OBSTETRICS PART-I - 1 File Download

"OBSTETRICS & GYNECOLOGY” Run By :Dr. Pranav Goyal

Dr. Pranav Nursing Academy

67 Metro Pillar, Main Gurjar Ki Thadi, Jaipur, 302019

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Chapter 1

BASICS OF REPRODUCTION GERM Cell and its Differentiation:

Germ cell dk fuekZ.k Epiblast ;k Yolk Sac ds Ectoderm ls gksrk gSA

SRY Gene (Sex determining Region Present on Y Chromosome)

Present Absent

Spermatogonia Oogonia

GERM CELL DIFFERENTIATION:

1) SPERMATOGENESIS:

Primordial Germ Cell ds }kjk Spermatid dk fuekZ.k rFkk Spermatids dk Spermatozoa ¼;k

Sperm½ esa differentiation spermatogenesis dgykrk gSA

Spermatogenesis Puberty ds le; Males esa Testis dh Seminiferous tubules esa Start gksrk gSA

Complete Spermatogenesis esa yxHkx 72&74 fnu dk le; yxrk gSA

Spermatogonia

Enlarge, Mature (Mitosis)

Primary Spermatocyte (2n)

1st Meiotic Division

(n) (n)

Secondary Spermatocyte (2 in No.)

Spermatids (4 in No.)

Undergo transformation

Spermiogenesis

Sperms (4 in No.)

,d spermatgonia ls yxHkx 16 primary spermatocytes dk fuekZ.k gksrk gSA

44 + X Y

44 + X Y

22 + X 22 + Y

22 + Y 22 + X 22 + X 22 + Y




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,d primary spermatocyte ls 4 sperms dk fuekZ.k gksrk gSA

vFkkZr~ ,d spermatogonia ls (16 × 4) = 64 sperms dk fuekZ.k gksrk gSA

Spermatids dk maturation mainly epididymis ds caudal part vFkkZr~ Tail of Epididymis esa gksrk gSA

Sperm dk size - 55 microns

Sperm dk life spam - 72 hours.

Ion Responsible for motility of sperm - Calcium.

SPERMIOGENESIS:

bl process ds }kjk spherical vkdkj dk spermatid longitudinal sperm esa convert gks tkrk gSA

bl process esa fuEu changes gksrs gSa%&

Part of Spermatid Part formed in Sperm

Nuclear material Head of Sperm

Golgi Body Acrosomal Cap

Mitochondria Middle Piece

Microtubules / Centrioles Axial Filament / Tail of Sperm.

Sperm esa Rough Endoplasmic Reticulum ugha ik;k tkrk gSA

Spermiogenesis esa yxHkx 14 days dk le; yxrk gSA

HORMONE RESPONSIBLE FOR SPERMATOGENESIS:

- ve feedback

FSH

LH

Spermatogenesis Release Inhibin

Testosterone

Spermatogenesis ds fy, FSH, LH rFkk Testosterone rhuksa Hormone vko’;d gSA

Spermatogenesis ds fy, lcls Main Hormones Testosterone gSA

CAPACITATION:

Sperm esa dqN Biochemical Changes gksrs gSa ftlls og Ovum ls fpidus ,oa mls Fertilize djus esa l{ke

gks tkrk gS bl process dks Capacitation dgrs gSaA

Capacitation mainly Female Genital Tract esa gksrk gS ;g Cervix esa Start gksrk gS but major part

fallopian tube eaas complete gksrk gSA

Capacitation esa yxHkx 7 hours dk Time yxrk gSA

Pitutory gland

Leydig cells

Sertoli Cells




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Capacitation ds ckn sperm iwjh rjg ls Mature rFkk Hypermobile gks tkrk gSA

OOGENESIS:

Primordial Germ Cells ds }kjk Mature Ovum dk cuuk oogenesis dgykrk gSA

Enters the gonads of female and differentiate into

Mitosis

At birth, No more mitosis occurs & all

oogonia replaced by primary oocyte

Enter 1st Meiotic Division

Arrested in Prophase - Diplotene Stage

1st Meiotic division completed after puberty, just prior to ovulation & releasing

2nd Meiotic Division

Arrested in Metaphase

Division completed at the time of fertilization

IMPORTANT POINTS

Oogenesis, Intrauterine life esa Ovary esa yxHkx 6-8 weeks of gestation ij start gksrk gSA

Oocytes / Oogonia dh la[;k Ovary eaas lcls vf/kd 5th month of Intrauterine life esa gksrh gSA (20th

week of gestation yxHkx 6&7 million)

Birth ds le; lHkh Oogonia Primary Oocyte esa Convert gks tkrh gSA Birth ds le; nksuksa Ovary dks

feykdj yxHkx 2 million primary oocyte gksrh gSA

Puberty ds le; rd Primary oocytes ?kVdj yxHkx 3 yk[k ls 5 yk[k rd jg tkrh gS ftuesa ls flQZ

500 Primary Oocytes Mature gksdj Ovum Release djrh gSA

Primordial Germ Cell

Oogonium 44 + XX

Primary Oocyte 44 + XX

First Polar body 22 + X Secondary Oocyte 22 + X

Ovum 22 + X 2nd Polar Body 22 + X




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Birth ds le; lHkh Primary Oocyte esa Growth, Diplotene Stage of Prophase esa Arrest gks tkrh gS

tks fd Meiosis Division dh ,d stage gSA

Ovary esa Primary Oocyte pkjksa vksj ls Follicular cells }kjk f?kjk gksrk gS ftls Primordial Follicle

dgrs gSaA

Puberty ds le; Mid Cycle Preovulutory Surge gksrk gS (LH Surge) ftlls Meiosis iqu% Start gksrk

gS rFkk Ovulution ds Just igys Complete gksrk gS vFkkZr~ Meiosis-I ,d Hormonal Dependent

Process gS tks fd LH Hormone ij depend gksrk gSA

Primary Oocyte ls Secondary Oocyte dk cuuk Ovulution dgykrk gSA

Secondary oocyte cuus ds ckn immediate 2nd Meiotic Division Start gksrk gS यह

metaphase stage arrest ह ह A Fertilization स य 2

nd meiotic division complete ह ह 2nd

polar body ovum

release ह ह A Size of Mature Ovum - 120 - 130 Micron (Largest cell in Body)

Life Spam of Ovum - 12-24 hours.

FERTILIZATION:

Fertilization ,d Process gS ftlds }kjk Male Pronucleus ,oa Female Pronucleus vkil esa feydj

Zygote cukrs gSaA

Fertilization Fallopian Tube ds Ampula okys Part esa gksrk gSA

Male rFkk Female Pronucleus ds Fusion ds fy;s Fertilin uked Gene Responsible gksrk gSA

Fertilization ds ckn Zygote Fallopian Tube esa 3 fnu rd jgrk gS rFkk blesa Cell Division gksrk jgrk gSA

Fertilization ds 4 fnu ckn vFkkZr~ Cycle ds 18th day ij Zygote Uterine Cavity esa izos’k djrk gS bls

Morula Stage dgrs gSaA (16 Cell Stage)

Morula ds pkjksa vksj ,d layer ह ह स Zona Pellucida dgrs gSaA Zona pellucida polyspermy ह A Fertilization ds 5 fnu ckn vFkkZr~ Cycle ds 20th day ij ;g Zona Pellucida lost gks tkrh gS bl izfØ;k dks

Zone Hatching dgrs gSaA

Morula - Mulberry Shaped




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tSls gh Morula Uterine Cavity esa izos’k djrk gS morula Fluid enter gksrk gS rFkk ;s Blastocyst esa convert gks

tkrk gS&

cells of blastocyst cells defferntiate ह ह - - Inner Cell Mass

- Trophoblast

Protein E- Cadherin bl differentiation esa Help djrh gSA

Inner Cell Mass Future esa Embryo cukrh gS tcfd Trophoblast ls Placenta rFkk Fetal Membranes

curh gSA

IMPLANTATION:

bl izfØ;k ds }kjk Blastocyst Uterine Mucosa dks Penetrate djds Endometrium esa Implant gks tkrk

gSA

Implantation Fertilization ds 6&7 fnu vFkkZr~ Menstrual Cycle dds 20&21 osa fnu ij gksrk gSA

Implantation Site - Posterior surface of upper uterine segment (mainly 2/3rd cases)-

Anterior surface of upper uterine segment. (1/3rd

cases)

DECIDUA:

Implanantation ds ckn Endometrium Decidua dgykrh gSA

Decidua become differentiated into -

(i) Decidua Basilis: Decidua dk og Part tks Myometrium rFkk Embryo ds chp fLFkr gksrk gS mls

Decidua Basilis dgrs gSaA ;g Maternal Side of Placenta cukrk gSA

(ii) Decidua Capsularis: Embryo rFkk Uterine Cavity ds chp okyk Part Decidua Capsularis dgykrk gSA

(iii) Decidua Parietalis: Rest of Decidua which lines the cavity of uterus .




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dqN Females esa Implantation ds le; Slight Bleeding gksrh gS ftls Hartman Sign dgrs gSaA

Differentiation of Blastocyst

Fertilization 8 trophoblast 2 layers differentiate ह ह Cytotrophoblast: ;g vanj dh vksj Mono Nucleate Cell Layer gksrh gSA bls Langhan‘s Cell Layer Hkh dgrs

gSaA

Syncytiotrophoblast: ;g ckgj dh vksj Multilayered rFkk Multi Nucleated Cell Layer gksrh gSA

cytotrophoblast vkxs Differentiate gksdj Chorion Frondosum cukrh tks fd Fetal side of Placenta

cukrk gSA

Trophoblast – Placenta rFkk Fetal Membrane Chorion cukrk gSA

Inner Cell Mass – Embryo cukrk gSA

Important Points:

Langhans Cells – Cytotrophoblast

Hofbauer cells – Placenta

Peg Cells – Fallopian Tube




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Chapter 2

Placenta, Fetal Membranes, Umbilical Cord and Amniotic Fluid

PLACENTA:

Human Placenta Discoid, Haemochorial & Deciduate gksrk gSA

Discoid – Disc Shaped

Haemochorial – Direct contact of chorion with maternal blood.

Deciduate – Maternal tissue shed at Parturition.

DEVELOPMENT OF PLACENTA:

Placenta dk development nks source ls gksrk gSA

Fetal Part – Chorion Frundosum (Cytotrophoblast)

Maternal Part – Decidua Basilis

FORMATION OF PLACENTA:

Trophoblast Fertilization ds 8osa fnu Syncytiotrophoblast rFkk Cytotrophoblast esa differentiate gks tkrk gSA

Cytotrophoblast vanj dh vksj fLFkr gksrh gS rFkk Mononucleate Single Cell Layer gksrh gS tcfd

Syncytiotrophoblast ckgj dh vksj Multinucleate Cells dh Layer gksrh gSA




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Cytotrophoblast Mesoderm ds Åij dh vksj fLFkr gksrh gSA

Syncytiotrophoblast esa small cavities cu tkrh gS tks fd Lacunae ह agSA Syncytiotrophoblast Endometrium esa grow djrk gS tSls gh Endometrium eroded gksrh gS dqN

Maternal Blood Vessels Open gks tkrh gSa vkSj Blood Lacunar Space esa Hkj tkrk gSA

’kq:vkr esa izR;sd Trabeulae flQZ Syncytiotrophoblast dh cuh gksrh gS ckn esa Cytotrophoblast dh Cells

foHkkftr gksdj Trabeulae esa grow djrh gS ftls Primary Villi dgrs gSaA

izR;sd Primary Villi ds chp esa Extra Embryonic Mesoderm Invade djrh gS ftls Secondary Villi dgrs

gSaA

izR;sd Secondary Villi ds vanj dh vksj Fetal Blood Vessels grow djrh gS ftls Tertiary Villi dgrs gSaA

Lacunar Space esa Maternal Blood rFkk Fetal Blood vkil esa dHkh ,d nwljs ds Direct Contact esas ugha

gksrs ;s ,d nwljs ls Placental Barrier }kjk Seperate jgrs gSaA

Syncytiotrophoblast

Cytotrophoblast Placental Barrier

Extra Embryonic Mesoderm

Endothelium of Fetal Capillaries

Primary Villi – 13th day after Fertilization

Secondary Villi – 16th day after Fertilization

Tertiary Villi – 21st day after Fertilization

Fetoplacental Circulation Fertilization ds ckn D17 – D21 ij Establish gks tkrk gSA

Maternal Arterial Blood Fertilization ds ckn D15 ij Intervillous Space esa vkrk gSA

Functional Unit of Placenta – Cotyledon.

Term ij Placenta ,d Circular Disc dh rjg gksrk gS ftldk Diameter yxHkx 15–20 Cm rFkk

Thickness yxHkx 3 Cm gksrh gSA

Term ij Placenta dk Weight – 500 gm gksrk gSA

Term ij Ratio of Weight of Placenta & baby. is – 1: 6.

17th week of Gestation ij Placenta ,oa Fetus dk Weight yxHkx cjkcj gksrk gSA

Placenta Uterine wall dk yxHkx 30% Part Cover djrk gSA Mainly ;g yxHkx 2/3rd Cases esa Uterus

dh Posterior Wall ls Attach gksrk gS tcfd 1/3rd cases esa Uterus dh Anterior Wall ls Attach gksrk gSA

Term ij Placenta dk yxHkx 4/5 Part Fetal Origin dk gksrk gS tcfd Only 1/5 Part Maternal Origin

dk gksrk gSA

Nitabuch’s Membrane: ;g Outer Syncytiotrophoblast ds ckgj dh vksj Fibrinoid Material dh ,d Layer

gksrh gS tks fd Trophoblast dks vkxs Decidua esa Invasion ls jksdrh gSA

Nitabuch‘s Membrane ds Absence esa Placenta Accreta, Increta rFkk Percreta dh laHkkouk c<+ tkrh gSA




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Fetal Fibronectin (FFN):- bls Trophoblast glue Hkh dgrs gSaA ;g Protein mainly Trophoblast dss Maternal

Decidua esa Migration ds fy;s vko’;d gksrh gSA

Fetal Fibronectin (FFN) ds Cervical ;k Vaginal Fluid esa Preterm Labour ;k PROM dks Indicate

djrh gSA

Placenta dk fuekZ.k 6 week ls start gksrk gS tks fd yxHkx 14 – 15 week ij Complete gksrk gSA USG esa

Placenta dks yxHkx 10 weeks ij ns[kk tk ldrk gSA

Placental Circulation:

Placenta esa Villi rFkk Intervillous Space ik;k tkrk gSA

Villi – Foetal Blood (350 ml)

Intervillous Space – Maternal Blood (150 ml).

Vol. of Placenta – 350 + 150 = 500 ml.

Placenta esa Maternal rFkk Foetal Blood nksuksa Present gksrs gSa ysfdu nksukas vkil esa dHkh Mix ugha gksrsA Uteroplacental Circulation:

Circulation of Maternal Blood through Intervillous Space.

Uteroplacental circulation D12 ij establish gks tkrk gSA

Term ij Uteroplacental Blood Flow yxHkx 450 – 650 ml/min gksrk gSA Foetoplacental Circulation:

Foetoplacental circulation mainly Umbilical arteries & Umbilical veins ds }kjk gksrk gSA

Umblical Vein – Oxygenated Blood ¼’kq) jDr½ Placenta ls Foetus rd ykrh gSA

Umblical Artery – Deoxygenated Blood ¼v’kq) jDr½ dks Foetus ls okil Placenta rd ykrh gSA

Umblical Cord esa 2 Umbilical Artery rFkk 1 Umbilical Vein ikbZ tkrh gSA(Left umbilical vein Left)

Foetoplacental circulation D21 ij Establish gks tkrk gSA

Placental Pathology:

1) Placental Infarction: Most common placental lesion.

– Mainly Associated with Preeclampsia and lupus Anticoagulant.

– This leads to placental Abruption.

2) Placentomegaly: Pregnancy ds nkSjku Placenta dh Thickness yxHkx 1 mm / week c<+rh gSA ;fn Term

ij Placenta dh Thickness 40 mm ls T;knk gS rks bls Placentomegaly dgrs gSaA

Causes of Placentomegaly: lksuksxzkQh appearance ds vk/kkj ij Causes of Placentomegaly fuEu gS &




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Causes of Homogeneous Placental Thickening:

Diabetes Mallitus or Gestational Diabetes

Anemia

Hydrops Foetalis

TORCH Infection

Aneuploidy

Causes of Heterogeneous Placental Thickening:

Intraplacental Haemorrhage.

3) Small Placenta:

Postdatism

IUGR

Placental Infarction.

Abnormalities of Placenta:

(1) Succenturiate Placenta: Placenta dk ,d NksVk lobe main placenta ls blood vessels ds }kjk connect

jgrk gSA

(2) Placenta Bilobata: tc placenta ds nks lobe size gksrs gSa rFkk ,d nwljs ls blood vessels ds }kjk

connect jgrs gSa rks bls Placenta Bilobata dgrs gSaA

(3) Placenta Spuria: tc placenta dk ,d NksVk lobe main placenta ls separate jgrk gS ysfdu muds chp

blood vessels dk dksbZ connection ugha gksrk bls Placenta Spuria dgrs gSaA

Fig:A.Placenta Succenturiata Fig:B. Placenta Bilobata Fig:C. Placenta spuria

Extrachorial Placenta:

Normally Chorionic Plate Placenta ds Periphery rd Extend djrh gS rFkk Basal Plate ,oa Chorionic Plate

dk Diameter cjkcj gksrk gSA




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Extrchorial Placenta esa Chorionic Plate Basal Plate ls NksVh gksrh gSA

a) Circumarginate Placenta: Chorionic Plate Amnion rFkk Chorion dh single fold ls cover gksrh gSA

Fibrin rFkk Old Haemorrhage Placenta rFkk Overlying amnio-chorion ds chp fLFkr gksrk gSA

b) Circumvallate Placenta: Chorionic Plate Amnion rFkk Chorion dh double fold ls cover gksrh gSA

ftlls Maternal rFkk foetal surface ds chp ,d Valve like lajpuk fn[kkbZ nsrh gSA

Placental Tumors :-

Most common benign tumor of placenta chorioangiona ह ! Chorioangioma avasvular mass

ह ह , chorion स Arise ह ह ! Incidence 1%

Small chorioangioma – Insignificant

Large chorioangioma (>5cm) can leads to

(a) Maternal Complication

Polyhydroaminosis

PIH

Preterm labour

Increased AFP

(b) Fetal Complication :-

Hydrops fetalis

Fetal cardiomegaly

IUGR

Tumor placenta metastasize ह स ह ! Melanoma

Leukemia

Lymphoma

Breast cancer




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Melanoma स Placental tumor ह , fetus metastasize ह स ह !

