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Recent Updates in OBG - DNB/MS Theory Exam Prep (2024-2026)

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OBSTETRICS

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1. HYPERTENSIVE DISORDERS IN PREGNANCY (HDP)

• Gestational Hypertension, Preeclampsia (with/without severe features), Chronic Hypertension, Superimposed PE, Eclampsia

• BP thresholds: systolic ≥140 OR diastolic ≥90 mmHg on two readings ≥4 hours apart (or ≥160/110 requiring treatment within 15-30 min)
• Proteinuria: ≥300 mg/24 hrs OR PCR ≥0.3 OR urine dipstick 2+ (only if other tests not available)
• Severe features: now include thrombocytopenia (<100,000), renal insufficiency (creatinine >1.1 or doubling), impaired liver function (2x upper limit), pulmonary edema, new-onset headache, visual symptoms

• Hourly BP recording in labour for all HDP patients
• If BP ≥160/110 mmHg, repeat every 15-30 minutes until controlled

• IV Labetalol (bolus 20mg, can increase to 40-80mg every 10 min, max 300mg)
• Oral Nifedipine immediate release 10-20mg (NOT sublingual)
• IV Hydralazine 5-10mg bolus
• IV Nicardipine 1.5mg/hr up to 6mg/hr (newer option - more titratable)

• Drug of choice for seizure prophylaxis in severe PE and treatment of eclampsia
• Pritchard regime: 4g IV loading + 10g IM (5g each buttock), then 5g IM 4-hourly
• Zuspan regime: 4g IV loading, then 1-2g/hr IV infusion

• Low-dose Aspirin (75-150mg at night) from 12-16 weeks in high-risk women
• Calcium supplementation (1.5-2g/day) in low-calcium populations (India especially)
• Combined first trimester screening (11-14 weeks): uterine artery Doppler + PAPP-A + MAP + biomarkers

• PE without severe features: deliver at 37 weeks
• PE with severe features at ≥34 weeks: deliver after stabilisation
• Expectant management <34 weeks only in selected cases in tertiary centres
• Induction: misoprostol 25-50 mcg PV every 4 hrs or 50-100 mcg oral every 2 hrs for non-scarred uterus
• Scarred uterus with HDP: prostaglandins and misoprostol NOT recommended - use mechanical methods + oxytocin

• Continue antihypertensives postpartum; nifedipine, labetalol, methyldopa all safe in breastfeeding
• ACOG now recommends postpartum visit within 3 weeks of birth (changed from 6 weeks), then comprehensive visit by 12 weeks

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2. POSTPARTUM HEMORRHAGE (PPH)

• Cumulative blood loss ≥1000 mL with signs/symptoms of hypovolemia within 24 hrs of delivery (regardless of route)
• WHO: >500 mL after vaginal / >1000 mL after CS

1. Oxytocin 10 IU IM - remains first-line for AMTSL
2. Carbetocin 100 mcg IM/IV - increasingly preferred over oxytocin + ergometrine (longer half-life, no cold chain needed for heat-stable formulation)
   • WHO 2023/FIGO support heat-stable carbetocin as alternative to oxytocin where cold chain is an issue
3. Misoprostol 600 mcg sublingual - alternative when injectables unavailable
4. Tranexamic acid (TXA) 1g IV - give within 3 hours of PPH onset (WOMAN trial); second dose of 1g if bleeding continues after 30 min; reduces death from bleeding but NOT hysterectomy rates
5. Carboprost (15-methyl PGF2α) 250 mcg IM every 15-90 min (max 8 doses); avoid in asthma
6. Ergometrine/Methylergometrine - avoid in hypertension

• Oxytocin immediately after delivery of baby (within 1 min)
• Controlled cord traction (CCT) - optional component per WHO 2023 (not always essential if oxytocin given)
• Uterine massage after placental delivery

• Condom-catheter UBT (uterine balloon tamponade) - low-cost, effective in India
• Bakri balloon, COOK balloon
• Panicker's vacuum suction hemostatic device - studied in India (Cureus 2025)
• Transvaginal uterine artery clamp (TVUAC) - emerging tool

• B-Lynch suture, uterine devascularisation (stepwise: uterine → ovarian → internal iliac artery ligation)
• Peripartum hysterectomy as last resort

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3. GESTATIONAL DIABETES MELLITUS (GDM)

• First global WHO guidelines for diabetes management in pregnancy
• Emphasize individualized care, regular glucose monitoring, multidisciplinary team
• Integrate diabetes care into routine antenatal services

• 75g OGTT at 24-28 weeks
• FPG ≥5.1 mmol/L (92 mg/dL), 1-hour ≥10.0 mmol/L (180 mg/dL), 2-hour ≥8.5 mmol/L (153 mg/dL) - ANY ONE value diagnostic

• 75g glucose challenge (non-fasting): 2-hour value ≥140 mg/dL = GDM (used widely in India)

• 70-85% of GDM cases can be managed with lifestyle modification alone
• Metformin: acceptable second-line oral agent, but insulin preferred if pharmacotherapy needed (metformin crosses placenta)
• Post-delivery screening: 75g OGTT at 4-12 weeks postpartum; lifetime annual HbA1c thereafter
• GDM confers 7-fold increased lifetime risk of T2DM

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4. LABOR MANAGEMENT

• Active phase: begins at 6 cm (not 4 cm as previously defined)
• Arrest of active phase: ≥6 cm with membranes ruptured and NO progress for 4 hours with adequate contractions OR 6 hours with inadequate contractions - only then diagnose arrest
• Adequate push time before cesarean: 3 hours for nulliparous (with epidural), 2 hours without; 2 hours multiparous with epidural, 1 hour without
• Goal: reduce unnecessary primary cesarean sections

• ARRIVE trial (key): elective induction at 39 weeks does NOT increase cesarean rates and may reduce them
• Bishop score ≥8: favorable, can use oxytocin directly
• Bishop score <6: need cervical ripening
• Methods: Foley balloon (mechanical), PGE2 (dinoprostone), misoprostol 25-50 mcg PV
• Buccal/sublingual misoprostol NOT recommended for IOL in viable pregnancies (FOGSI 2026)

