---

🩺 MBBS Final Year - Obstetrics & Gynaecology

LAST-MINUTE EXAM NOTES (Hinglish)

Kal ka paper - yeh sab topics zaroor padhna! Sources: Creasy & Resnik's Maternal-Fetal Medicine, Berek & Novak's Gynecology, Family Medicine Textbook.

---

📋 EXAM MEIN SABSE IMPORTANT TOPICS

Obstetrics (10-mark questions):

1. Pre-eclampsia / Eclampsia ⭐⭐⭐
2. PPH (Postpartum Hemorrhage) ⭐⭐⭐
3. Placenta Previa ⭐⭐⭐
4. Breech Presentation ⭐⭐
5. Gestational Diabetes ⭐⭐
6. Twin Pregnancy / TTTS ⭐⭐
7. Anaemia in Pregnancy ⭐⭐
8. Normal Labour & Stages ⭐⭐

Gynaecology:

1. Carcinoma Cervix ⭐⭐⭐
2. Fibroid Uterus (Leiomyoma) ⭐⭐
3. Ovarian Cysts / PCOD ⭐⭐
4. DUB (Dysfunctional Uterine Bleeding) ⭐⭐
5. Ectopic Pregnancy ⭐⭐⭐

---

---

1. PRE-ECLAMPSIA / ECLAMPSIA ⭐⭐⭐

Definition

• Pre-eclampsia: Pregnancy ke baad BP ≥140/90 mmHg (2 readings, 4 hr apart) + Proteinuria (≥300mg/24hr) after 20 weeks
• Eclampsia: Pre-eclampsia mein convulsions aa jaaye (tonic-clonic seizures)

Risk Factors (yaad karo - "N-A-R-C-O"):

Pathophysiology (simple):

Abnormal trophoblast invasion
         ↓
Spiral arteries remain narrow (don't remodel)
         ↓
Placental ischemia
         ↓
Release of vasoactive substances (sFlt-1↑, VEGF↓)
         ↓
Endothelial dysfunction THROUGHOUT body
         ↓
HTN + Proteinuria + Edema + Multi-organ damage

Severe Features (ANY ONE = Severe Pre-eclampsia):

• BP ≥ 160/110 mmHg
• Severe headache / visual disturbances
• Pulmonary edema
• Thrombocytopenia (<100,000)
• Serum Creatinine >1.1 mg/dL
• Transaminases 2x normal (liver involvement)
• Epigastric/RUQ pain (liver capsule stretch)

HELLP Syndrome:

Hemolysis, Elevated Liver enzymes, Low Platelets

HELLP SYNDROME
├── Hemolysis → Microangiopathic hemolytic anemia
├── Elevated LFTs → AST/ALT ↑
└── Low Platelets → <100,000/μL
     → Tx: MgSO4 + Delivery

Flowchart: Management of Pre-eclampsia

┌─────────────────────────────────────┐
│        Pre-eclampsia diagnosed      │
│     (BP≥140/90 + Proteinuria >20wk) │
└──────────────────┬──────────────────┘
                   │
        ┌──────────┴──────────┐
        │                     │
   MILD (<34 wks)        SEVERE or ≥34 wks
        │                     │
   Expectant Mgmt         DELIVER
        │                     │
   • Bedrest               • MgSO4 (seizure prophylaxis)
   • BP monitoring         • Antihypertensives:
   • Fetal surveillance       - Labetalol IV
   • Steroids if <34wk        - Hydralazine IV
   • NST, BPP, Doppler        - Nifedipine oral
        │                     │
   Deliver at 37 wks     Cesarean/Induction

Eclampsia Treatment - "ABCDE":

• A - Airway (lateral decubitus, prevent aspiration)
• B - Breathe (O2 supplementation)
• C - Control seizures: MgSO4 4-6g IV bolus → 1-2g/hr infusion
• D - Deliver the baby (DEFINITIVE treatment!)
• E - Evaluate (BP, urine output, reflexes)

MgSO4 Antidote: Calcium Gluconate 1g IV

---

---

2. POSTPARTUM HEMORRHAGE (PPH) ⭐⭐⭐

Definition:

• Primary PPH: Blood loss >500 mL (vaginal) or >1000 mL (C-section) within 24 hours of delivery
• Secondary PPH: Excessive bleeding 24 hrs to 6 weeks after delivery

Causes - "4 T's" (most important!)