Function of Placenta :-

(i) Transfer of gases, nutrients & waste products

Example : Respiratory

Nutritive

Excretomy

Important Points :-

Fetus oxygen delivery गभग 8mL/kg of fetal wt/min हस स ह ह , placental

blood flow achieve ह !(Placental blood flow गभग 400 mL/min ह ह ) Fetus energy main sourse glucose ह ह ! Fetus maternal blood स glucose facilitated diffusion ह ! (Using GLUT-1

& GLUT-3).

Early pregnancy lipid mother स foetus direct transfer ह ह , late pregnancy fetus य lipid synthesis ग ह , स fetus lipid daul origon ह ह !

Water electrolytes simple diffusion transfer ह ह ! (i) Immunological function

(ii) Hormonal function/ Endocrine function

(iii) Enzymatic function

(iv) Barrier function

Hormonal function of placenta :-

Placenta Mainly hormones synthesis ह ह ! 1. Progesterone

2. Estrogen

3. Human placental lactogen (HPL)

4. Human chorionic gonadotropin (HCG)

5. Human chorionic thyrotropin

6. Pregnancy specefic β glycoprotein

7. Pregnancy associated plasma protein A (PAPP-A)

Placenta hormones mainly syncytiotrophoblast य ह ! Progestrone :-

Pregnancy 6-7 weeks progesterone mainly corpus luteum य ह !




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8-10weeks progesterone placenta start ह ह ! Pregnancy maintain स स ह Hormone progesterone ह ह !

Abnormal level of progestrone :-

Low level Ectopic pregnancy

abortion

High level Molar pregnancy

Rh isoimmunization

Estrogen:- Estrogen placenta स भ ह ह य 17-α-hydroxylase enzyme ह स यह C21 steroid use ह ! Fetal adrenal gland DHEA-S ह , सस placenta estradiol estriol ह !

Important Points :-

Most common estrogen during pregnancy Estradiol (E2)

Most specefic estrogen during pregnancy Estriol (E3)

Hormone which can be used as a marker for fetal well being Estriol (E3)

Main product of fetal adrenal gland DHEA-S

Fetal Adrenal Gland :-

Morphologically, functionally and physiologically fetal adrenal gland remarkable

organ ह ! Term foetal adult adrenal gland weight ह ह ! Fetal adrenal gland mainly steroid hormone synthesis ह !

Human placental Lactogen(hPL) :-

स human chorionic somatotropin भ ह ह ! (hCS)

यह mainly syncytiotrophoblast synthesis ह ह ! Function :-

यह maternal lipolysis ह , सस produce ह free fatty acids mother source of

energy ह ! यह Hormone Breast lactation prepare ह ! Note :- hPL Lactation role !

Human chorionic gonadotropin (hCG) :-

यह Glycoprotein hormone ह !




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Human सभ hormones स स य Carbohydrate content hCG य ह hCG 2 sub unit ह -

α-Submit :- Biologically यह FSH, LH TSH ह ह ह ! (Non specefic)

β- Submit :- Unique to hCG (Specefic)

Structurally यह FSH, LH TSH ह ह ह , Functionally यह LH ह ह ह (LH Leutotropic) Corpus luteum maintain help ह !

Half life of hCG 24-36 hrs.

Doubling time 2 days (1.4- 2 days)

यह hormone maternal serum fertilization 8 , menstrual cycle 22

appear ह ह ! Period missed ह ह स स य hCG level 100 IU/L ह ह ! 8-10 weeks गभग (70 days ) hCG level maximum 1,00,000 IU/L ह ह , स

यह ह start ह ह ! 16 weeks स level maximum ह ह , term स level minimum ह ह ! hCG delivery 48 urine स disappear ह ह ! hCG delivery 1-2 weeks maternal serum स disappear ह ह ! hCG abortion 4-6 weeks matrenal serum स disappear ह ह !

hCG ह titre gestational sac TVS (Transvaginal) sonography visible ह ह 1500 IU/L .

HCG ह titre gestational sac TAS (Transabdominal) sonography visible ह ह 6000-

6500 IU/L.

Clinical importance of the measurement of hCG

Increased hCG Decreased hCG

Multi fetal pregnancy Abortion

Gestational trophoblastic disease Trisomy other than down syndrome

Down syndrome Ectopic pregnancy

Underestimated gestational age

Erythroblastasis foetalis

Note :- Ectopic pregnancy hCG level Normal Pregnancy rise ह ह ! Function Of HCG :-

Corpus luteum maintain ह ! hCG, LH hormone stimulate ह , स ह स fetal testis स testosterone release ह ह




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hCG immunosuppresive ह ह , fetus rejection ह ! hCG uterine muscles relaxation uterine vessels vasodilation ह ! hCG maternal thyroid gland stimulate ह !

Fetal membrane :-

AMNION :- यह Innermost fetal membrane ह ह , यह avascular ह ह ! Amnion smooth muscle cells,

nerves, lymphatic blood vessels ह ह ! यह membrane fertilization 10-11 ह ! CHORION :- यह outer membrane ह ह , easily break ह ह ! यह chorionic leave ह ! यह

memembrane fertilization 8 ह !

UMBILICAL CORD / FUNIS :-

Umblical cord स स ह ह , fetal umbilicus स ह placenta fetal surface

य chorionic plate स ह ह ! Umblical cord connecting stalk स develop ह ह ! Early fetal life umbilical cord 2 arteries 2 veins ह ह , right umbilical vein

disappear ह ह , स left umbilical vein ह ह ,(Left is left) umbilical cord 2

umbilical arteries 1 umbilical vein ह ह ! Umbilical arteries diameter, vein ह ह ! Umbilical cord स amnion cover ह ह , chorion absent ह ह ! Normal PH of umbilical cord 7.2

Structure & Function of umbilical cord :-

Umbilical cord whartons jelly ह ! (Connective tissue of umbilical cord).-mesoderm स derived ह ह !

Normal length of umbilical cord 55 cm

Range 30-100 cm

If < 30 cm Short cord

If > 100 cm Long cord

Umbilical cord arteries veins folded tortous ह ह , false knot ह ! Umbilical arteries lumen transverse fold ह , ह fold of hoboken ह ह !

Umbilical cord coils ह ! cm umbilical cord coils ह स umbilical coiling

index ह ह USG ह ! Normal coiling index 0.17 coils/cm




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Hypocoiling < 0.07 coils/cm (causes IUD)

Hypercoiling causes IUGR & fetal acidosis

umbilical vein oxygenated blood carry ह umbilical artery deoxygenated blood carry ह !

Abnormalities of cord insertion:-

1) Normal- Normally umbilical cord placenta स centre attach ह ह ! 2) Marginal/Battledore – umbilical cord placenta स margin attach ह ह ! स placenta

Battledore placenta भ ह ह ! 3) Furcate- umbilical cord placenta स centre attach ह ह insertion स ह furcate ह ह ! 4) Velamentous- umbilical cord placenta स ह ह fetal membranes (chorioamniotic membrane)

insert ह ह membranes ह placenta lateral side insert ह ह !

Fig:A.Normal Fig:B. Marginal Fig:C. Furcate Fig :D. Velamentous

SINGLE UMBILICAL ARTERY (SUA)

यह Umbilical cord most common vascular anomally ह ! Single umbilical artery foetal congenital malformation स associated ह ह !

Short cord associated with Excessively long cord associated with

-IUGR -Cord entanglement

-Abnormal lie/ presentation -Cord around the neck of foetus

-Congenital malformation -Foetal distress

-Premature placental separation -Cord prolapse

-Foetal anomallies




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Mainly ----- Cardiovascular anomally

----- Renal anomally

Single umbilical artery य isolated finding ह , aneuploidy chances increase ह ह ! य single umbilical artery स other congenital malformation भ ह , aneuploidy

chances increase ह ह स situation amniocentasis य ह !

Most common aneuploidy associated with single umbilical artery- trisomy 18

Single umbilical artery स chances of Abortion,Prematurity ,IUGR Perinatal mortality

ह ! Amniotic Fluid :-

Specefic gravity of amniotic fluid 1-008-1.010.

Osmolality 250 mosm/L

Amniotic fluid completely replaced in 3 hrs.

Rate of amniotic fluid turn over 500 cc/hr.

Amniotic fluid volume maximum 36-38 weeks ह ह (approx 1 litre)

Composition of amniotic fluid :-

Water 98-99%

Solid 1-2%

Organic solid Protein, glucose, lipid, urea, creatinine,Hormone like

prolactin, Insulin &Renin

Inorganic solid Na, K, Cl

Origin of amniotic fluid :- Amniotic fluid mother fetus स ह ह ! In early pregnancy Forming by Ultra filtration of maternal plasma.

By beginning of the 2nd

trimester यह extracellular fluid स ह , fetal skin स secrete

ह ह ! After 20 weeks 20 week skin cornification ह ह , skin स secrete ह

extracellular fluid ह ! स स य amniotic fluid mainly fetal lung ह secretion

fetal urine स ह ! Major contributor Fetal urine

Colour of amniotic fluid:-

Early pregnancy colorless




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Near term Pale straw colour (Due to presence of exfoliated lanugo hair and epidermal cell

from fetal skin)

Abnormal colour of amniotic fluid :-

1. Green (Meconium stained) Fetal distress/ listeria infection

2. Golden yellow Rh incompatibility (Because billirubin levels are increased in amniotic

fluid in case of Rh incompatibility).

3. Greenish yellow Saffron Postmaturity

4. Tobacco juice or Prue juice or Dark brown IUD

5. Dark Marron Concealed hemorrhage

2nd

trimester amniotic fluid fetal urine (approx 1000ml/day) fetal lung

secretion (Approx 350ml/day) ह ह ! Amniotic fluid balance process ह ह ! Fetal swallowing 750ml/day

Intramembranous flow across fetal vessels 400ml/day

Function of amniotic fluid :-

Protect the foetus

यह shock absorber ह ह य ह foetus trauma स ह ! Amniotic fluid temperature maintain ह ! Amniotic fluid amniotic cavity distend ह सस foetus Growth movement

space ह ! Amniotic fluid foetus body parts amniotic sac स adhesion ह स ह !

Important points :- Amniotic fluid foetus nutrition role ह ह !

Amniotic fluid index (AFI):-

Uterine cavity 4 quadrant divide य ह , य quadrant amniotic fluid largest vertical

measurement cm. य ह , quadrant largest vertical distance AFI ह AFI normal value 5-24 cm

AFI < 5 cm Oligohydramnios

AFI > 25 cm Polyhydramnios

Single deepest pocket (SDP) :- स quadrant largest amniotic fluid pocket स umbilical

cord ह ह cm. य ह ! Normal range 2-8 cm

>8cm Polyhydramnios

< 2 cm. Oligohydramnios

Abnormalities of amniotic fluid :-

Oligohydramnios :- amniotic fluid volume 200 ml स ह ! Sonographically oligohydramnios is defined as :-

Absence of amniotic fluid




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Single quadrant maximum vertical diameter < 2cm. स ह ! Amniotic fluid index (AFI) < 5cm.

Causes of oligohydramnios :-

i. Drugs Prostaglandin synthatase inhibitor

ACE inhibitor

ii. IUGR

iii. Leaking of fluid (after amniocentesis/ chorionic villous sampling).

iv. Maternal hypertension/preeclampsia.

v. Post term pregnancy

vi. Premature rupture of membrane

vii. Amnion nodosum

viii. Chromosomal anomalies like triploidy

ix. Renal anomalies of foetus (decrease urine production)

Renal agenesis

Urethral obstruction (posterior urethral valve)

Prune belly syndrome

Bilateral multicystic dysplastic kidney

Important points :- Most common cause of mild oligohydramnios Idiopathic Most common cause of severe oligohydramnios Gross congenital anomaly (Renal anomalies).

Complication of oligohydramnios :-

Fetal complication:-

Amniotic sac amniotic fluid स foetus development space ह ह सस foetus anomaly ह स भ ह ह !

Pulmonary hypoplasia

limb deformities like talipes

Potter face

IUGR

य oligohydramnios late pregnancy ह ह ( organogenesis complete ह ह ) स ह

स cord compression meconium aspiration syndrome ह स ह !

Maternal complication :-

Prolonged labour

Increased chances of cesarean delivery due to malpresentation

Treatment :-

Third trimester य only oligohydramnios ह , foetus normal ह , conservatively manage

य ह !

Oral administration of water amniotic fluid volume increase ह !




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Amnioinfusion (prophylactic and therapeutic) amnioinfusion normal saline amniotic cavity

infuse य ह , सस amniotic fluid volume ह ! Indication of amnioinfusion :-

Treatment of fetal distress

For dilute /Wash Out thick meconium

Renal agenesis

PROM

Note :-

Temperature at which saline is infused 370C.

250 ml Saline गभग 30 minutes infuse य ह ! Infusion स य intrauterine cavity resting pressure 25 mm of Hg स य ह ह ह

Polyhydramnios :- य Amniotic fluid volume 2000 ml (2 litre) स य ह AFI > 25 cm

Single pocket diameter > 8 cm

Grade of polyhydramnios :-

Mild single pocket diameter 8-11cm ह ! Moderate single pocket diameter 12-15 cm ह ! Severe single pocket diameter 16 cm स य ह !

Causes of polyhydramnios :-

Amniotic fluid main contributor fetal urine ह ह , य foetus य urine produce ह , polyhydramnios ह ग , स -

A. Twin/Multifetal pregnancy ( य Foetus ह , य urine produced ह ग ). B. Maternal hyperglycemia/Diabetes

Maternal hyperglycemia Fetal hyperglycemia Fetal polyurea Increased Amniotic fluid

C. Twin to twin transfusion syndrome

Foetus Amniotic fluid swallow ह , सस production of amniotic fluid absorption of

amniotic fluid balance ह ह ! य स भ स Amniotic fluid swallow impaired ह ह , polyhydramnios स भ

ह , स - Cleft lip & Cleft palate

Esophageal atresia/Stenosis

Dudoneal atresia/Stenosis

Bowel obstruction

Anencephaly (Swallowing is decreased + increased transudation of CSF into

Amniotic fluid due to absence of cranial vault )

Other important cause of polyhydramnios :-

Placental Cause:-




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Chorioangioma of placenta

Circumvallate Placenta

Fetal Cause :-

-Hydrops Fetalis

-Rubella, syphilis, toxoplasma infection

-Sacrococcygeal teratoma

-Thalassemia of foetus

Important points :-

Most common cause of mild polyhydramnios Idiopathic

Most common cause of severe polyhydramnios Gross congenital anomaly (Cleft lip & cleft

palate)

Complication :-

Polyhydramnios ह ह स Membrane Overstretching ह ह , सस Premature rupture of

membrane Preterm labour स भ ह ! Abruptio Placenta

PPH

Subinvolution of uterus

Cord prolapse

Malpresentation

Unstable lie

Treatment:-

1. Serial amniocentesis :- 500 ml/lt. Fluid removed (Maximum 1500-2000ml).

2. Indomethacin therapy :- Indomethacin foetal urinary output decrease ह , lung fluid absorption ह !

Dose 1.5-3 mg/Kg/Day

Side effect of indomethacin therapy :-

Premature closure of fetal ductus arteriosus

स Indomethacin therapy 32 weeks stop य ह !

Chapter 3

FETAL PHYSIOLOGY & FETAL CIRCULATION

Landmarks in Fetal development :-




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Event Time of occurrence

Genital ridge is formed 5 weeks

Gonads develop by :

Testes

Ovary

7 weeks

8 weeks

Internal genitalia develop by 10 weeks

External genitalia 12 weeks

Sex can be identified on USG by 14 weeks

Gross body movement 8 weeks

Fetal breathing movements 11 weeks

Swallowing begins by 10-12 weeks

Urine production begins by 12 weeks

Meconium passage 16 weeks

Snoring movements 24 weeks

Fetus can hear by 24 weeks

Fetal fibrinogen production 5 weeks

ACTH synthesis 7 weeks

Glucagon synthesis 8 weeks

Post pituitary hormone synthesis 10-12 weeks

Thyroxine synthesis 11 weeks

Insulin synthesis and all clotting factors produced by 12 weeks

Growth hormone and LH 13 weeks

Rest all pituitary hormones 17 weeks

Fetal growth period :-There are three phases in the prenatal fetal development.

A. Ovular period : Ovular period fertilization स 2 weeks time period ह ह ! B. Embryonic period :- Embryonic period 3

rd week स 8

th week time period ह ह !

यह Time period organogenesis ह ह , यह Time period most teratogenic time period ह ह ! C. Fetal period :- Fetal period 9

th week after fertilization स delivery time period ह ह !

Pregnancy य Time period of gestation (POG) last menstrual period 1st day स count य

ह , ह स female period missed ह ह , स स य Gestational age 4 weeks

ह ह !

Day 1 Day 14 Day 28




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1st day of Ovulation Missed

menstrual period Fertilization Period

Pregnancy period यह स calculate य ह !

Pregnancy total duration 10 lunar months य 9 calander months + 7 days य 280 days य 40

weeks ह ह ! यह Time period 1st day of last menstrual period स count य ह , Actual

gestation time period 266 ह ह !

Calculation of EDD (Expected date of delivery) :

EDD calculation Naegele formula ह ! EDD=LMP (1

st day) + 9 month + 7 days

य Leap year ह , (Leap year=29 days in feb. month)

EDD=LMP (1st day) + 9 month + 6 days

Only 4-6% female ह Exact date delivery ह ह ! 50% Females EDD गभग 1 week ह य 1 week Delivery ह ह !

HAASE RULE :-(fetal length calculation)

Up to 5 month:-Fetal length is square of lunar months in centimeters.

From the 6th

month :- Fetal length is 5 times the No. of month.

