SECTION - 1

Que. 1 (Option 1): Ectopic Pregnancy

Definition

Diagnosis of Ruptured Ectopic Pregnancy

1. Amenorrhoea (missed period, usually 6-8 weeks)
2. Acute lower abdominal pain - sudden, severe, colicky or tearing; may radiate to the shoulder (diaphragmatic irritation from haemoperitoneum - Kehr's sign)
3. Abnormal vaginal bleeding (dark, scanty - "prune juice" bleeding)

• Sudden onset severe abdominal pain
• Syncope / fainting (vasovagal or haemorrhagic shock)
• Shoulder tip pain (referred from subdiaphragmatic blood)
• Rectal tenesmus (blood in pouch of Douglas)

• Pallor, sweating, tachycardia (pulse >100), hypotension - signs of shock
• Abdominal tenderness and rigidity
• Guarding and rebound tenderness
• Per vaginal: Cervical excitation tenderness (Chandelier sign), forniceal tenderness (fullness in posterior fornix), uterus slightly enlarged but pushed to one side
• Cullen's sign: Bluish discolouration around umbilicus (rare)

Management of Ruptured Ectopic Pregnancy

• Two large-bore IV cannulae
• Rapid IV fluid infusion (crystalloids - NS/RL)
• Blood grouping and cross-matching, send CBC, clotting profile
• Catheterize (monitor urine output)
• Oxygen inhalation
• Inform senior obstetrician and OT team

1. Salpingectomy (removal of the affected tube) - treatment of choice for ruptured ectopic
   • Partial salpingectomy if partial rupture and future fertility desired
2. Salpingostomy (linear incision, remove conceptus, leave tube open) - considered if contralateral tube is absent/damaged and future fertility desired; higher risk of persistent trophoblast

• Monitor vitals, Hb, urine output
• Anti-D immunoglobulin if Rh-negative
• Serum beta-hCG monitoring post-op to rule out persistent trophoblast
• Counsel about future fertility and risk of recurrence (~10-15%)
• Advise delay next pregnancy by 6-12 months

Que. 1 (Option 2): Normal Labour

Definition

Stages of Labour

• Latent phase: 0 - 4 cm dilatation (slow; up to 8 hrs in primigravida, 4 hrs in multigravida)
• Active phase: 4 - 10 cm dilatation (rapid; at least 1 cm/hr in primigravida, 1.5 cm/hr in multigravida)
• Duration: ~12 hours in primi, ~6 hours in multi

• Duration: up to 2 hrs in primi (3 hrs with epidural), 1 hr in multi

• Duration: up to 30 minutes

Management of the First Stage of Labour

• Confirm labour (regular contractions, show, ROM)
• Detailed history: parity, gestational age, last ANC visit, blood group
• General examination: vitals (BP, pulse, temperature, RR)
• Obstetric examination: fundal height, fetal lie, presentation, engagement, FHS
• Per vaginal examination: cervical dilatation, effacement, consistency, position; station of presenting part; status of membranes
• Investigations: CBC, urine routine, blood group

• FHS recorded every 30 minutes in latent phase, every 15 minutes in active phase
• Maternal vitals (BP, pulse, temperature) every 4 hours
• Cervical dilatation plotted on partograph (alert line and action line)
• Uterine contractions: frequency, duration, strength - every 30 min
• Colour of amniotic fluid if membranes ruptured
• Caput and moulding

• Ambulation encouraged in latent phase
• Oral fluids (light diet) in early latent phase; IV fluids if prolonged
• Emotional support and companionship (birth companion)
• Bladder care - empty every 2-4 hours
• Pain relief: Non-pharmacological (breathing exercises, position changes) or pharmacological (epidural analgesia - gold standard, Entonox, opioids)

• Intermittent auscultation with Pinard's stethoscope or Doppler
• Continuous CTG if high-risk (e.g. meconium, IUGR, oxytocin use)
• Watch for fetal distress: late decelerations, prolonged bradycardia, variable decelerations

• Artificial rupture of membranes (ARM/AROM) if labour slow
• Oxytocin infusion if uterine contractions inadequate (after ARM)

• Prolonged latent/active phase (dystocia)
• Fetal distress
• Cord prolapse (after membrane rupture)
• Obstructed labour

