K.M.S.K. GMC Chandrapur - OB/GYN 5th Internal Assessment Answers

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Q.1 SAQ ANSWERS

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SAQ 1 - Contraception: Male and Female Barrier Methods

Female Barrier Methods

• Made of polyurethane or nitrile; pre-lubricated
• Inserted into the vagina before intercourse, covering cervix and vaginal walls
• One end is closed (intravaginal ring), other end is open and covers the vulva
• Failure rate: ~5% (perfect use), ~21% (typical use)
• Advantages: STI protection, can be inserted before sex, female-controlled
• Disadvantages: Less aesthetically acceptable, higher cost

• Dome-shaped rubber/silicone cup; inserted vaginally before sex to cover the cervix
• Always used with spermicide for added efficacy
• Must be left in place for 6 hours after last intercourse; must be fitted by a provider
• Failure rate: ~6% (perfect use), ~12% (typical use)
• Does not protect against STIs

• Smaller silicone cap fitting directly over cervix
• Used with spermicide; efficacy varies with parity
• Parous women: higher failure rate (~26% typical use)
• Nulliparous women: ~9% typical use

• Polyurethane sponge impregnated with nonoxynol-9 (spermicide)
• Inserted before sex; blocks cervical os, releases spermicide, absorbs semen
• Left in for 6 hours post-coitus; single use only
• Failure rate: ~9-12% (nulliparous), ~20-24% (parous)

• Chemical agents (nonoxynol-9): creams, gels, foams, suppositories
• Destroy sperm cell membranes
• High failure rate (~28%) when used alone; generally used with other barriers

Male Barrier Methods

• Most widely used barrier; made of latex, polyurethane, or polyisoprene
• Rolled onto erect penis before intercourse
• Failure rate: ~2% (perfect use), ~13-18% (typical use)
• Only contraceptive method providing dual protection: pregnancy AND STIs (including HIV)
• Advantages: Widely available, cheap, no hormonal side effects, OTC
• Disadvantages: Requires cooperation, may reduce sensitivity, can tear/slip
• Contraindicated: Latex allergy (use polyurethane)

• Not in widespread clinical use

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SAQ 2 - Carbetocin

• Onset of action: ~2 minutes IV, ~7 minutes IM
• Half-life: ~40 minutes (compared to oxytocin: ~4-10 minutes)
• Duration of uterotonic effect: ~1 hour IV, ~2 hours IM
• Route: IV (100 mcg slow bolus) or IM (100 mcg)

• Binds to oxytocin receptors in myometrium
• Produces sustained tetanic uterine contractions
• Reduces uterine relaxation

• Prevention of uterine atony and PPH following:
  • Elective or emergency caesarean section
  • Vaginal delivery (in high-risk cases)
• Single-dose regimen (advantage over oxytocin infusion)

• Longer duration of action = single dose sufficient
• No need for IV infusion
• More stable at room temperature (heat-stable formulation available - WHO preferred)
• Reduced need for additional uterotonics
• No significant cardiovascular side effects at recommended doses

• Nausea, vomiting, abdominal pain
• Flushing, headache, tremors
• Hypotension (mild, transient)

• Carbetocin 100 mcg IV/IM is recommended for prevention of PPH in caesarean section settings
• Heat-stable carbetocin is now preferred in low-resource settings

• Pre-eclampsia/eclampsia (relative - use cautiously)
• Serious cardiovascular disease
• Hepatic/renal impairment

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SAQ 3 - Shoulder Dystocia Management

• Antenatal: Fetal macrosomia (>4000 g), GDM, maternal obesity, prior shoulder dystocia, previous macrosomic baby
• Intrapartum: Prolonged 2nd stage, operative vaginal delivery (mid-cavity), oxytocin augmentation
• Note: 50% of cases have NO identifiable risk factor