Fetal Hemopoisis :-

Embryonic life स स ह Hemopoisis yolk sac ह ह ! 6 weeks Hemopoisis liver start ह ह [Mainly HbF (α2β2)].

24 weeks Hemopoisis bone marrow start ह ह , Adult haemoglobin start ह ह [HbA(α2β2)]

Fetal RBC size Adult RBC य ह ह life span ह ह Life span of fetal RBC Approx 80-90 days

At birth :-

Total Hb 16-18 g/dL

Fetal Hb 70-80%

Adult Hb (HbA) 20%

HbA2 5-10%




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Note :- Birth लगभग 6-12 fetal Hb (HbF), Adult Hb (HbA) convert (HbF 1-2%)

Difference between HbF & HbA

Fetal Hb (HbF) Adult Hb (HbA)

Fetal Hb Oxygen स Adult Hb Oxygen स य affinity ह ह affinity ह ह

Fetal Hb, Acid Alkali Adult Hb Acid alkali Resistant ह ह sensitive ह ह Fetal Hb Carbonic anhydrase Adult Hb Carbonic anhydrase

enzyme ह ह enzyme य ह ह

Clinical significance:-

य Fetal Hb Acid alkali Resistant ह ह maternal blood स Adult Hb

य ह , Acid alkali sensitive ह ह Fetal Blood maternal bood differentiate test use ह ! (i). Singers Alkali Denaturation test (APT-Downey test) सTest NaOH KOH use य ह , यह Qualitative test ह ! (ii). Kleihauer Betke Test :- स Test citric acid phosphate buffer use य ह , यह

Quantitative test ह !

Important Points :-

Fetal blood maternal blood स differentiate Test Singers Alkali Denaturation

test

Fetal RBC maternal RBC स differentiate Test Kleihauer Betke Test

Fetal Circulation :-

Embryo fertilization day 17 seperate fetal circulation establish ह , fetal

heart fertilization day 21 ह ! Fetal cardiovascular system mesoderm स ह ! Fetus oxygenated blood source placenta ह ह lungs.

Placenta स oxygenated blood umbilical vein liver portal vein left branch

ह ! Portal vein left branch IVC connection ह ह स Ductus venosus ह ह

Ductus venosus oxygenated blood IVC ह ह




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IVC oxygenated blood right atrium ह ह

Right atrium Left atrium foramen ह ह स foramen ovale ह ह

Right atrium गभग 75% blood forman ovale left atrium ह , 25% blood right ventricle ह

Right ventricle स blood pulmonary circulation ह , maximum blood Ductus

arteriosus स aorta ह , Intrauterine life pulmonary artery aorta

connection ह ह , स Ductus arteriosus ह ह !

Left atrium स blood left ventricle ह , ह स aorta स ह ह यह 2 umbilical arteries स placenta ह ह !

Changes in the circullation after born :- Fetal blood circulation changes ह ह , सस Adult type circulation establish ह ह !

(i). Umbilical arteries muscles contract ह ह सस umbilical arteries lumen ह ह , सस fetal blood स placenta ह !




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(ii). Umbilical vein ductus venosus lumen भ ह ह यह स य ह ह सस , maximum blood स placenta स fetus स ! (iii). Ductus arteriosus भ close ह ह , सस right ventricle blood lungs ह ह blood oxygenation ह ह ! (iv). Pulmonary vessels size increase ह ह सस स blood lung स oxygenation left atrium ह ह left atrium य blood ह ह , सस left atrium pressure

ह स स य right atrium pressure ह ह , य umbilical vein placenta स blood ह ह ! (v). Left atrium pressure right atrium य increase ह ह , सस foramen ovale

close ह ह ! Vessels ह ह , ह fibrous tissue replace ह , ligaments ह !

Vesseles Remnant

Umbilical Arteries Medial umbilical ligament

Left umbilical vein Ligamentum teres of liver

Ductus venosus Ligamentum venosum

Ductus arteriosus Ligamentum arteriosum

Important Points :-

Median umbilical ligaments, Urachus remnant ह ह ! Lateral umbilical ligament, inferior epigastric artery remnant ह ह

Maternal Adaptation in Pregnancy Maternal Adaption in Pregnancy :-

Pregnancy BMR 10-20% increase ह ह ! Pregnancy total retain water 6.5 ltr. ह ह ! Pregnancy Na

+ K+ retention increase ह ह , serum Na

+ K+ value

overall ह ह , य water retention य ह ह ! Pregnancy water retention ह स osmolality decrease ह ह ! Pregnancy Extra calories requirement 350kcal/day ह ह !

Weight Gain During pregnancy:-




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Pregnancy total weight gain 11-12 kg ह ह ! 1

st trimester गभग 1 kg 2nd

& 3rd

trimester 5-5 kg weight increase ह ह ! Mother weight gain maximum 2

nd trimester fetus weight gain maximum 3

rd

trimester ह ह ! Pregnancy mother net weight gain गभग 6kg ह ह !

Note :- smoking व mother weight gain पर अ र smoking mainly fetus weight gain पर अ र ल व IUGR !

Systemic changes in pregnancy

1. Hematological System

Blood volume (30-40%) Decrease hematocit

Plasma volume (40-50%) Decrease packed cell volume

RBC Volume (20-30%) Decrease viscosity of blood

(Plasma RBC

volume increase ह ह Pregnancy hemodilution ह ह ) Decrease platelet count

Hb mass (in gm‘s) य RBC Voume increased ह ह !

WBC count(Neutrophilic leucocytosis) Decrease clotting factor 11 &13

O2 carrying capacity of blood

All clotting factor (Except factor Decrease Hb count ( य plasma

11 & 13) --Pregnancy hyper volume य Increase ह ह !)

coagulable state ह ! S. Fibrinrogen (Clotting factor 1) -- Increases by 50%

ESR (Increase 4 times)

Note :- Pregnancy र Bleeding time and clotting time unaffected र ! 2. Cardiovascular system

Cardial output = Stroke volume X HR Peripheral vascular Resistance( य

Progesterone smooth muscle relaxant ह ह !) Diastolic & Systolic BP (Decrease

Parameter increases in Pregnancy Parameter decreases in Pregnancy

Parameter increases in Pregnancy Parameter decreases in Pregnancy




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in DBP > SBP)

Parameter pregnancy affected ह ह - JVP or central venous pressure

Pulmonary capillary wedge pressure

Pregnancy maximum cardiac output 28-32 week ह ह term यह ह !

Maximum Cardiac output:

Immediate after delivery >2nd

stage of labour>Late 1st satge of labour> 28-32 week> Early 1

st

stage of labour

Pregnancy total plasma protein increase ह ह plasma protein concentration

decrease ह ह !

Respiratory system :

Increase Decrease Unaffected

Tidal Volume Functional residual capacity Respiratory rate

Minute ventilation Expiratory reserve volume Vital Capacity

Inspiratory capacity Residual volume Inspiratory reserve volume

Minute O2 up take Total lung capacity

PCO2 (mild respiratory alkalosis)

Renal System :-

Pregnancy right kideny ureter hydroureteronephrosis ह ह , य uterus dextro rotation स right ureter pressure ह सस right hydroureteronephrosis ह ह

1st & 3

rd trimester urine frequency increase ह ह !

Increase Decrease

Renal Blood flow (+50%) Plasma osmolality

GFR (+50%) S.creatinine

Creatinine clearance S.Uric acid

Glucosuria S. K+,

Na+

S.Cl-

Changes in Iron Metabolism during pregnancy :

Marker Change

Serum iron concentration Decreases

Serum ferritin (reflecting Iron stores) Decreases

Serum total iron binding capacity Increases

Percentage saturation (Serum ferritin/TIBC) Decreases

Serum transferrin Increases




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GIT :-

Pregnancy hCG hormone ह स nausea vomitting ह ह ! Progesterone hormone ह स smooth muscles relax ह ह , सस peristaltic movement

ह ह (constipation) HCl production ह ह !

Changes in genital organ during pregnancy

Vagina :-

Pregnancy vagina, edematous य vascular ह ह ,vagina bluish

discloration ह ह स Jacquemier sign/Chadwick sign ह ह ! Pregnancy vagina doderlein bacteria growth ह ! Doderlein bacteria

glycogen lactic acid convert ह , सस vagina pH decrease ह ह (pH3.5-6)

Uterus :

Weight of non pregnant uterus 70 gm

Weight of pregnant uterus 1000gm

Length of non pregnant uterus 7.5 cm

Length of pregnant uterus 35 cm

Capacity of non pregnant uterus 10ml

Capacity of pregnant uterus 5000 ml

Shape of Uterus :

Non Pregnant Pyriform

6th

week Hen‘s egg

8th

week Cricket Ball

12th

week Globular

28th

week Pyriform

36th

week Spherical

Uteroplacental blood flow :

Non pregnant uterus blood flow 10 ml/min

Term uteroplacental blood flow 400-600 ml/min

Position of Uterus :- Non pregnant state uterus anteverted anteflexed ह ह ,pregnancy

uterus size increase ह ह abdominal cavity ह ! uterus mainly long axis rotate ह ह , dextrorotation ह ह ! Braxton Hicks -Contraction :- Mainly 2

nd trimester स uterus nonrhythmic, spordic, painless

contraction start ह ह स Braxton Hicks contraction ह ह Braxton Hicks contraction ह स cervix

dilatation ह ह ह !




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Fergusons reflex :-Labour cervix pressure ग य ह cervix nerve supply

ह स uterus contraction ह ह स fergusons reflex ह ह Cervix :- Pregnancy गभग 6 weeks cervix soft ह ह स Goodell‘s sign भ ह ह !

Progesterone hormone ह स cervix स ग secretion ह स physiological

leucorrhoea of pregnancy भ ह ह labour स य यह thick cervical secretion, blood स

cervix स ह ह स show ह ह ! Ovary :-

Pregnancy ovulation ह ह ! Pregnancy corpus luteum 8 weeks progesterone release ह !8-10 weeks

corpus luteum सभ function mainly placenta ग ह ! Pregnancy corpus luteum life span गभग 10-12 weeks ह ह !

Breast :-

Pregnancy estrogen hormone ह स breast mammary ducts alveoli hypertrophy proliferation ह ह , सस breast size increase ह ह !

Nipple size increase ह ह स pigmentation ह ह ! Nipple ओ sebaceous gland hypertoophy ह ह स montgomery‘s

tubercle ह ह ! Colostrum : Pregnancy गभग 12

th week breast स thick,sticky,yellowish fluid ह

ग ह स colostrum ह ह ! Importants Point :-

Comparison between Breast milk & colostrum

Colostrum ग य ह ह , Alkaline ह ह ! Colostrum breast milk स य Immloglobulin स स स य ह ह , Except

K Pottasium

F Fat

C Carbohydrate (Sugar), Cesin

SKIN CHANGES IN PREGNANCY

(i) Chloasma Gravidarum or Pregnancy Mark : Pregnancy ds nkSjku Cheek, Forehead rFkk Eyes ds pkjksa

vksj Pigmentation gks tkrk gS] tks fd Delivery ds ckn vius vki lekIr gks tkrk gSA

(ii) Linea Nigra :Pregnancy ds nkSjku Abdomen ds Mid Line esa Xiphisternum ls ysdj Public Symphysis

rd ,d black Pigmented Line cu tkrh gS] ftls Linea Nigra dgrs gSaA ;g Changes Mainly Anterior Pitutory

Gland ds }kjk Secrete gksus okys Melanocyte Stimulating Hormone dh otg ls gksrs gSaA ;g Pigmentation Hkh




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Delivery ds ckn Disappear gks tkrs gSaA Oral Contraceptive Pills ysus okyh Females esa Hkh blh rjg ds

Pigmentation fn[kkbZ nsrs gSaA

(iii) Striae Gravidarum : Pregnancy ds nkSjku Umbilicus ds uhps okys Part esa Abdominal Wall dh Stretching

dh otg ls Deep Skin Layer esa Scar Tissue Develop gks tkrk gSA Pregnancy ds nkSjku Excessive Stretching rFkk

Aldosterone Hormone dh otg ls ;s Stretch Marks curs gSaA

Supine Hypotension Syndrome (Mangert’s syndrome) : tc Female Supine Position esa ysVrh gS] rc

Pregnancy ds nkSjku 2nd rFkk 3rd

Trimester esa Female Gravid Uterus ds Inferior Vena Cava ij Pressure dh

otg ls Heart esa Venous Return de gks tkrk gSA

Venous Return de gksus dh otg ls Mother dk Cardiac Output de gks tkrk gSA Mother dk Cardiac Output

tc de gksrk gS] rks Foetus dks Blood Supply de gksrh gS] ftlls Fetel Distress iSnk gksrk gSA bls Supine

Hypotension Syndrome dgrs gSaA ;gh dkj.k gS fd Late 2nd

& 3rd

Trimester esa Pregnant Female dks Supine

Position esa ysVus dh lykg ugha nh tkrh gSA mls Left Lateral Position esa ysVuk pkfg,A

Carbodydrate Metabolism during Pregnancy : Pregnancy ds nkSjku Glucose Mother l s Fetus esa s

Facilitiated diffusion }kjk Transfer gksrk gSA

Mother esa Glucose rFkk Amino Acids dh otg ls Insulin dk Secretion c<+ tkrk gSA Pancreas ds beta-Cell

dh Hypertrophy rFkk Hyperplasia gks tkrk gSA

;|fi Pregnancy ds nkSjku Insulin dk Secretion c<+ tkrk gS] ysfdu Estrogen, Progesterone, Cortisol rFkk

Free Fatty Acid dh otg ls Insulin Resistance Develop gks tkrk gS] ftlls Mother esa Postprandial

Hyperglycemia ¼[kkus ds ckn Sugar dk c<+uk½ gks tkrk gSA Pregnancy ds le; 24-28 lIrkg esa Maximum Insulin

Resistance dh lEHkkouk gksrh gSA vr% Gestational Diabetes dk irk djus ds fy, ;g lcls vPNk le; gksrk gSA

Diagnosis of Pregnancy :

Important Terminology :

Early term pregnancy : 37 to 38 weeks + 6 days

Term pregnancy : 39 to 40 weeks + 6 days

Late term pregnancy : 40 to 41 weeks + 6 days

Post term pregnancy : > 42 weeks

Preterm pregnancy : < 37 weeks

The entire duration of pregnancy is divided in three trimester

First trimester : First 12 weeks

Second trimester : 13-28 weeks

Third trimester : 29-40 weeks

Ist Trimester :

Symptoms :




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1. Increased Urinary Frequency.

2. Amenorrhea.

3. Morning Sickness due to hCG.

4. Breast Discomfort.

5. Fatigue.

Sign Feature Seen in

Jacquemier‘s/

Chadwick‘s sign

Dusky hue of the vestibule and anterior vaginal wall due

to local vascular congestion

8th

week of pregnancy

Osiander‘s sign Increased pulsation felt through the lateral fornices 8th

week of pregnancy

Goodell‘s sign Softening of cervix (Cervix feels like lip of mouth

whereas in nonpregnant state it feels like tip of nose)

6th

week of pregnancy

and in OC pill users

Hegar‘s sign On Bimanual examination with 2 fingers in anterior

fornix and fingers of other hand behind the uterus, the

abdominal and vaginal fingers seem to appose below the

body of uterus. It occurs because of softening of isthmus.

6-10 week of

pregnancy

Palmer‘s sign Regular and rhythmic uterine contraction which can be

felt on bimanual

4-8 weeks of pregnancy

IInd Trimester :

Symptoms :

Quickening : Pregnancy ds nkSjku Primipara Female esa Active Fetal Movement yxHkx 18 Weeks

ij Start gks tkrs gSaA Multipara Female esa ;g yxHkx 2 Weeks igys Start gks tkrs gSaA

Braxton Hick Contraction : ;s Irregular, Infrequent, Spasmodic rFkk Painless Uterine

Contraction gksrs gSaA budh otg ls Cervix dk Dilatation ugha gksrk gSA ;s Mainly Pregnancy ds nkSjku 2nd

Trimester esa Start gksrs gSa rFkk Term rd jgrs gSaA

Sign :

Chloasma : Pigmentation of Forehead & Cheeks.

Breast Changes : Appearance of Secondary Areola, Secretion of Colostrum.

Palpation of Fetal Part :

Ballottement of Uterus : tc Uterus dks Compress djrs gSa] rks Floating Object Feel gksrk gSA bls

Ballottement dgrs gSaA

Auscultation of Fetal Heart Rate : ;g Pregnancy dk Most Conclusive Sign gSA

Fetoscope ds }kjk Heart Beat 18-20 Week ij lquh tk ldrh gSaA

Doppler ds }kjk Heart Beat dks 10 Weeks ij lquk tk ldrk gSA

USG esa Heart Beat dks 6 Weeks ij ns[kk tk ldrk gSA




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IIIrd Trimester :

Symptoms :

Amenorrhoea Persist.

Enlargment of Abdomen.

Lightening : Pregnancy ds nkSjku 36 Weeks ds ckn Head dk Engagement Pelvis esa gks tkrk gS] ftlls

Head uhps dh vksj f[kldrk gSA Head ds uhps dh vksj vkus dh otg ls Diaphragm ij Pressure de gks tkrk gS]

ftlls Mother dks Relax Feel gksrk gSA bls Lightening dgrs gSaA

Micutaration Frequency :

Presumptive Sign & Symptoms of Pregnancy : ¼,sls Sign rFkk Symptoms tks Pregnancy dh

Possibility dks crkrs gSa] ysfdu Pregnancy dks Confirm ugha djrsA½

1. Amenorrhoea.

2. Nausea/Vomitting.

3. Frequancy of Micturation.

4. Quickening.

5. Breast Discomfort.

6. Fatigue.

7. Skin Changes.

Positive or Absolute Sign of Pregnancy :

1. Palpation of Fetal Parts.

2. Auscultation of Fetal Heart Sound.

3. USG evidence of Embryo.

4. Radiological Demonstration of Fetal Skelton at 16 Weeks and onwards.

Pseudocyesis ((Phantom Pregnancy/Spurious Pregnancy/False Pregnancy) : ;g ,d Psychological

Disorder gSA blesa Female dks ,slk yxrk gS fd ह Pregnant gS tcfd okLrfodrk esa mlesa Pregnancy ds dksbZ Sign Present

ugha gksrsA ;s Female Infertile gksrh gSa] ftuesa cPps ds fy, izcy bPNk gksrh gSA Patient esa fuEufyf[kr Sign Present gksrs gSa %

1. Cessation of Menstruation.

2. Enlargement of Abdomen (Due to Fat deposition)

3. Secretion from Breast.

4. Fetal Movement (actually Intestinal Movement)

Antenatal Care : Ideally fuEu Schedule Antenatal Visit ds fy, gksuk pkfg, %

(i) 28th Week rd izR;sd ekg Visit gksuh pkfg,A

(ii) 28-36 Week rd izR;sd 15 fnu esa Visit gksuh pkfg,A

(iii) 36th Week rFkk mlds vkxs izR;sd 7 fnu esa Visit gksuh pkfg,A




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vr% dqy 12-15 Visit gksuh pkfg,A

WHO Recommends atleast 4 Visit :

Ist Visit : 16 Weeks

2nd Visit : 24-28 Weeks

3rd Visit : 32 Weeks.