4 T's of PPH
├── TONE (70%) → Uterine Atony - MOST COMMON
├── TISSUE (10%) → Retained placenta/products
├── TRAUMA (20%) → Lacerations, uterine rupture, inversion
└── THROMBIN (<1%) → Coagulopathy (DIC, hemophilia)

Risk Factors for Atony (most common cause):

• Overdistended uterus (twins, polyhydramnios, macrosomia)
• Prolonged/rapid labor
• Oxytocin use (uterine fatigue)
• High parity (grand multipara)
• Intraamniotic infection

Flowchart: Management of PPH

┌───────────────────────────────────────┐
│    POSTPARTUM HEMORRHAGE SUSPECTED    │
│    (Excessive bleeding after delivery)│
└──────────────────┬────────────────────┘
                   ↓
    ┌──────────────────────────────┐
    │  RESUSCITATE SIMULTANEOUSLY  │
    │  • 2 large bore IV lines     │
    │  • O2, Foley catheter        │
    │  • CBC, coagulation, X-match │
    └──────────────┬───────────────┘
                   ↓
         IDENTIFY CAUSE (4 T's)
                   ↓
    ┌──────────────────────────────────────┐
    │          TONE (Atony)?               │
    │  Uterus soft/boggy on palpation?     │
    └──────────────┬───────────────────────┘
                   ↓
    Step 1: Bimanual uterine massage
    Step 2: Oxytocin 20-40 IU in 1L IV
    Step 3: Methylergonovine 0.2mg IM (AVOID in HTN!)
    Step 4: Misoprostol 800mcg rectal/sublingual
    Step 5: Carboprost (15-methyl PGF2α) 0.25mg IM
    Step 6: Balloon tamponade (Bakri balloon)
    Step 7: Surgical - B-Lynch suture / UAE
    Step 8: Hysterectomy (LAST RESORT)

• Oxytocin immediately after delivery
• Controlled cord traction
• Uterine massage

---

---

3. PLACENTA PREVIA ⭐⭐⭐

Definition: Placenta partly/completely covers the internal os

Types:

PLACENTA PREVIA TYPES
├── Type I - Low-lying: lower segment, not reaching os
├── Type II - Marginal: reaches internal os
├── Type III - Partial: partially covers os
└── Type IV - Complete/Central: completely covers os (most dangerous!)

Classic Presentation:

"Painless, Painless, Painless BRIGHT RED bleeding" in 3rd trimester

• NO pain (vs. Abruptio - painful)
• Bright red blood
• Typically stops on its own (sentinel bleed)
• Uterus soft, non-tender

Diagnosis: ULTRASOUND (Never do vaginal exam - can cause massive hemorrhage!)

Placenta Accreta Spectrum:

Accreta → Placenta attached to myometrium (no decidua)
Increta → Invades myometrium
Percreta → Penetrates through serosa (most severe)

Management:

Placenta Previa Diagnosed
         ↓
    ┌────────────┬─────────────┐
  Stable       Active       Fetal distress
  No bleeding  Bleeding     or Term
    ↓            ↓              ↓
Expectant     Hospitalize    Emergency
Management    Steroids       C-SECTION
• Pelvic rest  (<34wks)      (delivery of
• Avoid        Blood type    choice in ALL
  intercourse  & crossmatch  complete PP)
• Steroids     Tocolytics
  if <34 wks   If <34 wks
    ↓
Elective C-Section at 36-37 wks

---

---

4. BREECH PRESENTATION ⭐⭐

Definition: Fetal buttocks/feet present at pelvic inlet (instead of head)

Incidence: 3-4% at term (24% at 18-22 weeks - most correct spontaneously!)

Types:

BREECH TYPES
├── Frank Breech (65%) → Hips flexed, knees extended ("pike position") - MOST COMMON
├── Complete Breech → Hips & knees both flexed ("sitting cross-legged")
└── Footling/Incomplete → One or both feet presenting (highest cord prolapse risk!)