• CTG classifications: ACOG 3-tier (Category I normal, II indeterminate, III abnormal)
• Meconium stained liquor: thick meconium + Category II/III CTG = LSCS

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5. PRETERM LABOR AND ANTENATAL CORTICOSTEROIDS

• Betamethasone 12mg IM x2 doses 24 hrs apart (OR dexamethasone 6mg IM x4 doses 12 hrs apart)
• Administer at 24-34+6 weeks for preterm labor/PPROM/planned preterm delivery
• Single rescue course if initial course >7-14 days prior and delivery expected within 7 days
• Benefits: reduces RDS, IVH, NEC, neonatal death
• Indications now extended to late preterm (34-36+6 weeks) in selected cases

• Nifedipine (calcium channel blocker) - first-line in India
• Atosiban (oxytocin receptor antagonist) - first-line in Europe, fewer maternal side effects
• Indomethacin - used <32 weeks (ductal constriction risk beyond 32 weeks)
• Ritodrine (betamimetic) - falling out of favor due to adverse effects (GDM risk, VTE, liver dysfunction - data from Japanese real-world study 2026)
• Tocolysis goal: 48 hours to allow ACS, NOT to prevent delivery indefinitely

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6. PERIMORTEM CESAREAN SECTION (PMCS)

• Begin PMCS within 4 minutes of maternal cardiac arrest
• Complete delivery by 5 minutes (4-minute rule / "resuscitative hysterotomy")
• Aim is maternal resuscitation (decompresses aortocaval compression) as well as fetal survival
• Do NOT transfer to OT - perform at the bedside

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GYNAECOLOGY

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7. CERVICAL CANCER SCREENING

• India National Cancer Screening Programme: VIA (visual inspection with acetic acid) and HPV testing for age 30-65
• Cervavac (India's indigenous HPV vaccine, Serum Institute) - 9-valent equivalent, approved for girls 9-26 years; expanding to adolescent immunisation programme

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8. ENDOMETRIOSIS

• Replaces Practice Bulletin 114 and Committee Opinion 760
• Most significant change: presumptive/clinical diagnosis is now acceptable without waiting for surgical confirmation
• A diagnosis can be made based on: patient history + symptoms + physical exam + imaging
• Reduces diagnostic delay (currently 4-11 years average)
• Addresses racial and gender-identity biases in diagnosis

• Dysmenorrhoea, dyspareunia, chronic pelvic pain, infertility in context of normal/abnormal examination
• Transvaginal ultrasound: can identify ovarian endometrioma, deep infiltrating endometriosis (DIE)
• MRI: for mapping DIE, bowel/bladder involvement
• Laparoscopy: gold standard for definitive diagnosis but NOT required to start empirical treatment

• Combined OCP or progestins for pain
• GnRH agonists (with add-back therapy)
• LNG-IUS for dysmenorrhoea

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9. PREMATURE OVARIAN INSUFFICIENCY (POI)

• Definition unchanged: amenorrhoea >4 months + FSH >25 IU/L on TWO occasions >4 weeks apart, below age 40
• Hormone Replacement Therapy (HRT) is now strongly recommended until natural menopause age (~50) in all women with POI (unless contraindicated)
• HRT is protective against: cardiovascular disease, osteoporosis, cognitive decline, sexual dysfunction
• Fertility: 5-10% spontaneous pregnancy rate; oocyte donation is most effective fertility treatment
• Psychological support is mandatory component of care
• Screen for Turner syndrome (karyotype in all cases), Fragile X premutation (FMR1), autoimmune disorders (thyroid, adrenal)

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10. ENDOMETRIAL CANCER

• Sentinel lymph node (SLN) biopsy using indocyanine green (ICG) or technetium-99 is now preferred over full lymphadenectomy in early-stage endometrial cancer
• SLN has equivalent staging accuracy with reduced morbidity (lymphoedema, lymphocyst)
• ICG injection into cervix: SLN detection rate >90%
• Low-risk endometrial cancer (Stage IA, grade 1-2, endometrioid): observation after surgery
• Adjuvant therapy based on ESMO/ESGO/ESTRO 2023 risk stratification

• Power morcellation in laparoscopy is contraindicated if uterine malignancy suspected (FDA black box warning - still relevant)

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11. MISCARRIAGE AND RECURRENT PREGNANCY LOSS

• Vaginal micronized progesterone (400mg BD) in women with recurrent miscarriage AND first-trimester bleeding - PRISM trial evidence
• Progesterone support from confirmed viability up to 16 weeks in women with 3+ previous miscarriages
• Does NOT benefit women without prior losses or without bleeding

• PRISM: 800mg/day vaginal progesterone vs placebo - live birth rate improved by ~5% in women with prior losses + current bleed
• No teratogenicity established

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12. GYNAECOLOGICAL CANCERS DURING PREGNANCY

• Chemotherapy can be given after 14 weeks gestation (organogenesis complete)
• Cervical cancer diagnosed in pregnancy: treatment depends on stage and gestational age; radical trachelectomy possible in early stages
• Ovarian cancer in pregnancy: staging laparotomy with ovarian cystectomy/unilateral oophorectomy; adjuvant platinum-based chemotherapy after 14 weeks
• Delayed delivery for fetal maturity is key principle; avoid preterm delivery before 34 weeks if oncologically safe

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INDIA-SPECIFIC AND OTHER KEY UPDATES

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13. HPV VACCINATION - INDIA 2025-2026

• Universal Immunisation Programme (UIP): Government of India approved Cervavac (quadrivalent HPV vaccine by Serum Institute) for inclusion in NIS in 2023, rollout ongoing for girls 9-14 years
• Two-dose schedule (0 and 6 months) for <15 years; three-dose schedule for ≥15 years
• Target: girls 9-14 years (school-based programme)
• High-risk types covered: HPV 16, 18 (Cervavac 4-valent: 6, 11, 16, 18)