4th Visit : 36 Weeks

As per Indian scenario minimum 3 visits are essential

Ist Visit : 20 Weeks(or as soon as pregnancy is known)

2nd Visit : 32 Weeks

3rd Visit : 36 Weeks

tc igyh ckj Pregnant Female Health Care Facility ij vkrh gS] mls Booking Visit dgrs gSaA

Folic Acid Supplementation during Pregnancy : Pregnancy ds nkSjku Folic Acid Supplementation

Neural Tube Defect dks Prevent djrk gSA

When to Initiate Folic Acid : Folic Acid Conception ls rhu ekg igys ;k Atleast 1 Month igys Start

djuh pkfg, rFkk Pregnancy ds rhu ekg rd Continue j[kuh pkfg,A bl Dose dks Prophylactic Dose of Folic

Acid dgrs gSaA

Govt. of India, Iron rFkk Folic Acid dh Tablets Free of Cost Supply djrh gSA blesa 100 mg Elemental Fe

rFkk 500 mcg Folic Acid gksrk gSA

RDA of folic Acid during Pregnancy — 500 mcg

High Risk Patient tSls %

a) Females with H/o Previous NTD Babies.

b) Diabetic Females.

c) Female with sickle cell Anemia.

d) Female on Antiepileptic drugs like Valproic Acid.

bu High Risk Patient esa NTD dks Prevent djus ds fy, Folic Acid dh dose 4 mg gksrh gSA bls therepeutic

Dose of Folic Acid dgrs gSaA

Pregnancy ds nkSjku Megaloblastic Anemia dks Treat djus ds fy, Folic Acid dh Dose 1 mg/day gksrh gSA

Iron Supplementation during Pregnancy : Pregnancy ds nkSjku Total Iron dh Requirement yxHkx

1000 mg gksrh gSA (4-6 mg/daily)

Fetal & Placenta Require — 300 mg

Growing RBC of Mother Require — 500 mg

Lost through Sweat, Urine & Faeces — 200 mg

Lost at the time of delivery — 200 mg

Amount of Iron saved due to Amenorrhoea — 300 mg




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So 1200 –300 = 900 – 1000 mg Iron Required gksrk gSA

Iron dks ftl Hkh form (Oral, IM) esa fy;k tk,] ;g Only 10% gh Absorbed gksrk gS] vr% Pregnancy ds nkSjku 4-

6 mg/daily requirement dks iwjk djus ds fy, 40-60 mg Iron daily diet esa gksuk t:Lh gS] tks fd Impossible gSA

blfy, Pregnancy ds nkSjku 6 Months rd Iron Absolutely Required gksrk gSA

National Anaemia Control Programme : lHkh Pregnant Females dks 100 mg Elemental Iron

(Ferrous Sulphate) + 500 mg Folic Acid atleast 100 days ds fy, nh tkrh gSA Iron Tablets 12-14 Weeks

ij Start dh tkuh pkfg,A

Important Points :

RDA of Calcim during Pregnancy — 1000 mg/day

RDA of Iodine during Pregnancy — 250 μg/day

Vaccination during Pregnancy :

Tetanus Vaccine : 0.5 ml Tetanus toxiod dh 2 dose IM 6 Weeks ds vUrjky ij nh tkuh pkfg,A

Ist Dose : 16-20 Weeks

IInd Dose : 20-24 Weeks

,slh Females ftuesa Vaccination igys ls gks j[kk gS] mues a Only Booster Dose 0.5 ml IM Delevery l s 4

Weeks igys nh tkuh pkfg,A

Other Vaccine in Pregnancy : Killed Vaccine Pregnancy esa Safe gksrs gSa tcfd Live Vaccine dks

Pregnancy esa Avoid fd;k tkrk gSA

Safe Only in

epidemics

To be given in case of travel to highly

endemic area or exposed to contacts

Contraindicated

H-Hepatitis

A/B

Tab-Typhoid

P-Pneumococcus

C-Cholera

Yellow fever

Japanese encephalitis

Polio (IPV)

Rubella

Measles

Mumps

I-Influenza

T-Tetanus

Rabies-Rabies

M-

Meningococcus

(Tab PCM)

BCG

Smallpox

Chickenpox

Grvida & Parity :

Gravida : ;g Pregnant State dks crkrk gSA ;g Frequency of Pregnancy dks crkrk gSA

Parity : ;g crkrk gS fd fdruh Previous Pregnancy Period of Viability rd igqaph gSA pkgs Period of

Viability ds ckn mudk dqN Hkh gqvk gksA (period of viability-20 weeks)

Example :

Eg.1. ,d 10 Weeks Pregnant Female gS] ftls ,d 4 lky dk cPpk gSA




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G2P1

;gka og nwljh ckj Pregnant gS vFkkZr Gravida 2 gS tcfd ,d Pregnancy Viability rd igqaph gS vFkkZr Parity 1 gSA

Eg.2. ,d 10 Weeks Pregnant Female gS] ftldk ,d Abortion 12 Weeks ij gks x;k FkkA

G2P0

;gka ij nwljh ckj Pregnant gS vFkkZr Gravida 2 gS] ysfdu vHkh dksbZ Hkh Pregnancy Viability rd ugha igqaph vFkkZr

Parity 0 gSA

Eg.3. ,d 12 Weeks Pregnant Female gS ftlesa igys 38 Weeks ij Twin Delivery dh History gSA

G2P1

;gka og nwljh ckj Pregnant gS vFkkZr Gravida 2 gS] ysfdu Last Pregnancy esa 38 Week ij Twin Delivery gS

vFkkZr ,d Pregnancy Period of Viability rd igqaph gS vFkkZr Parity 1 gSA ;gka cPpksa dh la[;k Count ugha dh tkrh]

Only Frequency Count dh tkrh gSA

Present pregnancy Parity include ह य ह ! GPT + P + A + L Method :

T : No. of Term Pregnancy (37-42 Weeks)

P : No. of Pretern Delivery (28-36 Weeks)

A : No. of Abortion (Death before 20 Weeks)

L : No. of Live children.

Still Birth : ;fn cPps dh Delivery 20 Weeks ds ckn gks rFkk cPpk Dead gks x;k gksA

Miscarriage : ;fn cPps dh Death 20 Weeks ls igys gks xbZ gks] rks bls Miscarriage dgrs gSaA

Primipara : ,slh Female tks igyh ckj Pregnant gqbZ gksA

Multipara : ,slh Female tks nks ;k nks ls T;knk ckj Pregnant gqbZ gSA

Elderly Primigravida : ,slh Female tks 30 Years dh Age ds ckn igyh ckj Pregnant gqbZ gSA

Grand Multipara : ,slh Pregnant Female tks igys ls 4 ;k 4 ls T;knk ckj Pregnant gks pqdh gSA

Nullipara : ,slh Female tks dHkh Hkh Pregnant ugha gqbZ gSA

Chapter 4

DIAGNOSIS IN OBSTETRICS & FETAL MONITORING

USG in Obstetrics :

Level I Examination (Routine/Basic Examination) : ;g Pregnancy ds nkSjku Routine Sonography

Examination gksrk gS] tks fd Dating ,No. of fetus, Amniotic Fluid rFkk Placenta ds Localization ds fy, fd;k tkrk gSA




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Level 2 (Tragated Examination/TIFFA : Targated imaging for Fetal Anomalies) : ;g Sonography Fetus

esa Congenital Anomally dks Detect djus ds fy, dh tkrh gSA

Important Points :

TIFFA Scan lHkh Pregnant Females esa 18-20 Weeks ij fd;k tkuk pkfg,A

Time for Routine Ultrasound Scan

-At the Booking Visit (Ist Trimester)

-18-22 Weeks.

-In 3rd Trimester

;fn iwjh Pregnancy ds nkSjku flQZ ,d gh Ultrasound djuh gks] rks lclss Best Time 18-20 Weeks gSA

Placenta dks Localize djus ds fy, USG dk Best Time 3rd Trimester gSA

Twins Pregnancy esa Chorionicity dks Detect djus ds fy, USG dk Best Time 11-14 weeks gSA

First Trimester Ultrasound Examination :

Pregnancy ds nkSjku lksuksxzkQh esa Pregnancy dk First Sign Gestation Sac dk fn[kkbZ nsuk gSA

Gestation Sac esa Yolk Sac dk fn[kkbZ nsuk 100% Intrauterine Pregnancy dks Confirm djrk gSA

USG esa Cardiac Activity 6 Weeks ij Appear gks tkrh gSA

For Determination of Gestational Age in Ist Trimester :

CROWN-RUMP LENGTH : Longest Straightline measurement of the embryo from the outer margin of

cephalic pole to rump.

Ist Trimester esa Fetal age Determine djus ds fy, lcls Best Parameter CRL

Second Trimester Ultrasound Examination :

BPD (Biparietal Diameter) : 14 Week ls 20 Week ds chp Fetal Age Determine djus ds fy, Best Parameter gksrk

gSA

HC : (Head Circumference) ;fn Fetus ds Head dh Shape esa dksbZ Changes gS] rks Head Circuference (HC) T;knk

Better Parameter gksrk gS] BPD dh rqyuk esaA

FL (Femur Length) : 3rd Trimester esa Fetal Age dks Determine djus ds fy, Best Parameter gksrk gSA

AC (Abdominal Circumference) : Fetal Growth dks Determine djus ds fy, Best Parameter gksrk gSA Eg. IUGR,

Macrosomia.

Fetal Congenital Anomallies :

Anencephaly

USG esa lcls igys Detect gksus okyh Anomally — Anencephaly

Anencephaly dks Earliest 10 Weeks ij USG esa Diagnose fd;k tk ldrk gSA

Sign of Anencephaly on USG :




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Fetal Head has an Irregular contour and No Bone.

No calcified Cranium.

Face Shows Mickey Mouse Sign.

Eye of Fetus are big- Frog eye sign.

Anencephaly ,d Neural Tube Defect gSA blesa Forebrain rFkk Midbrain Absent gksrk gSA

Diagnosis :

Screening Method :

(i) Increased level of Maternal serum alpha fetoprotein.

(ii) Most Specefic Marker of Anencephaly — Acetylcholinesterase.

(iii)Investigation of Choice — Ultrasound.

Spina Bifida : Spina Bifida dks 2nd Trimester esa Sonography }kjk Diagnose fd;k tk ldrk gSA

Sonographic Sign in Spina Bifida :

Small biparietal Diameter.

Ventriculomegaly.

Frontal Bone Scalloping (Lemon Sign)

Elongation & downward displacement of the cerebellum (Banana Sign)

Prenatal Diagnostic Techniques :

(i) Chorionic villi Sampling.

(ii) Amniocentesis.

(iii)Cordocentesis.

(iv) Fetal Tissue Biopsy (Not Done)

(i) Chorionic Villi Sampling (CVS) :

Study Material : Chorionic Villi from which Trophoblastic cells are used for study

Time --10-13 Weeks.

Indication :

To detect chromosomal Anomallies.

For DNA analysis-- in Haemoglobinopathies,sickle cell anemia.

To detect Inborn error of Metabolism like Phenylketonurea.

Ist Trimester diagnosis of Down Syndrome.

Risk :

Chances of Fetal loss/Abortion (1-2%)

;fn CVS 9 Weeks ls igys fd;k tkrk gS] rks Limb Reduction Defect dh lEHkkouk c<+ tkrh gSA

(ii) Amniocentesis : Amniotic Sac ls Amniotic Fluid dks fudkyuk Amniocentesis dgykrk gSA blds }kjk Fetal

Congenital Anomallies dks Detect fd;k tk ldrk gSA

Time : 15-20 Weeks




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Early Amniocentesis : 11-14 weeks

(iii) Cordocentesis : (Perumbilical Blood Sampling) [PUBS]

Time >20 Weeks.

Cordocentesis esa Umbilical vein ls Blood Sample fy;k tkrk gSA ¼Site tgka Cord Placenta ls Attach gksrh gSA½

Chances of Fetal Loss = 3%

Most Common Indication of Cordocentesis is Evaluation & Treatment of Fetal Isoimmunization.

Biochemical Test :

a) Double Marker Test :

Beta-hCG

PAPP - A (Pregnancy associated Plasma Protein - A)

Down Syndrone esa Beta-hCG dk Level Increase gksrk gS rFkk PAPP-A dk Level Decrease gksrk gS tcfd ckdh lHkh

Aneuploidy esa Beta-hCG rFkk PAPP-A nksuksa dk Level Decrease gksrk gSA

Double Marker Test Ist Trimester esa 11-14 Week ds chp fd;k tkrk gSA

b) Tripple Marker Test :

;g Test 16-18 Week ds chp fd;k tkrk gSA

blesa 3 Hormones gksrs gSa-

1. Beta-hCG

2 AFP

3 Unconjugated Estriol (UE3)

HCG AFP UE3

Down Syndrome Increase Decrease Decrease

Edward syndrome Decrease Decrease Decrease

c) Quadruple Marker Test :

;g Test Mainly 18-22 Weeks ds chp fd;k tkrk gSA

blesa 4 Harmones gksrs gSa-

1. Beta-hCG

2. AFP

3. UE3

4. Inhibin-A

HCG AFP UE3 Inhibin A

Down Syndrome Increase Decrease Decrease Increase

Down Syndrome esa Inhibin-A dk Level Increase gks tkrk gSA

DOWN SYNDROME :

Mainly due to trisomy 21

Trisomy 21 — Nondisjunction of Chromosome

Non lethal trisomy.

Prevalance 1 : 1000 Pregnancies

;fn Mother dh Age Increase gksrh gS (At the time of Pregnancy) rks Down Syndrome ds Chances c<+ tkrs gSaA

Clinical Finding :




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Brachycephaly

Epicanthal Fold

Upslanting Palpebral Fissure

Brushfield Spot (Greyish spot on Iris)

Flat Nasal Bridge

Hypotonia

Single Palmar Crease

Hypoplasia of the middle Phalynx of 5th finger

Sandle Toe Gap

Cardiac Defeet — Endocardial cushion defect, VSD

GI Defect — Dudoneal Atresia, Esophageal Atresia, Hirschsprung Disease

Mental Retardation

Screening Test for Down Syndrone :

First Trimester Screening :

(i) Nuchal Translucency : ;g Down Syndrome ds fy, Sonographic Marker gSA ;g Mainly Ist Trimester esa ns[kk

tkrk gSA

Nuchal Translucency : ;g Sagittal Plane esa Fetus ds xnZu dh Skin Fold Thickness gksrh gSA

Fig : Correct method of measurement of nuchal translucency

Nuchal Translucency dks 11-13.6 Weeks ds chp ns[kk tkrk gSA

Nuchal Translucency upto 3mm = Normal

NT > 3mm= Possibility of Down Syndrome

(ii) Absent Nasal Bone

(iii) Biochemical Test — Double Marker Test

Second Trimester Screening :

(i) Sonography Marker for Down syndrome in 2nd Trimester.

Sonography Marker for Down syndrome in 2nd Trimester

Brachycephaly or shortened frontal lobe




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Clinodactyly (hypoplasia of the 5th

digit middle phalanx)

Hyperechogenic bowel

Echogenic intracardiac focus

Nasal bone absence or hypoplasia

Nuchal fold thickening

Aberrant right subclavian artery

‗Sandal gap‘ between first and second toes

Shortened ear length

Single umbilical artery

Short femur

Short humerus

Mild hydronephrosis ventriculomegaly

(ii) Biochemical Test :

a) Triple Marker Test

b) Quadruple Marker Test

Antepartum Fetal Monitoring :

Fetal Heart Rate : Base Line Fetal Heart Rate = 110-160 bpm

i)Bradycardia : FHR < 110 bpm

Causes :

2nd Stage of Labour esa Mild Head Compression dh otg ls Bradycardia gksrk gSA

Cogenital Heart Block

Fetal Bradycardia Serious Fetal Compromise dks iznf’kZr djrk gSA

ii)Tachycardia : FHR > 160 bpm

Causes :

Maternal Fever due to amnionitis.

Cardiac Arrythmias.

Maternal Parasympathomimetics (Atropine) or Sympathomimetics (Terbutaline)

May indicate Fetal compromite.

Beat to Beat Variability :

Baseline variability 5-25 bpm. Normal Fetal well being dk Sign gksrk gSA

Acceleration :

Acceleration vFkkZr Foetal Heart Rate dk 15 bpm ;k T;knk c<+uk de ls de 15 Sec. rdA (> 32 Weeks)

Acceleration ;g iznf’kZr djrk gS fd Fetal dk Neurohormonal rFkk Cardiovascular Activity intact gSA ;g iznf’kZr djrk

gS fd Fetus Healthy gSA

;fn Fetus 32 Weeks ls de gS] rks Fetal Heart Rate 10 bpm ;k blls T;knk c<+uh pkfg, de ls de 10 Sec. rdA

Deceleration :

Fetal Heart Rate dk Uterine contraction ds lkFk 15 Beat Per Minute, 15 Sec. rd de gksuk Deceleration dgykrk gSA

Deceleration esa 3 Pattern ik, tkrs gSa %




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(i) Early Deceleration;

(ii) Late Deceleration

(iii) Variable Deceleration.

