---

Gynaecology Examination - Structured Model Answers

---

CASE IV - Mrs. Khadka, 58-year-old Postmenopausal Woman with Bleeding Per Vaginum

---

Q.16 - Possible Causes of Bleeding Per Vaginum in a 58-year-old Postmenopausal Woman [6 marks]

• Cervical carcinoma
• Cervical polyp
• Cervicitis / cervical ectropion

• Atrophic vaginitis (post-menopausal estrogen deficiency)
• Vaginal carcinoma (rare)

• Functioning (estrogen-secreting) ovarian tumors - e.g., granulosa cell tumor

• Urethral caruncle
• Rectal/urinary tract bleeding (mistaken as vaginal)
• Anticoagulant therapy

• Blood dyscrasias (thrombocytopenia, von Willebrand disease)
• Liver disease (coagulopathy)

Note: The rule of thumb - "Any postmenopausal bleeding is carcinoma until proved otherwise." - Berek & Novak's Gynecology

---

Q.17 - Investigation for Further Evaluation of Postmenopausal Bleeding [5 marks]

1. Transvaginal Ultrasonography (TVS)
   • Investigation of choice for PMB
   • Endometrial thickness (ET):
     • ET < 4-5 mm: cancer unlikely (NPV ~99%)
     • ET ≥ 5 mm: requires further evaluation by biopsy
     • In this case (Case II): ET = 32 mm - highly suspicious for malignancy
2. Endometrial Sampling / Biopsy
   • Pipelle endometrial biopsy (OPD procedure) - first choice
   • Sensitivity ~90% for endometrial carcinoma
   • Fractional curettage (D&C) if office biopsy inconclusive
3. Pap Smear / Cervical Cytology
   • To rule out cervical pathology

1. Hysteroscopy + Directed Biopsy - Gold standard for intrauterine pathology; allows direct visualization
2. Sonohysterography (saline infusion sonography) - Defines intrauterine lesions (polyps, submucous fibroids) more precisely

1. Complete blood count, coagulation profile (PT, aPTT)
2. LFT, RFT
3. Serum CA-125 (if malignancy suspected - elevated in 80% advanced cases)
4. Blood sugar (screen for diabetes - associated risk factor)

1. Chest X-ray (pulmonary metastasis)
2. MRI pelvis - best imaging for myometrial invasion depth and cervical involvement
3. CT abdomen/pelvis - lymph node assessment, distant metastasis
4. ECG + cardiac evaluation

"An endometrial thickness of less than 5 mm measured by transvaginal ultrasonography is unlikely to indicate endometrial cancer." - Berek & Novak's Gynecology

---

Q.18 - Risk Factors for Endometrial Carcinoma [6 marks]

1. Obesity - Excess peripheral aromatization of androstenedione to estrone in adipose tissue leads to unopposed estrogen stimulation
2. Nulliparity / Infertility / Anovulation - Chronic exposure to estrogen without progesterone opposition (e.g., PCOS)
3. Late menopause - Prolonged estrogenic stimulation
4. Unopposed exogenous estrogen - HRT without progestogen; risk increases with dose and duration; reduced to baseline with 10+ days of progestin
5. Tamoxifen use - Partial estrogen agonist effect on endometrium
6. Atypical hyperplasia / EIN - Direct precancerous precursor; 40-50% have concurrent carcinoma
7. Lynch II syndrome (HNPCC) - Germline mutations in mismatch repair genes (MLH1, MSH2, MSH6); 40-60% lifetime risk
8. Polycystic Ovary Syndrome (PCOS) - Chronic anovulation, prolonged unopposed estrogen
9. Functioning ovarian tumors - Estrogen-secreting (granulosa cell tumor)
10. Diabetes mellitus - Independent risk even after adjusting for obesity
11. Hypertension - Associated (mechanism unclear)

• Oral contraceptive pill use (50% risk reduction)
• Multiparity
• Smoking (increases estrogen metabolism - controversial protective effect)
• Physical activity

---

Q.19 - Staging of Endometrial Carcinoma [8 marks]

• Grade 1: Well differentiated; ≤5% non-squamous, non-morular solid growth pattern
• Grade 2: Moderately differentiated; 6-50% solid growth
• Grade 3: Poorly differentiated; >50% solid growth pattern

