Reproductive health kmtc notes detailed exam oriented

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Here are your comprehensive, exam-oriented KMTC Reproductive Health notes:

🏥 REPRODUCTIVE HEALTH — KMTC EXAM-ORIENTED NOTES

UNIT 1: INTRODUCTION TO REPRODUCTIVE HEALTH

Definition: Reproductive health is a state of complete physical, mental, and social well-being in all matters relating to the reproductive system and its functions, not merely the absence of disease.

Key components (exam favourite):

Safe motherhood
Family planning
Prevention and management of STIs
Prevention of unsafe abortion
Management of infertility
Adolescent reproductive health

UNIT 2: FAMILY PLANNING & CONTRACEPTION

2.1 Contraceptive Effectiveness (Failures per 100 Woman-Years)

Method	Failures/100 woman-years
Vasectomy	0.02
Tubal ligation	0.13
Combined OCP (>50 µg estrogen)	0.32
Combined OCP (<50 µg estrogen)	0.27
Progestin-only pill	1.2
IUD (Copper 7)	1.5
Diaphragm	1.9
Condom	3.6
Withdrawal	6.7
Spermicide	11.9
Calendar/Rhythm	15.5

Source: Ganong's Review of Medical Physiology, 26th ed.

2.2 Combined Oral Contraceptive Pills (COCPs)

Mechanism:

Suppress FSH and LH → prevent ovulation
Thicken cervical mucus → impede sperm entry
Interfere with implantation

Common combination: Ethinyl estradiol + norethindrone (progestin)

Taken for 21 days, then withdrawn 5–7 days to permit menstrual flow

Absolute contraindications (memorise ALL 5):

Personal history of cardiovascular disease
Thromboembolic disease
Migraine with aura
Gynaecological or breast cancer
Pregnancy

Relative contraindication: Pre-existing hypertension

Important exam point: Smoking + OCP use → ↑ thromboembolism risk, especially in women >30 years

Monitoring: Check blood pressure at 3 months after starting, then annually

Protective effect: OCP use decreases risk of endometrial and ovarian cancer — family history of cancer is NOT a contraindication

2.3 Intrauterine Devices (IUDs)

Types:

Copper IUD — spermatocidal effect; does NOT alter menstrual cycle
Hormonal IUD (progesterone/progestin-releasing) — thickens cervical mucus + prevents sperm entry

Mechanism (general): Prevent sperm from fertilising ova

Complication: Intrauterine infection — mostly in first month after insertion, especially in women exposed to STIs

2.4 Progestin Implants (e.g., Levonorgestrel)

Inserted subcutaneously
Effective for up to 5 years
Often produce amenorrhoea
Well tolerated

2.5 Natural Family Planning (Fertility Awareness-Based — FAB Methods)

Historical methods:

Calendar rhythm
Basal Body Temperature (BBT)

Current FAB methods (4):

Standard Days method
Ovulation method
TwoDay method
Symptothermal method

Physiology of fertility window:

Sperm viability: up to 5 days
Ovum viability after ovulation: <24 hours

Probability of pregnancy from unprotected intercourse:

5 days before ovulation: 4%
2 days before ovulation: 25–28%
24 hours after ovulation: 8–10%
Rest of cycle: 0%

Cervical mucus changes:

Before ovulation (estradiol effect): clear, wet, elastic secretions
After ovulation (progesterone effect): thick, sticky secretions
Dry phase: ~3–4 days after menstruation, then ~11–14 days before next cycle

Indication: Couples who wish to avoid hormonal/operative/barrier methods; also useful for those desiring pregnancy

No absolute contraindications to FAB methods

2.6 Medical Abortion

Evidence-based regimen (up to 63 days gestation):

Mifepristone 200 mg orally (single dose)
Followed by Misoprostol 800 µg buccally 24–72 hours later

Success rate: 94–98%

Complications (similar to surgical abortion):

Bleeding requiring transfusion: 0.05%
Rare infections (with non-evidence-based methods)

Side effects: Nausea, abdominal pain, bleeding, expulsion of conception products

Exam tip: Providers must register with the company to prescribe mifepristone

UNIT 3: ANTENATAL CARE (ANC)

3.1 Goals of ANC

Screen for high-risk pregnancies and triage appropriately
Identify and manage medical conditions
Reduce behavioural risk factors (smoking, alcohol, poor nutrition)
Promote healthy pregnancy and good birth outcomes

3.2 Calculating EDD — Naegele's Rule

Formula: EDD = First day of LMP − 3 months + 7 days

Example: LMP = 1 Jan → EDD = 8 October

Note: Adjust for cycles shorter or longer than 28 days

3.3 First Prenatal Visit (most important visit)

Includes:

Full medical and obstetric history
Psychosocial history (smoking, alcohol, drugs, social support)
Risk assessment
Physical examination
Laboratory investigations
Establishment of gestational age
Education and counselling

Education topics:

Physiologic changes in pregnancy
Breastfeeding (strongly encouraged)
Teratogens: smoking, alcohol, drugs, medications, herbal remedies
Immunisations (influenza, H1N1)
Nutrition and appropriate weight gain
Exercise (if no obstetric contraindication)
STI prevention
Intercourse during pregnancy (safe unless: placenta praevia, preterm labour)