(i) Early Deceleration : Early Deceleration rFkk Uterine Contraction nksuksa ,d lkFk gksrs gSaA

Early Deceleration Head Compression esa fn[kkbZ nsrk gSA ;g ,d Physiological Process gSA blesa Fetal Hypoxia ugha gksrk

gSA

(ii) Late Deceleration : Late Deceleration esa Uterine Contraction tc Peak ij gksrk gS rFkk end ij gksus okyk gksrk gS rc

FHR esa deh vkrh gSA Late Deceleration Mainly Uteroplacental Insufficiency esa fn[kkbZ nsrk gSA

Late Deceleration lcls Worst Type dk Deceleration gksrk gSA

Management :

Check Fetal pH

Immediate Delievery.

(iii) Variable Deceleration : Uterine Contraction ds lkFk Variable Relationship gksrk gSA ;g Mainly Umbilical

Cord Compression esa fn[kkbZ nsrk gSA




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Management :

Turn the Patient on her side (Relieve Pressure on the Cord)

Maintain Hydration.

Stop Oxytocics.

Give Oxygen by Face Mask.

If Persistent variable Deceleration (3 in 20 Minutes) check the fetel pH & deliver.

Sinusoidal Heart Rate :

It is stable baseline FHR with fixed baseline variability without any acceleration seen in case of severe

Fetal Anemia.

Rh isoimmunization

Ruptured Vasa Previa

Twin to Twin transfusion

Fetal Intracranial Haemorrhage

Daily Fetal Movement Count (DFMC) : Pregnant Female dks Rest ds nkSjku nks ?k.Vs ds Time Period esa de ls

de 10 Fetal Movements Feel gksus pkfg,A tc dHkh Hkh Pregnant Female dks Fetal Movement de Feel gks] rks

Immediate Modified Biophysical Score ¼ftlesa NST rFkk AFI½ ;k NST djuk pkfg,A

NST (Non Stress Test) : Most commonly used screening Test for Antepartum evaluation of the Fetal

Status.

Principle : Normally Fetal Movements ds lkFk Fetal Heart Rate esa Acceleration gksrk gSA ;g iznf’kZr djrk gS fd

Fetus Normal gSA ;fn Fetal Movement ds lkFk Fetal Heart Rate esa Acceleration ugha gksrk gS] rks ;g iznf’kZr djrk gS

fd Fetus Hypoxia dh Condition esa gSA ;fn NST Reactive gS vFkkZr Normal gS] rks bldk eryc gS fd Fetus atleast

vxys lkr fnu rd lqjf{kr gSA




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Biophysical Score/Manning Score : ;g Antepartumly Fetal Well Being dk Indicator gSA blesa 5 Parameter gksrs

gSaA

1. Fetal Tone,

2. Fetal Breathing Movement (Seen in 30 Minute)

3. Fetal gross body Movement (Seen in 30 Minute)

4. Amniotic Fluid Volume

5. Non Stress Test

Biophysical Profile (BPP) is a diagnostic test for Uteroplacental insufficiency.

Score 8-10 — Normal

Score 6 — Equivocal

Score <5 — Abnormal

Contraction Stress Test (CST) : bl Test esa Oxytocin }kjk Uterine Contraction dks Induce fd;k tkrk gS rFkk

Uterine Contraction ds nkSjku FHR esa Change dks Note fd;k tkrk gSA

No Change in FHR — Non Reactive — Normal

Change in FHR — Reactive — Abnormal

Whenever a female complains of decreased fetal movement

Do a modified biophysical score or do a nonstress test

≥ 2 accelerations in 20

minute

< 2 accelerations but no late

decelerations

Persistent late decelerations or

presistent variable decelerations

Reactive NST Delivery Repeat NST for 20 more minutes,

i.e. 40 minutes total

Repeat NST weekly or twice

weekly (72 hours) in high

risk pregnancy

Do Biophysical score

(Confirmatory test)

Non-Reactive Reactive

≥ 2 accelerations < 2 accelerations




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Chapter 5

PELVIS & FETAL SKULL

Pelvis

Anatomy : Human Pelvis 4 Bones ls feydj cuh gksrh gSA

(1) Sacrum - 1

(2) Coccyx - 1

(3) Innominate Bone – 2

izR;sd Innominate Bone Ileum,ischium rFkk Pubis ls feydj curh gSA

Pelvic Joint : Pelvis esa Mainly 4 Joints gksrs gSa %

(1) Symphysis Pubis

(2) Sacroiliac Joint (Rt. & Lt.)

(3) Sacrococcygeal Joint.

Type of Joints :

Joints Type

Symphysis Pubis Fibrocartilagenous

Sacroiliac Joint Synovial Joint

Sacrococcygeal Joint Synovial Hinge Joint

Anatomically Pelvic Brim Pelvis dks nks Hkkxksa esa Devide djrh gSA

False Pelvis : ;g Pelvic Brim स ऊ part ह स obstetrical significance ह ह ! True Pelvis :-Pelvic Brim ds uhps okyk Part True Pelvis dgykrk gSA True Pelvis ,d Bony Canal cukrk gS] tgka ls

Labour ds le; Fetus dks xqtjuk iM+rk gSA

True Pelvis vkxs dh vksj Pubic Symphysis rFkk ihNs dh vksj Sacrum rFkk Coccyx ls curk gSA

True Pelvis dks rhu Hkkxksa esa Devide fd;k x;k gSA

(i) Pelvic Inlet

(2) Pelvic Cavity

(3) Pelvic Outlet

Pelvic Inlet : Most Common variety of Pelvis (Gynecoid Pelvis) esa Pelvic Inlet dk Shape Transverse Oval

gksrk gSA




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Angle of Inclination : Pelvic Inlet Horizontal ls 55° dk Angle cukrk gSA bls Angle of Inclination dgrs gSaA

;fn Angle of Inclination > 55º ls T;knk gS rks

-Delay in Engagenent of Fetal Head

-Delay in Descent of Fetel Head

;fn Angle of Inclination < 55º ls de gS] rks Early Engagement

Diameter of Pelvic Inlet :

(i) Anteroposterior Diameter :

(a) True Conjugate/Anatomical Conjugate (11 Cm) : ;g Diameter Sacral Promontory ds Mid Point ls ysdj

Pubic Symphysis ds Upper Border rd gksrk gSA

(b) Obstetric Conjugate (10-10.5 Cm) : ;g Pelvic Inlet dk Most Important Antero- Posterior Diameter gSA

;g Smallest Antero-Posterior Diameter gksrk gSA

;g Diameter Sacral Promontory ds Mid Point ls ysdj Pubic Symphysis ds Mid Part rd gksrk gSA

Normal Vaginal Delivery ds fy, Obstetric Conjugate de ls de 10 Cm ;k blls vf/kd gksuk pkfg,A

;fn Obstetric Conjugate 10 Cm ls de gS] rks Pelvic Inlet Contracted ekuk tkrk gSA

(c) Diagonal Conjugate (12 Cm) : ;g Diameter Sacral Promontory ds Mid Point ls ysdj Pubic Symphysis ds

Lower Border rd gksrk gSA Pelvic Inlet ds rhuksa Antero Posterior Diameter esa ls Only Diagonal Conjugate dks gh

Labour ds nkSjku Clinically assess fd;k tk ldrk gSA

(ii) Transverse Diameter of Pelvic Inlet (13 Cm) : ;g Diameter nksuksa Side dh Ileopectineal Line ds chp

Maximum Distance gksrk gSA




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;g Pelvic inlet dk maximum diameter gksrk gSA

;g Sacral Promontory ls 4 Cm vkxs rFkk Pubic Symphysis ds 7 Cm ihNs gksrk gSA

(iii) Oblique Diameter of Pelvic Inlet : Right Oblique rFkk Left Oblique nks Oblique Diameter gksrs gSaA (12 Cm)

Pelvic Cavity : Pelvic Cavity Round Shape esa gksrh gS tks fd Åij dh vksj Pelvic Brim, uhps dh vksj Pelvic Outlet,

vkxs dh vksj Pubic Symphysis rFkk ihNs dh vksj Sacrum ls curh gSA

Pelvic Cavity ds Anteroposterior rFkk Tranverse Diameter nksuksa cjkcj gksrs gSaA (12 Cm)

Mid Pelvis : Mid Pelvis Ischial Spine ds level ij gksrk gSA bls Midplane ;k Plane of Least Pelvic Dimension Hkh

dgrs gSaA

Plane of Least Pelvic Dimension vkxs dh vksj Pubic Symphysis ls ysdj ihNs dh vksj S4-S5 Sacral Vertebrae ds

Junction rd gksrk gSA Laterally ;g Ischial Spine ij [kqyrk gSA

Labour ds nkSjku Plane of Least Pelvic Dinestion egÙoiw.kZ gksrk gS] D;ksafd

bl Level ij Internal Rotation gksrk gSA

Deep Transverse Arrest T;knkrj ;gha gksrk gSA

Ischial Spine Level ij Head dk Zero Station gksrk gSA

External OS blh Level ij gksrk gSA

Levator Ani Muscle dk Origin ;gha gksrk gS] vr% Pudendal Block ds fy, ;g Landmark gksrk gSA

Diameter of Mid Pelvis :

AP Diameter of Mid Pelvis : ;g Diameter Juction of S4-S5 Vertebrae ls ysdj Lower Border of Pubic

Symphysis rd gksrk gSA (11-12 Cm)




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Transverse Diameter/Bispinous/Interspinous Diameter :

;g Diameter nksuksa Ischial Spine ds chp dk Diameter gksrk gSA (10 Cm).

Interspinous Diameter Smallest Pelvic Diameter gksrk gSA

Pelvic Outlet : Pelvic Outlet Ischial Tuberosity ds Level ij gksrk gSA

Anatomy : ;g ,d Lozenge ;k Rhombus Shaped Cavity gksrh gS tks fd anterior Border of Pubic Symphysis,

Pubic Arch, Ischial Tuberosities, Sacrotuberous Ligament, Sacrospinous Ligament rFkk Tip of Coccyx ls curk

gSA

Clinically Pelvic Outlet ds rhu Diameter important gksrs gSaA

Anteroposterior : ;g Diameter Pubic Symphysis ds Lower Border ls ysdj Coccyx ds Tip rd gksrk gSA (11.5-13.5

Cm)

Transverse (Intertuberous) Diameter : ;g Inner Border of Ischial Tuberosity ds chp dk Diameter gksrk gSA (11

Cm)

Posterior Sagittal Diameter : ;g Diameter Tip of Sacrum ls ysdj Bituberous Diameter ds Centre rd gksrk gSA

Sub Pubic Angle : ;g Two Pubic Rami ds chp dk Angle gksrk gSA Normal Female Pelvis esa ;g 90-100º gksrk gSA

Varietries of Pelvis : Pelvic Inlet dh Shape ds vk/kkj ij Pelvis pkj izdkj dh gksrh gS %

caldwell and mohoy classification---

(1) Gynecoid 50%

(2) Anthropoid 25%

(3) Android 20%

(4) Platypelloid 5%.

Characteristic of each type of pelvis

Characteristic Gynecoid pelvis Android pelvis Anthropoid pelvis Platypelloid pelvis

Introduction Female type(M/C Male type pelvis Ape like pelvis Flat pelvis(least common




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variety) variety)

Shape of inlet

Transverse oval

Heart shape

AP oval

Flat bowl like

Relationship of

transverse

diam. to AP

diam. of inlet

Transverse

diameter of inlet is

slightly bigger

than AP diameter

Transverse diam.

is > AP diam.

Only pelvis with- AP

diameter > transverse

diameter

Pelvis with- Transverse

diameter >>> (Much

more than AP diameter)

Obstetric

outcome

Normal female

pelvis

No difficulty in

engagement.

M/C position of

head LOT/LOA

Engagement is

delayed

Deep transverse

arrest/persistent

occipito posterior

position common

Diam of engagement

is AP diam

Direct occipito

posterior position is

M/C.

Nonrotation is

common

Head engages in

transverse diameter with

marked asynclitism

Engaging diameter is

supersubparietal diam

(18.5 cm) instead of usual

biparietal diam (9.5)

Type of

delivery

Normal delivery Difficult

instrumental

delivery

Face to pubes delivery If head is able to

negotiate the inlet by

means of asynclitism then

normal labour otherwise

cesarean section

Contracted Pelvis : ;fn Pelvis dk dksbZ Hkh Major Diameter 0.5 Cm ls T;knk de gS] rks ,slh Pelvis dks Contracted

Pelvis dgk tkrk gSA Contracted Pelvis esa ges’kk Delivery Cessarean Section }kjk dh tkrh gSA

Type of Contracted Pelvis :

(i) Rachitic Pelvis Rickets

(ii) Triradiate Pelvis

(iii) Osteomalacic Pelvis

(iv) Naegele‘s Pelvis — One ala Absent

(v) Robert‘s Pelvis — Both ala Absent

;fn Female dh Height 140 Cm ls de gS] rk s Contracted Pelvis dh lEHkkouk c<+ tkrh gSA

;fn Pelvic Inlet Mild Contracted gS] rks Management of Choice — Trial of Labour

ysfdu ;fn igys ls Cessarean Section gks j[kk gks] rks trial of Labour Contraindicated gksrk gSA

;fn Severe contracted Pelvis gS] rks Management of Choice cessarean Section.

Fetal Skull & Diameters :




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Sutures :

(i) Sagittal/Longitudinal Suture : ;g Suture nks Parietal Bone ds chp ik;k tkrk gSA

(ii) Coronal Suture : ;g Suture Frontal Bone rFkk nksuksa Parietal Bone ds chp ik;k tkrk gSA

(iii) Frontal/Metopic Suture : ;g Suture nks Frontal Bone ds chp ik;k tkrk gSA

(iv) Lambdoid Suture : ;g Suture Occipital Bone rFkk nksuksa Parietal Bone ds chp ik;k tkrk gSA

Fontanelle :

Suture Line ds chp Wide Gap Fontanelle dgykrs gSaA

Birth ds Time ij Fetal Skull esa 6 Fontanelle gksrs gSaA buesa ls Anterior rFkk Posterior Fontanelle dk Obstetric

Significence gksrk gSA

(i) Anterior Fontanelle (Bregma) : ;g Fontanelle 4 Sutures ls feydj cuk gksrk gSA

Anteriorly — Frontal/Metopic

Posteriorly — Sagittal Suture

Laterally — Coronal Suture ¼nksuksa Side ls½

;g fontanelle Diamond Shape gksrk gSA ;g tUe ds 18 Months ds ckn Ossified gksrk gSA

(ii) Posterior Fontanelle (Lambda) : ;g 3 Suture Line ds Junction ls curk gSA

Anteriorly — Sagittal Suture

Laterally — Lambdoid Suture ¼nksuksa lkbM ls½

;g Triangular Shape gksrk gSA ;g tUe ds 2-3 Month ckn Ossified gksrk gSA

Presenting Part of Fetal Skull :

(i) Vertex Presentation

(ii) Brow Presentation

(iii) Face Presentation

Important Diameter of Fetal Skull :

1. Anteroposterior Diameters




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Presenting part Engaging AP diameter Measurement in cms

Vertex (Completely flexed head) Suboccipito-bregmatic 9.5 cms

Vertex (Incompletely flexed head, slight deflexion) Suboccipitofrontal 10 cms

Extended vertex (in marked deflexion ) Occipitofrontal 11.5 cms

Brow presentation

(Partial extension)

Mento vertical 14 cms

Face presentation

Mento anterior position

Mento posterior

Submento-bregmatic

Submento- Vertical

9.5 cms

11.5 cms

2. Transverse Diameter :

(i) Biparietal diameter (9.5 Cm)

(ii) Subparietal Diameter (8.5 Cm)

(iii) Bitemporal Diameter (8.0 Cm)

(iv) Bimastoid Diameter (7.5 Cm)

Important Points :

1. Longest AP Diameter of Fetal Skull Mentovertical (14 Cm)

2. Brow Presentation esa Engaging Diameter Mentovertical Diameter gksrk gS tks fd Largest Diameter gksrk gSA blfy,

Brow Presentation esa ges’kk Cessarean Section fd;k tkrk gSA

3. Anencephaly esa Face Normal gksrk gS tcfd Fetal Skull Absent gksrk gSA Anencephaly esa Most Common

Presentation Face Presentation gksrh gSA

Swelling on Fetal Skull :

Caput Succedanenum :

;g Scalp esa Periosteum ds Åij Localized Swelling gksrh gSA

;g Suture Line dks Cross dj ldrh gSA

;g Mainly Fetal Head ds ,d gh Position esa yEcs le; rd jgus dh otg ls gks ldrh gSA

;g Birth ij Present gksrh gS rFkk dqN ?k.Vksa ckn vius vki Disappear gks tkrh gSA

Cephalohematoma :

;g Scalp esa Periosteum ds uhps Blood ds Collect gks tkus ls Swelling gksrh gSA

;g Suture Line dks Cross ugha dj ldrhA

;g Mainly Instrumental Delivery ds le; Trauma dh otg ls gksrk gSA




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;g tUe ds dqN le; ckn Appear gksrk gS rFkk yxHkx ,d lIrkg ckn Disappear ह ह SA

UTERUS FUNDAL HEIGHT ASSESMENT :

Weeks Fundal Height

12 weeks Palpable above pubic symphysis

16 weeks Between umbilicus & Pubic symphysis

20 weeks 2 finger below umbilicus

22-24 weeks At umbilicus

28 weeks 1/3 above umbilicus, 2/3 below xiphoid

32 weeks 1/3 below xiphoid, 2/3 above umbilicus

36 weeks Just below xiphoid

38 weeks At xiphoid

40 weeks At 36 weeks

(18-30 weeks (Fundal height in cm) = Fetal age +2 cm)

Obstetrical Grips/Leopold Maneuver

Mother Abdomen Palpate Fetus Presentation Identify य ह

Mother Dorsal Recumbent Position ह Examiner/doctor ,Patient Rt.