1. Former stages IA and IB were combined into new IA
2. Endocervical glandular involvement (former stage IIA) eliminated - now considered Stage I
3. Positive peritoneal cytology no longer upstages disease (though still reported)
4. Stage IIIC divided into IIIC1 (pelvic nodes) and IIIC2 (para-aortic nodes)

1. Peritoneal washings/cytology on entering abdomen
2. Total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH + BSO)
3. Inspection and palpation of all peritoneal surfaces
4. Pelvic and para-aortic lymph node assessment (dissection or sentinel node biopsy)
5. Omentectomy + peritoneal biopsies in non-endometrioid (Type II) tumors

---

CASE II - Mrs. X, 45-year-old Perimenopausal Woman with Menorrhagia + Bulky Uterus

---

Q.7 - Possible Differential Diagnosis [5 marks]

1. Uterine Leiomyoma (Fibroids) - Most common; submucous fibroids cause heavy bleeding; intramural fibroids cause bulk symptoms. Top differential.
2. Adenomyosis - Diffuse uterine enlargement, dysmenorrhea, menorrhagia in perimenopausal women
3. Endometrial Polyp - May cause heavy/irregular bleeding
4. Endometrial Hyperplasia - Especially atypical/EIN at this age
5. Endometrial Carcinoma - Must be excluded given age, perimenopausal status, and ET of 32 mm on USG
6. Uterine Sarcoma - Leiomyosarcoma (rapidly enlarging uterus); endometrial stromal sarcoma

1. Anovulatory DUB (Dysfunctional Uterine Bleeding) - Common in perimenopausal state due to declining ovarian function
2. Coagulation disorders - von Willebrand disease
3. Iatrogenic - Anticoagulants, antiplatelet therapy

---

Q.8 - Investigations for Definite Diagnosis [8 marks]

1. Transvaginal Ultrasonography (TVS)
   • First-line investigation
   • Endometrial thickness, uterine size, myometrial invasion, adnexa
   • ET 32 mm in this case is highly abnormal (normal postmenopausal ET <4-5 mm)
   • Assess for submucous fibroids, polyps, vascularity (Doppler)
2. Sonohysterography (SIS) - Saline infusion: better delineation of intracavitary lesions
3. MRI Pelvis (Investigation of choice for staging)
   • Depth of myometrial invasion (most accurate: 85-92%)
   • Cervical stromal involvement
   • Parametrial extension
   • Lymph node assessment
4. CT Abdomen and Pelvis
   • Lymph node metastasis, peritoneal deposits, distant metastasis
   • Less accurate than MRI for local staging

1. Endometrial Biopsy (Pipelle biopsy)
   • OPD procedure, first-line tissue sampling
   • Sensitivity ~90% for endometrial carcinoma
2. Hysteroscopy + Directed Biopsy - Gold standard
   • Direct visualization of endometrial cavity
   • Targeted biopsy of suspicious areas
   • Also defines associated polyps, fibroids
3. Fractional Curettage (D&C)
   • Separate curettage of endocervix and endometrium
   • Determines cervical involvement (Stage II disease)
   • Done if office biopsy inadequate or inconclusive

1. Complete blood count - assess anaemia (chronic blood loss)
2. Coagulation profile
3. Liver and renal function tests
4. Blood sugar (diabetes risk factor screening)
5. Serum CA-125 - elevated in 78-80% of advanced/metastatic endometrial cancer; useful as tumor marker

1. Chest X-ray - pulmonary metastasis
2. ECG + cardiac evaluation

---

Q.9 - Risk Factors for Endometrial Carcinoma (High-Grade Adenocarcinoma) [4 marks]

• Unopposed estrogen exposure (exogenous HRT without progesterone)
• Obesity (peripheral aromatization)
• Nulliparity / infertility / anovulation (PCOS)
• Late menopause (>52 years)
• Diabetes mellitus
• Tamoxifen use
• Atypical endometrial hyperplasia / EIN (RR: 8-29)
• Functioning ovarian tumors (granulosa cell tumor)

• Lynch II syndrome / HNPCC (RR: 20) - MLH1, MSH2, MSH6 mutations
• Older age (typically presents in postmenopausal women, type II)
• Prior pelvic radiation

"Obesity, PCOS, tamoxifen use, and unopposed estrogen use are all associated with increased risk of endometrial cancer. Other associated findings include late onset of menopause, nulliparity, diabetes mellitus, and hypertension." - Berek & Novak's Gynecology

---

Q.10 - Stage-wise Management of Endometrial Carcinoma [8 marks]