Associated conditions:

• Prematurity, Placenta previa, Hydrocephaly, Uterine anomalies, Oligohydramnios

Complications:

• Cord prolapse (especially footling)
• Head entrapment (in preterm - dangerous!)
• Birth trauma (extended arms, nuchal cord)
• Perinatal asphyxia

Management Flowchart:

Breech detected at 36 weeks
          ↓
  ┌───────────────────────────┐
  │  External Cephalic Version │
  │  (ECV) - attempted at     │
  │  36-37 weeks, success 50% │
  └──────────┬────────────────┘
             ↓
    ECV successful?
    /         \
  YES          NO
   ↓            ↓
Vertex    Plan C-Section
position  (recommended for
Normal    most breech at term)
delivery

---

---

5. GESTATIONAL DIABETES (GDM) ⭐⭐

Definition: Diabetes first diagnosed/occurring during pregnancy (any degree of glucose intolerance)

Mechanism:

Pregnancy → ↑ Human Placental Lactogen (hPL)
                        ↓
            Insulin resistance ↑↑↑
                        ↓
        Most women compensate (↑ insulin secretion)
                        ↓
    Some CANNOT → GDM (3-5% of pregnancies)

Screening:

• Screen all pregnant women at 24-28 weeks
• High risk groups (obese, >25yr, family h/o DM, previous GDM, certain ethnicities): screen EARLY

Diagnosis - 2 Step Approach:

Step 1: 50g GCT (Glucose Challenge Test) - NON-FASTING
        1 hour glucose ≥ 140 mg/dL = ABNORMAL → do Step 2

Step 2: 100g OGTT (3-hour) - FASTING
        Fasting:  ≥105 mg/dL   (Carpenter: ≥95)
        1 hour:   ≥190 mg/dL   (Carpenter: ≥180)
        2 hours:  ≥165 mg/dL   (Carpenter: ≥155)
        3 hours:  ≥145 mg/dL   (Carpenter: ≥140)
        
        2 or more abnormal values = GDM DIAGNOSIS

Fetal Complications (yaad rakho):

• Macrosomia (>4000g) - big baby
• Shoulder dystocia during delivery
• Neonatal hypoglycemia
• Respiratory distress syndrome
• Stillbirth (if uncontrolled)

Management:

GDM Diagnosed
      ↓
Diet + Exercise first (2 weeks)
      ↓
FBG >95 or PP >120 still?
   YES → Start Insulin (drug of choice in pregnancy!)
   NO  → Continue diet therapy
      ↓
Weekly fetal monitoring (NST, AFI)
Delivery at 38-39 weeks (no later!)

---

---

6. TWIN PREGNANCY ⭐⭐

Types (VERY IMPORTANT - exam favorite!):

TWINS
├── DIZYGOTIC (Fraternal) - 70%
│   └── Di-chorionic, Di-amniotic (DCDA) - separate placentas
│
└── MONOZYGOTIC (Identical) - 30%
    ├── Division day 1-3 → DCDA (25%)
    ├── Division day 4-8 → MCDA - Mono-chorionic, Di-amniotic (75%)
    └── Division day 8-12 → MCMA - Mono-chorionic, Mono-amniotic (rare, dangerous!)
    └── Division >13 days → Conjoined twins

Twin-to-Twin Transfusion Syndrome (TTTS):

• Only in MONOCHORIONIC twins
• Donor twin: small, anemic, oligohydramnios (stuck twin)
• Recipient twin: large, plethoric, polyhydramnios
• Treatment: Laser ablation of anastomotic vessels

Complications of Twin Pregnancy:

• PPH (overdistended uterus - most common)
• Preterm labor (#1 cause of perinatal morbidity)
• Pre-eclampsia (3x higher risk)
• IUGR, cord prolapse
• Congenital anomalies (especially monochorionic)

---

---

7. ANAEMIA IN PREGNANCY ⭐⭐

Definition (WHO criteria):

• Hb <11 g/dL in 1st & 3rd trimester
• Hb <10.5 g/dL in 2nd trimester

Classification:

ANAEMIA IN PREGNANCY
├── Mild: Hb 10-10.9 g/dL
├── Moderate: Hb 7-9.9 g/dL
└── Severe: Hb <7 g/dL (blood transfusion!)

Causes (India context):

• Iron Deficiency (most common - 75%) → microcytic hypochromic
• Folate deficiency → megaloblastic anemia
• Vitamin B12 deficiency
• Hemoglobinopathies (Sickle cell, Thalassemia)
• Malaria (in endemic areas)

Effects:

Treatment:

• Iron: Ferrous sulfate 200mg TDS (elemental iron 60mg)
• Folate: 5mg/day (400mcg for prevention)
• Severe (<7g/dL): Blood transfusion