3.4 Prenatal Visit Schedule

Gestation	Frequency
1st–2nd trimester (no complications)	Every 5–6 weeks
After 30 weeks	More frequent
After 37 weeks	Weekly

3.5 Key Antenatal Screening Schedule

Gestation	Test
10w2d – 13w6d	1st trimester chromosomal screening
16–18 weeks	AFP-based quad screen (neural tube defects, chromosomal abnormalities)
26–28 weeks	Gestational Diabetes Mellitus (GDM) screening
26–28 weeks	Anaemia screening (Hb/Haematocrit)
26–28 weeks	Antibody screen; RhoGAM for Rh-negative mothers
35–37 weeks	Group B Streptococcus (GBS) rectocervical swab

3.6 Group B Streptococcus (GBS) — HIGH YIELD

Leading cause of early-onset neonatal sepsis
Screen all pregnant women at 35–37 weeks (rectocervical culture)
Give intrapartum antibiotic prophylaxis if:
- GBS culture positive
- GBS bacteriuria
- Previous infant with GBS disease (no screening needed — treat directly)

Antibiotic choice:

Allergy status	Drug
No penicillin allergy	Penicillin (5 million units IV load, then 2.5 million units IV q4h)
No allergy (alternative)	Ampicillin 2g IV load, then 1g IV q4h
Penicillin allergy, mild (rash only)	Cefazolin IV
GBS sensitive to clindamycin & erythromycin	Clindamycin
Severe penicillin allergy or resistant GBS	Vancomycin

Not indicated: Prophylaxis if elective caesarean section is planned with no labour or ruptured membranes

UNIT 4: SEXUALLY TRANSMITTED INFECTIONS (STIs)

4.1 Key STIs to Know

Organism	Disease	Treatment
Neisseria gonorrhoeae	Gonorrhoea	Ceftriaxone (per current CDC/WHO guidelines)
Treponema pallidum	Syphilis	Benzathine Penicillin G
Chlamydia trachomatis	Chlamydia	Azithromycin / Doxycycline
HIV	AIDS	ART (combination therapy)
HPV	Genital warts / Cervical cancer	Vaccines (HPV vaccine); treatment per stage
Herpes simplex virus (HSV-2)	Genital herpes	Acyclovir

4.2 Screening Recommendations

Screen all sexually active adolescents and at-risk adults for chlamydia and gonorrhoea
Screen HIV-positive patients for curable STIs (gonorrhoea, chlamydia, syphilis) at least annually; more frequent if behaviour warrants
Condom use counselling is a key prevention strategy

4.3 STI in Pregnancy — High Yield

STI	Risk to fetus/neonate
Syphilis	Congenital syphilis (stillbirth, rash, hepatosplenomegaly)
Gonorrhoea/Chlamydia	Neonatal conjunctivitis (ophthalmia neonatorum)
HIV	Mother-to-child transmission; prevent with ART + avoid breastfeeding
Herpes (HSV)	Neonatal herpes; caesarean section if active lesions at delivery
GBS	Early-onset neonatal sepsis

UNIT 5: HYPERTENSIVE DISORDERS IN PREGNANCY

5.1 Classification (Exam Favourite)

Condition	Definition
Gestational hypertension	BP ≥140/90 mmHg after 20 weeks, no proteinuria
Preeclampsia	BP ≥140/90 + proteinuria (≥300 mg/24h) after 20 weeks
Severe preeclampsia	BP ≥160/110 + severe features (headache, visual changes, epigastric pain, HELLP)
Eclampsia	Seizures in a preeclamptic patient; can occur up to 12 weeks postpartum
Chronic hypertension	BP ≥140/90 before 20 weeks or pre-pregnancy

5.2 HELLP Syndrome

H — Haemolysis EL — Elevated Liver enzymes LP — Low Platelets

Suspect HELLP in pregnant/postpartum women with abdominal pain

5.3 Management of Eclampsia

Magnesium sulphate (MgSO₄) — first-line anticonvulsant; also given in severe preeclampsia to prevent progression to eclampsia
Watch for magnesium toxicity: ↓ deep tendon reflexes (first sign), respiratory depression
Antidote: Calcium gluconate
Antihypertensives: Labetalol, hydralazine, nifedipine
Definitive treatment: Delivery

5.4 Causes of AKI in Pregnancy (exam differentials)

Preeclampsia / eclampsia
HELLP syndrome
Postpartum HUS/TTP
Obstetric haemorrhage (abruptio placentae, postpartum haemorrhage)
Acute fatty liver of pregnancy
Amniotic fluid embolism

UNIT 6: POSTPARTUM HAEMORRHAGE (PPH)

Definition: Blood loss >500 mL after vaginal delivery, or >1000 mL after caesarean section

The 4 T's of PPH Causes (HIGH YIELD)

T	Cause	Example
Tone	Uterine atony (most common, 80%)	Overdistended uterus, prolonged labour
Tissue	Retained placenta/products	Incomplete placenta, adherent placenta
Trauma	Genital tract lacerations	Cervical, vaginal, perineal tears
Thrombin	Coagulation defects	DIC, von Willebrand disease