• Surgery: Total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH + BSO) + surgical staging (peritoneal washings, pelvic/para-aortic lymph node assessment)
• Sentinel lymph node biopsy is increasingly used
• Stage IA, Grade 1-2: Surgery alone; vaginal brachytherapy may be added
• Stage IA, Grade 3 / Stage IB (any grade): Surgery + adjuvant vaginal brachytherapy OR external beam radiotherapy (EBRT) based on risk stratification
• High-risk histology (serous, clear cell): Surgery + chemotherapy (carboplatin + paclitaxel) ± radiotherapy

• Surgery: Radical/modified radical hysterectomy (Wertheim's type) + BSO + pelvic lymph node dissection is preferred if feasible
• Alternatively: TAH + BSO + EBRT to pelvis + vaginal brachytherapy
• Adjuvant chemotherapy for high-grade tumors

• Stage IIIA (serosa/adnexa): Surgery (cytoreduction) + EBRT + chemotherapy
• Stage IIIB (vagina/parametrium): Surgery (if operable) + EBRT + brachytherapy + chemotherapy
• Stage IIIC1 (pelvic nodes+): Surgery + EBRT to pelvis + chemotherapy (carboplatin + paclitaxel)
• Stage IIIC2 (para-aortic nodes+): Surgery + extended-field RT (pelvis + para-aortic) + chemotherapy

• Stage IVA (bladder/bowel involvement): Primary radiotherapy (EBRT + brachytherapy) + chemotherapy; surgery if feasible for palliation/cytoreduction
• Stage IVB (distant metastasis):
  • Systemic chemotherapy: Carboplatin + Paclitaxel (first-line; standard of care)
  • Hormonal therapy: Medroxyprogesterone acetate (MPA) or megestrol acetate for grade 1-2 endometrioid, ER/PR-positive tumors
  • Targeted therapy: Pembrolizumab (anti-PD-1) + lenvatinib (for mismatch repair-proficient tumors)
  • Trastuzumab for HER2-positive serous carcinoma
  • Palliative radiotherapy for bone/CNS metastasis

Source: Berek & Novak's Gynecology, Chapter 37 - Uterine Cancer; FIGO Revised Staging 2009

---

1. Berek JS, Novak E. Berek & Novak's Gynecology, 16th ed., Chapter 37
2. Dutta DC. Textbook of Gynecology, 8th ed.
3. Shaw RW. Shaw's Textbook of Operative Gynaecology, 8th ed.
4. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynecol Obstet 2009;105:103-104

---

Obstetrics Examination - Structured Model Answers

---

CASE I - Mrs. G2P1L1, 18 yrs, 41 weeks, Referred in Active Labor - Unable to Deliver for 2 Hours

---

Q.1 - How will you approach her? Write in terms of History and Examination Findings [5 marks]

A. History

• Duration and character of labor pains
• Duration of membrane rupture (SROM/AROM)
• Time of full cervical dilatation (confirmed at referring centre)
• Duration of inability to deliver (2 hours at full dilatation = prolonged second stage)

• G2P1L1 - details of previous delivery (vaginal/LSCS, any complications)
• Previous baby's weight, mode of delivery, any disproportion
• Current pregnancy: ANC attended or not, USG reports (estimated fetal weight, lie, presentation)

• Reason for referral (failure to deliver despite full dilatation)
• Any medications/interventions given at the referring centre (oxytocin, misoprostol, vacuum/forceps attempted)
• Time taken to reach this centre (4 hours - prolonged transit)

• Bleeding per vaginum
• Fetal movements felt or not
• Urinary output (indicator of hydration status)

---

B. Examination Findings

• Conscious level, orientation
• Pallor, dehydration, icterus, oedema
• Pulse rate, blood pressure, respiratory rate, temperature

• Fundal height and lie of fetus
• Fetal presentation and engagement
• Uterine contour - whether well-defined or obliterated
• Retraction ring (Bandl's ring) - a transverse groove between upper and lower uterine segments at or above the umbilicus (pathognomonic of obstructed labor)
• Uterine tenderness - between or during contractions
• Frequency, duration, and strength of uterine contractions
• Fetal Heart Sounds (FHS) - rate, rhythm, presence/absence