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14. MATERNAL IMMUNIZATION (ACOG 2026 Schedule Updates - June 2026)

• Influenza vaccine: every pregnancy, any trimester
• Tdap: every pregnancy at 27-36 weeks (regardless of prior vaccination)
• COVID-19: updated formulation recommended in pregnancy; Paxlovid (nirmatrelvir/ritonavir) 300/100mg BD x5 days - now explicitly recommended for COVID+ pregnant women (ACOG Oct 2025 update)
• RSV vaccine (Abrysvo): 32-36 weeks gestation - single dose, protects neonate via maternal antibody transfer; now in 2026 ACOG schedule
• Hepatitis B: if unvaccinated
• Hepatitis A + Hepatitis B combo: for at-risk women

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15. POSTPARTUM CARE - ACOG UPDATES

• Postpartum visit should occur within 3 weeks of delivery (previously 6 weeks was standard)
• Comprehensive visit by 12 weeks
• Screen for postpartum depression at every postpartum visit (EPDS score)
• Postpartum contraception counselling: LARC (IUD/implant) can be inserted immediately postpartum (within 10 min of placental delivery - intracavitary IUD)
• India: ASHA workers + KILKARI programme for postpartum telehealth follow-up endorsed

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16. SEPSIS IN PREGNANCY (SOMANZ 2025 Position Statement)

• Sepsis definition in pregnancy: use SOFA score criteria (not modified obstetric criteria alone)
• Maternal sepsis: organ dysfunction as result of infection during pregnancy/postpartum
• Chorioamnionitis is most common source
• Hour-1 bundle: blood cultures x2, serum lactate, broad-spectrum antibiotics within 1 hour
• Note: fever, tachycardia, leukocytosis are normal in pregnancy/labour - have HIGH clinical suspicion

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HIGH-YIELD EXAM SUMMARY TABLE

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QUICK VIVA POINTS

• PMCS: 4 minutes to start, 5 minutes to deliver
• MgSO4 therapeutic range: 4-7 mEq/L; toxicity: loss of patellar reflex at 7-10 mEq/L; respiratory arrest at >12 mEq/L; antidote: Calcium gluconate 1g IV
• TXA in PPH: WOMAN trial, 1g IV within 3 hours
• Carbetocin heat-stable formulation: CHAMPION trial, WHO endorsed
• First-line tocolytic in India: Nifedipine; in Europe: Atosiban
• sFlt-1:PlGF ratio <38: rules out PE in next 1 week (negative predictive value >98%); ratio >85: confirms PE with severe features (PROGNOSIS study)
• Low-dose Aspirin for PE prevention: start at 11-16 weeks, continue until 36 weeks
• Calcium for PE prevention: 1.5-2g/day (especially important in India where dietary intake is low)
• Sentinel node mapping in endometrial cancer: ICG injection into cervix, bilateral mapping preferred

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E-MOTIVE Bundle - Deep Dive (PPH) 🔴

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THE LANDMARK TRIAL

• Lead investigator: Prof Arri Coomarasamy, University of Birmingham / WHO Collaborating Centre
• Funded by: Bill & Melinda Gates Foundation + WHO
• ClinicalTrials.gov: NCT04341662
• Countries: Kenya, Nigeria, South Africa, Tanzania (all secondary-level hospitals)

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WHAT IS E-MOTIVE?

• E = Early detection of PPH (using a calibrated drape)
• MOTIVE = The treatment bundle triggered immediately after PPH is diagnosed

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PART 1: THE "E" - EARLY DETECTION

The Calibrated Blood-Collection Drape

• Healthcare providers typically UNDERESTIMATE blood loss by 30-50%
• This causes delayed diagnosis and delayed treatment
• In the control arm of E-MOTIVE, PPH was only detected in 51.1% of cases

• A calibrated obstetric drape placed under the mother at delivery
• Has graduated measurement lines in mL (not just a plain drape)
• Provides objective, real-time, cumulative blood loss measurement

• HR >100 bpm or increase ≥30 bpm from baseline
• Systolic BP <100 mmHg or drop ≥20 mmHg from baseline
• Soft uterine tone
• Heavy vaginal blood flow, large clots, or constant trickle

The ≥300 mL + clinical sign trigger is the most important because it catches PPH BEFORE it reaches the 500 mL threshold - this is the early part.

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PART 2: THE "MOTIVE" BUNDLE

Critical Point for Exam:

• All components are given concurrently (not one by one waiting for response)
• Even if bleeding settles after oxytocics, ALL bundle components must still be completed
• The V (examination) is non-negotiable - atony accounts for 70-80% but you must rule out trauma, retained placenta, coagulopathy

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PART 3: THE IMPLEMENTATION STRATEGY

1. Simulation-based training with peer-assisted learning (small groups, practice on mannequins)
2. Local E-MOTIVE champions at each facility (a designated clinician who owns the protocol)
3. Feedback of actionable data to providers (monthly audits of PPH cases)
4. MOTIVE emergency trolley / carry case - all bundle drugs pre-stocked at bedside, ready to go
5. Calibrated drape with trigger line (a visual red line at 300 mL to alert the provider)

The trolley is key - it eliminates the 10-15 minute delay of running to the pharmacy during an emergency.