Management

Uterotonic drugs:
- Oxytocin (first-line)
- Ergometrine / methylergonovine (note: contraindicated in hypertension)
- Misoprostol
- Carboprost (PGF2α)
Bimanual uterine compression
Balloon tamponade
Surgical: B-Lynch suture, uterine artery ligation, hysterectomy (last resort)

UNIT 7: MEDICATIONS IN PREGNANCY — TERATOGENS

Principle: Choose medications with the greatest first-trimester safety profile for women of reproductive age

Drug	Teratogenic Risk
Warfarin	Warfarin embryopathy (nasal hypoplasia, stippled epiphyses)
ACE inhibitors	Renal dysgenesis (2nd/3rd trimester)
Thalidomide	Phocomelia (limb defects)
Valproate	Neural tube defects, cognitive impairment
Methotrexate	Spontaneous abortion, craniofacial defects
Lithium	Ebstein anomaly (cardiac)
Isotretinoin	Craniofacial, CNS, cardiac defects

Antidepressants in Pregnancy

Generally safe in pregnancy
SSRIs may increase risk of postpartum haemorrhage
Postpartum depression screening is essential
Do NOT abruptly stop antidepressants; taper gradually over weeks

UNIT 8: ADOLESCENT REPRODUCTIVE HEALTH

Key issues:

Early/unintended pregnancy
STI prevention and screening
Access to family planning
Menstrual health
Sexual and gender-based violence (SGBV)

Behavioural counselling is recommended for sexually active adolescents to prevent STIs

UNIT 9: INFERTILITY

Definition: Failure to conceive after 12 months of regular unprotected intercourse (or 6 months if woman is >35 years)

Causes:

Female factor (40%): Ovulatory dysfunction (PCOS), tubal disease, uterine anomalies, endometriosis
Male factor (40%): Oligospermia, azoospermia, poor motility
Combined/unexplained (20%)

Investigations:

Semen analysis (first test done)
Ovulation tracking (BBT, LH surge, Day-21 progesterone)
HSG (hysterosalpingography) — assess tubal patency
Hormone profile (FSH, LH, prolactin, TSH)

UNIT 10: CERVICAL CANCER & REPRODUCTIVE CANCERS

Cervical cancer:

Caused by HPV (Human Papillomavirus), mainly types 16 and 18
Risk factors: early coitarche, multiple partners, immunosuppression, smoking, multiparity
Screening: Pap smear from age 21 (or 3 years after sexual debut)
Prevention: HPV vaccine (ideally before sexual debut, age 9–14; can give up to 26 years)

OCP protective effect: Reduces risk of endometrial cancer and ovarian cancer

QUICK REVISION — EXAM MNEMONICS

Mnemonic	Meaning
4 T's	Tone, Tissue, Trauma, Thrombin (PPH causes)
HELLP	Haemolysis, Elevated Liver enzymes, Low Platelets
PROM	Premature Rupture Of Membranes
Naegele's Rule	LMP − 3 months + 7 days = EDD
FAB methods (current 4)	Standard Days, Ovulation, TwoDay, Symptothermal
GBS screen timing	35–37 weeks
GDM screening	26–28 weeks

COMMON EXAM QUESTION STEMS & EXPECTED ANSWERS

Q: What is the most effective reversible contraceptive method? A: Combined oral contraceptive pill (or IUD — depends on context; vasectomy/tubal ligation are most effective overall but permanent)

Q: A woman on OCP develops high BP. What do you do? A: Stop OCP; monitor BP. Hypertension is a relative contraindication to OCP use. Monitor BP at 3 months after starting OCPs.

Q: What is the first-line anticonvulsant in eclampsia? A: Magnesium sulphate (MgSO₄)

Q: A pregnant woman at 36 weeks has a positive GBS culture. What is the management? A: Intrapartum IV Penicillin prophylaxis during labour

Q: What is the most common cause of PPH? A: Uterine atony (Tone — accounts for ~80%)

Q: What cervical changes occur before ovulation? A: Clear, wet, elastic (stretchy) cervical mucus due to rising estradiol levels

Q: At what gestational age is GDM screening done? A: 26–28 weeks

Q: What drug is used in medical abortion and at what dose? A: Mifepristone 200 mg orally, followed by Misoprostol 800 µg buccally 24–72 hours later; effective up to 63 days gestation

Sources: Textbook of Family Medicine 9e; Goldman-Cecil Medicine; Ganong's Review of Medical Physiology 26th ed; Pfenninger & Fowler's Procedures for Primary Care; Creasy & Resnik's Maternal-Fetal MedicineThese notes cover the 10 core units of KMTC Reproductive Health. Here's what's included:

Unit	Topic
1	Introduction & Definition
2	Family Planning & Contraception (FAB methods, OCPs, IUDs, medical abortion)
3	Antenatal Care (Naegele's rule, visit schedule, GBS, GDM screening)
4	STIs (table, screening, neonatal risks)
5	Hypertensive disorders (Preeclampsia, Eclampsia, HELLP, MgSO₄)
6	Postpartum Haemorrhage (4 T's, uterotonic drugs)
7	Teratogens & drugs in pregnancy
8	Adolescent reproductive health
9	Infertility
10	Cervical cancer & HPV

Exam hot spots: The 4 T's of PPH, HELLP criteria, GBS screening timing (35–37 weeks), GDM screening (26–28 weeks), Naegele's rule, and contraceptive failure rates are the most frequently tested areas. Let me know if you want any unit expanded further!