• Cervical dilatation and effacement
• Station of presenting part
• Presence of caput succedaneum and moulding (degree: 0, +1, +2, +3)
• Position of fetal head (asynclitism)
• Colour of liquor - clear, meconium-stained, or absent (dry vagina suggests prolonged rupture of membranes)
• Pelvic assessment - adequacy of pelvis

---

Q.2 - What is the Likely Diagnosis? [2 marks]

• BP 80/40 mmHg, Pulse 110/min (shock)
• Uterine contour not defined, FHS not localized
• Vagina dry and hot, Head station high
• Unable to deliver for 2 hours after full dilatation
• 4-hour transit delay after referral

"The classical picture of complete uterine rupture: sudden cessation of uterine contractions, severe abdominal pain, signs of haemorrhagic shock, recession of presenting part, inability to palpate FHS." - DC Dutta's Obstetrics

• Impending rupture (Bandl's ring visible/palpable)
• Concealed abruption placentae
• Severe obstructed labor with fetal distress

---

Q.3 - Write the Management Plan for Her [4 marks]

Step 1: Resuscitation (A-B-C)

1. Airway - ensure patent airway; give high-flow oxygen (10-15 L/min by mask)
2. IV access - two large-bore IV cannulae (16G or 18G)
3. IV fluids - rapid infusion of crystalloids (Normal saline / Ringer's lactate): 1-2 litres stat
4. Blood - send for cross-matching; arrange 4-6 units packed red blood cells urgently
5. Catheterize - Foley's catheter; monitor urine output (target >30 mL/hr)
6. Blood tests - CBC, coagulation profile, blood group and type, RFT, LFT, blood culture
7. NPO - nil by mouth; call anaesthesiologist

Step 2: Informed Consent

• Explain the emergency situation to patient/relatives
• Consent for emergency laparotomy, hysterectomy if required, blood transfusion, sterilization

Step 3: Emergency Laparotomy (Definitive Treatment)

• Midline vertical incision under general anaesthesia
• Deliver the baby and placenta from abdominal cavity
• Assess rupture site: location, extent, edges (clean vs. ragged), involvement of bladder or broad ligament

• This case: 8 cm rupture in lower uterine segment - repair was done (as described) - appropriate if edges were viable and hemostasis achieved

Step 4: Antibiotics

• Broad-spectrum IV antibiotics (ampicillin + gentamicin + metronidazole) - given dry/hot vagina suggests infection

Step 5: Postoperative (see Q.4)

---

Q.4 - What Special Care will you take in the Postoperative Period? [3 marks]

A. Monitoring

1. Vital signs - pulse, BP, respiratory rate, temperature - every 15 min initially, then hourly
2. Urine output - hourly via Foley's catheter; target >30 mL/hr; oliguria suggests ongoing haemorrhage or renal failure
3. Abdominal drain output - note colour, amount (haemorrhage vs. serous)
4. Haemoglobin/haematocrit - check 6-hourly until stable; transfuse if Hb <7-8 g/dL

B. IV Fluids and Transfusion

• Maintain IV crystalloids until oral intake established
• Blood transfusion as indicated (target Hb >10 g/dL post-surgery in haemorrhagic shock)
• Fresh Frozen Plasma (FFP) and platelets if DIC features present

C. Antibiotics

• Continue broad-spectrum IV antibiotics for 5-7 days (ampicillin + gentamicin + metronidazole)
• Step down to oral antibiotics when clinically stable

D. Pain Management

• Adequate analgesia (IV morphine/pethidine or PCA initially, then NSAIDs)

E. Respiratory Care

• Deep breathing exercises, incentive spirometry to prevent atelectasis
• Ambulation when stable (Day 1-2 post-op)

F. DVT Prophylaxis

• LMWH (enoxaparin 40 mg SC once daily) once haemostasis is secure
• Compression stockings, early mobilisation

G. Nutritional Support

• IV fluids until bowel sounds return, then oral fluids progressing to full diet
• High-protein diet for wound healing

H. Psychological Support

• Counseling - regarding loss of fetus (if IUD), surgical procedure performed
• Discuss future pregnancy plans and risks

I. Wound Care

• Daily wound dressing; watch for wound infection, dehiscence

J. Catheter Care

• Maintain Foley's catheter for at least 7-10 days (especially if bladder was involved in repair)

---

Q.5 - What are the Immediate and Long-term Complications of Obstructed Labor? [4 marks]