Side ह ह

1. Ist Leopold Maneuver/fundal Grip : स Maneuver Examiner Face Mother Face ओ ह ह ह स Uterus Fundal Part Palpate ह य :




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(a) Fundus Part Broad, Soft Irregular Mass Feel ह ह स ह Fundus part Buttocks ह Fetus Head Pelvic Region ह Cephalic Presentation ह

(b) य Fundus Part Smooth, Hard Globular Mass Feel ह ह , स ह Fundus Part Head ह Pelvic Region Buttock ह Breech Presentation ह

(c) य भ Part Fundus Area Feel ह ह ह स ह Fetus Transverse Lie ह स ह

(ii) IInd Leopold Maneuver/Lateral or Umbilical Grip : स Maneuver भ Examiner Face Mother

Face ओ ह ह ह स Umbilicus Lateral Side Palpate ह स

Maneuver Fetus Rt. Lateral Position ह Lt Lateral य स ह

(a) य Smooth Curved, Bony Hard Part Feel ह ह : Back

(b) Fetal Limb : Face

(c) य Transverse Lie ह , Side Head Opposite Side Buttocks Feel ह ह (iii) Pawlick’s Grip/2

nd Pelvic Grip/3

rd Leopold Maneuver : स Maneuver भ Examiner Face

Mother Face ह ह स Grip Rt. Hand स Overstresched Hand 4 Finger

Uterus Lower Pole ह

य Hard Globular Part :- Head

Broad Soft Part : Buttocks

Absent Part : Transverse Lie

स Grip Fetal Descent Position Confirm स ह (iv) Pelvic Grip 1 (Fourth Leopold Maneuver) : स Maneuver Examiner Face Mother Feet ह ह स Grip ह Finger स Pelvic Region Inguinal Ligament Parellel ह स Grip Head Engagement ग य स ह

Converge Finger : Head Not Engaged

Diverge Finger : Head Engaged




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Chapter 6

Normal & Abnormal Labor Labor :Labor ह य ह , स Conception Viable Product गभ स Vagina ह य ह

Parturient : A patient in Labor.

Parturition : Process of giving Birth.

Normal Labor (EUTOCIA) : Labor is called Normal if it fulfills the following criteria.

i) Spontaneons in onset and at term

ii) With Vertex Presentation

iii) Without Prolongation.

iv) Natural termination with Minimal aids.

v) Without having any complication affecting the health of Mother & Baby.

Abnormal Labor (DYSTOCIA) : Any deviation from the definition of Normal Labor is called

abnormal Labor.

Pre Labor :

» It is premonitory stage of Labor and begins 2-3 weeks before the onset of true Labor in

Primigravida and few days before in Multigravida.

» It is associated with Increase oxytocin receptors in myometrium.

Following changes seen in Prelabor :

a) Lightening : Term Fetus Presenting Part Maternal Pelvis Descent ह स Fundal height Decrease ह ह , सस Mother Diaphragm Pressure ह ह औ

Mother Relax Feel ह ह स Lightening ह ह

b) Cervical Ripening : Softening of Cervix

Difference b/w True Labor Pain & False Labor Pain

Features True Labor pain False Labor pain

Cevical changes (Dilatation and

effacement)

Present Absent

Frequency and duration of contractions Regular and gradually increase Irregular

Pain Lower abdomen and back,

radiating to thighs

Lower abdomen only

Bag of water Formed Absent

Show Present Absent

Relief with enema/Sedation No Yes




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True Labor : Onset of True Labor Pain characterized by :

» Appearance of True Labor Pain.

» Appearance of Show.

True Labor is divided in four functional Stages-

Stages of True Labor :

1. First Stage : यह Stage True Labor Pain स Start ह ह Cervix Full Dilatation स

ह ह (Full Dilatation of Cervix = 10 cm)

2. Second Stage : यह Stage full Dilation of Cervix स Start ह ह स Stage Fetus Mother

स ह ह Primipara यह Stage 1 hr. Multipara 30 Min. ह ह

3. Third Stage : यह Stage Fetus Delivery Start ह ह स Stage Placenta Fetal

Membrane Uterus स ह ह Primipara Multipara यह Stage गभग 15-25 Min.

ह ह

4. Fourth Stage : यह Stage Placenta Delivery गभग Observation Period ह ह

Physiological chills are experienced by the Mother in this Stage.

Uterine Contraction :

» Braxton Hicks Contraction : यह Painless, Irregular, Involuntary, Spasmodic Uterine

Contraction ह ह Mainly 2nd

Trimester Start ह ह Contraction ह स Cervix Dilatation ह ह ह

» True Labor Pain : यह Contraction Painful ह ह स ह स Cervix Dilatation ह ह

» Pacemaker of Uterine Contraction Cornu ह ह (Rt Pacemaker Predominant over

the left)

» Contraction mainly fundus Part स Start ह ओ ह

Intrauterine Pressure

Event Intrauterine pressure

Contractions are palpable 10 mm of Hg

Contractions are painful 15 mm of Hg

Cervix dilates 15 mm of Hg

Fundus cannot be indented 40 mm of Hg

1st stage of Labor 40-50 mm of Hg

2nd

and 3rd

stage of Labor 100-120 mm of Hg

Adequate Uterine Contraction :3 Contraction in 10 Min. each lasting for 45 Sec. & causing Intra

Uterine Pressure of 65-75 mm of Hg or 220 montevideo Unit.




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Tachysystole : More than 5 contraction in 10 Min.

Unit for Measuring Uterine contraction :

» mm of Hg

» Montevideo Unit (MV Unit)

1 Montevideo Unit = Intensity of Uterine Contraction X No. of Contraction in 3 Min.

Abnormal Uterine Contraction :

1. Hypotonic Contraction (Uterine Inertia) : No. of Contraction are <3 in 10 Min. lasting for < 45

Sec. and <180 Montevideo Unit.

2. Excessive Contraction : It can Result in Precipitate Labor. Entire process of delivery completed in

less than 3 hours.

Requirement for Normal Labor : For Normal Labor 3 Most important thing are (3 P‘s.)

» Push (Uterine Contraction)

» Passage (Normal Pelvis)

» Passanger (Fetus)

Some Important points on Fetus (Passanger)

1. Lie : It is relationship between long axis of fetus to long axis of Mother

Most common lie = longitudinal lie.

Longitudinal Lie Transverse Lie Oblique Lie

(99-99.5%) (0.5%) (0.5%)

Transverse Lie Oblique Lie Mainly Mode of Delivery Cesarean Section

2. Presentation : It is the Part of the Fetus which lies over the Pelvic Inlet and Occupies the

Lower pole of the Uterus. Longitudinal Lie Presentation Cephalic Breech ह स ह

Cephalic :- 96.8%

Breech : -2.7-3%

Transverse Lie Presentation Shoulder ह ह




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Presenting Part : It is the Part of Fetus which Lies directly over the internal os. In cephalic

Presentation, Presenting part can be :

» Vertex (Most Common)

» Face

» Brow : Brow Presentation ह Cesarean Section य ह

Attitude : Relationship of different part of Fetus to one another.

Most Common Fetal Attitude is Flexion attitude.

Denominator : It is an Arbitary fixed point on the presenting part which comes in relation with various

quadrants of maternal pelvis.

Presenting Part Denominator

Vertex Occiput

Face Chin (Mentum)

Brow Frontal Eminence

Breech Sacrum

Position : It is relationship of the denominator to the different quadrant of the Pelvis.

Important Point :

» Most Common Position during Labor = LOT

» 2nd

Most Common Position during Labor = LOA

Important Concepts in stages of Labor :

1. first Stage of Labor : It begins with the onset of true Labor pain and ends with full dilatation of

Cervix.

First Stage of Labor Mainly Cervical Effacement Cervical Dilatation ह ह स Stage Phase Divide य गय ह




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a) Latent Phase

b) Active Phase

Difference B/W Latent Phase & Active Phase

Latent Phase Active Phase

It starts at the point at which the

mother percieves true about pains and

ends when cervix is 5 cm dilated.

It begins with cervical dilation of ≥ 6 with regular uterine

contractions

Its duration in primiparous is 12 hours

and 8 hour in multiparous females

Normal minimum cervical dialation rate of 1.2 cm/hr for

primiiparous and 1.5 cm/hr for multiparous women.According

to WHO Minimum dialation should be 1 cm/hr

Mainly concerned with cervical

effacement and dilatation

Mainly concerned with cervical dilatation and descent of

fetal head

Descent of fetal head

Primiparous = 1cm/hr

Multiparous = 2cm/hr

Abnormalities of Latent Phase :

Prolonged Latent Phase :latent Phase Prolonged ह ह य -

i) Greater than 20 hrs. in primipara.

ii) Greater than 14 hrs. in Multipara.

Causes of Prolonged latent Phase :

(i) Excessive sedation/Epidural analgesia

(ii) Poor Cervical Condition (Thick Uneffaced or Undilated)

(iii) False Labor (Most Common Cause in Multipara)

Management :

Therepeutic Rest : 15 mg Morphine is given Intramuscularly. Most of the patient are asleep

with in 1 hrs. & awake 4-5 hr. later.

Abnormalities of Active Phase : Cervix 6 cm य सस य Dilate ह ह , Active Phase Start

ह ह Active Phase Mainly 2 event ह ह

a) Dilatation of Cervix

b) Descent of Fetal Head




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Normal

Dilatation of Cervix Descent of Fetal Head

Primiparous Female = 1.2 cm/hr. Primiparous = 1 cm/hr.

Multiparous Female = 1.5 cm/hr. Multiparous = 2 cm/hr

(According to WHO-

Minimum should be 1 cm/hr.)

Protracted Active Phase : य Dilatation of Cervix Head Descent ऊ ग Value स ह , स Protracted Active Phase ह ह

Management of Protracted Active Phase :

1. Rule out Cephalo-pelvic disproportion

2. Rule out Occipito posterior Position

य य Condition Rule Out ह ह , Artificial Rupture of Membrane Oxytocin IV

Infusion Labor Augment ह

Important Point :

Artificial Rupture of Membrane : स Method Labor Augment य ह यह

Mainly Kocher‘s Artery forceps य ह

Condition where ARM (Artificial Rupture of Membrane) is contraindicated :

1. Intrauterine Fetal Death,

2. Maternal HIV

3. Active Genital Herpes

Active Phase Arrest : Active Phase Arrest where Cervix is

> 6cm dilated with membranes Ruptured

Adequate Uterine Contraction are Adequate Uterine Contraction are not Present.

Present & No Dilatation for 4 hrs. Oxytocin given & No dilatation for 6 hrs.

Cesarean Section




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Concept Box

1st Situation

A G2P1 is admitted in Labor at 8 AM on Monday.

P/V findings = Cervix 2 cms dilated, 20% effaced

At 10 PM findings are: Cervix=3cms dilated,60% effaced.

FHR=Regular, 140-146 bpm,

Membranes = intact.

What is next step of management

Solution

-This female is multiparous

-Stage of Labor = Latent phase (as cervix is < 6 cms dilated)

-Total duration = 8AM to 10 PM = 14 hours

-Latent phase is said to be prolonged if it is 14 hours in multiparous female

-Hence diagnosis is :- Prolonged latent phase

-Management :- Sedation/Therapeutic Rest

2nd

Situation

A G2P1 is admitted in Labor at 8 AM on Monday.


At 12 PM(midnoon):Cervix 6 cms dilated,80% effaced.

At 3 PM = Cervix 8 cms dilated, membranes intact

FHR is 140, Regular uterine contractions are present.

What is next step of management

Solution

Here again

female is multiparous

When she was admitted, she was in latent phase (cervix 2 cms dilated) but it ended in 4 hours

(at 12 PM = cervix is 6 cms dilated). Hence latent phase was normal. Now she came in active

phase at 12 PM. Since she is a multigravida, dilation of cervix should be 1.5 cm/hr (In 3 hours =

4.5 cms, already at 12 pm she is 6 cms dilated therefore by 3 pm she should be 6+4.5 = 10 cms,

i.e. fully dilated ). But here she is only 8 cms dilated, i.e. it is a case of protracted active phase.

Management should be ARM followed by Oxytocin.

3rd

Situation

A G2P1 female is admitted in Labor at 8 AM on Monday.


Membranes ruptured, No meconium

FHR = 140-148, Regular uterine contractions = Adequate




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At 12 PM(midnoon): Same finding

Next step of management

Solution

Now here patient is :

-Multiparous

-She is admitted in active phase (cervix 6 cms dilated) at 8 am and 12 pm inspite of good uterine

contractions and membranes ruptured, there is no dilatation for 4 hours, hence diagnosis is

arrest of active phase

Management is cesarean section.

Second Stage of Labor : It begins from full dilatation of Cervix and end with expulsion of

Fetus. Second Stage of Labor Mother Bearing Down Effort Role Uterine contraction स य Important ह ह

Prolonged Second Stage

Normal Prolonged

Primiparous 1 hrs. 2 hrs.

Multiparous 30 Min. 1 hrs.

Management of Prolonged Second Stage of Labor : It depends on station of Fetal Head.

If Station of Fetal Head

At or Below +2 Station Above + 2 Station

Delivery by Forceps Vaccum Delivery by Cesarean section

Second Stage Arrest :

Primiparous : 3 hrs.

Multiparous : 2 hrs.

Second Stage Arrest Obstructed Labor भ ह ह Obstructed Labor Management of

Choice = Cesarean Section.

Mechanism of Labor : Mechanism of Labor is defined as the manner in which the fetus adjust

itself to pass through the parturient canal with minimal difficulty.

There are 8 cardinal movements of the Head in Normal Labor.




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i) Engagement : Presenting Part Greatest Transverse Diameter Pelvic Inlet Fix ह ह , स Engagement ह ह Engagement स य Presenting Part Ischial Spine Level ह ह स Zero Head Station भ ह ह




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Head Station 0 (+4 to –4) य Head Ischial Spine स ऊ ह , स –ve स Denote ह य

Ischial Spine स ह , स +ve स Denote ह

य Head –ve Station ह Ischial Spine स ऊ ह , स ह Delivery भ य स य ह औ य Head +ve Station ह Ischial Spine स ह स ह ह स य Delivery ह ह

Multipara Female Engagement, Labor स य ह Late Ist Stage य at the time of

Rupture of Membrane ह ह

Nullipara Female Engagement गभग 38 Weeks ह ह

Causes of Nonengagement of Head in nullipara female : -

a) Malpresentation/Occipitoposterior Position /deflexed Head.

b) Cephalopelvic Disproportion

c) Placenta Previa/Tumor in Lower Uterine segment.

d) Tumor of Fetal neck, cord around neck

e) Hydrocephalus

f) Polyhydroamnios

g) Distended Bladder & Rectum

ii) Descent : यह Natural Process ह स Fetus Downward Movement ह ह Labor Pain

Mother Bearing Down effort ह Descent Promote ह स Universal Step भ ह ह य Descent Continuous Process ह Fetus Delivery Continous सभ Stage ह ह

iii)Flexion : स Stage Pelvis Soft Tissues Resistance ह स Fetal Head Flexion ह ह सस Fetal Chin, Chest ह

iv) Internal Rotation :

Internal Rotation Ischial Spine (Zero station) ह ह

Upper Side Uterine Contraction Lower Side Pelvic Tissues Resistance ह

स Rotation ह ह

यह Fetal Head Rotation Clockwise direction ह ह Distance 1/8 ह ह

य Head Neck स ह ह स Head Rotation स Neck भ Clockwise Direction Twist/ Torsion ह ह

v) Crowning : Internal Rotation Fetal Head just Pubic Symphysis ह ह यह स Fetal Head Ist Time Visualize ह ह

vi) Extension : यह Most important Movement ह स Fetal Head Delivery ह ह




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vii) Restitution :

Head Internal Rotation स य Neck Twisting ह , Restitution Movement Relieve ह ह

Direction Internal Rotation Opposite ह ह anti Clockwise Distance 1/8 ह ह

viii) External Rotation : Head Restitution Shoulder Externally rotate ह ह Expulsion : Head Shoulder Delivery Rest of the Body स स ह ह

Second Stage management Approach :

1. Provide Lithotomy Position with Perineal care.

2. Encourage Bearing Down efforts by Mother.

3. Monitor Uterine Contraction with Base line FHR monitoring.

4. Promote Flexion by putting force on Perineum.

5. Episiotomy if required.

6. Umbilical cord clamping & cutting.

Partogram : Partogram is the best method to access progress of Labor.

Partogram is a graphical recording of stages of Labor including cervical dilatation, descent &

rotation of the Head.

Various Partograph have been made.

1. Friedman Curve : Friedman Ist Stage of Labor Stage Divide य ह :- (a) latent Phase

(b) Active Phase.

Friedman स >3 cm Cervix Dilatation Active Phase Start ह ह Normal Labor Cervical dilatation Pattern Latent Active Phase Sigmoid Curve ह ह




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Friedman Active Phase 3 Phase Subdivide य ह - 1. Accleration Phase : 3-4 cm Cervical Dilatation.

2. Phase of Maximum Slope : 4-9 cm

3. Deceleration Phase : 9-10 cm

ii) Philpott & Castle Partograph : ह Alert Line Action Line Concept य

Labor is said to be progressing Normally till it remains to the left of Alert Line.

iii) WHO Partograph : Composite Partograph :

Introduced by WHO as a part of the safe Motherhood initiative.

Main purpose of Partograph is to avoid Prolonged Labor & intervene timely.

Cervical dilatation and descent of the Head (which are the best parameter to access the

progress of Labor) are plotted on Y axis and time in hours is plotted on X-axis.

The latent phase of Labor is upto 3 cm. dilatation & should not be more than 8 hrs.

In the active Phase which extends from 3 cm to complete dilatation, Labor is expected to

progress at the rate of at least 1 cm cervical dilatation per hour which correspond to the

alert line.

The Action line is drawn 4 hrs to the right and parallel to the alert line in the WHO

Partogram.

Labor is considered normal as long as the progress of cervical dilatation is to the left of

the alert line.

Prolonged Labor is diagnosed once the alert line is crossed ,there is shift to the right.

If the patient is in a peripheral hospital,once the alert line is crossed, It is an indication for

referral to a higher centre for extra vigilance.




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Induction of Labor :

Induction : Stimulation of contraction before the spontaneous onset of Labor.

Normally cervix closed Uneffaced ह ह स Induction of Labor स ह Cervix Soft

य ह स Process Cervical Ripening ह ह Before Labor is induced, Bishop scoring is done to access whether induction will be successful

or not.

BISHOP Score : Bishop score is a quantitative method for prediction of successful induction of Labor.