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🏥 OBSTETRICS & GYNAECOLOGY — KMTC EXAM-ORIENTED NOTES

UNIT 1: NORMAL LABOUR & DELIVERY

1.1 Definition of Labour

Regular uterine contractions producing progressive cervical change (effacement + dilation).

True vs False Labour:

Feature	True Labour	False Labour (Braxton Hicks)
Contractions	Regular, increasing in frequency & intensity	Irregular, no progression
Cervical change	Present	Absent
Effect of walking	Intensifies contractions	No effect or diminishes
Pain location	Back → abdomen	Abdomen only

1.2 Stages of Labour (HIGH YIELD — always in exams)

Stage	Onset	End
First stage — Latent + Active	Onset of true labour	Full cervical dilation (10 cm)
Second stage	Full dilation	Delivery of baby
Third stage	Delivery of baby	Delivery of placenta
Fourth stage	Delivery of placenta	Contracted uterus (first 1–2 hours)

First Stage — Latent Phase

Variable length
Nullipara: <20 hours; Multipara: <14 hours
Little cervical dilation; mainly cervical preparation (softening, effacement, anterior positioning)
Conduction anaesthesia in this phase may prolong or arrest progress
Prolonged latent phase → treat with morphine in hospital setting

First Stage — Active Phase

Begins at approximately 4–5 cm cervical dilation
Rapid dilation
Normal dilation rate:
- Nullipara: ≥1.2 cm/hr
- Multipara: ≥1.5 cm/hr
Progress depends on: uterine contraction strength/frequency, fetal head size/position/attitude, and pelvic shape

1.3 Cardinal Movements of Labour (7 — memorise in order)

Engagement — fetal head enters pelvic inlet
Descent — downward movement
Flexion — chin to chest; reduces AP diameter
Internal rotation — occiput rotates anteriorly
Extension — head extends under symphysis pubis
External rotation (restitution) — head aligns with shoulders
Expulsion — delivery of body

Mnemonic: "Every Decent Family Is Exceedingly Extraordinary"

1.4 Fetal Heart Rate (FHR) Monitoring

Normal baseline FHR: 110–160 beats/min

Reactive NST (Non-Stress Test): ≥2 accelerations of ≥15 bpm above baseline lasting ≥15 seconds in 20 minutes

Types of Decelerations:

Type	Cause	Shape	Relation to Contraction	Significance
Early	Fetal head compression → vagal	Smooth mirror image	Begins with contraction, nadir at peak	Benign/Reassuring
Variable	Umbilical cord compression	"V", "U", or "W" shape	Variable relationship	Most common (50–80% of deliveries); concerning if severe
Late	Uteroplacental insufficiency	Gradual; begins AFTER contraction peak	Begins late, returns after contraction ends	Ominous — Category III
Sinusoidal	Fetal anaemia / severe hypoxia	Smooth sine-wave, 2–5 cycles/min	—	Ominous — Category III

FHR Tachycardia (>160 bpm) causes:

Chorioamnionitis, maternal fever
Sympathomimetic drugs (terbutaline)
Atropine, fetal tachyarrhythmia
Fetal hypoxia, prematurity

FHR Bradycardia causes:

Cord prolapse/compression
Tetanic contractions
Paracervical/epidural block
Maternal seizure

Late deceleration management:

Turn patient on side (lateral position) → ↑ cardiac output & uterine blood flow
IV fluids to correct hypotension
Stop oxytocin infusion
Administer oxygen

Tachysystole: >5 contractions in 10 minutes (averaged over 30 minutes)

1.5 NICHHD FHR Classification

Category	Interpretation	Action
I (Normal)	Normal pH, fetal well-being	Continue current management
II (Indeterminate)	Uncertain	Further evaluation
III (Abnormal)	Fetal hypoxia/acidosis	Immediate intervention; expedited delivery

UNIT 2: COMPLICATIONS OF PREGNANCY — ANTEPARTUM HAEMORRHAGE

2.1 Causes of Antepartum Haemorrhage (APH)

Complicates 3–5% of pregnancies; leading cause of maternal and perinatal mortality

Main causes:

Placenta praevia (painless)
Abruptio placentae (painful)
Vasa praevia
Cervical/vaginal lesions

2.2 Placenta Praevia

Definition: Placenta implanted in the lower uterine segment, covering or near the internal cervical os

Classification (3 types):

Type	Description
Complete/Total	Placenta completely covers the cervical os
Partial	Placenta partially covers the os
Marginal	Placenta extends to the edge of the os

Incidence: 1 in 200–250 pregnancies

Classic presentation:

Painless, bright-red vaginal bleeding in the 3rd trimester
Average first bleed: 27–32 weeks
Abnormal lie (transverse/breech) — suspicious
Initial bleed is usually not fatal and stops spontaneously, then recurs

Risk factors:

Advanced maternal age
Increased parity (multiparity)
Previous uterine surgery (C-section scar)
Prior placenta praevia
Multiple gestation
Uterine abnormalities
Smoking

Diagnosis: Transabdominal ultrasound (93–98% accurate); use transvaginal US if position unclear — do NOT do vaginal examination (risk of massive haemorrhage)