MATERNAL COMPLICATIONS

"The obstructed labor injury complex includes: VVF, RVF, urethral loss, stress incontinence, hydroureteronephrosis, renal failure, vaginal stenosis, osteitis pubis, foot drop, and secondary infertility." - Campbell-Walsh Urology

FETAL COMPLICATIONS:

• Fetal distress (hypoxia, acidosis)
• Birth asphyxia
• Stillbirth / intrauterine fetal death (IUFD)
• Meconium aspiration syndrome
• Intracranial haemorrhage (from moulding)
• Hypoxic ischemic encephalopathy (HIE)
• Neonatal death

• Cerebral palsy
• Developmental delay
• Epilepsy

---

Q.6 - Write about the Preventive Measures for Obstructed Labor [2 marks]

A. Primary Prevention (Before Labour)

1. Adequate antenatal care (ANC) - minimum 4-8 ANC visits to identify high-risk pregnancies
2. Nutritional support in childhood and adolescence - prevent rickets, stunting, contracted pelvis
3. Prevention of child marriage - girls married before pelvic maturity are at high risk; legal minimum marriage age
4. Education of girls - social awareness, empowerment
5. Pre-pregnancy assessment - identify CPD, malpresentation early
6. Ultrasound in antenatal period - detect malpresentation, macrosomia, multiple pregnancy
7. Clinical pelvimetry - detect inadequate pelvis; plan elective LSCS if CPD identified

B. Secondary Prevention (During Labour)

1. Partograph use - WHO partograph plotting cervical dilatation, descent, uterine contractions; action line and alert line to detect abnormal labour early
2. Skilled birth attendant at every delivery
3. Early diagnosis of malpresentation - external cephalic version before labor where appropriate
4. Timely referral - do NOT allow prolonged labour without progress; refer at alert line
5. Avoid prolonged trial of labour in CPD
6. Avoid fundal pressure (Kristeller manoeuvre) - increases risk of rupture

C. Tertiary Prevention

1. Timely LSCS when labour does not progress
2. Strengthening referral systems - transport, communication infrastructure
3. Training of birth attendants - TBAs and ANMs trained to use partograph and refer early
4. EmOC (Emergency Obstetric Care) services - ensure 24-hour availability at referral centres

---

CASE II - Mrs. X, G5P4L4, 40 years, 40 weeks, Referred with Labour Pain 3 days, Bearing Down 1 day

---

Q.5 (Case II) - What is your Probable Diagnosis? [2 marks]

• Grand multipara (G5P4L4) - uterine wall thinned from repeated pregnancies
• 3 days of labor pain + 1 day of bearing down = prolonged, neglected labor
• Dehydrated and disoriented = severe systemic deterioration
• Foul-smelling discharge = intrauterine infection/sepsis

• BP 80/50, Pulse 140/min (severe shock)
• Uterine contour absent, fetal parts easily palpable
• FHS absent (dead fetus)
• Dry, edematous vulva + big dry caput + high fetal station

---

Q.6 (Case II) - Enlist the Symptoms and Signs of Obstructed Labor [10 marks]

SYMPTOMS

• Labour pains of unusually long duration (>18 hours primigravida, >12 hours multigravida) without delivery
• Contractions become more painful, frequent but non-progressive

• No descent of presenting part despite good uterine contractions
• Cervix fully dilated but baby not delivering (prolonged second stage)

• Spontaneous or early rupture of membranes
• Liquor may be meconium-stained or foul-smelling (infected)

• Severe exhaustion, inability to bear pain
• Nausea, vomiting (from dehydration and ketosis)
• Cessation of urination (dehydration + urinary retention)
• If rupture occurs: sudden severe tearing abdominal pain, then relief of contractions

---

SIGNS

• BP 80/50, Pulse 140 = severe shock ✓
• Uterine contour absent, fetal parts palpable = rupture ✓
• FHS absent = IUFD ✓
• Dry edematous vulva = prolonged labour + infection ✓
• Big dry caput + high fetal station = obstructed labour + rupture ✓

---

Q.7 (Case II) - What is the Most Probable Complication of the Above Condition? [3 marks]

1. Uterine contour could not be made out
2. Fetal parts easily palpable (fetus extruded into abdominal cavity)
3. FHS absent (fetal death from haemorrhage/hypoxia)
4. BP 80/50, Pulse 140 = haemorrhagic shock
5. 3 days of obstructed labour in a grand multipara (maximum risk group)