Que. 2 - Case Based

Case 1: Antepartum Haemorrhage (APH) / Placenta Praevia

Diagnosis: Placenta Praevia with haemorrhagic shock

• Painless bright red vaginal bleeding = hallmark of placenta praevia
• No abdominal pain (differentiates from placental abruption which has painful bleeding)
• 36 weeks gestation - risk period
• Tachycardia (136 bpm) + hypotension (90/60) = haemorrhagic shock
• FHS 132 bpm = fetal heart currently normal (but at risk if haemorrhage worsens)

Management

• Admit immediately to labour ward/OT
• Two wide-bore IV lines - start IV fluids (Ringer's Lactate)
• Send blood for CBC, coagulation profile, blood grouping and cross-matching
• Arrange 2-4 units of packed red blood cells
• Catheterize - monitor urine output
• Oxygen by face mask (6-8 L/min)
• Do NOT do per vaginal examination (risk of torrential haemorrhage - "double set-up" only in OT)

• Bedside USG - confirm placental site (low-lying/praevia), fetal presentation, estimated fetal weight
• Kleihauer-Betke test if Rh-negative
• Coagulation profile (PT, aPTT, fibrinogen) - watch for DIC

• At 36 weeks with haemorrhagic shock + active bleeding = Emergency LSCS (Caesarean Section)
• If major praevia (Type III/IV): Caesarean is definitive
• Give betamethasone 12 mg IM x 2 doses 24 hrs apart only if <34 weeks (already 36 weeks - not required here)
• Prepare for PPH post-Caesarean (uterine atony is common with placenta praevia as lower segment contracts poorly)
• Anti-D immunoglobulin if Rh-negative mother

• Haemorrhagic shock and death
• DIC (disseminated intravascular coagulation)
• Placenta accreta/increta/percreta (abnormal placental invasion, risk increases with praevia + prior CS)
• PPH (massive, requiring blood transfusion, B-Lynch suture, uterine artery ligation, hysterectomy)
• Air embolism (rare)

• Preterm birth (36 weeks here)
• Intrauterine hypoxia / fetal distress
• Intrauterine growth restriction (IUGR)
• Malpresentation (unstable lie, transverse lie)
• Fetal death if severe haemorrhage

Case 2: Anaemia in Pregnancy

Probable Diagnosis: Severe Anaemia in Pregnancy (Iron Deficiency Anaemia - IDA, most likely)

• WHO defines anaemia in pregnancy as Hb <11 g/dL; severe anaemia = Hb <7 g/dL
• Construction worker = low socioeconomic status, poor diet, no antenatal care
• Pallor, fatigue, bilateral pedal oedema (cardiac failure/hypoproteinaemia)
• Multiparous = depleted iron stores from repeated pregnancies
• Bilateral pedal oedema - may suggest cardiac decompensation from severe anaemia

Investigations

Management

• Admit if Hb <7 g/dL (severe) - especially at 32 weeks gestation
• High-protein, high-iron diet counselling
• Treat underlying cause (deworm if hookworm infection)

• Blood transfusion: Packed red cells transfusion is indicated (Hb 7 g/dL at 32 weeks with symptoms) - give slowly to avoid cardiac overload; use frusemide cover
• Oral iron: Ferrous sulphate 200 mg TDS or ferrous fumarate after clinical stabilization; continue postpartum
• IV iron: Iron sucrose or iron carboxymaltose - can be given if oral iron not tolerated or rapid correction needed
• Folic acid: 5 mg/day
• Vitamin C to enhance iron absorption

• Serial USG for fetal growth monitoring (2-4 weekly)
• Non-stress test (NST) - monitor fetal well-being
• Deliver in an institution with blood bank facility
• Active management of third stage of labour (AMTSL) - oxytocin 10 IU IM after delivery

Maternal and Fetal Complications

• Cardiac failure (high output failure from severe anaemia)
• Increased susceptibility to infections (reduced immunity)
• Preterm labour
• PPH (atonic uterus due to hypoxia of uterine muscle)
• Poor wound healing, puerperal sepsis
• Cardiac decompensation during labour
• Maternal death

• Intrauterine growth restriction (IUGR) - chronic placental insufficiency
• Preterm birth
• Low birth weight (LBW)
• Intrauterine fetal death (IUFD)
• Neonatal anaemia
• Increased perinatal mortality and morbidity