Management:

If actively bleeding → IV access, crossmatch blood, IV fluids, oxygen
If fetus viable but compromised → urgent caesarean section
Rh-negative mothers → D immune globulin (RhoGAM)

2.3 Abruptio Placentae (Placental Abruption)

Definition: Premature separation of a normally situated placenta before delivery of the fetus

Incidence: 1 in 129 births (~1–2% of pregnancies)

Classic presentation:

Painful vaginal bleeding — hallmark
Uterine tenderness (board-like/woody uterus)
Frequent contractions
Fetal distress
Blood is characteristically dark red

Note: Vaginal bleeding occurs in 70% of cases; in 30%, bleeding is concealed (retroplacental)

Grades:

Grade	Features
Grade I (Mild)	<150 mL blood loss; mother/fetus stable
Grade II (Moderate)	Fetal distress; maternal compromise
Grade III (Severe)	Fetal death; DIC possible; 25% of cases

Complications:

DIC (disseminated intravascular coagulation)
Hypovolaemic shock
Renal failure
Couvelaire uterus (blood penetrates uterine wall)

Key investigations:

CBC, coagulation studies (PT/PTT, fibrinogen, D-dimer)
Kleihauer-Betke test (feto-maternal haemorrhage)
Blood type and crossmatch

Management:

Aggressive IV fluids/resuscitation
Packed RBCs on standby
Continuous fetal monitoring
Rh-negative mothers → D immune globulin
Urgent C-section if fetus viable but compromised

2.4 Placenta Praevia vs Abruptio — EXAM COMPARISON TABLE

Feature	Placenta Praevia	Abruptio Placentae
Pain	Painless	Painful
Blood colour	Bright red	Dark red
Uterine tone	Soft	Rigid/tender ("woody")
Onset	3rd trimester; 27–32 wks	Any time
Shock	Proportional to visible blood	Out of proportion to visible blood
Fetal lie	Often abnormal	Usually normal
Diagnosis	Ultrasound	Clinical (US may be false-negative)
Vaginal examination	CONTRAINDICATED	Can be done

UNIT 3: HYPERTENSIVE DISORDERS OF PREGNANCY

3.1 Classification

Condition	BP	Proteinuria	Onset
Gestational hypertension	≥140/90 mmHg	Absent	>20 weeks
Preeclampsia	≥140/90 mmHg	Present (≥300 mg/24h)	>20 weeks
Severe preeclampsia	≥160/110 mmHg	Present + end-organ damage	>20 weeks
Eclampsia	Any	Present	Seizures in preeclamptic
Chronic hypertension	≥140/90 mmHg	Variable	<20 weeks or pre-pregnancy

3.2 Preeclampsia

Signs/symptoms of severe preeclampsia:

Severe headache
Visual disturbances (photopsia, scotoma)
Epigastric/RUQ pain (liver capsule stretch)
Pulmonary oedema
Oliguria

HELLP Syndrome:

H — Haemolysis (microangiopathic)
EL — Elevated Liver enzymes (↑AST, ↑ALT, ↑LDH)
LP — Low Platelets (<100,000/µL)

Suspect HELLP in a pregnant/postpartum woman with abdominal pain

Labs in HELLP: Peripheral blood smear → microangiopathic haemolytic anaemia; ↑transaminases; ↓platelets

3.3 Eclampsia

Definition: Seizures in a woman with pre-eclampsia; can occur up to 12 weeks postpartum

Incidence: 0.2% of pregnancies; terminates 1 in 1000 pregnancies

Major cause of maternal death: Intracranial haemorrhage

Perinatal mortality: 2–8.6%

3.4 Management of Severe Preeclampsia/Eclampsia

Magnesium Sulphate Protocol (MgSO₄ · 7H₂O):

Loading dose: 4 g (range 2–6 g) in 500 mL 5% dextrose over 15 minutes IV
Maintenance: 1–3 g/hr continuous infusion
Continue for 24 hours after delivery or last seizure
Keep calcium gluconate at bedside as antidote

Monitoring on MgSO₄:

Deep tendon reflexes (first sign of toxicity = loss of DTRs)
Respiratory rate (>12/min)
Urine output (>25 mL/hr)
Plasma Mg levels

Antihypertensives for acute severe HTN:

Labetalol IV (first-line)
Hydralazine IV
Nifedipine oral

Definitive treatment: DELIVERY of the baby

Gestational hypertension resolves within 10 days postpartum

UNIT 4: PRETERM LABOUR

Definition: Labour occurring between 20–37 weeks of gestation

Risk factors:

Prior preterm labour (most important risk factor)
Low socioeconomic status
Multiple gestation
Uterine anomalies
Bacterial vaginosis / UTI
Placenta praevia/abruption
Polyhydramnios
Low maternal weight (<50 kg)
Smoking, cocaine use
Poor prenatal care

Management of preterm labour:

Tocolytics (delay delivery 48 hrs to allow corticosteroids to work):
- Nifedipine (calcium channel blocker — preferred)
- Terbutaline (β₂-agonist)
- Indomethacin (PG inhibitor; <32 weeks)
- MgSO₄ (also neuroprotective)
Corticosteroids (fetal lung maturity):
- Betamethasone 12 mg IM × 2 doses, 24 hours apart OR
- Dexamethasone 6 mg IM × 4 doses, 12 hours apart
- Give between 24–34 weeks
Antibiotics if GBS positive or PROM

