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1. Methods of Induction of Labour

A. Mechanical Methods

• The examining finger is swept around the internal os, separating the chorioamniotic membranes from the lower uterine segment.
• Releases prostaglandins locally; can be done in the outpatient setting.

• Using an amniohook or Kocher's forceps to rupture the membranes.
• Releases prostaglandins, reduces intrauterine volume, and applies the presenting part to the cervix.
• Effective when the cervix is already favourable (Bishop score ≥6).
• Risks: cord prolapse, chorioamnionitis, fetal distress.

• Hygroscopic dilators (laminaria tents, Lamicel): Absorb water, expand over 4-12 hours, and mechanically dilate the cervix.
• Foley catheter (extra-amniotic): A 30 mL balloon is inflated just above the internal os to apply mechanical pressure, ripen the cervix, and stimulate prostaglandin release.

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B. Pharmacological Methods

• Prostaglandins ripen the cervix by breaking down collagen fibers and are the method of choice when the cervix is unfavorable.
• Contraindicated in previous uterine scar (risk of uterine rupture with misoprostol especially), fetal distress, or if oxytocin is being used concomitantly.

• Synthetic posterior pituitary hormone; acts on oxytocin receptors in myometrium.
• Given as IV infusion: low-dose protocol starting at 0.5-2 mU/min, increased every 15-40 min to a maximum of ~20-40 mU/min.
• Most effective when the cervix is already favourable.
• Requires continuous CTG monitoring.
• Risks: uterine hyperstimulation (tachysystole), fetal distress, water intoxication (antidiuretic effect).

• 200-600 mg oral, 24-48 hours before induction.
• Blocks progesterone receptors, softens the cervix, and increases uterine sensitivity to prostaglandins.
• Used in second trimester medical termination in combination with misoprostol.

• Extra-amniotic oestrogen in oil: rarely used today; causes cervical ripening.

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C. Surgical Methods

• As above; often combined with oxytocin.

• Hypertonic saline (20%) or urea instilled intra-amniotically causes fetal death followed by expulsion (used in 2nd trimester terminations).
• Extra-amniotic ethacridine lactate (Rivanol): Used in India for 2nd trimester induction.

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D. Induction Score - Bishop Score (Pre-induction Assessment)

• Score ≥8: Favourable cervix; oxytocin alone is appropriate.
• Score <6: Cervical ripening needed first (prostaglandins/mechanical).

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2. Secondary Changes (Degenerations) of Fibroids (Leiomyoma)

1. Hyaline Degeneration (Most Common ~65%)

• Most common degeneration.
• Fibromuscular tissue is replaced by avascular homogeneous hyaline material.
• Grossly: Cut surface has a white, whorled, glassy appearance.
• Due to impaired blood supply.

2. Cystic Degeneration

• Further liquefaction of hyaline degeneration; cavities fill with clear fluid.
• More common in large fibroids.
• USG: irregular cystic spaces within the fibroid.

3. Fatty (Adipose) Degeneration

• Rare; fat cells accumulate within the fibroid.
• Final stage of hyaline → cystic → fatty transformation.
• Very echogenic on USG.

4. Calcification ("Womb Stone")

• Calcium deposits appear in previously hyalinized/fatty areas.
• Common in postmenopausal women.
• X-ray: "Womb stone" appearance (dense opaque calcifications).
• USG: Shadowing echogenic foci.

5. Carneous (Red) Degeneration

• Also called necrobiosis; most common in pregnancy (especially 2nd trimester).
• Acute onset of severe pain, fever, and uterine tenderness.
• Mechanism: Venous obstruction → infarction → hemolysis → myoglobin deposits give red/brown colour.
• Management: Analgesics + rest (conservative); surgery only if diagnosis is uncertain.

6. Infection / Suppuration

• Secondary infection, especially in submucous fibroids or those protruding through the cervix.
• Can lead to pyomyoma (rare; life-threatening).
• Organisms: Gram-positive cocci, E. coli.

7. Sarcomatous Change (Malignant Transformation)

• Rate: 0.1-0.5% (rare).
• Suspect if a fibroid rapidly enlarges, especially post-menopausally.
• Leiomyosarcoma: defined as >10 mitoses per 10 high power fields (HPF).

8. Torsion (Pedunculated Fibroids)

• Pedunculated fibroids may twist on their pedicle.
• Presents as acute abdomen.
• Leads to venous obstruction → hemorrhage → infarction.

9. Parasitic Fibroid

• A pedunculated fibroid detaches from the uterus and gains blood supply from an adjacent organ (omentum, bowel, broad ligament).

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3. Tests for Human Pregnancy

A. Biological Tests (Older, Now Replaced)

• All biological tests are positive in hydatidiform mole, choriocarcinoma, ectopic pregnancy, and pituitary tumors (false positive).
• Accuracy: ~94-96% (Galli-Mainini). Now largely replaced by immunological tests.

B. Immunological Tests (Standard)

• Latex particles coated with hCG antigen + anti-hCG antibody.
• Urine mixed with antiserum on a glass slide; then latex particles added.
• No agglutination = Pregnancy positive (urine hCG has bound all the antibody, so none left to agglutinate latex).
• Agglutination = Not pregnant.
• Time: 2 minutes. Detects pregnancy from 41-42 days after LMP.

• RBCs coated with hCG + anti-hCG serum.
• No hemagglutination = Positive (urine hCG inhibits agglutination of coated RBCs).
• More sensitive than latex test.

• Uses radiolabelled hCG competing with patient's hCG for antibody binding.
• Can detect as little as 0.003 IU/mL in serum.
• Positive from 8-10 days post-conception (before missed period).
• Problem: Cross-reacts with LH from pituitary (false positive).