Bishop score includes the following Parameter.

Cervical Dilatation

Cervical Position

Cervical Effacement

Cervical Consistency

Head Station

Modified Bishop Score :

स Scoring Cervical Effacement गह Cervical Length ह य

Category Maximum Score 2 ह ह Maximum Score 10 ह ह

90% of patient Bishop Score 6-8 ह ह , 6 hrs. Delivery ह ह

Score य <6 ह ह , Delivery Unpredictable ह ह

Score Dilatation

(cm)

Length of

cervix

Station Cervical

consistency

Cervical position

0 0 2 cm -2 Firm Posterior

1 1cm 1 cm -1 Soft Midposition

2 2 cm < 0.5 cm 0 Soft and Stretchable Anterior

Cervical Ripening : Ripening of Cervix is changing the cervical matrix from sol to gel state by

dissolving the collagen bundles, ultimately the cervix becomes soft.

Technique for Cervical Ripening

Pharmacological method Non pharmacological method

Prostaglandin

-Dinoprostone gel (PGE2)

-It is the gold standard for cervical ripening

-Misoprostol (PGE1) tablet

(Vaginal or oral)

Stripping the membrane

Steroid receptor antagonist

-Mifepristone

Mechanical dilators

-Osmotic dilators




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-Onapristone -Ballon catheter/ Transcervical catheter placed

through internal os

Relaxin Extra amniotic saline infusion

Glyceryl trinitrate,isosorbide mononitrate

Absolute Contraindication of Induction of Labor

Absolute contraindication of induction of Labor

Severe degree of contracted pelvis

Cancer cervix

Cord prolapse in early Labor

Major malpresentations like transverse lie, brow, mentoposterior face

Previous uterine scar of hysterotomy, classical cesarean section, repair of uterine rupture

Active genital herpes

Grade II posterior, Grade III and Grade IV placenta previa

Relative contraindication

Fetal distress

Cervical fibroid

Impacted ovarian cyst in pouch of doughlas

Third Stage of Labor:Third Stage of Labor Fetus Expulsion Start ह ह स Stage Placenta Fetal Membrance Expulsion ह ह

Average Time taken = 15-20 Minute

With Active Management of Third Stage of Labor (AMTSL) = 5 Min.

If time taken more than 30 Minute Prolonged 3rd

Stage

Key Concepts

In AMTSL, placental separation is actively facilitated and uterine contraction are initiated to

reduce the incidence of third stage complications (like PPH)

In AMTSL- Duration of third stage reduced (to 5 minutes)

Less bleeding

Less changes of PPH

Less maternal mortality

Hence active management of third stage of Labor is preferred these days.




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Placental Seperation :

Schultz Method

(Inverted Umbrella)

Duncan’s Method

Placental Seperation begins from the center Placental Seperation begins from

periphery

Blood Collects behind the Uterus and bleeding is

appearing only after complete seperation of Placenta

Extenal bleeding begins with

Seperation

Formation of Retroplacental Clot No Retroplacental Clot formed

Total Blood loss is less Total Blood loss is more

Shiny Fetal surface of placenta come first to expel Dull material surface of Placenta come

first to expel.

M/c seen in 80% cases Seen in 20% cases

Active Management of Third Stage of Labor

Component :

1. Use of Oxytocics after the birth of Baby.

2. Delayed cord clamping (> 1-3 Minutes)

3. Delivery of Placenta by controlled cord traction.

4. Intermittent Uterine tone assessment.

Note : Uterine Massage is no longer a part of AMTSL as per the latest guideline of WHO.

Step 1.

1. Use of Oxytocics :

Oxytocin : It is preferred drug and the drug recommended by WHO for preventing PPH

Dose = 10 IU IM/IV infusion.

य Oxytocin Available ह ह , WHO स Other Oxytocics use स ह स :




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a) Ergometrine (0.25 mg) or methylergometrine (0.20 mg) : यह Tetanic Contraction ह

स स Labor Induction Use ह ह

Side Effect : Transient Increase in BP

Contraindication :

1. Twin Pregnancy

2. Organic Health Disease

3. Preeclampsia

4. Eclampsia

5. Rh Negative Female.

b) Inj PGF-2α (Carboprost) : Dose 250 μg I/M

contraindicated in Bronchial Asthma.

यह Mainly Myometrium act ह स स Active Management of third stage of Labor

(AMTSL) PPH Use ह

c) PGE1 (Misoprostol) : Available as Tablet (600 mcg)

PGE1 Cervix Uterus Act ह स स Condition Use ह - 1. Ripening of Cervix

2. Induction of Labor

3. AMTSL

4. for Treating PPH

Side Effect : Nausea, vomitting, Abdominal Pain, Hyperpyrexia, Hypotension

य Previous Cesarean Section ह ह , Misoprostol contraindicated ह ह

d) Syntometrine : यह 5 Unit of Oxytocin 0.5 mg methargin combination ह ह

e) Carbetocin : Dose 100 mg I/V over 1 Minute.

यह Oxytocin Analogue ह ह स Function Oxytocin ह ह ह ह

Use : -Treatment of PPH,

-AMTSL

स Half Life Oxytocin य ह ह (85-100 min.)

f) Tranexamic Acid:यह Antifibrinolytic Drug ह , PPH Prevent Use ह

Step 2 : Delayed cord Clamping :

Delayed Cord Clamping ह Cord Fetus Delivery गभग 1-3 Min.

Clamp Early Cord Clamping ह Cord Fetus Delivery 1 Min. Clamp




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Advantage of Delayed Cord Clamping : गभग 80 ml blood (50 mg elemental Iron) Cord Present ह ह Delayed Clamping ह स स Fetus ह , Newborn Neonatal Anemia Prevent ह स Conditions सभ Conditions Delayed Cord clamping Prefer ह

Condition in which early cord clamping is done :

1. Baby is Hypoxic and needs Resuscitation or Mother is Haemodynamically Unstable.

2. Known Heart disease in Baby.

3. If cord is avulsed or IUGR with abnormal cord doppler evaluation.

Important Point : ह Preterm Babies, HIV Positive Mothers Rh Negative Females Early Cord Clamping Advise , Conditions भ Delayed Cord

Clamping Advise ह

Step III : Delivery of Placenta by Controlled Cord Traction (Modified Brandt. Andrew

Technique) : स Method Placenta Remove य ह ह Uterus Upward Backward Push य ह स ह स Downward Forward Direction Cord Traction य ह Placenta Complete Expulsion ह ह

य Placenta 30 min. भ Deliver ह ह ह , स Retained Placenta ह ह

Step IV : Intermittent Uterine Tone Assessment : Delivery Atonic Uterus Early

Identification Uterine Tone Assessment य ह Uterine Massage Active Management of Third Stage of Labor Include ह य

Most Important Component of AMTSL is Use of Oxytocics




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4th

Stage of Labor :Fetus Placenta Delivery यह गभग 2-4 Observation

Time Period ह ह स Stage Newborn Airway Care, APGAR, Cord Care, Newborn

Assessment, weight, Tag य ह

Vital Monitoring

Fluid & Diet

Intake & Output Recording

COMPLICATION OF 3rd

STAGE OF LABOR :

Post Partum Haemorrhage (PPH) : Vaginal Delivery Genital Tract स 500 ml स य Blood Loss Cesarean Delivery 1000 ml स य Blood loss Postpartum Haemorrhage

(PPH) ह ह

Mild PPH if Blood loss 500-1000 ml

Moderate PPH > 1000 ml

Severe PPH > 2000 ml

Types of PPH :

Primary PPH Secondary PPH

य Haemorrhage Delivery 24

hrs. ह ह

य Haemorrhage Delivery 24 स 12 Weeks ह ह

Most Common Cause- Atonic PPH Most Common Cause- Retained Placenta

Causes of PPH : Cause of PPH = 4 T‘s

1. Atonic PPH (Tone) : यह Primary PPH Most Common Cause ह (90%)

Uterine Muscles Tone ह ह स Uterine Muscles Contraction Retraction ह ह ह सस Uterine Blood Vessels स ग Bleeding ह ह ह

2. Traumatic PPH (Trauma) :यह Mainly Delivery Genital Tract Injury ह स ह ह

3. Coagulopathy (Thrombosis) : Disseminated Intravascular Coagulation (DIC) Hypo-

fibrinogenemia Rare Cause ह

4. Other Cause (Tissue) : Retained Product of Conception (RPOC). Retained Placenta ह

स Mainly Secondary PPH ह ह

Predisposing Factor of PPH :




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Atonic PPH : Grand Multipara

Malnutrition/anemia

Previous H/o Atonic PPH

Overdistended Uterus due to

o Multiple Pregnancy

o Polyhydroamnios

o Macrosomia

Precipitate Labor (Labor < 3 hrs.)

Prolonged Labor (Labor > 12 hrs.)

Inadvertant use of Oxytocin

Use of General/Epidural Anaesthesia especially Halothane

Fibroid Uterus

Traumatic PPH :

Instrumental Delivery

Vaginal Birth after Cesarean(VBAC)

Face to Pubis delivery

Blood Coagulopathy :

Abruption

Sepsis

IUD

Severe preeclampsia

HELLP syndrome

Important Point :

Most Common Cause of PPH = Atonic Uterus

Most Common Cause of Primary PPH = Atonic Uterus

Most Common Cause of Secondary PPH = Retained Placenta

Structural Placental Abnormalities which can lead to PPH = Succenteuriate Placenta/Placenta

Bilobata.

Diagnosis of PPH :

Shock Index =

Normal Value = 0.5 – 0.7

य shock Index 0.9 – 1.1 Increase ह ह , Intensive Resuscitation य ह ह

Obstetric Shock Index (OSI) : During Pregnancy Normal Value = 0.7 – 0.8

OSI > 1 Indicate Massive Haemorrhage & need for Blood Transfusion.

Management of PPH :

First & Basic step in Management of PPH is resuscitation of Pt. which includes-

Securing I/V Lines

Volume Restroration by crystalloids (Normal saline/Ringer lactate)

Oxygen Inhalation




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Crossmatching & Arranging for Blood

स स य Investigation स Blood Group, Haemoglobin, Clotting Time, Coagulation

Profile, Electrolytes भ ह

Concept Box : PPH Cause Atonic ह Tramatic Case Mother Abdomen Palpate

ह य Uterus Palpate ह ह ह , स स -स ह Uterus Tone Normal

ह PPH Cause Traumatic ह स ह औ य Uterus Abdomen स Palpate ह ह ह , स ह PPH Cause Atonic Uterus ह

Management of Atonic PPH :

1. Medical management : Atonic PPH Uterus tone Increase

Uterotonic Drugs Use ह

Eg. Oxytocin

Carbetocin

Ergometrine/Methylergometrine

Carboprost (Contraindication in Asthma)

Misoprostol

Tranexamic Acid

2. Mechanical Methods : य Medical management Fail ह ह , स Mechanical

Methods Use ह

(a) Uterine Massage and Bimanual Compression :

Active Management of 3rd

Stage of Labour Uterine Massage Remove य गय ह , WHO स PPH Treat Uterine Massage य ह




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(b) Intra Uterine Packing (Tamponode) : यह GA (General Anaesthesia) य ह स

Process गभग 5 Antiseptic Solution भ ग ह Gauge Piece Uterus भ य ह

(c) Ballon Tamponade : स Process Condom Catheter य Sangstaken Blakemore Esophageal

Catheter य Bakri Ballon Catheter Use य ह Catheter गभग 200-500 ml Warm

Saline गभग 12-24 ह

(d) Military Anti Shock Garment or Treatment (MAST) : स Gaint BP cuff Patient Legs

Abdomen य ह सस Blood Vital Organs ह ह

3. Surgical Method : Mechanical Method भ Fail ह ह , Surgical Methods Use

ह

Surgical Methods

If Family is not Completed Family is Completed

Applicatiion of B-lynch Suture

Uterine Artery Embolization Subtotal hysterectomy

Uterine & Ovarian artery Ligation

Internal iliac Artery Ligation

If all methods fail than finally Hysterectomy done.

Management of Traumatic PPH : PPH 2nd Most Common Cause Genital Tract Trauma

ह ह Traumatic PPH Mainly Perineal Tear, Haematoma, Cervical Tear Uterine Rupture

ह स ह ह




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Pelvic Haematoma :

Most Common Site for Pelvic Haematoma – Vulva

Most Common Artery to form Vulval Haematoma – Pudendal Artery

Most Common artery to form Vaginal Haematoma – Uterine Artery & its branches

Most Common Symptom of Pelvic Haematoma – Pain, Inability to Pass Urine.

Local Examination : Bluish Tender Swelling.

Management : य Samll Haematoma ह (< 3 cm) Cold Compression Analgesics Conservatively Manage य ह य Large Haematoma ह (>3 cm) Surgical

Management य ह Clot Drain ह य Bleeder Present ह , Figure of

8 Suture ग ह

Perineal Tear : Vagina स Anus Skin Soft Tissue Normal Vaginal

Delivery laceration/Tear ह ह , स Perineal Tear ह ह

Grade Description

1st degree Tear involving vaginal epithelium or skin only

2nd

degree Tear involving both vaginal skin and muscles (mediolateral episiotomy

corresponds to 2nd

degree perineal tear)

3rd

degree

Grade 3a

Grade 3b

Grade 3c

Involvement of anal sphincter

Tear of < 50% of external anal sphincter

Tear of ≥ 50% of external anal sphincter

Tear of external and internal anal sphincter

4th

degree Third degree tear along with involvement of anal epithelium

Note : Instrumental Delivery ह स Perineal Tear स भ ह Forceps Delivery

Ventouse Delivery Perineal Trauma स भ ह ह

Management of Perineal Tear :

First & Second Degree Tear :

Repaired in Labor Room.

Using Mainly Epidural Analgesia.

Technique : Vaginal Mucosa Repaired

Muscles Repaired

Vaginal Skin Repaired




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Third & Fourth Degree Tear :

Anal Epithelium Repair

Internal Anal Sphinctor Repaired

External Anal Sphinctor Repaired

Vaginal Mucosa Repaired

Vaginal Muscle Repaired

Skin Repaired

3rd

& 4th

Degree Perineal Tear Repair स स 6 ह

Pregnancy Avoid ह

Cervical Tear : Most Common Site 3 ‗O‘ Clock Position followed by 9 ‗O‘ Clock Position.

Retained Placenta : य Placenta Delivery 30 Min. भ Uterine cavity स Expell ह ह ह , स Retained Placenta ह ह

Types

Category 1

Seperated Yet Retained Placenta Adherent to Uterus

Category 2

Simple Adherent Placenta Morbidly adherant Placenta

It is most Common cause of PlacentaAccreta

Retention. It can be due to Placenta Increta ,

Atonic Uterus Placenta Percreta

Management of Retained Placenta : (Category 1 & 2) as Recommended by WHO

Initial Step : य Placenta Expell ह ह ह , WHO स Oxytocin (10 IU I/M

or I/V) Controlled Cord Traction 30 Min. ह WHO स Drug

Retained Placenta Management Use ह ह :

(1) Ergometrine

(2) Denoprost.




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Most of the Cases Category 1 Category 2 Placenta Deliver ह ह , य Placenta

भ भ Deliver ह ह ह Manual Removal ह

Manual Removal of Placenta (MRP) :

Done in OT.

Under General Anaesthesia

Single Dose of Antibiotic (Ampicillin)

After the Procedure – I/V Oxytocin Infusion.

Placenta Accreta/Morbidly adherant Placenta : Placenta Accreta Morbidly Adherant

Placenta Type ह , Decidua Basilis Fibrinoid Layer Nitabuch‘s Membrane Absent ह ह स Develop ह ह स Placenta Uterine Wall Firmly Adherant ह ह

Classification :

Placenta Accreta : Chorionic villi attached to superficial Myometrium.

Placenta Increta : Chorionic villi Invade deep in the Myometrium.

Placenta Percreta : Choronic villi Penetrate the full thickness Myometrium and reach upto the

serosal layer.

Complication :

Excessive Bleeding

Shock

Sepsis

Uerine Inversion

Management :

Placenta Accreta

If Female has Complete her Family If Female has not Complete her Family

Cesarean followed by Hysterectomy Conservative Approach

Uterine Inversion : Uterine Inversion is a condition in which there is inside out turning of the

Uterus.

It is Rare cause of postpartum collapse but collapse occurs suddenly after labor.

Etiology :

Most Common Cause is Mismanagement of Third stage of Labor य Placenta Separate

ह ह ह औ सस ह ह Cord Traction Method Placenta Delivery ग ह




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Spontaneous Inversion Atonic Uterus Condition ह स ह Placenta Accreta is rare Cause.

Clinical Feature :

Patient Present with shock immediately after delivery.

Uterine Inversion condition Haemorrhagic Shock ह स Patient Death ह स ह

Important Points :

Important Points

A patient after delivery goes into shock- Most probable cause is - : PPH

A patient after delivery goes immediately, into shock- Most probable cause is – :

Uterine inversion

A patient after delivery goes into unexpected shock- Most probable cause is – :

Amniotic fluid embolism

Management :

Manual Replacement

Hydrostatic O Sullivan Method

Surgery

Amniotic Fluid Embolism : Inevitable cause of Maternal Mortality.

Clinical Feature : Breathlessness

Cyanosis

Collapse




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Chapter 7

MALPRESENTATION

Malposition : Flexed Occipito Anterior Occipito Transverse Position य औ

Position ह , स Malposition ह ह

Most Common Malposition = Occipito Posterior Position

Malpresentation:Vertex Presentation सभ Presentation Malpresentation ह ह

Most Common Malpresentation Breech Presentation ह ह

Face Presentation :

Presenting Part is Face.

Abnormal Attitude : Normal Delivery Head Attitude Flexion ह ह य Head Attitude Extension ह ह , स Face Presentation ह ह

Denominator = Mentum

Most Common seen in Multiparous Female.

Most Common Pelvis in which face Presentation seen platypelloid Pelvis.

Engaging Diameter = submentobregmatic (9.5 cm) and submentovertical (11.5 cm)

Brow Presentation :

यह Rarest Presentation ह यह Mainly Head Partial Extension ह स ह ह

Engaging Diameter = Mentovertical (14 cm)

Delivery = by cesarean section.