---

---

8. NORMAL LABOUR - STAGES ⭐⭐

LABOUR STAGES
│
├── FIRST STAGE (Onset of labour → Full dilation 10cm)
│   ├── Latent phase: 0-4cm (slow, up to 20hrs primigravida)
│   └── Active phase: 4-10cm (1cm/hr primigravida, faster multipara)
│
├── SECOND STAGE (Full dilation → Delivery of baby)
│   ├── Primigravida: up to 2 hours
│   └── Multipara: up to 1 hour
│
├── THIRD STAGE (Delivery of baby → Placenta delivered)
│   └── Normally 5-30 minutes
│
└── FOURTH STAGE (1 hour after placental delivery - observation)

Cardinal Movements of Labour (vertex presentation):

1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. Restitution (External Rotation)
7. Expulsion

---

---

9. CARCINOMA CERVIX ⭐⭐⭐ (Gynaecology)

Epidemiology:

• Most common gynecological cancer in developing countries
• HPV 16 & 18 → 70% of cases
• Other risk factors: Multiple sexual partners, early coitarche, smoking, HIV, multiparity

CIN (Cervical Intraepithelial Neoplasia):

CIN I → Mild dysplasia (lower 1/3 of epithelium)
CIN II → Moderate dysplasia (lower 2/3)
CIN III → Severe dysplasia (full thickness) = Carcinoma in situ
         ↓ (if untreated, takes 10-15 years)
INVASIVE CARCINOMA

Screening - PAP SMEAR:

• Start at 21 years or 3 years after first intercourse
• Every 3 years (Pap alone) or 5 years (Pap + HPV co-test)

Presentation:

• Post-coital bleeding (most common early symptom!)
• Intermenstrual bleeding
• Offensive vaginal discharge
• Late: Backache, hematuria, rectal bleeding (spread)

FIGO Staging Flowchart:

CARCINOMA CERVIX STAGING (FIGO)
│
├── Stage I: Confined to cervix
│   ├── IA: Microscopic (IA1 ≤3mm, IA2 3-5mm depth)
│   └── IB: Clinically visible (IB1 <4cm, IB2 ≥4cm)
│
├── Stage II: Beyond cervix, NOT to pelvic wall/lower 1/3 vagina
│   ├── IIA: No parametrial involvement
│   └── IIB: Parametrial involvement
│
├── Stage III: Extends to pelvic wall/lower 1/3 vagina OR hydronephrosis
│
└── Stage IV:
    ├── IVA: Bladder/rectum involvement
    └── IVB: Distant metastasis

Treatment:

---

---

10. ECTOPIC PREGNANCY ⭐⭐⭐

Definition: Implantation outside uterine cavity

Sites:

ECTOPIC SITES
├── Fallopian Tube (95%) - MOST COMMON
│   ├── Ampulla (70%) - most common site
│   ├── Isthmus (12%)
│   └── Fimbria (11%)
├── Ovary (3%)
├── Abdominal (1%)
└── Cervix (<1%)

Classic Triad:

Amenorrhea + Abdominal Pain + Vaginal Bleeding (Only present together in 45% of cases!)

Diagnosis:

• Beta-hCG + TVS (Transvaginal Ultrasound) - gold standard combination
• Serum beta-hCG <1500 mIU/mL with empty uterus on TVS = ectopic until proven otherwise
• Discriminatory zone: If hCG >1500-2000 IU/L, IUP should be visible on TVS

Management Flowchart:

Ectopic Pregnancy Diagnosed
           ↓
    ┌──────────────────────────────────┐
    │     STABLE or UNSTABLE?         │
    └──────┬───────────────┬──────────┘
           │               │
        STABLE          UNSTABLE
      (no rupture)     (ruptured/
           │           hemoperitoneum)
    ┌──────┴──────┐          ↓
    │             │    Emergency Surgery
  Medical      Surgical   (Laparoscopy/
  therapy      (Laparo-    Laparotomy)
  MTX*         scopy)     Salpingectomy
    │
    └── Criteria for MTX:
        • hCG <5000 IU/L
        • No fetal cardiac activity
        • Tube <3.5cm
        • Hemodynamically stable
        • No contraindications

---

---

11. FIBROID UTERUS (Leiomyoma) ⭐⭐

Definition: Benign smooth muscle tumor of uterus

Types (by location):

FIBROID LOCATIONS
├── Subserosal (under serosal layer) - least symptomatic
├── Intramural (within myometrium) - MOST COMMON
├── Submucosal (under endometrium) - MOST SYMPTOMATIC (menorrhagia!)
└── Pedunculated (on a stalk)
└── Cervical / Broad ligament / Parasitic (rare)