1. McRoberts Maneuver (FIRST - used in >40% cases)
   • Hyperflexion and abduction of maternal thighs onto abdomen
   • Straightens lumbar lordosis, rotates symphysis pubis superiorly
   • Increases relative A-P diameter of pelvis
   • 40-42% success rate alone or combined with suprapubic pressure
2. Suprapubic Pressure (Rubin's)
   • Applied by assistant above symphysis pubis
   • Directed downward and laterally to dislodge anterior shoulder
   • NOT fundal pressure (worsens impaction)
3. Internal Rotational Maneuvers:
   • Rubin II: Pressure on posterior aspect of anterior shoulder to rotate fetus
   • Woods Screw: Pressure on anterior aspect of posterior shoulder (rotate 180°)
   • Barlow: Combination of Rubin II + Woods (reverse screw)
4. Delivery of Posterior Arm:
   • Hand sweeps posteriorly to deliver posterior arm
   • Reduces biacromial diameter
5. Gaskin Maneuver (All-Fours):
   • Flip patient to hands-and-knees position
   • Gravity aids disimpaction; most effective last resort
6. Last Resort Maneuvers:
   • Zavanelli maneuver (cephalic replacement followed by caesarean section)
   • Deliberate clavicle fracture
   • Symphysiotomy (developing countries)

• Maternal: PPH, 3rd/4th degree perineal tears, bladder injury
• Fetal: Brachial plexus injury (Erb's palsy 10-20%), clavicle/humerus fracture, hypoxia/asphyxia, death

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SAQ 4 - Induction of Labour (IOL)

• Post-term pregnancy (>41-42 weeks)
• Pre-eclampsia / Hypertensive disorders
• Diabetes mellitus (gestational or pre-existing)
• Prelabour rupture of membranes (PROM/PPROM) at term
• Intrauterine growth restriction (IUGR)
• Oligohydramnios
• Intrauterine fetal death (IUFD)
• Chorioamnionitis
• Maternal medical conditions (renal disease, cardiac disease)
• Previous caesarean section (selected cases)

• Placenta praevia, vasa praevia
• Transverse/oblique lie
• Active genital herpes
• Previous classical (vertical) uterine scar
• Cord prolapse
• Severe fetal compromise requiring immediate delivery by C-section

• Gestational age confirmed
• Vertex presentation
• No CPD
• Informed consent
• CTG monitoring available
• Operating theatre available

• Score ≥8: Favourable cervix - oxytocin can be used
• Score <6: Unfavourable - cervical ripening needed first

1. Prostaglandins:
   • PGE2 (Dinoprostone): Gel 0.5 mg intracervical or 1-2 mg vaginal; maximum 3 doses 6-hourly
   • PGE1 (Misoprostol): 25-50 mcg vaginally or sublingually 4-6 hourly; cheap, heat-stable
   • Balloon/Foley catheter: Mechanical ripening by pressure; useful in scarred uterus
2. Membrane sweeping (stretch and sweep): Done at 38-40 weeks; releases endogenous prostaglandins

• Forewater rupture with amniohook
• Used when cervix is favourable (Bishop ≥6-8)
• Increases prostaglandin release, allows head to press on cervix
• Augmented with oxytocin if contractions don't establish within 1-2 hours

• Low-dose protocol: Start at 1-2 mIU/min, increase by 1-2 mIU every 30-40 min
• High-dose protocol: Start 4-6 mIU/min, increase every 15-40 min
• Titrate to 3-4 contractions in 10 minutes, each lasting 45-60 seconds
• Maximum dose: 20-40 mIU/min
• Side effects: Uterine hyperstimulation (tachysystole), fetal distress, water intoxication (hyponatraemia), amniotic fluid embolism

• Failed induction (leading to caesarean section)
• Uterine hyperstimulation / Uterine rupture
• Cord prolapse (after ARM)
• Fetal distress
• Infection
• Placental abruption

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SAQ 5 - PCOS (Polycystic Ovary Syndrome)

1. Oligo/anovulation
2. Clinical/biochemical signs of hyperandrogenism
3. Polycystic ovarian morphology on USG (≥12 follicles 2-9mm per ovary OR ovarian volume >10 mL)

• Increased LH pulsatility from hypothalamus
• Elevated LH:FSH ratio (>2:1 or >3:1)
• Excess androgen (mainly testosterone) from theca cells
• Arrested follicular development at 5-10 mm (follicular arrest)
• Insulin resistance → compensatory hyperinsulinaemia → stimulates androgen production
• Decreased SHBG → more free androgens

• Menstrual irregularities: Oligomenorrhoea, amenorrhoea, irregular cycles
• Hyperandrogenism: Acne, hirsutism, male-pattern alopecia
• Obesity (central adiposity) in 50%
• Subfertility/infertility (anovulatory)
• Acanthosis nigricans (insulin resistance)
• Psychological: Depression, anxiety

