	No	1-3%
Hyperplasia with atypia (EIN - Endometrial Intraepithelial Neoplasia)	YES	25-50% concurrent endometrial cancer (in hysterectomy specimens)

Diagnosis: Endometrial biopsy (Pipelle) - office procedure; D&C or hysteroscopy-directed biopsy

Management:

Hyperplasia without atypia: Progestin therapy (oral MPA or LNG-IUS) - regression in >80%; surveillance biopsy in 6 months
Hyperplasia with atypia (EIN):
- Definitive: Hysterectomy (preferred)
- Conservative (if desiring fertility): High-dose progestins (MPA 80-160 mg/day or megestrol) + surveillance biopsy q3-6 months; ONLY if confirmed no concurrent endometrial cancer

9. HIGH-YIELD GYNECOLOGICAL CLINICALS

Vaginal Infections

Feature	Bacterial Vaginosis	Candidal Vaginitis	Trichomonas vaginalis
Organism	Polymicrobial overgrowth (Gardnerella vaginalis, anaerobes); NOT STI but sexual association	Candida albicans (90%)	T. vaginalis (STI)
Discharge	Thin, gray-white, homogeneous, malodorous ("fishy")	Thick, white, cottage-cheese, curdy; adherent	Profuse, frothy, yellow-green, malodorous
pH	>4.5	<4.5 (normal/acidic)	>4.5
Odor	Fishy (amine odor)	None	Fishy/musty
Symptoms	Odor; minimal irritation	Intense pruritus, burning, dysuria	Pruritus, dysuria, dyspareunia
Exam	"Strawberry cervix" - NO	Normal/erythema	"Strawberry cervix" (colpitis macularis)
KOH prep	Clue cells on wet prep (NOT KOH)	Pseudohyphae/spores on KOH (10%)	Motile trichomonads on wet prep
Whiff test	Positive (amine odor with KOH)	Negative	Often positive
Treatment	Metronidazole 500 mg BID x7d or gel; or Clindamycin	Fluconazole 150 mg PO single dose; or topical azoles	Metronidazole 2g PO single dose (treat partner too)
Pregnancy complications	Preterm birth, PROM, chorioamnionitis	Neonatal thrush during delivery	Preterm birth

Amsel's Criteria for BV (3 of 4):

Thin, gray-white discharge
pH >4.5
Positive whiff test
Clue cells on wet prep (>20% of epithelial cells)

Nugent score: Gram stain scoring for BV (0-10; ≥7 = BV)

Ovarian Cysts & Tumors

Functional cysts (not true neoplasms):

Follicular cyst: failed ovulation; thin-walled, unilocular, <8 cm; resolves spontaneously in 4-6 weeks
Corpus luteum cyst: after ovulation; can rupture and bleed (hemoperitoneum); may mimic ectopic
Theca lutein cysts: bilateral, multiple; from excess hCG stimulation (molar pregnancy, multiple gestation, ovarian hyperstimulation)

Ovarian tumor classification:

Category	Tumors	Key Features
Epithelial (60-70%)	Serous, Mucinous, Endometrioid, Clear cell, Brenner	Most common; peak 40-60s; serous = most common subtype; BRCA1/2 mutations (serous); CA-125 marker
Germ cell (15-20%)	Dysgerminoma, Teratoma (dermoid), Endodermal sinus (yolk sac), Choriocarcinoma, Embryonal	Young women/girls; LDH (dysgerminoma), AFP (yolk sac, embryonal), hCG (choriocarcinoma); good prognosis
Sex cord-stromal (5-10%)	Granulosa cell tumor, Thecoma, Fibroma, Sertoli-Leydig	Hormone-producing; granulosa → estrogen (precocious puberty or postmenopausal bleeding); Call-Exner bodies; Sertoli-Leydig → testosterone (virilization); Meigs syndrome (fibroma + ascites + hydrothorax)

Mature cystic teratoma (dermoid): Most common benign ovarian tumor in reproductive age; contains all 3 germ layers; teeth/hair/sebum; Rokitansky protuberance; calcification on X-ray; low-level echoes with echogenic nodule on US; risk of malignant transformation (1-2%) to squamous cell carcinoma

Risk of Malignancy Index (RMI): M x U x CA-125; guides triage to MDT/oncology

ADNEX model and IOTA criteria (simple rules): US features distinguishing benign vs malignant ovarian masses

Cervical Cancer - Screening & Diagnosis

Epidemiology: Second most common gynecological cancer worldwide; caused by HPV (99% of cases); HPV 16 + 18 account for 70% of cervical cancers.