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TRIAL RESULTS (NEJM 2023)

Secondary outcomes also improved:

• Reduction in blood transfusion rates
• Reduction in uterine tamponade use
• Reduction in maternal ICU admissions
• No increase in harmful effects

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WHO RECOMMENDATION (December 2023)

1. Objective measurement of blood loss using a calibrated drape is recommended for all vaginal births (replaces visual estimation)
2. Use of a first-response treatment bundle (MOTIVE) is recommended for management of PPH - all components given simultaneously as soon as PPH is diagnosed

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COST-EFFECTIVENESS (Nature Medicine, 2024)

• E-MOTIVE is cost-effective compared to usual care
• Implementation costs can be absorbed within existing health systems
• No expensive new drugs - all components already existed and were individually recommended

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WHO PPH ROADMAP 2023-2030

• Target: Reduce PPH deaths by 50% by 2030
• Pillars: Prevention (AMTSL), Detection (calibrated drape), Treatment (E-MOTIVE bundle), Quality improvement

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COMPARISON: OLD vs NEW PPH APPROACH

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KEY VIVA POINTS

• E-MOTIVE = E (early detection) + MOTIVE (bundle)
• Published in NEJM, May 2023 - landmark study
• 60% reduction in severe PPH (RR 0.40)
• Bundle must be given within 15 minutes of PPH diagnosis
• All components given simultaneously (not sequentially)
• The calibrated drape trigger line is at 300 mL (+ clinical sign) or 500 mL alone
• TXA dose: 1g IV over 10 min - can repeat once after 30 min
• WHO adopted E-MOTIVE recommendations in December 2023
• Works at secondary-level hospitals - not just tertiary centres
• Midwives can independently administer all bundle components
• E-MOTIVE applicable to vaginal deliveries (the trial was in vaginal birth settings)
• India context: FOGSI endorses the bundle approach; condom-catheter UBT and Panicker's device being studied as Indian adaptations

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PNEUMONIC TO REMEMBER THE BUNDLE

• E - Early detection (calibrated drape)
• M - uterine Massage
• O - Oxytocics
• T - Tranexamic acid
• I - IV fluids
• V - Vaginal/genital examination
• E - Escalation if needed

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PCOS - Complete Recent Updates (2023-2026)

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MOST IMPORTANT UPDATE: PCOS IS NOW CALLED PMOS

New Name: Polyendocrine Metabolic Ovarian Syndrome (PMOS)

Why the name changed:

• "Polycystic" was misleading - most women do NOT have true ovarian cysts; the name fixated diagnosis on ovaries and an ultrasound finding that up to 30% of women with the condition never show
• The old name led to delayed diagnosis, dismissed symptoms, and inadequate treatment
• "Polyendocrine" - recognises multiple hormone systems are involved (not just reproductive hormones - insulin, adrenal, thyroid axes all implicated)
• "Metabolic" - highlights insulin resistance, cardiovascular risk, T2DM risk as central to the condition, not secondary
• "Ovarian" - retains the ovarian component (PCOM, anovulation) without suggesting cysts are mandatory

Exam note: Both terms (PCOS and PMOS) will be used interchangeably until new comprehensive guidelines are released in 2028. You may see either in exam questions. Know both.

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THE 2023 ESHRE/ASRM INTERNATIONAL EVIDENCE-BASED GUIDELINE

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SECTION 1: DIAGNOSIS - WHAT CHANGED

Diagnostic Framework: Rotterdam Criteria RETAINED (2 of 3)

1. Oligo/anovulation (OD)
2. Clinical or biochemical hyperandrogenism (HA)
3. Polycystic ovarian morphology (PCOM)

CHANGE 1: Updated Ultrasound Thresholds for PCOM

Why raised to 20? Better ultrasound technology now shows more follicles normally - the old ≥12 threshold over-diagnosed PCOM.

CHANGE 2: AMH Can Now Substitute for Ultrasound in Defining PCOM

• AMH is now an acceptable alternative to ultrasound to define polycystic ovarian morphology
• Useful when transvaginal ultrasound is not acceptable (adolescents, virgins)
• However: No universal cutoff established yet - use local lab reference ranges
• AMH should NOT be used as a standalone diagnostic test for the whole syndrome
• AMH should NOT be used in adolescents (not validated)

CHANGE 3: Biochemical Hyperandrogenism - Androgen Measurement

• Total testosterone + free testosterone are the recommended androgens to measure
• DHEAS and androstenedione have poor specificity - should NOT be used if total/free testosterone is normal
• LC-MS/MS (liquid chromatography-mass spectrometry) is now the strongly recommended assay for androgens - immunoassays are inaccurate, especially in the low ranges typical in women
• Free androgen index (FAI) = total testosterone / SHBG x 100 - still acceptable as surrogate for free testosterone

CHANGE 4: Adolescent PCOS - "At Risk" Category

• Definitive PCOS diagnosis: requires BOTH oligo/anovulation AND clinical/biochemical hyperandrogenism (2 criteria, but PCOM alone not sufficient)
• Ultrasound NOT recommended for PCOS diagnosis within 8 years of menarche
• AMH NOT used in adolescents
• "At Risk of PCOS" category introduced: 1 criterion present - monitor for up to 8 years or until clarification; treat symptoms but withhold definitive label

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SECTION 2: SCREENING AND LONG-TERM HEALTH RISKS - NEW EMPHASIS

Mental Health - NEW Screening Recommendation

• 2023 guideline explicitly adds mandatory psychological screening at diagnosis (was not standard before)
• PCOS carries significantly elevated risk of depression, anxiety, eating disorders, and low self-esteem
• Body image and quality of life must be addressed as part of care

Cardiovascular Risk - Elevated Recognition (JAHA 2024 Systematic Review)

• PCOS women have elevated cardiovascular disease risk independent of obesity
• Increased risk of: hypertension, dyslipidaemia, coronary artery disease, stroke
• Even lean/non-obese women with PCOS have higher long-term CVD risk

• BP, waist circumference, BMI
• Fasting lipid profile
• Fasting glucose / 75g OGTT (GDM risk is 3x higher in PCOS)
• HbA1c in at-risk women

Obstructive Sleep Apnoea (OSA) - NEW Screening Recommendation

• 2023 guideline explicitly recommends screening for OSA in women with PCOS
• Screen with validated questionnaire (STOP-BANG, Epworth)
• Refer for sleep study if screening positive
• OSA is under-recognised in young women with PCOS

Endometrial Cancer Risk

• Anovulation causes unopposed oestrogen - increased endometrial cancer risk
• Counsel all women with PCOS; investigate abnormal bleeding promptly
• Endometrial protection: cyclical progestogens or levonorgestrel IUS in anovulatory women not trying to conceive