• LH, FSH (elevated LH:FSH ratio)
• Testosterone (free and total), DHEAS
• Fasting insulin, glucose, HOMA-IR
• Pelvic ultrasound (TVS preferred)
• Prolactin, TSH (to exclude differential diagnoses)
• Lipid profile, 2-hour GTT (screen for metabolic syndrome)

• Type 2 Diabetes mellitus
• Metabolic syndrome
• Cardiovascular disease
• Endometrial hyperplasia/carcinoma (from chronic anovulation)
• Obstructive sleep apnoea
• Subfertility

• Weight loss of 5-10% can restore ovulation
• Diet + exercise

• Combined oral contraceptive pills (COCPs): Regulate cycles, suppress androgens
• Cyclical progestogens: Prevent endometrial hyperplasia

• COCPs (especially cyproterone acetate-containing - Diane-35)
• Spironolactone (anti-androgen)
• Finasteride (not in women of childbearing age)

1. Clomiphene citrate (Clomid) - First-line; 50-150 mg day 2-6; anti-oestrogen
2. Metformin - Insulin sensitizer; improves ovulation, especially with CC
3. Letrozole (aromatase inhibitor) - Now preferred over CC (better outcomes, less multiples)
4. Gonadotrophins - FSH injections; risk of OHSS; requires monitoring
5. Laparoscopic Ovarian Drilling (LOD) - Surgical; destroys androgen-producing tissue; alternative to gonadotrophins
6. IVF - If above fail

• Metformin for insulin resistance/type 2 DM
• Statins for dyslipidaemia (if not planning pregnancy)

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SAQ 6 - PCPNDT Act

• Declining Child Sex Ratio (CSR) in India
• Female foeticide leading to adverse sex ratio
• Misuse of USG, amniocentesis, CVS for sex determination

• Central Supervisory Board (CSB) - chaired by Union Health Minister
• State Supervisory Board (SSB) - chaired by State Health Minister
• Appropriate Authority at district level
• Advisory Committee

1. Sex determination before OR after conception
2. Conducting prenatal diagnostic techniques for sex determination
3. Advertisement of facilities for sex determination
4. Communication of sex of fetus to pregnant woman or relatives

1. Family history of chromosomal abnormalities
2. Family history of genetic metabolic diseases
3. Family history of sex-linked genetic disorders
4. History of 2 or more spontaneous abortions or still births
5. Mother exposed to teratogens (drugs, radiation, infections)

• Patient must give written consent in Form F
• Doctor must explain in patient's language
• Patient must be told of her right NOT to know sex

• All ultrasound machines/clinics must be registered with Appropriate Authority
• Form A - Registration
• Form C - Consent for prenatal test
• Form D - Maintenance of records

• First conviction: Imprisonment up to 3 years + fine up to ₹10,000
• Subsequent conviction: Up to 5 years + fine up to ₹50,000
• Cancellation of registration

• Covers portable ultrasound machines
• Covers pre-implantation genetic diagnosis (PGD)
• Regulates online advertisements

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SAQ 7 - Gestational Trophoblastic Neoplasia (GTN)

• Benign: Hydatidiform mole (complete and partial)
• Malignant (= GTN):
  • Invasive mole (Chorioadenoma destruens)
  • Choriocarcinoma
  • Placental-site trophoblastic tumor (PSTT)
  • Epithelioid trophoblastic tumor (ETT)

• Scores risk factors: Age, antecedent pregnancy, interval from index pregnancy, pre-treatment hCG, largest tumor size, site of metastases, number of metastases, prior chemotherapy
• Score 0-6 = Low risk; Score ≥7 = High risk

1. Lung (most common - 80%)
2. Vagina
3. Liver
4. Brain (worst prognosis)

• Rising or plateaued beta-hCG after mole evacuation (plateau = <10% fall over 3 weeks; rise = >10% rise)
• Chest X-ray / CT chest
• MRI brain (if high-risk)
• No histological diagnosis needed for treatment (usually)

• Single-agent chemotherapy:
  • Methotrexate (MTX) with folinic acid rescue - FIRST LINE
  • Actinomycin-D (if MTX resistance)
• Cure rate: >95%

• Combination chemotherapy:
  • EMA-CO regimen: Etoposide + Methotrexate + Actinomycin-D / Cyclophosphamide + Oncovin (vincristine) - STANDARD
  • EMA-EP: For EMA-CO resistant cases
• Cure rate: 80-90% even with metastases