Case 3: Medical Termination of Pregnancy (MTP) / Abortion Counselling

Counselling for Termination of Pregnancy

• The request is voluntary and informed (no coercion)
• Confirm gestational age (8 weeks = 1st trimester - eligible for MTP)
• Under MTP Act 2021 (India): Pregnancy can be terminated up to 20 weeks by a single RMP; up to 24 weeks in special categories (rape, contraceptive failure, fetal anomaly - with 2 RMPs); up to viability by Medical Board in cases of substantial fetal anomalies
• G4P3 with last delivery 7 months back = grand multipara; short birth spacing = valid medical ground for MTP (spacing + family planning)
• Explain both medical and surgical options
• Explain risks, benefits, alternatives (adoption, contraception)
• Obtain written informed consent
• Confirm no contraindications

Medical Methods of Termination (up to 9 weeks / 63 days)

• Mifepristone 200 mg oral - Day 1 (antiprogestogen - sensitizes uterus)
• Misoprostol 800 mcg (vaginal/sublingual/buccal) - 24-48 hrs later (prostaglandin E1 analogue - causes uterine contractions)
• Efficacy: ~95-98% complete abortion up to 63 days
• Patient counsels: expect heavy bleeding, cramping, passage of products; follow-up in 2 weeks for completion confirmation

• Methotrexate + misoprostol (used if mifepristone unavailable)
• Gemeprost (prostaglandin, vaginal pessary)

Surgical Methods of Termination

• Manual Vacuum Aspiration (MVA): Preferred for <7 weeks; outpatient procedure under LA/sedation; handheld suction cannula (Karman cannula); safe, effective, minimal complications

• Electric Vacuum Aspiration (EVA) / Suction Evacuation: Under LA or GA; electric suction pump; most common surgical method in 1st trimester
• Dilatation and Curettage (D&C): Older method, now largely replaced by suction evacuation; higher risk of Asherman's syndrome

• Dilatation and Evacuation (D&E): Requires wider cervical dilatation (osmotic dilators - laminaria, or misoprostol); forceps + suction; requires skilled operator
• Intra-amniotic injection: Hypertonic saline or urea (rarely used now)
• Prostaglandin-induced abortion: Misoprostol/gemeprost vaginal pessaries; medical induction of labour; followed by surgical evacuation if needed

Post-procedure care and contraceptive counselling:

• Offer contraception immediately after MTP (IUCD insertion at time of procedure, or DMPA injection, or OCP)
• For G4P3 with completed family: counsel for permanent sterilisation (tubectomy/ligation) - can be done at same time as surgical MTP
• Follow-up visit in 2 weeks to confirm complete evacuation

Summary of Key Points:

• Q1.1 - Ectopic pregnancy = ectopic implantation; ruptured = surgical emergency requiring laparotomy + salpingectomy with simultaneous resuscitation
• Q1.2 - Normal labour = 3 stages; 1st stage managed by partograph, monitoring, pain relief, and timely intervention
• Case 1 - Painless APH at 36 weeks with shock = Placenta Praevia - Emergency LSCS
• Case 2 - Hb 7 g/dL at 32 weeks = Severe IDA in pregnancy - blood transfusion + iron therapy + fetal surveillance
• Case 3 - G4P3, 8 weeks, unwanted pregnancy = MTP Act counselling; medical (mifepristone + misoprostol) or surgical (MVA/suction evacuation) method; counsel for sterilisation

Que. 6 - Case Based Scenarios

Case 1: Pelvic Inflammatory Disease (PID)

Diagnosis: Pelvic Inflammatory Disease (PID)

• Young sexually active woman
• Acute lower abdominal pain (bilateral)
• Foul-smelling vaginal discharge = purulent/mucopurulent cervicitis/endometritis
• Burning micturition = urethritis component (common in PID due to N. gonorrhoeae / C. trachomatis)
• Classic triad of PID: lower abdominal pain + vaginal discharge + fever

• Primary: Neisseria gonorrhoeae, Chlamydia trachomatis
• Secondary (polymicrobial): E. coli, anaerobes (Bacteroides), Mycoplasma genitalium, streptococci

• Ectopic pregnancy (must rule out - check urine hCG)
• Acute appendicitis
• Urinary tract infection (UTI) / pyelonephritis
• Ovarian torsion
• Ruptured ovarian cyst
• Endometriosis

1. Lower abdominal/pelvic tenderness
2. Cervical motion tenderness (CMT / "chandelier sign")
3. Adnexal tenderness

Management

• Ceftriaxone 500 mg IM single dose (covers gonorrhoea) PLUS
• Doxycycline 100 mg oral BD x 14 days PLUS
• Metronidazole 400 mg oral BD x 14 days (covers anaerobes and BV)