UNIT 5: PREMATURE RUPTURE OF MEMBRANES (PROM)

Definition: Rupture of membranes before onset of labour

Types:

Type	Definition
PROM	At term (≥37 weeks)
PPROM	Preterm (<37 weeks)

Diagnosis:

Pooling of fluid in vagina
Ferning (amniotic fluid crystallises in fern pattern on glass slide)
Nitrazine test — amniotic fluid turns paper blue (alkaline)
Ultrasound — oligohydramnios

Complications: Cord prolapse, infection (chorioamnionitis), preterm labour, fetal distress

Management:

≥37 weeks: Induce labour (oxytocin)
<37 weeks: Expectant management, antibiotics (ampicillin/erythromycin), corticosteroids if <34 weeks

UNIT 6: ECTOPIC PREGNANCY

Definition: Implantation of the fertilised ovum outside the uterine cavity

Sites (order of frequency):

Ampulla of fallopian tube (most common — ~70%)
Isthmus
Fimbria
Ovary
Cervix
Abdominal (rarest)

Risk factors:

Previous ectopic pregnancy (greatest risk)
Previous tubal surgery
PID/salpingitis
IUD use
Infertility treatment (IVF)
Smoking
Prior pelvic surgery

Clinical features:

Amenorrhoea (missed period)
Unilateral pelvic/lower abdominal pain
Vaginal bleeding (brown, irregular)
Ruptured ectopic: Sudden severe pain + haemoperitoneum → shoulder tip pain (diaphragmatic irritation) → shock

Investigations:

Serum β-hCG (positive even at low levels; single low level does NOT exclude ectopic)
Transvaginal ultrasound — empty uterus + adnexal mass; free fluid in Pouch of Douglas
Serial β-hCG: In normal IUP, hCG doubles every 48–72 hours; slower rise or plateau → suspect ectopic
Falling hCG — most common indicator for spontaneous resolution of ectopic

Management:

Option	Criteria	Details
Expectant	Falling hCG, small ectopic, stable patient	Close monitoring
Medical — Methotrexate	Unruptured, hCG <5000 IU/L, no cardiac activity, stable	Folate antagonist; inhibits trophoblast cells; 70–95% success
Surgical — Laparoscopy	Ruptured/unstable OR medical failed	Salpingostomy (preserve tube for future fertility); Salpingectomy (not wanting future fertility)

Methotrexate contraindications: Hepatic/renal disease, active infection, breastfeeding, immunodeficiency

UNIT 7: ABORTION (MISCARRIAGE)

Definition: Expulsion of products of conception before 28 weeks (or fetal weight <1000 g)

Incidence: ~15% of clinically recognised pregnancies; sporadic chromosomal aneuploidy accounts for ~60% of losses

Types of Abortion (HIGH YIELD)

Type	Cervical Os	Bleeding	Products Passed	Pregnancy Viable?	Management
Threatened	Closed	Mild	None	Yes (Doppler confirms)	Reassure, bed rest, avoid coitus
Inevitable	Open	Profuse	None yet	No	D&C
Incomplete	Open	Heavy	Partial	No	D&C
Complete	Closed	Minimal	All passed	No	Confirm with USS; observe
Missed (Silent)	Closed	Absent or brown	None (retained >4 wks)	No	D&C or misoprostol
Septic	Open	Foul discharge	Present	No	IV antibiotics + D&C
Recurrent	—	—	—	—	≥3 losses; investigate cause

Rh-negative management:

<13 weeks: 50 µg anti-D (Rh immunoglobulin) IM
13 weeks: 300 µg anti-D IM

Causes of Recurrent Miscarriage (≥3 losses):

Chromosomal (parental/fetal aneuploidy) — most common
Antiphospholipid syndrome
Uterine anomalies (septum, fibroids)
Cervical incompetence
Luteal phase defect
Thyroid disease

UNIT 8: MOLAR PREGNANCY (GESTATIONAL TROPHOBLASTIC DISEASE)

Definition: Abnormal fertilisation resulting in proliferating trophoblastic tissue

Types:

Feature	Complete Mole	Incomplete Mole
Fetal parts	Absent	Present (usually abnormal)
Karyotype	46XX (diploid — all paternal)	Triploid (69XXY)
Villous changes	All villi hydropic	Some villi hydropic
Risk of malignancy (GTD)	15–20%	5–10%
Uterine size	Large for dates	Small or normal
hCG	Very high	Mildly elevated

Ultrasound (complete mole): "Snowstorm" appearance — distended cavity with numerous anechoic cysts

Presentation:

Vaginal bleeding
Uterus large for dates
Hyperemesis
Early preeclampsia (<20 weeks — pathognomonic!)
Very high hCG → bilateral theca lutein cysts → bilateral ovarian enlargement

Management:

Suction curettage (D&C)
Serial β-hCG monitoring until 3 consecutive normal levels
Contraception for 1 year (to allow hCG normalisation and detect malignant transformation)
Chest X-ray (metastases)