• Less sensitive to chemotherapy
• Primary treatment: Surgery (hysterectomy)

• Continue for 3 courses after first normal hCG level

• Weekly hCG until normal x3, then monthly for 12 months
• Avoid pregnancy for 1 year after completing treatment

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Q.2 LAQ ANSWERS

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LAQ 1 - Puerperal Pyrexia: Definition, Etiology, and Management of Puerperal Sepsis

Definition of Puerperal Pyrexia:

Definition of Puerperal Sepsis (WHO):

• Pelvic pain
• Fever (oral temperature ≥38.5°C)
• Abnormal vaginal discharge (purulent, offensive)
• Delay in rate of uterine involution

Etiology of Puerperal Pyrexia (Causes - 4 Ws + more):

1. Endometritis - Most common; infection of uterine decidua; typically caused by Group A & B Streptococcus, E. coli, anaerobes, S. aureus
2. Wound infection - Episiotomy site, perineal lacerations, caesarean section wound
3. Retained products of conception - Act as nidus for infection
4. Pelvic cellulitis / Parametritis - Spread to broad ligament
5. Septic pelvic thrombophlebitis - Infection of pelvic veins; high swinging fever

• Urinary Tract Infection (UTI) - Very common (catheterisation, trauma during delivery)
• Breast engorgement / Mastitis / Breast abscess - Usually after 10 days; S. aureus most common
• Respiratory - Pneumonia, Atelectasis - Especially after general anaesthesia
• Deep Vein Thrombosis (DVT) - Thrombophlebitis of leg veins; unilateral leg swelling, tender
• IV site infection / Phlebitis - Iatrogenic
• Malaria - In endemic areas

• Group A Streptococcus (most virulent, epidemic outbreaks)
• Gram-negative bacilli (E. coli, Klebsiella)
• Anaerobes (Bacteroides, Clostridium)
• Staphylococcus aureus (wound infections, mastitis)

Management of Puerperal Sepsis

1. Early recognition and rapid intervention
2. Resuscitation (IV access, fluids, oxygen)
3. Blood cultures before antibiotics
4. Antibiotics within 1 hour of diagnosis
5. Source control

• Temperature, pulse, BP, respiratory rate, SpO2
• Urine output (aim >0.5 mL/kg/hr)
• CBC, CRP, blood cultures (×2 peripheral)
• High vaginal swab + wound swab (culture and sensitivity)
• Urine cultures
• Chest X-ray
• Pelvic USS (to look for retained products, abscess)

• First choice: IV Piperacillin-tazobactam + Metronidazole
• OR: IV Amoxicillin-clavulanate + Metronidazole + Gentamicin
• For suspected Group A Strep: Add high-dose Penicillin G or Clindamycin
• Oral step-down once afebrile for 24-48 hours and clinically improving

• Retained products: Evacuation of uterus (surgical/medical)
• Abscess (pelvic/breast): Incision and drainage
• Wound dehiscence: Debridement and secondary closure
• Septic pelvic thrombophlebitis: Anticoagulation (heparin) + antibiotics

• IV fluids (crystalloids; target MAP >65 mmHg)
• Antipyretics (paracetamol)
• Analgesia
• DVT prophylaxis (if no anticoagulation)
• Thromboprophylaxis
• Nutritional support

• Septic shock (MAP <65 mmHg despite fluid resuscitation)
• Norepinephrine is vasopressor of choice in septic shock
• Hydrocortisone if vasopressor-refractory

• Aseptic technique during labour and delivery
• Minimize PV examinations
• Prophylactic antibiotics for caesarean section (cefazolin)
• Early ambulation
• Proper wound care

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LAQ 2 - AUB: Definition, Classification, Causes, Differential Diagnosis, Management

Definition:

• Frequency: 24-38 days
• Duration: 4-8 days
• Volume: 5-80 mL
• Regularity: Variation ≤7-9 days

Classification - PALM-COEIN System (FIGO 2011):

Causes (Expanded):

• PCOS (most common cause of anovulatory AUB)
• Fibroids (especially submucosal)
• Endometrial polyps
• Thyroid disorders (hypothyroidism)
• Coagulation disorders
• Pregnancy-related (miscarriage, ectopic, trophoblastic disease)
• Iatrogenic (IUDs - especially copper, anticoagulants)
• Cervical pathology (erosion, cancer)