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SECTION 3: LIFESTYLE MANAGEMENT - CORNERSTONE

• First-line treatment for ALL women with PCOS regardless of BMI or phenotype
• Even 5-10% weight loss in overweight women restores ovulation in up to 55-60% of cases
• Components: dietary modification (no specific diet is superior - caloric deficit matters), aerobic + resistance exercise, behavioural support
• 2023 emphasis: Avoid weight stigma; use compassionate, person-centred language about lifestyle

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SECTION 4: MEDICAL MANAGEMENT

Metformin - Expanded Role in 2023

• Dose: start 500mg OD, titrate to 1500-2000mg/day (divided doses)
• Primary benefit: improves insulin sensitivity, lowers androgens, may restore ovulation
• NOT first-line for ovulation induction (letrozole is)

COMBINED ORAL CONTRACEPTIVE PILL (COCP) - For Menstrual Regulation + Hyperandrogenism

• First-line for menstrual irregularity and hirsutism/acne in women not trying to conceive
• Any COCP works; anti-androgenic progestins (cyproterone acetate, drospirenone) may have added benefit for skin/hair

Inositols - Classified as Experimental

• Myo-inositol (alone or 40:1 ratio with D-chiro-inositol) - popular in practice
• 2023 guideline: evidence insufficient; classified as experimental - not first-line therapy
• No significant safety concerns at usual doses

GLP-1 Receptor Agonists - EMERGING (2024-2026)

• Semaglutide (Ozempic/Wegovy) and liraglutide are being studied in PCOS
• A 2025 RCT (Chen et al., Reprod Biol Endocrinol 2025): metformin + semaglutide combination vs metformin alone in overweight/obese PCOS women - improved weight, metabolic parameters, and reproductive outcomes
• Meta-analysis 2025 (Lin et al.): GLP-1 RAs effective for weight management and metabolic parameters in PCOS
• NOT yet in official PCOS/PMOS guidelines as standard treatment, but growing evidence; expect incorporation in 2028 guidelines
• Particularly relevant for obese PCOS women where weight loss is the primary goal

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SECTION 5: OVULATION INDUCTION - KEY CHANGES

NEW HIERARCHY (2023 Guideline):

Letrozole Dosing:

• 2.5-7.5 mg/day orally, days 3-7 of cycle (or days 2-6)
• Start at 2.5mg; titrate up if no response
• Mechanism: aromatase inhibition → reduced oestrogen → FSH release from pituitary → mono-follicular ovulation

Why letrozole beats clomiphene in PCOS:

• Higher cumulative pregnancy and live birth rates
• Less anti-oestrogenic effect on endometrium (thicker endometrium)
• Monofollicular ovulation - lower multiple pregnancy risk
• Shorter half-life (letrozole 2 days vs clomiphene 5-7 days)

Laparoscopic Ovarian Drilling (LOD) - Reduced Role

• No longer part of routine care per 2023 guideline
• Reserved for: resistance to oral ovulation induction agents OR when laparoscopy is already being done for another indication
• Mechanism: electrocoagulation of follicles → reduces androgen production → restores FSH/LH ratio
• Complication: adhesion formation, premature ovarian insufficiency if excessive drilling

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SECTION 6: IVF IN PCOS - PROTOCOL UPDATE

1. GnRH antagonist protocol (not long agonist) - shorter, flexible, lower OHSS risk
2. GnRH agonist trigger instead of hCG for final oocyte maturation - dramatically reduces severe OHSS
3. Freeze-all strategy (vitrification of all embryos) - no fresh transfer; allows ovaries to recover; FET in next cycle
4. Avoid high doses of FSH - start with 100-150 IU/day

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SECTION 7: PCOS IN PREGNANCY

• GDM (3x risk)
• Gestational hypertension / preeclampsia
• Preterm birth
• Miscarriage
• Large for gestational age (LGA) babies

• Early GDM screening (at first ANC visit + again at 24-28 weeks)
• Metformin continuation in pregnancy: reduces GDM risk and miscarriage rate (particularly in women already on it); not teratogenic, but data on long-term offspring outcomes still being gathered
• Monitor BP at every visit
• Aspirin prophylaxis for PE if additional risk factors

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MASTER SUMMARY TABLE: WHAT CHANGED IN 2023 + 2026

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HIGH-YIELD VIVA POINTS

• PCOS renamed PMOS - May 2026 - published in The Lancet
• Rotterdam criteria RETAINED - still 2 of 3 - but ultrasound threshold updated to ≥20 follicles
• AMH = new addition to define PCOM - but no universal cutoff; not in adolescents
• Letrozole is now 1st line for ovulation induction - replaced clomiphene (PPCOS II trial, NEJM 2014)
• LC-MS/MS for androgen measurement - immunoassays inaccurate
• Screen for depression, anxiety, OSA at diagnosis - all new 2023 recommendations
• GLP-1 agonists (semaglutide) - NOT yet official guideline therapy, but very hot evidence area
• PCOS in pregnancy: 3x GDM risk - screen early AND at 24-28 weeks
• GnRH agonist trigger + freeze-all strategy in IVF = best OHSS prevention
• 88% of PMOS women have measurable insulin dysfunction - insulin resistance is central, not peripheral

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Recent Advances in Contraception (2023-2026)

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CATEGORY 1: NEW FEMALE ORAL CONTRACEPTIVES

1. OPILL - First OTC Daily Contraceptive Pill (USA, 2023-2024)

• FDA approved: July 13, 2023
• Available on shelves/online: March 4, 2024 (ACOG announcement)
• First daily birth control pill available without prescription in history

• Progestin-only - no estrogen component
• Mechanism: thickens cervical mucus + may inhibit ovulation
• Approved for all adolescents and adults without age restriction
• NOT approved for menstrual suppression (contraception only)
• Significant for expanding access in low-resource settings

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2. NEW PROGESTINS IN COMBINED ORAL CONTRACEPTIVES

• Slynd = drospirenone 4 mg/day progestin-only pill (new-generation POP)
• Unlike norethindrone/norgestrel POPs, does NOT require strict 3-hour timing window - more forgiving
• Anti-androgenic + anti-mineralocorticoid properties (beneficial in PCOS, acne, bloating)
• 24 active + 4 inert tablets (24/4 regimen)