Symptoms:

• Menorrhagia (heavy periods) - most common symptom
• Pelvic pressure/bulk symptoms
• Urinary frequency (anterior fibroid)
• Constipation (posterior fibroid)
• Infertility (submucosal type - blocks tubes/implantation)
• Recurrent miscarriage

Degenerations (exam love!):

FIBROID DEGENERATIONS
├── Hyaline degeneration → MOST COMMON
├── Cystic degeneration
├── Calcific degeneration (in menopause)
├── Red (Carneous) degeneration → During PREGNANCY (painful!) 
│   → Treat conservatively (bed rest + analgesics)
└── Malignant (Sarcomatous) → RARE (<0.5%)

Management:

---

---

12. POLYCYSTIC OVARIAN SYNDROME (PCOS) ⭐⭐

Diagnosis - Rotterdam Criteria (2 out of 3):

PCOS DIAGNOSIS (Rotterdam) - need 2/3:
1. Oligo/anovulation (irregular periods)
2. Clinical/biochemical hyperandrogenism (acne, hirsutism, raised testosterone)
3. Polycystic ovaries on USG (≥12 follicles 2-9mm, or ovarian volume >10mL)

Pathophysiology:

↑ LH : FSH ratio
      ↓
↑ Androgen production from theca cells
      ↓
Peripheral conversion to estrone
      ↓
Anovulation + Follicular cysts
      ↓
Insulin resistance (in 50-70%)
      ↓
Further ↑ androgens + anovulation

Features:

• Irregular/absent periods (oligomenorrhea/amenorrhea)
• Acne, hirsutism, alopecia (androgenic features)
• Obesity (central)
• Infertility
• LH:FSH ratio >2:1 (classically >3:1)

Long-term risks:

• Endometrial carcinoma (due to unopposed estrogen)
• Type 2 Diabetes
• Cardiovascular disease
• Sleep apnea

Treatment:

PCOS Treatment
├── Weight loss (FIRST LINE for obese patients!)
├── OCP (regulate periods + anti-androgenic)
├── Metformin (insulin resistance + ovulation induction)
├── Clomiphene citrate (ovulation induction if fertility desired)
└── Surgical: Ovarian drilling (laparoscopic)

---

---

13. DUB - DYSFUNCTIONAL UTERINE BLEEDING ⭐⭐

Definition: Abnormal uterine bleeding with NO organic cause (no structural/systemic pathology found)

Types:

• Ovulatory DUB (less common) - polymenorrhea, menorrhagia
• Anovulatory DUB (more common) - irregular, unpredictable, heavy bleeding

AUB Classification (PALM-COEIN):

PALM = Structural causes
├── P - Polyp
├── A - Adenomyosis
├── L - Leiomyoma
└── M - Malignancy

COEIN = Non-structural causes
├── C - Coagulopathy
├── O - Ovulatory dysfunction (DUB!)
├── E - Endometrial
├── I - Iatrogenic
└── N - Not yet classified

Management:

• Medical (wants fertility / not severe):
  • OCP (combined) - regulate cycles
  • Progesterone (luteal phase)
  • Tranexamic acid (antifibrinolytic - reduce blood loss)
  • NSAIDs (mefenamic acid)
  • LNG-IUS (Mirena) - highly effective
• Surgical:
  • Endometrial ablation (completed family)
  • Hysterectomy (definitive, last resort)

---

---

QUICK REVISION TABLE - High Yield Facts

---

---

LAST-MINUTE DRUG LIST (must know!):

---

EXAM TIPS:

1. "Painless bleeding in 3rd trimester" = PLACENTA PREVIA (bright red, no pain)
2. "Painful bleeding in 3rd trimester" = ABRUPTIO PLACENTAE (dark, painful, woody uterus)
3. "Post-coital bleeding" = Ca Cervix until proven otherwise
4. "Amenorrhea + Pain + Bleeding" = ECTOPIC PREGNANCY
5. MgSO4 antidote = ALWAYS Calcium Gluconate (not calcium chloride in obstetrics!)
6. Drug of choice in pregnancy for HTN = Methyldopa (chronic) / Labetalol (acute)
7. Drug of choice for GDM = Insulin
8. C-section mandatory in: Complete placenta previa, cord prolapse with live fetus, failed forceps, brow presentation, transverse lie at term

---

Sources: Creasy & Resnik's Maternal-Fetal Medicine, Berek & Novak's Gynecology, Family Medicine Textbook