• Anovulatory cycles (immature HPO axis)
• Coagulation disorders (Von Willebrand disease)

• Anovulatory cycles
• Endometrial hyperplasia/carcinoma (must exclude)
• Submucosal fibroids

• Any bleeding is abnormal and requires investigation
• Endometrial cancer (must exclude urgently)
• Atrophic vaginitis/endometritis
• Cervical/vaginal pathology
• Hormone replacement therapy

Differential Diagnosis:

1. Pregnancy complications (miscarriage, ectopic pregnancy) - always exclude
2. Cervical cancer / Cervical erosion
3. Vaginal pathology (trauma, polyp, cancer)
4. Ovarian pathology (functional cysts, tumors)
5. Pelvic inflammatory disease (PID)
6. Bleeding disorders (Von Willebrand, ITP)
7. Systemic diseases (liver failure, renal failure, thyroid)
8. Iatrogenic

Investigations:

• All patients: Beta-hCG (pregnancy test), CBC, coagulation profile (PT, APTT, BT)
• Hormonal: TSH, prolactin, LH, FSH, testosterone (if PCOS suspected)
• Imaging: Pelvic USS (TVS preferred); saline infusion sonography (SIS) for polyps/fibroids
• Endometrial sampling: Pipelle biopsy / D&C - mandatory in women >45 years or any postmenopausal bleeding
• Hysteroscopy: Gold standard for uterine cavity assessment
• Pap smear / Colposcopy: If cervical pathology suspected
• MRI pelvis: For deep adenomyosis, complex fibroids

Management:

• IV Tranexamic acid (antifibrinolytic)
• IV Conjugated oestrogens (25 mg IV 4-6 hourly) - rapid haemostasis
• High-dose oral norethisterone (progestogen)
• Surgical: Balloon tamponade, uterine artery embolisation, emergency hysteroscopy/D&C

1. Hysteroscopic procedures:
   • Polypectomy - for polyps
   • Transcervical resection of fibroid (TCRM) - submucosal fibroids
   • Endometrial ablation/resection (2nd generation: Thermachoice balloon, NovaSure) - definitive for AUB without wanting future fertility
2. Myomectomy - Laparoscopic/open; for fibroids in women wanting fertility
3. Hysterectomy - Definitive treatment; offered when conservative measures fail or malignancy present

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LAQ 3 - Infertility: Definition, Cervical, Uterine and Tubal Factors

Definition of Infertility:

Causes of Female Infertility (Overview):

• Ovulatory factors: 25-30%
• Tubal factors: 25-30%
• Uterine factors: 10%
• Cervical factors: 5%
• Unexplained: 10-15%
• Combined/multiple factors: 10-15%

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A. Cervical Factors

• At mid-cycle (peak oestrogen), cervical mucus becomes thin, watery, acellular (Spinnbarkeit - stretches >6 cm), alkaline (pH 7-8.5) - facilitates sperm penetration
• Crypts in endocervical canal act as sperm reservoir (capacitation)

1. Cervical Mucus Abnormalities:
   • Hostile cervical mucus: Thick, viscid, acidic, cellular - at mid-cycle (poor oestrogen response)
   • Immunological: Anti-sperm antibodies (ASAb) in cervical mucus - agglutinate or immobilize sperm
2. Structural Cervical Defects:
   • Cervical stenosis (post-cone biopsy, LLETZ, cryotherapy, D&C, infection)
   • Cervical incompetence (usually causes miscarriage, not infertility per se)
   • Cervical polyps
3. Infections:
   • Chlamydia, gonorrhoea: Cause cervicitis; hostile mucus
   • Bacterial vaginosis: Alters vaginal/cervical environment
4. Iatrogenic:
   • Previous cervical surgery (LLETZ, conisation) - reduces mucus-producing crypts
   • Post-radiation changes

• Post-coital test (PCT/Sims-Huhner test) - performed at mid-cycle, 6-24h after intercourse; normal = >20 actively motile sperm per HPF
• Cervical mucus score (Insler score)
• Anti-sperm antibody testing (serum and mucus)
• Cervical swabs (infection screen)

• Anti-sperm antibodies: Condom use for 3-6 months (reduce antigen exposure), corticosteroids (controversial), IUI
• Hostile mucus: Oestrogen supplementation; IUI (bypasses cervix entirely)
• Cervical stenosis: Dilatation; IUI
• Infection: Antibiotics (doxycycline for chlamydia, partner treatment)
• IUI is the primary treatment bypassing cervical factor
• IVF if IUI fails