• Contains estetrol (E4) - a natural fetal oestrogen - instead of ethinyl estradiol
• Estetrol has selective oestrogen receptor modulator-like properties - potentially lower VTE risk than EE-containing pills
• Less impact on clotting factors and liver than EE
• Approved in USA and EU; research ongoing

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CATEGORY 2: NEW INTRAUTERINE DEVICES (IUDs)

3. Miudella (Copper 175 mm²) - FDA Approved February 2025

• Less copper = potentially less bleeding and cramping (major discontinuation reason for Cu-IUD)
• Narrower inserter = easier insertion, especially in nulliparous women
• Nitinol frame has "memory" - springs back to shape after insertion
• Still non-hormonal LARC - effective as emergency contraception

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4. Liletta (LNG-IUS) - Extended Duration Approval

• Levonorgestrel IUS 52 mg - now approved for 8 years (extended from 6 years)
• Joins Mirena (approved for 8 years) in the high-dose LNG-IUS category
• Kyleena (19.5 mg LNG) remains 5 years
• Skyla/Jaydess (13.5 mg LNG) remains 3 years

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CATEGORY 3: NEW NON-HORMONAL FEMALE CONTRACEPTIVES

5. Phexxi (Lactic Acid Vaginal Gel) - FDA Approved 2020, Now Widely Available

• Non-hormonal, on-demand (applied up to 1 hour before each intercourse)
• Typical use efficacy: ~86% (Pearl Index ~14) - less effective than hormonal methods
• Best combined with condoms or other methods
• Safe for breastfeeding women, those who cannot use hormones
• NOT effective against STIs

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6. Ovaprene - Investigational Hormone-Free Monthly Intravaginal Ring

• A monthly vaginal ring that releases ferrous gluconate (iron compound)
• Mechanism: creates a microenvironment in cervical mucus that is hostile to sperm, without affecting hormones or ovulation
• Completely non-hormonal
• One ring per month (unlike NuvaRing which is also monthly but hormonal)
• No systemic absorption - suitable for women who cannot use hormones

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CATEGORY 4: EMERGENCY CONTRACEPTION - UPDATES

7. Ulipristal Acetate (UPA/EllaOne) - Extended Window Guidance

• UPA (EllaOne, 30 mg) - available up to 120 hours (5 days) after unprotected sex
• More effective than levonorgestrel EC across the full 5-day window
• Superior efficacy in overweight/obese women compared to LNG-EC (levonorgestrel does not work as well in women >70-75 kg; UPA is weight-independent)
• Mechanism: progesterone receptor modulator - primarily delays/inhibits ovulation (not abortifacient)

• Efficacy markedly reduced in women >70 kg body weight
• 1.5 mg single dose or 0.75 mg × 2 doses (12 hours apart) - both equivalent
• In India: i-pill is widely available OTC; access is good but weight-related limitation important to counsel

Copper IUD as EC:

• Most effective EC available - >99% effective when inserted within 5 days of unprotected sex
• Can be retained for long-term contraception
• Also effective if inserted within 5 days of earliest predicted ovulation
• Now recommended in FOGSI and WHO guidelines as first-line EC for highly effective protection

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CATEGORY 5: LONG-ACTING INJECTABLE - NEW ENTRY

8. Depo-Subq Provera 104 (Subcutaneous DMPA)

• Medroxyprogesterone acetate 104 mg subcutaneous injection (vs 150 mg IM for Depo-Provera)
• Can be self-administered at home (patient-administered subcutaneous injection)
• Self-injection capability = major advance for access and autonomy
• Same 3-monthly interval
• Lower dose + subcutaneous route = potentially fewer side effects (bone density, weight gain)

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CATEGORY 6: VAGINAL RINGS WITH DUAL PROTECTION

9. Dapivirine-Levonorgestrel Vaginal Ring (Population Council)

• Combines dapivirine (antiretroviral, HIV prevention) + levonorgestrel (contraception) in one vaginal ring
• Used monthly
• Provides dual protection: HIV prevention + contraception simultaneously
• Critical for high-burden HIV regions (sub-Saharan Africa, and relevant for India's high-risk populations)
• In advanced trials as of 2025-2026

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CATEGORY 7: MALE CONTRACEPTION - THE FRONTIER

10. YCT-529 - Non-Hormonal Male Pill (Phase 1 Completed 2025)

• Drug by YourChoice Therapeutics
• Mechanism: Retinoic Acid Receptor Alpha (RARα) blocker - RARα is essential for spermatogenesis
• Non-hormonal - does NOT affect testosterone levels (avoids mood changes, libido reduction, fatigue seen with hormonal male contraceptives)
• Phase 1 safety trial: passed with good safety profile (July 2025)
• Larger Phase 2 trial ongoing (50+ men, 28 and 90-day dosing) - results expected mid-2026
• Completely reversible - sperm production restored after stopping

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11. NES/T Gel (Nestorone + Testosterone Transdermal Gel)

• NES (Nestorone) = potent progestin that suppresses LH/FSH → stops spermatogenesis
• Testosterone added back to prevent hypogonadism symptoms
• Applied to shoulders and upper arms daily (skin absorption)
• Population Council + Contraline executed global licensing agreement: February 4, 2026
• Phase 3 trials completed; regulatory submission expected 2026-2027
• First male contraceptive gel to reach late-stage development globally

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12. ADAM Hydrogel (Contraline) - Intravascular Sperm Occlusion

• Anti-sperm Durable Access to Men
• Hydrogel injected into vas deferens (like a reversible vasectomy)
• Physically blocks sperm passage without hormones
• Naturally degrades over ~2 years
• Reversal procedure also available
• Phase 1 human trial: 24-month safety and efficacy milestone reached, April 2025
• Two participants achieved azoospermia at 24 months

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13. Vasalgel (NEXT Life Sciences) - 10-Year Hydrogel Occlusion