Indications for chemotherapy: Rising or plateauing hCG after evacuation → gestational trophoblastic neoplasia (GTN) → Methotrexate ± Actinomycin D

UNIT 9: PREECLAMPSIA IN LABOUR — MgSO₄ PROTOCOL (STRUCTURED)

Step	Action
Position	Lateral recumbent
Diet	Nothing by mouth (NBM); clear liquids if muscle tone adequate
IV access	Lactated Ringer's 5% dextrose
Loading dose	MgSO₄ 4g IV over 15 min
Maintenance	MgSO₄ 1–3 g/hr IV infusion
Antidote at bedside	Calcium gluconate
Monitor	DTRs, urine output (I&O), lung bases (pulmonary oedema), plasma Mg levels
Duration	Continue 24 hours post-delivery

UNIT 10: GYNAECOLOGY — KEY TOPICS

10.1 Pelvic Inflammatory Disease (PID)

Definition: Ascending infection from the cervix/vagina → uterus, fallopian tubes, ovaries

Causative organisms:

Chlamydia trachomatis (most common in developed countries)
Neisseria gonorrhoeae
Anaerobes, Gram-negative rods

Clinical features (Chandelier sign):

Lower abdominal pain (bilateral)
Cervical motion tenderness (CMT) — "chandelier sign"
Adnexal tenderness
Fever
Vaginal discharge (mucopurulent)
↑WBC, ↑ESR, ↑CRP

Complications:

Tubo-ovarian abscess (TOA)
Infertility (blocked tubes)
Ectopic pregnancy risk ↑
Fitz-Hugh-Curtis syndrome (perihepatitis — RUQ pain + perihepatic adhesions)
Chronic pelvic pain

Treatment:

Outpatient: Ceftriaxone IM + Doxycycline + Metronidazole
Inpatient: IV Cefoxitin + Doxycycline OR Clindamycin + Gentamicin

10.2 Ovarian Cysts & Torsion

Common types:

Cyst	Features
Follicular cyst	Most common; resolves spontaneously in 4–8 weeks
Corpus luteum cyst	Can rupture → haemoperitoneum
PCOS (polycystic ovaries)	Multiple small follicles; anovulation, hyperandrogenism
Dermoid (teratoma)	Most common benign tumour in women <30; contains hair/teeth/fat
Endometrioma ("chocolate cyst")	Endometriosis; filled with old blood

Ovarian torsion:

Sudden severe unilateral pelvic pain
Nausea and vomiting
Tender adnexal mass on exam
Doppler USS: absent/reduced blood flow
Management: Surgical untwisting (detorsion) → salpingo-oophorectomy if necrotic

10.3 Uterine Fibroids (Leiomyomata)

Most common benign tumour of the uterus; oestrogen-dependent; regress after menopause

Types by location:

Intramural (most common)
Subserosal
Submucosal (most likely to cause heavy bleeding and infertility)
Pedunculated

Symptoms: Heavy menstrual bleeding (menorrhagia), pressure symptoms, infertility, recurrent miscarriage

Management:

Medical: GnRH analogues (shrink fibroid pre-surgery), tranexamic acid (bleeding), NSAIDs
Surgical: Myomectomy (fertility-sparing), hysterectomy (definitive)

10.4 Endometriosis

Definition: Presence of endometrial tissue outside the uterus

Sites: Ovaries (most common), peritoneum, Pouch of Douglas, bladder, bowel

Symptoms (3 Ds):

Dysmenorrhoea (painful periods — cyclical)
Dyspareunia (painful intercourse)
Dyschezia (painful defaecation)

Gold standard diagnosis: Laparoscopy + biopsy

Treatment: NSAIDs, OCPs (cycle suppression), GnRH analogues, laparoscopic ablation, hysterectomy

10.5 Cervical Cancer

Cause: HPV types 16 and 18 (responsible for ~70% of cases)

Risk factors:

Early sexual debut
Multiple sexual partners
Multiparity
Immunosuppression
Smoking
STIs

Screening: Pap smear (cervical cytology)

Start: Age 21 or 3 years after sexual debut
Frequency: Every 3 years if normal (cytology alone)

HPV vaccine: Ideally age 9–14 (before sexual debut); can be given up to age 26 routinely

Staging (FIGO):

Stage	Description
I	Confined to cervix
II	Extends beyond cervix but not pelvic wall
III	Extends to pelvic wall / lower third of vagina
IV	Bladder/rectum or distant metastases

Treatment: Stage I → surgery (Wertheim's hysterectomy); Stage II–IV → chemoradiotherapy

10.6 Menstrual Disorders

Term	Definition
Amenorrhoea	Absence of periods
Primary amenorrhoea	No period by age 16 (with secondary sex characteristics) or age 14 (without)
Secondary amenorrhoea	No period for ≥6 months in previously menstruating woman
Menorrhagia	Heavy periods (>80 mL/cycle)
Metrorrhagia	Irregular intermenstrual bleeding
Menometrorrhagia	Heavy + irregular bleeding
Dysmenorrhoea	Painful periods
Oligomenorrhoea	Cycles >35 days
Polymenorrhoea	Cycles <21 days

UNIT 11: POSTPARTUM HAEMORRHAGE (PPH)

Definition: Blood loss:

Vaginal delivery: >500 mL
C-section: >1000 mL

Primary PPH: Within 24 hours of delivery Secondary PPH: 24 hours–6 weeks postpartum

The 4 T's of PPH (EXAM GOLD)

T	Cause	Frequency
Tone	Uterine atony	~80% (most common)
Tissue	Retained placenta/products	~10%
Trauma	Genital tract lacerations	~7%
Thrombin	Coagulopathy (DIC, von Willebrand)	~3%

Risk factors for uterine atony:

Overdistended uterus (macrosomia, multiple gestation, polyhydramnios)
Prolonged labour
Grand multiparity
General anaesthesia
Oxytocin use

Management of PPH (stepwise)

Uterine massage (bimanual compression)
Uterotonic drugs:
- Oxytocin (1st line): 10 IU IM or IV infusion
- Ergometrine/Methylergonovine (Syntometrine): 0.2 mg IM (CI in hypertension)
- Misoprostol: 600–1000 µg rectal/sublingual (useful in low-resource settings)
- Carboprost (PGF2α): 0.25 mg IM q15 min (CI in asthma)
Balloon tamponade (Bakri balloon)
Surgical:
- B-Lynch compression suture
- Uterine artery ligation
- Internal iliac artery ligation
- Hysterectomy (last resort)
Blood products: Fresh frozen plasma (FFP), packed RBCs, cryoprecipitate for DIC

UNIT 12: PUERPERAL SEPSIS

Definition: Fever ≥38°C on ≥2 occasions, >24 hours apart, within the first 10 days postpartum (excluding first 24 hours)

Sources of infection:

Uterus (endometritis — most common)
Urinary tract
Breast (mastitis)
Wound (episiotomy, C-section)

Causative organisms: Group A Streptococcus, Staphylococcus aureus, E. coli, anaerobes

Features of endometritis:

Fever
Uterine tenderness
Foul-smelling lochia
Subinvolution of uterus

Treatment: IV Clindamycin + Gentamicin

QUICK REVISION SUMMARY TABLES

Antihypertensive Drugs in Pregnancy — Safety

Drug	Safe?	Notes
Methyldopa	✅ Safe (1st line)	—
Labetalol	✅ Safe	Also used IV for acute HTN
Nifedipine	✅ Safe	Oral; 2nd line
Hydralazine	✅ Safe	IV for acute HTN
ACE inhibitors (enalapril etc.)	❌ Contraindicated	Renal dysgenesis (2nd/3rd trimester)
ARBs	❌ Contraindicated	Same as ACE inhibitors

Types of Caesarean Section

Type	Indication
Elective	Planned; no emergency
Emergency Category 1	Immediate threat to mother/fetus; <30 min
Emergency Category 2	Maternal/fetal compromise; not immediate
Emergency Category 3	Needs early delivery; no compromise

HIGH-FREQUENCY EXAM QUESTIONS

Q: Painless APH in the 3rd trimester — diagnosis? A: Placenta praevia. Do NOT do vaginal examination. First-line investigation: ultrasound

Q: Painful APH with rigid uterus — diagnosis? A: Abruptio placentae. Clinical diagnosis; ultrasound has high false-negative rate

Q: Seizures in a patient with BP 170/110 at 34 weeks — diagnosis & management? A: Eclampsia. Give MgSO₄ (loading dose 4g IV over 15 min), stabilise, deliver baby. Antidote = calcium gluconate

Q: Empty uterus on TVS + positive hCG + unilateral pain in a woman with history of PID — diagnosis? A: Ectopic pregnancy. Manage with methotrexate if unruptured and stable; laparoscopy if ruptured

Q: Type of abortion where cervical os is closed, no products passed, but the fetus is dead on ultrasound? A: Missed abortion

Q: What is the most important risk factor for preterm labour? A: Previous preterm labour

Q: What is the 7th cardinal movement of labour? A: Expulsion

Q: At what cervical dilation does the active phase of labour begin? A: 4–5 cm

Q: What type of FHR deceleration is associated with umbilical cord compression? A: Variable deceleration

Q: What is the most common benign ovarian tumour in women under 30? A: Dermoid cyst (mature cystic teratoma)

Q: What is the gold standard for diagnosing endometriosis? A: Laparoscopy + biopsy

Sources: Textbook of Family Medicine 9e; Goldman-Cecil Medicine; Morgan & Mikhail's Clinical Anesthesiology 7e; Creasy & Resnik's Maternal-Fetal Medicine; Swanson's Family Medicine Review; Berek & Novak's Gynecology; Tintinalli's Emergency Medicine; Rosen's Emergency Medicine

These notes cover 12 units of core O&G content. Summary of topics:

#	Topic
1	Normal Labour — stages, cardinal movements, FHR monitoring
2	Antepartum Haemorrhage — placenta praevia vs abruption
3	Hypertensive disorders — preeclampsia, eclampsia, HELLP
4	Preterm labour — tocolytics, steroids
5	PROM
6	Ectopic pregnancy
7	Abortion types (6 types with complete comparison table)
8	Molar pregnancy/GTD
9	MgSO₄ protocol structured table
10	Gynaecology — PID, fibroids, endometriosis, cervical cancer, menstrual disorders
11	PPH — 4 T's + stepwise management
12	Puerperal sepsis

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