1. Haemorrhagic shock (from intraperitoneal haemorrhage)
2. Intrauterine fetal death (IUFD) - FHS absent
3. Septicaemia / Septic shock - foul-smelling discharge + 3 days of obstructed labour
4. Disseminated Intravascular Coagulation (DIC) - from prolonged shock + dead fetus
5. Acute Renal Failure (ARF) - prolonged hypoperfusion
6. Peritonitis - fetus + infected liquor in peritoneal cavity
7. Multi-organ dysfunction syndrome (MODS) - terminal if untreated

"Complete uterine rupture: loss of uterine contour, fetal parts palpable abdominally, cessation of uterine contractions, fetal heart absent, maternal shock." - Williams Obstetrics

---

Q.8 (Case II) - How will you Manage this Case? [10 marks]

---

STEP 1: IMMEDIATE RESUSCITATION

1. Call for help - senior obstetrician, anaesthetist, senior nurse, blood bank
2. Airway and Oxygen - High flow O₂ 10-15 L/min via face mask
3. IV access - Two large-bore (16G) IV cannulae in both arms
4. IV Fluids - Ringer's lactate 1-2 litres STAT; second litre running
5. Blood - Send for urgent cross-match (4-6 units); meanwhile use O-negative blood if collapse
6. Urinary catheter - Foley's catheter; monitor hourly urine output
7. Investigations stat:
   • CBC, coagulation (PT, aPTT, fibrinogen), blood group/cross-match
   • Blood culture, urine culture
   • RFT, LFT, blood glucose, electrolytes
   • Serum lactate (severity of shock)
8. Treat DIC if present - FFP, cryoprecipitate, platelet transfusion as guided by coagulation profile

---

STEP 2: INFORMED CONSENT

• Explain diagnosis: ruptured uterus, IUFD, haemorrhagic shock
• Consent for: emergency laparotomy, hysterectomy, blood transfusion, sterilization (irreversible if uterus removed)

---

STEP 3: EMERGENCY LAPAROTOMY

• Haemoperitoneum
• Fetus ± placenta in peritoneal cavity
• Rupture site in lower uterine segment / posterior wall

1. Deliver the baby from abdominal cavity (dead fetus in this case)
2. Deliver placenta - manual removal
3. Control haemorrhage - clamp bleeding vessels
4. Assess rupture site - size, location, edges, involvement of bladder/ureters/broad ligament
5. Decide: Repair vs. Hysterectomy

• Subtotal/Total Hysterectomy is the procedure of choice
• Thorough peritoneal lavage with warm saline
• Place abdominal drains
• Close abdomen in layers

---

STEP 4: POSTOPERATIVE MANAGEMENT

• ICU/HDU care - continuous vital sign monitoring
• Hourly urine output - target >30 mL/hr
• Abdominal drain output - monitor for ongoing haemorrhage
• Serial CBC, coagulation studies, RFT every 6-12 hours

• IV fluids to maintain euvolemia
• Blood transfusion to target Hb ≥8-10 g/dL
• Correct DIC with FFP, cryoprecipitate, platelets as needed

• IV Ampicillin 2g 6-hourly
• IV Gentamicin 1.5 mg/kg 8-hourly (dose-adjust for renal function)
• IV Metronidazole 500 mg 8-hourly
• Continue for 7-10 days; switch to oral after 48-72 hours afebrile

• IV opioids (morphine/tramadol) for 24-48 hours, then NSAIDs + paracetamol

• LMWH when haemostasis confirmed + compression stockings

• Oral fluids when bowel sounds return (Day 2-3), then soft diet, then normal
• Consider nasogastric feeding if delayed recovery

• Foley's catheter for 7-14 days (especially if bladder involved)
• Urine output monitoring; renal function tests

• If oliguric/anuric despite adequate fluid: consider furosemide
• Nephrology consultation if ARF develops

• Grieve for lost baby - psychological support, counselling services
• Explain procedure done (hysterectomy) - no future pregnancies possible
• Reassure about recovery

---

---

1. DC Dutta. Textbook of Obstetrics, 9th ed. Chapters: Obstructed Labour, Rupture of Uterus
2. Williams Obstetrics, 25th ed. Cunningham et al. Chapter: Abnormal Labor
3. Creasy & Resnik's Maternal-Fetal Medicine, 8th ed.
4. Tintinalli's Emergency Medicine - Uterine Rupture section
5. Campbell-Walsh Urology - Obstetric Fistulae / Obstructed Labour Injury Complex