Risk factors: Early coitarche, multiple partners, HPV infection (especially 16, 18), smoking, immunosuppression (HIV), OCP use >5 years, high parity

FIGO 2018 Staging (clinical + imaging + pathology):

Stage	Description
I	Confined to cervix
IA	Microscopic invasion; IA1: <3 mm depth; IA2: 3-5 mm
IB	Clinically visible or >5 mm; IB1: <2 cm; IB2: 2-4 cm; IB3: ≥4 cm
II	Beyond uterus, NOT to pelvic wall/lower 1/3 vagina
IIA	No parametrial involvement; IIA1: <4 cm; IIA2: ≥4 cm
IIB	Parametrial involvement
III	Lower 1/3 vagina OR pelvic wall OR hydronephrosis
IV	Bladder/rectum (IVA) or distant (IVB)

Cervical Screening:

Pap Smear (Cytology):

Start at age 21 regardless of sexual activity
Age 21-29: cytology alone every 3 years
Age 30-65: co-testing (cytology + HPV) every 5 years (preferred) OR cytology alone every 3 years
Stop screening at 65 (if adequate negative prior screening)

Bethesda classification:

NILM (Negative for intraepithelial lesion/malignancy)
ASC-US (Atypical squamous cells of undetermined significance)
LSIL (Low-grade squamous intraepithelial lesion) = CIN 1
HSIL (High-grade squamous intraepithelial lesion) = CIN 2-3
ASC-H (cannot exclude HSIL)
AGC (Atypical glandular cells)
AIS (Adenocarcinoma in situ)

Colposcopy indications: ASC-US + HPV positive, LSIL, HSIL, ASC-H, AGC, AIS, abnormal-appearing cervix

CIN management:

CIN 1: observe (usually regresses); treat if persistent >2 years
CIN 2-3: LEEP (Loop Electrosurgical Excision Procedure) or cold-knife conization (CKC); cryotherapy; ablation for CIN 2 in young women

Diagnosis: Colposcopy-directed biopsy; cone biopsy (excisional) for AIS

Treatment by stage:

IA1: Simple hysterectomy (or conization if fertility desired)
IA2-IB1: Radical hysterectomy (type III) + pelvic lymph node dissection (PLND) OR chemoradiation
IB2-IVA: Concurrent chemoradiation (cisplatin + EBRT + brachytherapy)
IVB (metastatic): Palliative chemo ± bevacizumab (pembrolizumab for PD-L1+ or MSI-H)

HPV Vaccination

Available vaccines:

Vaccine	Types covered	Doses
Gardasil 4 (quadrivalent)	6, 11, 16, 18	3 doses (now largely superseded)
Gardasil 9 (9-valent)	6, 11, 16, 18, 31, 33, 45, 52, 58	Standard recommendation
Cervarix (bivalent)	16, 18	2-3 doses

Immunization schedule (Gardasil 9 - ACIP):

Age 11-12 (recommended): 2-dose series (0, 6-12 months apart) if started before age 15
Age 15-26: 3-dose series (0, 1-2, 6 months)
Age 27-45: Shared clinical decision-making (may benefit from catch-up)

Types 6 & 11: Genital warts (condyloma acuminata) - low risk Types 16 & 18: Cervical cancer, anal, oropharyngeal, vulvar, vaginal cancers - HIGH RISK Types 31, 33, 45, 52, 58: Additional high-risk types in Gardasil 9

Important: Vaccine does NOT treat existing infection; must be given BEFORE exposure for maximum efficacy; still need Pap screening post-vaccination

PCOS (Polycystic Ovary Syndrome)

Most common endocrinopathy in reproductive-age women (affects 8-15%); leading cause of anovulatory infertility.

Rotterdam Criteria (2003, diagnosis requires 2 of 3):

Oligo/anovulation (irregular cycles >35 days or <8/year)
Clinical/biochemical hyperandrogenism (acne, hirsutism, alopecia; elevated free testosterone)
Polycystic ovarian morphology (PCOM): ≥20 follicles per ovary (2018 updated threshold), each 2-9 mm; OR ovarian volume >10 mL on TVU

Pathophysiology: Insulin resistance → hyperinsulinemia → stimulates LH + androgen production → follicular arrest + anovulation. LH:FSH ratio often elevated (>2:1, but not required for diagnosis).