• Tubo-ovarian abscess (TOA)
• Failure to respond to oral therapy in 72 hours
• Pregnancy
• Severe illness (high fever, vomiting, unable to take oral medications)
• Surgical emergency cannot be excluded

• Cefoxitin 2g IV 6-hourly + Doxycycline 100 mg oral/IV BD (switch to oral after 24 hrs of clinical improvement)
• Continue oral doxycycline + metronidazole for total 14 days

• Tubo-ovarian abscess (TOA)
• Chronic pelvic pain
• Infertility (tubal factor - adhesions, blocked tubes)
• Ectopic pregnancy (x6-10 increased risk)
• Fitz-Hugh-Curtis syndrome (perihepatitis - right upper quadrant pain)

Case 2: Carcinoma Cervix

Diagnosis: Carcinoma of the Cervix

• Postmenopausal woman (age 64)
• Contact bleeding (bleeding on touch = friable tumour)
• Foul-smelling vaginal discharge (tumour necrosis)
• Visible growth on cervix on speculum

Differential Diagnoses

1. Carcinoma cervix (most likely - growth + contact bleeding + PMB)
2. Cervical polyp (benign, pedunculated, soft, bleeds on touch - but no foul discharge usually)
3. Cervical fibroid (firm, smooth)
4. Endometrial carcinoma (PMB - but uterine in origin, cervix may look normal)
5. Cervicitis / cervical erosion (ectropion)
6. Metastatic tumour to cervix

Investigations

FIGO Staging (Clinical)

Management

• Radical (Wertheim's) hysterectomy + bilateral pelvic lymph node dissection (BPLND)
• OR Concurrent chemoradiation (cisplatin-based) - equally effective, used if surgical risk high

• Concurrent chemoradiation (External Beam Radiotherapy + Brachytherapy + Cisplatin weekly)

• Palliative chemotherapy (cisplatin + paclitaxel ± bevacizumab)
• Palliative radiotherapy for symptom control

• Punch biopsy to confirm diagnosis
• Staging workup (MRI pelvis, CECT)
• If Stage IB - Radical hysterectomy + BPLND or chemoradiation

Case 3: Uterine Fibroid (Leiomyoma) with Menorrhagia

a) Drugs Used for Excessive Menses (Menorrhagia) in Fibroids

b) Surgical Management of Fibroid

• Removal of fibroid(s) while preserving the uterus
• Indicated if: wants to preserve fertility, young age
• Routes: Open (abdominal) myomectomy - preferred for large/multiple fibroids; Laparoscopic myomectomy; Hysteroscopic myomectomy (submucous fibroids)
• Risk: Recurrence (~15-30%), blood loss, adhesions

• Complete removal of uterus
• Best option for: completed family, perimenopausal (50 yr), large fibroid (8x7 cm), failed medical Rx
• Types:
  • Total hysterectomy (uterus + cervix) - preferred
  • Subtotal hysterectomy (uterus only, cervix preserved) - less common
• Routes: Abdominal (TAH), vaginal (VH), laparoscopic (TLH/LAVH)
• For this patient: TAH (Total Abdominal Hysterectomy) is most appropriate given large fibroid size

• Uterine Artery Embolization (UAE): Radiological procedure; blocks blood supply to fibroids; fibroids shrink ~50%; preserves uterus; not ideal >35 weeks pregnancy planning
• MRI-guided Focused Ultrasound (MRgFUS): Non-invasive ultrasound ablation; outpatient; emerging option
• Endometrial ablation: For menorrhagia without large fibroids; not useful for large intramural fibroid

c) Secondary Changes in Fibroid (Degenerative Changes)

Summary:

• Case 1 - Young woman with lower abdominal pain + foul discharge + burning micturition = PID; treat with Ceftriaxone + Doxycycline + Metronidazole; rule out ectopic first
• Case 2 - 64-yr-old, PMB, growth on cervix with contact bleeding + foul discharge = Carcinoma Cervix; confirm by punch biopsy; stage with MRI/CECT; treat with radical hysterectomy or chemoradiation
• Case 3 - 50-yr-old, large intramural fibroid (8x7 cm), failed medical treatment = surgical management (TAH preferred); drugs include tranexamic acid, GnRH agonists, LNG-IUS; secondary changes include hyaline, cystic, red, calcific, and sarcomatous degeneration