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B. Uterine Factors

• Uterine cavity must be normal for implantation
• Endometrium must undergo proper proliferative-secretory changes

1. Congenital Uterine Anomalies (Mullerian anomalies):
   • Arcuate uterus (mildly bicornuate): Minimal impact on fertility
   • Septate uterus: Most common anomaly causing RPL and infertility; septum is avascular
   • Bicornuate uterus: Affects implantation
   • Unicornuate uterus: Reduced uterine volume
   • Didelphys uterus: Double uterus
   • Agenesis/hypoplasia (Mayer-Rokitansky-Kuster-Hauser syndrome)
2. Acquired Lesions:
   • Fibroids (Leiomyomata):
     • Submucosal: Greatest impact on fertility (distort cavity, affect implantation)
     • Intramural: Impact if >4-5 cm (compress cavity)
     • Subserosal: Least impact on fertility
   • Endometrial polyps: Interfere with implantation; may be found incidentally
   • Asherman's Syndrome (Intrauterine adhesions/synechiae):
     • Cause: Previous D&C (especially post-abortion/post-partum), infection, surgery
     • Features: Hypomenorrhoea/amenorrhoea, dysmenorrhoea, infertility, RPL
     • Diagnosis: Hysteroscopy (gold standard); SIS; hysterosalpingography (HSG)
     • Treatment: Hysteroscopic adhesiolysis + post-op oestrogen + IUD/balloon to prevent re-adhesion
   • Endometritis: Chronic endometritis (plasma cell infiltration); often asymptomatic
   • Endometriosis (uterine involvement): Adenomyosis reduces implantation

• Pelvic USS (2D/3D)
• Saline infusion sonography (SIS) / Sonohy sterography - for cavity lesions
• Hysterosalpingography (HSG) - outlines cavity + tubes
• Hysteroscopy (gold standard for uterine cavity)
• MRI pelvis - for Mullerian anomalies, deep adenomyosis

• Uterine septum: Hysteroscopic resection of septum (metroplasty) - improves pregnancy rates
• Submucosal fibroids: Hysteroscopic myomectomy; laparoscopic/open myomectomy for large intramural fibroids
• Asherman's syndrome: Hysteroscopic adhesiolysis
• Polyps: Hysteroscopic polypectomy
• Congenital anomalies: Bicornuate - Strassman's metroplasty; Unicornuate - counselling
• Endometritis: Doxycycline + metronidazole

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C. Tubal Factors

1. Pelvic Inflammatory Disease (PID):
   • Most common cause of TFI worldwide
   • Organisms: Chlamydia trachomatis (most common in developed countries), Neisseria gonorrhoeae, anaerobes
   • Each episode of PID increases risk: 1 episode = 12%, 2 episodes = 25%, 3 episodes = 54%
   • Causes peritubal adhesions, tubal scarring, blocked fimbriae
2. Endometriosis:
   • Peritoneal endometriosis creates peritubal adhesions and occlusion
   • Affects tubal motility and pickup function
3. Previous Pelvic/Abdominal Surgery:
   • Appendicectomy (especially ruptured appendix)
   • Previous tubal surgery, ectopic pregnancy surgery
   • Peritonitis (any cause)
   • Ovarian cystectomy
4. Congenital:
   • Tubal aplasia/hypoplasia (rare; associated with other Mullerian anomalies)
5. Previous Ectopic Pregnancy:
   • Salpingectomy removes tube
   • Salpingotomy leaves damaged tube
6. Tuberculosis (TB) of the female genital tract:
   • Major cause of TFI in India and developing countries
   • Causes cornual block, rigid "pipe-stem" tubes, caseous nodules
   • HSG shows beaded appearance, irregular filling, calcification
7. Post-septic abortion

• Hydrosalpinx: Distally occluded tube filled with fluid; has toxic effect on endometrium and embryos (reduces IVF success by 50%); salpingectomy recommended before IVF
• Proximal tubal block: Cornual block on HSG - may be spasm (false positive); confirmed by laparoscopy
• Peritubal adhesions: Tubes patent but function impaired