• Similar concept to ADAM but designed for up to 10 years protection
• 100% success rate in North American trial (June 2025)
• Uses a minimally invasive delivery system
• Completely reversible on demand

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CATEGORY 8: DIGITAL / APP-BASED CONTRACEPTION

14. Natural Cycles (FDA-Cleared Digital Contraceptive App)

• FDA-cleared as Class II medical device (2018, updated evidence 2023-2024)
• Uses basal body temperature (BBT) + algorithm to identify fertile window
• Typical-use effectiveness: ~93%; perfect-use: ~98%
• Now integrates with Apple Watch and other wearables for continuous temperature tracking
• Not suitable for women with irregular cycles or PCOS (reliability drops)
• India context: FAMs (fertility awareness methods) are accepted but less preferred; apps are emerging tool

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CATEGORY 9: INDIA-SPECIFIC UPDATES

15. Centchroman (Chhaya/Saheli) - India's Unique Contribution

• Ormeloxifene (non-steroidal SERM) - once-a-week oral contraceptive
• Purely Indian development (CDRI, Lucknow)
• Mechanism: accelerates ovum transport → asynchrony between endometrium and embryo
• Now available as Chhaya through Government health facilities
• Efficacy: Pearl Index ~2.3 (good)
• No hormonal side effects, irregular menstruation main complaint
• FOGSI endorses its use in India's family planning programme

16. India National Family Planning Programme Updates 2024-2025

• Injection DMPA (Antara) - expanded rollout through ASHA workers; subcutaneous self-injection being piloted
• Injectable MPA 150mg IM (Depo-Provera) now freely available at government health centres
• IUCD 375 (copper IUD with 375 mm² copper) - added to India's FP basket alongside Cu-T 380A and Cu-T 200
• Mission Parivar Vikas: basket of contraceptive choices expanded in high fertility districts
• Postpartum IUD (PPIUCD) insertion within 48 hours of delivery - widely promoted in India

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MASTER SUMMARY TABLE

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HIGH-YIELD VIVA POINTS

• Opill = first OTC daily contraceptive pill (norgestrel 0.075 mg POP, USA, July 2023/sold March 2024)
• Miudella = smallest copper IUD (175 mm²) with Nitinol frame - FDA February 2025
• Phexxi = lactic acid gel - maintains vaginal pH ≤4.5 - non-hormonal on-demand contraceptive
• Ulipristal acetate is superior to LNG-EC in obese women (>70 kg) and up to 120 hours
• Copper IUD is most effective EC (>99%); can be inserted up to 5 days post-unprotected sex
• YCT-529 = first non-hormonal male contraceptive pill in Phase 1 human trials (2025) - blocks RARα, reversible
• NES/T Gel = first male contraceptive gel at late-stage - global license signed February 2026
• Vasalgel = 100% success in North American trial (June 2025); 10-year vas deferens hydrogel
• Chhaya (ormeloxifene/centchroman) = India's SERM-based once-weekly pill - non-hormonal
• PPIUCD = postpartum IUD within 48 hours - key India national programme promotion
• Estetrol (E4) = natural fetal oestrogen in new COC (Nextstellis) - potentially lower VTE risk than EE
• Dapivirine + LNG ring = dual HIV prevention + contraception ring (high-burden settings)

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Ultrasonography in Labor (Intrapartum Ultrasound)

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WHY INTRAPARTUM ULTRASOUND? - THE PROBLEM WITH CLINICAL ASSESSMENT

• Accuracy of DVE for fetal head position: only ~30-40% correct for occiput position
• Operator variability: huge inter-observer disagreement
• Discomfort and infection risk: especially with repeated examinations
• Cannot visualize deep structures: pelvic floor, anal sphincter

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PROBE APPROACHES - WHERE TO PLACE THE PROBE

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PART 1: ASSESSING FETAL HEAD POSITION

Suprapubic (Transabdominal) Scan for Position

• DVE correct: ~30-40%
• Transabdominal USS correct: >90%
• Guidelines (RCOG, ACOG, ISUOG): recommend confirming fetal head position with USS before any instrumental delivery (forceps/ventouse)

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PART 2: TRANSPERINEAL ULTRASOUND - THE KEY MEASUREMENTS

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MEASUREMENT 1: ANGLE OF PROGRESSION (AoP) ⭐ MOST IMPORTANT

• A line along the long axis of the pubic symphysis (inferior border of pubis)
• A line from the inferior border of the pubic symphysis to the leading edge of the fetal skull

        Pubic Symphysis
              |
              |  ← line 1 (long axis of symphysis)
              |
              └──────── line 2 (to leading edge of skull)
              
        AoP = angle between line 1 and line 2

• As the fetal head descends and rotates under the pubic symphysis, the AoP increases
• Larger AoP = fetal head is lower and more advanced = better prognosis

• ΔAoP ≥10° between measurements = labor progressing normally
• Highest sensitivity and predictive accuracy for successful vaginal delivery (Hans et al., 2025)
• Used to monitor active pushing in 2nd stage

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MEASUREMENT 2: HEAD-PERINEUM DISTANCE (HPD) ⭐

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MEASUREMENT 3: HEAD-SYMPHYSIS DISTANCE (HSD)

• Uses a fixed bony landmark (symphysis pubis) instead of soft tissue → more reproducible
• Used in the AIDA (Artificial Intelligence Dystocia Algorithm) protocol
• HSD <35 mm = favorable for instrumental delivery

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MEASUREMENT 4: PROGRESSION DISTANCE (PD) / HEAD PROGRESSION DISTANCE (HPrD)

• PD ≥2.7 cm at ≥6 cm dilation → predicts vaginal delivery (in combination with AoP ≥120°) - Hans et al., 2025

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MEASUREMENT 5: MIDLINE ANGLE (MLA)

• Normal OA position: MLA is small (head aligned with pelvis)
• OP or asynclitism: MLA is large (head tilted, not aligned)
• MLA >45° = "very unfavourable" parameter (Sainz et al.) for instrumental delivery