• Most modern tests (home pregnancy kits).
• Use monoclonal antibodies specific to beta-subunit of hCG.
• Serum: detects 5-10 mIU/mL (positive from ~8 days after conception).
• Urine: typically positive 12-15 days after implantation (or 1 day after missed period).
• Accuracy: ~98%.
• An early morning urine (highest hCG concentration) is preferred.

• Peaks at 7-10 weeks (~100,000 mIU/mL), then falls to lower plateau by 16 weeks.
• False positive: hydatidiform mole, choriocarcinoma, ectopic pregnancy.
• False negative: very early pregnancy (<10 days), very late pregnancy (>20 weeks).

C. Ultrasound

• Gestational sac visible by 5-6 weeks (TVS).
• Fetal heartbeat by 6-7 weeks (TVS) or 10 weeks (TAS).
• Most reliable for confirming intrauterine pregnancy and viability.

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4. Medical Termination of Pregnancy (MTP) Act - 2021 Amendments

Key Amendments in 2021

1. Revised Gestational Limits

2. Expansion of Eligible Categories (20-24 weeks)

• Survivors of sexual assault or rape
• Minors
• Women with change in marital status (widowhood, divorce)
• Women with mental illness or disability
• Fetal malformations incompatible with life / substantial fetal abnormality
• Pregnant women in humanitarian settings / disasters

3. Inclusion of Unmarried Women

• Previously, the contraceptive failure ground (Section 3(2)(b)) applied only to married women.
• 2021 amendment: Extended to all women (married or unmarried).
• This is a landmark change recognizing women's autonomy.

4. Confidentiality Clause (New)

• Section 5A added: Name and identity of the woman must be kept confidential.
• No RMP can reveal the name except to persons authorized by law.
• Violation is punishable with imprisonment up to 1 year, or fine, or both.

5. Medical Board

• Each state/UT must constitute a State-Level Medical Board.
• Composition: Gynecologist, Radiologist/Sonologist, Pediatrician, and other members.
• Functions: Decide on termination beyond 24 weeks for severe fetal anomalies.

6. Contraceptive Failure - Broader Scope

• Now covers both married and unmarried women.

7. Consent Requirements (Unchanged)

Summary of Key 2021 Changes

1. Upper limit extended from 20 to 24 weeks for special categories.
2. Upper limit removed for fetal anomalies (Medical Board required).
3. Unmarried women now included for contraceptive failure ground.
4. Strict confidentiality provisions added (Section 5A).
5. Medical Board constituted at State level.

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5. Anemia in Pregnancy

Definition (WHO Criteria)

• Hemoglobin <11 g/dL during pregnancy (any trimester).
• Hb <10.5 g/dL in 2nd trimester (physiological hemodilution nadir).
• Severe anemia: Hb <7 g/dL.
• Very severe: Hb <4 g/dL.

Physiological Changes

Classification by Severity (WHO)

Etiology / Types

1. Iron Deficiency Anemia (Most Common - ~75%)

• Due to increased iron demand (fetal iron transfer, expanded RBC mass, blood loss at delivery).
• MCV low, MCH low (microcytic hypochromic).
• Serum ferritin <12 mcg/L (most sensitive early marker).
• Management:
  • Oral iron: Ferrous sulfate 325 mg (= 65 mg elemental iron) TDS.
  • ACOG recommends 27 mg/day elemental iron supplementation in pregnancy.
  • IV iron (ferric carboxymaltose or iron sucrose) if: intolerance to oral, non-compliance, severe anemia in late pregnancy, or malabsorption.
  • Blood transfusion: if Hb <6 g/dL or symptomatic severe anemia near term.

2. Folic Acid Deficiency

• Second most common cause of nutritional anemia in pregnancy.
• Macrocytic (megaloblastic) anemia.
• Increased demand in pregnancy; also required for neural tube development.
• Prevention: Folic acid 400-500 mcg/day from pre-conception through 12 weeks (for NTD prevention); 5 mg/day in high-risk women.
• Treatment: Folic acid 1-5 mg/day.

3. Vitamin B12 Deficiency

• Less common; seen in strict vegetarians.
• Macrocytic anemia + neurological involvement.
• Treatment: IM B12 injections (cyanocobalamin 1000 mcg).

4. Anemia Due to Infections/Inflammation

• Malaria (most important in India), HIV, hookworm infestation.
• Anemia of chronic disease: low serum iron + low TIBC + high ferritin.

5. Hemolytic Anemias

• Sickle cell disease, thalassemia, G6PD deficiency.
• Require specialist management.

Effects of Anemia in Pregnancy

• Cardiac failure (Hb <6 g/dL)
• Preterm labour
• Increased susceptibility to infections
• Poor wound healing, postpartum hemorrhage risk
• Maternal mortality (severe anemia)

• Intrauterine growth restriction (IUGR)
• Low birth weight
• Preterm birth
• Perinatal mortality
• Fetal iron stores may be adequate even with maternal anemia (fetal compartment is preferentially supplied), but severe depletion affects the baby.

Management Summary

• Universal iron + folic acid supplementation: IFA tablet (100 mg elemental iron + 500 mcg folic acid) daily from 14-16 weeks in India (NRHM recommendation).

• Mild-moderate: Oral iron + dietary advice (green leafy vegetables, citrus fruits to enhance absorption; avoid tea/coffee with meals).
• Severe (Hb 5-7 g/dL, no cardiac failure): IV iron preferred over transfusion.
• Very severe (Hb <5 g/dL) or cardiac failure: Packed RBC transfusion (10-20 mL/kg slowly, with diuretic cover).
• Treat underlying cause (anti-malarials, anthelmintics if hookworm).