• Hysterosalpingography (HSG):
  • Outpatient radiological procedure
  • Contrast injected through cervix; visualizes uterine cavity and tubal patency
  • Fallopian tubes fill and spill freely if patent
  • Disadvantages: Radiation, cannot assess peritubal adhesions, may miss fimbrial disease
  • Therapeutic effect: Increases pregnancy rates for ~3 months after
• Laparoscopy with Chromotubation:
  • Gold standard for tubal assessment
  • Methylene blue dye injected transcervically and observed for spill from fimbriae
  • Also assesses peritubal adhesions, endometriosis (not visible on HSG)
  • Invasive - requires general anaesthesia
• Sonosalpingography / HyCoSy: Uses ultrasound contrast; avoids radiation; good for outpatient assessment

1. Tubal Surgery (Tubal Reconstruction):
   • Salpingolysis: Division of adhesions around tubes
   • Fimbriolysis / Fimbriplasty: Opening of fimbrial end
   • Neosalpingostomy: Creating new opening in distally occluded tube
   • Success rate: 30-50% for mild disease; <10% for severe hydrosalpinx
   • Risk of ectopic pregnancy is increased after surgery
2. Tubal Cannulation:
   • For proximal tubal obstruction
   • Hysteroscopic/fluoroscopic; selective salpingography
3. Salpingectomy:
   • For hydrosalpinx before IVF
   • Improves IVF success rates by up to 50%

• IVF (In Vitro Fertilisation):
  • Treatment of choice for bilateral tubal disease
  • Completely bypasses tubes
  • Live birth rate per cycle: ~30-40% (age dependent)
  • Multiple pregnancy risk with multiple embryo transfer
• IUI (Intrauterine Insemination): Not effective for tubal disease (cannot bypass block)

• Anti-TB treatment (ATT) for 6-9 months
• Tubal surgery generally ineffective (extensive fibrosis)
• IVF is the treatment of choice for TB-related TFI

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Summary of All Answers

SAQ Answers (Q.1):

1. Contraception - Male & Female Barrier Methods - Female (female condom, diaphragm, cervical cap, sponge, spermicide) and Male (male condom) with failure rates, mechanisms, advantages/disadvantages
2. Carbetocin - Long-acting oxytocin analogue; 100 mcg IV/IM single dose; used for PPH prevention post-delivery/caesarean; longer acting than oxytocin (~1-2 hours), heat-stable
3. Shoulder Dystocia Management - HELPERR mnemonic: Help → Episiotomy → Legs (McRoberts) → Pressure (suprapubic) → Enter (rotational maneuvers) → Remove posterior arm → Roll (Gaskin); complications (Erb's palsy, PPH)
4. Induction of Labour - Indications, Bishop score, methods (PGE2, misoprostol, amniotomy, oxytocin infusion with low-dose/high-dose protocols), complications
5. PCOS - Rotterdam criteria (2 of 3: oligoanovulation, hyperandrogenism, PCO morphology); pathophysiology; management including lifestyle, COCPs, metformin, letrozole/clomiphene for ovulation induction
6. PCPNDT Act - 1994 (amended 2003); prohibits sex determination/selection; registration requirements; penalties (up to 3-5 years imprisonment)
7. GTN - Invasive mole, choriocarcinoma, PSTT, ETT; staged by FIGO (I-IV); low-risk treated with single-agent MTX; high-risk with EMA-CO combination chemotherapy; excellent prognosis; hCG is key marker

LAQ Answers (Q.2):

1. Puerperal Pyrexia & Sepsis - Definition (≥38°C on 2 of first 10 days postpartum); causes (endometritis, UTI, wound infection, mastitis, DVT, septic thrombophlebitis); management with sepsis bundle, IV antibiotics (ampicillin + gentamicin + metronidazole for endometritis), source control
2. AUB - PALM-COEIN classification (Polyp, Adenomyosis, Leiomyoma, Malignancy / Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified); D/D; management (Mirena LNG-IUS first line, tranexamic acid, NSAIDs, surgical options including endometrial ablation, myomectomy, hysterectomy)
3. Infertility - Definitions (primary/secondary); Cervical factors (hostile mucus, ASAb, stenosis - treated with IUI); Uterine factors (Asherman's syndrome, fibroids, septum, anomalies - hysteroscopic surgery); Tubal factors (PID/Chlamydia most common, TB important in India, HSG + laparoscopy with chromotubation for assessment, IVF is gold standard treatment for bilateral tubal disease)