Hormonal profile:

LH elevated, FSH normal → elevated LH:FSH ratio
Elevated androgens (testosterone, DHEAS)
Insulin resistance
AMH elevated (reflects large follicle pool)
Estrone elevated (peripheral conversion of androgens; no progesterone - endometrial hyperplasia risk)

Clinical features (mnemonic: HAIR-AN syndrome - severe form):

Hyperandrogenism, Insulin Resistance, Acanthosis Nigricans
Menstrual irregularity
Infertility
Metabolic syndrome
Obesity (not universal)
OSA (obstructive sleep apnea)

Management:

Goal	Treatment
Menstrual regulation	Combined OCP (first-line): reduces androgens, regulates cycle, prevents endometrial hyperplasia
Hyperandrogenism	OCP + spironolactone (anti-androgen, 100-200 mg/day); finasteride
Fertility/Ovulation induction	Letrozole (aromatase inhibitor) - FIRST LINE per ACOG/ASRM; Clomiphene citrate; Gonadotropins; IVF if above fail
Insulin resistance/Metabolic	Lifestyle modification (weight loss - even 5-10% improves cycles/androgens/fertility); Metformin (adjunct, especially if impaired glucose tolerance)
Endometrial protection	Progesterone withdrawal/cyclic progestins or OCP (prevents hyperplasia from unopposed estrogen)

Letrozole vs Clomiphene: Letrozole achieves higher live birth rates in obese PCOS patients (NEJM 2014 - Legro RS); now first-line for ovulation induction.

Contraception

Effectiveness (Pearl Index = pregnancies per 100 woman-years):

Method	Typical Use Failure Rate	Perfect Use Failure Rate
Combined OCP	7%	0.3%
Progestin-only pill (POP)	7%	0.3%
Copper IUD (non-hormonal)	0.8%	0.6% - most effective emergency contraception
LNG-IUS (Mirena)	0.1-0.2%	Same - most effective overall
Implant (Nexplanon)	0.1%	Same
DMPA (Depo-Provera)	4%	0.2%
Condom (male)	13%	2%
Diaphragm + spermicide	17%	6%
Sterilization (BTL)	0.5%	0.5%

Combined Oral Contraceptive Pills (COCPs):

Estrogen (ethinyl estradiol) + Progestin
Mechanism: inhibit LH surge (prevent ovulation) + thicken cervical mucus + thin endometrium
Benefits: dysmenorrhea, endometriosis, PCOS, acne, reduced ovarian/endometrial cancer risk, regulated cycles
Contraindications (WHO Medical Eligibility Criteria - Category 4 = do not use):
- Active DVT/PE or thromboembolic disorder
- Migraine with aura
- Smoking + age >35 (≥15 cigarettes/day)
- Breastfeeding <6 weeks postpartum
- Ischemic heart disease, stroke
- Liver disease (active hepatitis, cirrhosis, hepatoma)
- Hypertension (SBP >160 or DBP >100)
- Breast cancer (current)

Progestin-only pill (POP/"mini-pill"):

Mechanism: thicken cervical mucus (primary); inhibit ovulation in ~50%
Advantage: safe in breastfeeding, contraindications to estrogen
Must take at SAME TIME daily (3-hour window for traditional POP; 24-hour window for desogestrel POP)

DMPA (Depo-Provera):

150 mg IM every 3 months (or 104 mg SC)
Advantages: no daily pill; good for endometriosis/HMB
Side effects: irregular bleeding, weight gain, delayed return to fertility (up to 12-18 months), bone mineral density loss (reversible)

Intrauterine Devices (IUDs):

Type	Duration	Mechanism	Benefits
Copper IUD (Paragard)	10-12 years	Copper ions spermicidal + foreign body reaction inhibits implantation	Hormone-free; emergency contraception if inserted within 5 days
LNG-IUS 52 mg (Mirena)	7-8 years	Primarily local progestin thickens mucus + thins endometrium; some ovulation inhibition	HMB, dysmenorrhea, adenomyosis, endometriosis; most effective LARC
LNG-IUS 13.5 mg (Kyleena)	5 years	Similar to Mirena	Nulliparous women (smaller)
LNG-IUS 19.5 mg (Liletta)	8 years	Similar	Cost-effective

Subdermal implant (Nexplanon/Implanon):

68 mg etonogestrel rod in upper arm
Duration: 3 years
Most effective reversible contraceptive (failure rate 0.05-0.1%)
Irregular bleeding is most common complaint

Emergency Contraception:

Method	Window	Efficacy
Levonorgestrel (Plan B) 1.5 mg	Within 72 hours (up to 120h)	85-89% (reduces risk by ~85%); less effective if BMI >70 kg
Ulipristal acetate (ella) 30 mg	Within 120 hours	Superior to LNG especially 72-120h; SPRM
Copper IUD	Within 5 days	>99% - most effective EC
Yuzpe regimen (estrogen + progestin)	Within 72 hours	75% - now rarely used

KEY EXAM MNEMONICS SUMMARY

Mnemonic	Stands For
GTPAL	Gravida, Term, Preterm, Abortions, Living
HELPERR	Help, Episiotomy, Legs (McRoberts), Pressure, Enter, Remove arm, Roll
EMOTIVE	Establish, Massage, Oxytocin, Tranexamic acid, Inspect, Vacuum, Embolize/Emergent surgery
4 T's	Tone, Trauma, Tissue, Thrombin (PPH causes)
PALM-COEIN	Polyp, Adenomyosis, Leiomyoma, Malignancy - Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not classified
Rotterdam (PCOS)	2 of 3: Oligo-anovulation, Hyperandrogenism, PCOM
Amsel (BV)	3 of 4: Thin discharge, pH >4.5, Whiff test+, Clue cells
Quintero (TTTS)	I-V: Fluid discordance → Absent bladder → Abnormal Doppler → Hydrops → Demise
Sapporo/Sydney (APLA)	1 clinical + 1 lab criterion, confirmed ≥12 weeks apart

Sources: Berek & Novak's Gynecology (Berek & Novak's Gynecology); Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice, 8th Edition; ACOG Practice Bulletins; FIGO Classifications 2018.

---That's your full, exam-focused OBGYN study guide. Here's a quick overview of what's covered:

What's Included

OBSTETRICS (6 Major Sections):

Early Pregnancy - Presumptive/probable/positive signs, Naegele's rule, preconceptional folic acid + vaccinations, GTPAL parity index, complete teratogen table with defects, trimester-wise screenings (NT, quad screen, NIPT, GBS), Leopold maneuvers with purpose of each
High-Yield Conditions - Cervical insufficiency (McDonald vs Shirodkar vs transabdominal cerclage), APLA/Sapporo criteria with pregnancy management, Ectopic pregnancy (expectant/medical/surgical criteria + MTX indications mnemonic), Molar pregnancy comparison table (complete vs partial - karyotype, hCG, US, GTN risk)
Placenta & Amniotic Fluid - Abnormal placental types (succenturiate, circumvallate, velamentous, vasa previa), polyhydramnios/oligohydramnios causes + DRIPPS mnemonic, Previa vs Abruption comparison table, PAS spectrum with C-section risk percentages
Multiple Pregnancy - Division timing → chorionicity chart, Lambda/Twin Peak vs T-sign on US, TTTS Quintero staging + management (FLP), TAPS, TRAP
Medical Disorders - HTN classification, preeclampsia criteria + MgSO4 protocol + toxicity levels, HELLP criteria, GDM screening (1-step vs 2-step), fetal complications including sacral agenesis
Labor & Delivery - Modified Bishop score table, AMTSL components, Breech types + ECV, Lovset's + Burns-Marshall maneuvers, HELPERR algorithm, PPH 4 T's + EMOTIVE protocol with uterotonics

GYNECOLOGY (4 Major Sections): 7. Menstrual Disorders - Mullerian anomalies (AFS Class I-VII), Primary amenorrhea approach by FSH/LH, Secondary amenorrhea (Asherman's, POI, Sheehan's, FHA), PALM-COEIN AUB classification 8. Uterine Conditions - Adenomyosis (MRI findings, LNG-IUS first-line), Fibroids (FIGO subclassification, red degeneration in pregnancy, management ladder), Endometriosis (3 D's, rASRM staging, management by goal), Endometrial hyperplasia (without atypia vs EIN - cancer risk + management) 9. High-Yield Clinicals - BV/Candida/Trichomonas comparison table (Amsel criteria, clue cells, whiff test), Ovarian cysts + tumor classification (epithelial/germ cell/sex cord-stromal, Call-Exner, Meigs), Cervical cancer FIGO 2018 staging + Pap/Bethesda classification + CIN management 10. HPV + PCOS + Contraception - Gardasil 9 schedule, Rotterdam criteria, PCOS management (Letrozole first-line), full contraception comparison table with failure rates, EC options

All key mnemonics are summarized in a final reference table. Let me know if you'd like any section expanded, turned into flashcards, or formatted as a downloadable document.

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