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MEASUREMENT 6: CERVICAL ASSESSMENT

• Cervical length in early labor can predict progress
• Funnel formation, cervical effacement visible
• Less commonly used than AoP/HPD but useful in latent phase

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PART 3: CLINICAL APPLICATIONS OF INTRAPARTUM USS

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APPLICATION 1: ASSESSING LABOR PROGRESS / DIAGNOSING DYSTOCIA

• AoP should increase with progressive dilation and descent
• ΔAoP ≥10° between examinations = progressing
• HPD should decrease with time

• Combination of AoP + clinical findings helps decide between:
  • Augmentation (oxytocin)
  • Instrumental delivery
  • Cesarean section

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APPLICATION 2: PREDICTING MODE OF DELIVERY

• AoP is more reliable than HPD for diagnosing engagement, monitoring labor, and predicting outcome
• AoP measured during active pushing = highest prognostic accuracy

• AoP ≥120°
• HPD ≤25 mm
• PD ≥2.7 cm
• MLA <45°
• OA position on suprapubic scan

• AoP <95°
• HPD >40 mm
• MLA >45°
• Persistent OP

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APPLICATION 3: BEFORE INSTRUMENTAL DELIVERY (FORCEPS/VENTOUSE)

1. Fetal position (OA vs OP vs OT) - transabdominal scan
2. Fetal head station (AoP/HPD) - transperineal scan
3. Degree of flexion/deflexion - affects cup/blade placement

• Applying forceps to a malpositioned head (especially OP mistaken for OA) = fetal and maternal injury
• Randomised data: transabdominal USS far more accurate than DVE for position pre-instrumental delivery

• New technique to identify optimal cup placement site for ventouse
• Identifies the "flexion point" - the ideal traction point on the fetal scalp
• Reduces failed ventouse and scalp injuries

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APPLICATION 4: OCCIPUT POSTERIOR POSITION - DIAGNOSIS AND MANAGEMENT

• Identify OP early in labour
• Guide Manual Rotation of Occiput Posterior (MROP):
  • USS confirms position before rotation
  • USS confirms successful rotation to OA after manual rotation
  • Reduces failed rotation and injury
• Guide instrumental rotation (Kielland's forceps, rotational ventouse)

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APPLICATION 5: BREECH DELIVERY OF SECOND TWIN

• In twin deliveries, after delivery of first twin, fetal lie and presentation of second twin can change
• USS immediately after first twin delivery to confirm:
  • Presentation (cephalic/breech/transverse)
  • Position
  • Cord position
• Guides decision: ECV, internal podalic version, or assisted breech delivery
• Dall'Asta 2024: Real-time USS guidance during assisted breech delivery of second twin improves safety

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APPLICATION 6: OBSTETRIC ANAL SPHINCTER INJURIES (OASIS) - POSTPARTUM

• Diagnose occult external anal sphincter (EAS) and internal anal sphincter (IAS) tears
• OASIS grades 3a, 3b, 3c, 4 - clinical examination misses up to 50% of sphincter injuries
• Intrapartum USS biofeedback during pushing helps reduce perineal trauma (growing evidence, 2024-2025)
• Meta-analysis 2025: Intrapartum USS significantly benefits perineal integrity (RR 3.62)

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APPLICATION 7: BIOFEEDBACK IN 2ND STAGE - NEW CONCEPT

• Real-time display of AoP/HPD on screen while woman is pushing
• Visual feedback helps woman and birth attendant see when pushing is effective
• Studies show improved pushing efficiency and shorter 2nd stage
• Called "ultrasound-guided pushing" or "biofeedback-assisted pushing"

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APPLICATION 8: ASSESSMENT IN SPECIFIC SITUATIONS

• DVE and Leopold's manoeuvres unreliable
• USS indispensable for position and station assessment

• Urge to push is blunted; cannot reliably assess engagement clinically
• USS confirms when head is low enough to begin directed pushing

• USS can assess lower uterine segment (LUS) thickness
• LUS <2.0-2.5 mm → increased risk of uterine rupture during TOLAC
• Guides decision on augmentation and delivery

• USS assessment of head size relative to bony pelvis
• Though no single measurement reliably predicts CPD, trending AoP during labor is informative

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PART 4: EMERGING TECHNOLOGIES (2024-2026)

AI-Assisted Intrapartum USS

• AI automatically segments pubic symphysis and fetal head from transperineal USS images
• Automatically calculates AoP, HSD, MLA in real-time
• Removes operator dependency
• Intrapartum Ultrasound Grand Challenge 2024 (IUGC2024): large multi-centre dataset (774 videos/68,106 images) for AI training released

• Conversano et al. (2025): automated ultrasound technique for AoP shows high accuracy vs manual measurement

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SUMMARY: AoP CUTOFFS (EXAM READY)

SUMMARY: HPD CUTOFFS

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HIGH-YIELD VIVA POINTS

• AoP = most reliable parameter for diagnosing engagement and predicting labor outcome (superior to HPD)
• AoP measured during active pushing gives highest prognostic accuracy
• ΔAoP ≥10° between scans = labor is progressing
• AoP ≥120° + PD ≥2.7 cm at 6 cm dilation = predicts vaginal delivery (Hans et al., 2025)
• HPD ≤25 mm = favorable for instrumental delivery; >35 mm = high CS conversion
• USS is more accurate (>90%) than DVE (~30-40%) for fetal head position
• Confirm position with USS before EVERY instrumental delivery - now in RCOG/ISUOG guidelines
• MLA >45° = unfavourable; indicates asynclitism or malposition
• USS guides MROP (manual rotation of OP) - confirms before and after rotation
• LUS thickness <2 mm on USS in VBAC = increased rupture risk
• Intrapartum USS improves perineal integrity (meta-analysis RR 3.62, IJGO 2025)
• OASIS diagnosis: transperineal USS postpartum detects up to 50% more sphincter injuries than clinical exam alone
• AI-assisted automated AoP calculation - emerging standard (IUGC2024 challenge)
• Probe approaches: transabdominal for position, transperineal for descent measurements