Breech Presentation :

Breech Presentatron Longitudinal lie ह ह Podalic Pole Pelvic Brim ह ह Fetus Buttock Part Maternal Pelvis ह ह

यह स स Common Malpresentation ह ह

Causes of Breech :

Prematurity – Most Common Cause

Twins

Oligohydroamnios

Congenital Malformation of Uterus Like Septate/Bicornuate Uterus

Short Cord

IUD

Hydrocephalus

Placenta Previa




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Contracted Pelvis

Varieties of Breech :

(i) Complete Breech/Flexed Breech :

Normal Attitude—Full flexion Maintained.

Thigh are Flexed at the hip and legs at the knees

Presenting Part-Buttocks, external genitalia, Feet

(ii) Breech with extended legs (Frank Breech) :

Thigh are flexed on the Trunk and legs are extended at the knee joints.

Presenting Part Buttocks & external genitalia only.

(iii) Knee Presentation :

Thighs are extended but knees are flexed.

(iv) Footling Presentation :

Both the thighs and the legs are partially extended so the feet become the presenting part.

Chances of cord prolapse are maximum in this presentation.

Fig :Complete Breech Fig : Frank breech Fig : Knee Presentation Fig : Footling Presentation

Normally Breech Presentation Fetal Head Flexed condition ह ह य Fetus Head Extended ह ह , स Strargazer Breech ह ह स condition Cesarean Section

य ह

Management of Breech : य >36 Weeks य Latent Phase Fetus Breech Presentation

ह External cephalic Version Try य स ह

External Cephalic Version (ECV) :

OPD Procedure

No Anaesthesia Required

Breech/transverse lie is tried to rotate per abdominally so that it converts to Cephalic

Prerequisite for ECV :

Period of Gestation >36 Weeks.

Liquor should be Adequate.

Membrane should be Intact.




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There should be no Contraindication for Vaginal delivery.

Mechanism of Labor in Breech : Lie = Logitudinal

Presentation = Podalic

Denominator = Sacrum

Concept Box :

General Principal in Breech Delivery :

Labor Specialized units Conduct य ह

Induction of Labor avoid ह

य Prolonged Second Stage ह , स Repture of Membrane Oxytocin Labor Induce ह ह य Cord Prolapse Possibility Maximum ह ह

य Breech Delivery Labor Ist य IInd Stage Prolonged ह , यह Mainly Cephalo- Pelvic

Disproportion ह स Cesarean Delivery Prefer ह

Delivery of Breech Occurs at 3 Level :

1. Delivery of Buttocks : Always give Episiotomy in Breech.

Pinard Maneuver : Used for delivery of extended legs. (Remember P for Pinard, P for

Popliteal Fossa)

2. Delivery of Shoulder : Lovset Maneuver – Delivery of Shoulder




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3. Delivery of After coming Head of Breech :

This is most important Stage of Breech Delivery.

Umbilicus Delivery Head Delivery 10 Min. स य स य ह ह ह

य Fetal Asphyxia Chances Increase ह ह Burns – Marshall Technique – Delivery of After coming Head

Transverse Lie :

Lie – Transverse

Presentation – Shoulder

Long Axis of Fetus Maternal Spine Perpendicular ह ह , स Transverse Lie ह ह Most Common Cause :

Prematurity > Platypelloid Pelvis > Multiparity




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Management : Transverse Lie य Shoulder Presentation ह LSCS ह ह Baby Live ह Dead.

Important Point : Chances of Cord Prolapse are Maximum with

Transverse lie > Footling > Knee Presentation.

Unstable Lie : 36th

Weeks Pregnancy भ Fetus Presentation Constantly Change

ह ह ह , स Unstable Lie ह ह

Causes :

Grand Multipara (Commonest Cause)

Polyhydroamnios

Placenta Previa

Pelvic Tumor

Oligohydroamnios Uterine Malformation ह स Malpresentation ह स ह , Unstable Lie ह ह

Management :

Unstable Lie Condition Premature Repture of Membrance Cord Prolapse स भ य ह ह

Unstable Lie Situation य Cases Elective Cesarean Section Prefer य ह

Cord Prolapse : Cord Prolapse is the Condition where the umbilical Cord lies below the

presenting part after rupture of Membranes.

Management of cord prolapse

Baby alive and viable Baby dead

Vaginal delivery not imminent Confirm by USG

Cesarean section Await spontaneous Labor

Vaginal Delivery imminent

Vertex of fetal head at ≥ +2 station Station < +2

Forceps delivery Cesarean section




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Obstructed Labor : Birth Canal Mechanical Obstruction ह स Good Uterine

Contraction ह भ य Presenting Part Descent ह ह ह , स Obstructed Labor

ह ह

Causes :

1. Fault in Passage :

Cephalo- Pelvic disproportion,

Contracted Pelvis,

Cervical or Broad Ligament Fibroid

Impacted Ovarian Tumor

2. Fault in Passanger :

Transverse Lie

Brow Presentation

Hydrocephalus

Fetal Ascites

Big Baby

Clinical Feature : Mother is exhausted, Dehydrated, Tachypnic, Acidotic breathing.

Per Abdominally :

Lower Uterine segment Obstruction ह ह Upper Uterine Segment Actively

Contraction ह ह स ह स Per Abdominally Ring Feel ह ह , स Bandl‘s Ring Retraction Ring भ ह ह Per Vaginally :

Dry, Hot Vagina.

Offensive, Purulent, Vaginal Discharge.

Fresh Vaginal Bleeding.

Urethra is Pressed Between Pubic symphysis & Fetal Head with Inability to pass Urine

causing Bladder distention, Haematuria may present.

Management :

Resuscitation of the Patient.

Correction of dehydration & ketoacidosis

Antibiotics given.

The Most important Principles in Management of Obstructed Labor.

a) Obstructed Labor भ भ Wait & Watch ह ह य Uterine Repture ह स ह

b) Obstructed Labor भ भ Oxytocin ह ह

Obstetric Management :




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Obstructed Labor ह Cesarean Section ह ह Fetus Dead ह Alive.

Obstructed Labor स 10 Bladder Drainage ह य Obstructed

Labor ह स Pressure Necrosis Develop ह ह , स ह स Vesicovaginal Fistula

Chance ह ह

Important Points :

Obstructed Labor Retraction Ring/Bandl‘s Ring ह Uterus Incoordinated

Contraction ह स Constriction Ring/Schroders Ring ह

Rupture Uterus : 28 Weeks Pregnancy य Uterus सभ Layer (Endometrium),

Myometrium Serosa Continuity Break ह ह , स Rupture of Uterus ह ह

There are two Terminology :

1. Uterine Rupture/Complete Rupture : स Situation Uterus सभ Layers Rupture ह ह Fetus Abdominal Cavity ह Haemoperitoneum Develop ह ह

2. Uterine Dehiscence/Incomplete Rupture : स Situation Uterine Serosa Intact ह ह Complete/Incomplete Uterine Rupture स भ स स य Prior Cesarean Delivery

ह ह

Sign of Impending Scar Rupture : Fetal Tachycardia

Scar Tenderness.

Management of Rupture :

Uterine Rupture Emergency Condition ह , स High maternal Mortality Mobidity ह ह

Immediate Resuscitation (Fluid & Blood) Laprotomy ह

Most of the Ruptures Sub Total Total Hysterectomy ह

Intra Uterine Fetal Death : Period of Viability (22 Weeks) य Intrauterine Fetus Death ह ह , स Intra Uterine Fetal Death ह ह (According to WHO fetus weight

should be>500gm)

Diagnosis : IUD can be diagnosed Clinically by;

Size of Uterus less than the period of Gestation.

Liquor decreased.

FHS Absent.

Fetal movement Absent.

Ultrasound : Earliest diagnosis is possible by USG




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Spalding Sign : Fetal Death Cerebrum Shrinkage ह स Skull Bone स - स ऊ Overlapp ह ह स Spalding Sign ह ह यह Fetal Death 1 Week

ह

Robert’s Sign : Presence of Gas in the Fetal large Vessel (Earliest Sing Seen 12 Hours

after Fetal Death)

Ball Sign : Hyperflexion of Fetal Spine यह Fetal Death 3-4 Weeks ह Crowding of Ribs

Halo Sign : Abnormal increase of Soft Tissue due to Maceration.

Fig : SPALDING SIGN

Management of IUD :

स ह IUD Diagnosed ह ह as Soon as Labor Induce ह

य BISHOP Score < 6 ह , Labor Induction PGE2 Gel स ह Cervix Soft

ह

य BISHOP Score > 6 ह , Labor Induction Oxytocin स ह

IUD Situation Artificial Rupture of Membrance (ARM) ह ह , य सस Infection Chances ह

Normally Dead Fetus Situation Cesarean Section Avoid य ह , Condition

स ह ह , ह Dead Fetus Situation भ Cesarean ह स : Previous Cesarean

Section, Placenta Previa, Transverse Lie.




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Chapter 8

OPERATIVE OBSTETRICS Forceps & Ventouse Delivery :

Forceps : Forceps Instrument ह ह , Fetal Head Delivery Help ह

Ventouse : स Device Fetal Head Vacuum Create य ह fetal Head Delivery ह

Types of Forceps :

1. High Forceps : स use य ह Head Engagement ह ह ह स use

ह य ह

2. Mid Forceps/Rotating Forceps : Head Engaged ह Presenting Part + 2 Station स ऊ

ह स Position Rotation य ह ह Eg. Kielland‘s Forceps

3. Low Forceps : Head + 2 Station स ह स Position भ Rotation य ह ह Eg.

Simpson Forceps.

4. Outlet Forceps : Head + 2 Station स ह Head Pelvic Floor ह स

Position ह Rotation Required ह ह Eg. Wrigley Forceps.

स Position Fetal Scalp Introitus स ग ह

Forceps has the following Parts :

Blade

Shank

Lock

Handles




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Vacuum : Vacuum or Ventouse Consist 2 parts :

Suction Machine

Suction Cups.

Suction Cup Metallic/Sialistic ह ह

Vacuum Cup Flexion Point apply य ह Posterior fontanelle स 3 cm ग Anterior Fontanelle 6 Cm ह ह

Fetal Distress Situation Vacuum Use ह ह

Vacuum Vertex Presentation य स Presentation Use ह य स ह

Prerequisite For Forceps & Vacuum Delivery :

F : Favourable Position/Station

O : Os should be fully dilated

R : Membranes should be Ruptured

C : Uterus should be contracting

E : Episiotomy should be given, Bladder should be empty, Head should be engaged.

P : No CPD

Forceps : Pressure/Traction Primi = 20 Kg

Multi = 13 Kg.

Forceps applied along Occipitomental direction.

Indication :

Maternal Distress,

Fetal Distress (Head Station >+2)

Prolonged 2nd

Stage of Labor.

Advantage of Forceps over Vacuum :

यह Vertex Presentation Other Position भ Use य स ह

यह Preterm Babies Use य स ह Fetal Distress Condition Use य स ह

Contraindication :

CPD/Contracted Pelvis

HIV Positive Female

Osteogenesis Imperfecta

Known Coagulopathy in Fetus




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Complication :

स ह स Maternal Injury Chances य ह ह Complete Perineal Tear is Most

Common.

Fetus Facial Nerve Palsy Brachial Plexus Injury ह स ह Maximum 3 Attempts स ह य 3 Attempts भ Fetal Head Delivery

ह ह ह , स Failed Forceps ह ह स Condition Cesarean य ह

Vacuum : य Cervix Full Dilated ह ह , भ Vacuum Use य स ह

Initial Pressure = 0.2 kg/cm3

Maximum Pressure = 0.8 kg/cm3

Fetal Distress Condition Vacuum Use ह ह

Preterm Babies भ Vacuum Use ह ह Vacuum स Fetal Injury Chances य ह ह

Complication :

Cephalohematoma

Retinal Nerve Injury

Sixth Nerve Palsy

Artificial Caput Succedaneum (Chignon)

Maximum 3 Attempts स ह य 3 Attempts भ Fetal Head Delivery ह ह ह , स Failed Vacuum ह ह स Condition Cesarean य ह

Episiotomy : Vaginal Delivery Vulval outlet Diameter Increase

Perineum Vulva Incision ग य ह सस Perineal Tear Develop ह स Episiotomy

ह ह

Episiotomy Second Degree Type Perineal Tear ह Vulval Outlet Diameter Increase य ह यह Routine Procedure ह ह यह Only Selective

Cases य ह Indication of Episiotomy :

1. In Rigid Perineum : Elderly Primigravida

2. Anticipating Perineal Tear : Big baby, Face to Pubis delivery, Breech Delivery shoulder

dystocia

3. Operative Delivery : Forceps Delivery, Ventouse Delivery.

4. Previous Perineal Surgery : Pelvic Floor Repair




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Timing of Episiotomy : Crowning Just ह Head 3-4 cm Visible ह ह यह Time Episiotomy

Best ह ह

Types of Episiotomy :

1. Median : यह Incision Midline Fourchette स Start ह Anus ओ ह ह , Anal

sphinctor Involve ह ह स Cut य Extension ह ह , 3rd

4th

Degree Perineal Tear ह Chances ह ह 2. Mediolateral : यह Cut Centre Midline स Start ह Outward ह ह स Cut Safe

ह ह य Extension ह स Rectal Involvement ह ह

3. Lateral : यह Cut Midline स गभग 1 cm Lateral ह ह Outward ह ह स Cut Mainly Bartholin Duct Injury ह Chances ह ह 4. J-Shaped : स Cut Midline गभग 1.5 cm Outward Cut ग य ह सस Rectal Involvement ह ह

Mediolateral Median Episiotomy Most Common Type Episiotomy ह ह

Commonly Rt. Mediolateral Episiotomy is Performed.

Median Episiotomy Extension ह स 3rd 4th

Degree Perineal Tear स भ ह ह

स Median Episiotomy Routine Use ह य

Cesarean Section : यह Operative Procedure ह स 28 Weeks Abdomen Uterus

Wall Incision ग Fetus Delivery ह

Indication :

Absolute Indication :

Central Placenta Previa

Contracted Pelvis or Cephalopelvic Disproportion

Pelvic Mass (Cervical or Broad Ligament Fibroid)

Advanced Carcinoma Cervix

Vaginal Obstruction (Atresia, Stenosis)

Relative Indication :

Cephalopelvic Disproportion

Previous Cesarean Delivery

Non Reassuring FHR (Fetal Distress)

Dystocia due to 3 ‗P‘ :

(1) Large Fetus (Passanger)

(2) Small Pelvis (Passage)

(3) Ineffective Uterine Contraction (Power)




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Antepartum Haemorrhage : Placenta Previa, Abruptio Placenta

Malpresentation : Breech, Shoulder, Brow

Failed Surgical Induction of Labor

Bad Obstetric History : Recurrent Obstruction

Hypertensive Disorder : Severe Preeclampsia, Eclampsia

Medical : Gynecological Disorder : Diabetes, Heart Disease

Skin Incision :

1. Pfannenstiel Incision : It is suprapubic curvilinear Incision, 2 finger breadth above pubic

symphysis.

2. Joel-Cohen Incision : It is suprapubic Transverse Incision above the level of pfannenstiel

Incision.

Fig : PFANNENSTIEL Incision Fig : JOEL-COHEN Incision

Uterine Incision : The Uterine Incision can be given on either.

1. Upper Uterine Segment : Classical Cesarean section.

2. Lower Uterine Segment : Lower Segment cesarean section (LSCS)

Upper Uterine Segment :

Sangers Incision

T-shaped Incision

Lower Uterine Segment :

Kerr Incision

Kronig Incision (Vertical Incision on lower Uterine Segment)

Fig A : Classical cesarean section Fig B : T Shaped Incision




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Fig C : Kerr incision Fig D : LSCS Kronig incision

Important Points :

Level of Anaesthesia in Cesarean section = T4

Ideal time to conceive after cesarean = 18 months

Best time to do Cesarean (Primary) for elective reason = 39 Weeks

Classical Cesarean Section Uterine Rupture ह स भ Lower Segment Cesarean

Section ह ह

VBAC (Vaginal Birth after Cesarean or Trial of Scar) : य Previous Pregnancy Nonrecurring Indication स Fetal Distress ह स LSCS य ह , Next Pregnancy Vaginal Delivery Try य स ह स VBAC (Vaginal birth After Ceserean) ह ह Mode of Delivery 37 Weeks Decide य ह Vaginal Delivery Contraindication स Placenta Previa ह ह ह

Previous Operation Uncomplicated LSCS ह ह Previous Child Healthy Alive ह ह

Woman Age 40 Years स ह ह

Interdelivery Time Interval स स ह ह

Present Pregnancy Uncomplicated Single ह ह स Malpresentation Malposition ह ह ह

Fetus Estimated Birth Weight 4 Kg स ह ह

Cephalopelvic Disproportion ह ह ह

Contraindicatron of VBAC :

Absolute Contraindication Relative Contraindication

Types of Incision on Uterus

1. Classical Cesarean

2. T-Shaped Incision

Macrosomia in Current Pregnancy

Breech in Current Pregnancy

Post Term Pregnancy

C




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3. Kronig Incision

H/o Previous Uterine Rupture

If any Contraindication to Vaginal Delivery is Present.

Management of VBAC :

VBAC (Vaginal Brith after Cesarean) well equiped Hospital य ह ह Continuous Intrapartum Care Monitoring Emergency Immediate Cesarean

Section, Blood Transfusion Neonatal Resuscitation स ह ह Labour Augment स Amniotomy ह

VBAC Induction of Labor भ भ Oxytocin Use ह ह , य Oxytocin

Strong Uterine Contraction Produce ह सस Uterine Rupture स भ ह ह

Vaginal Prostaglandin E2 Tablet (Dinoprostone) भ Cervix Ripening Use ह ह (Due to High Risk of Rupture)

Epidural Anaesthesia not Contraindicated.

Misoprost is Contraindicated in Previous Cesarean Section.

Labor Procedure Fetal Heart Rate Monitoring ह Fetal distress

is one of the Earliest Sign of Scar Dehiscence.




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Chapter 9

Preterm Labor, Premature Rupture of Membrance & Post Dated Pregnancy

Preterm Labor :

> य Onset of Labor (Regular Painful Uterine Contraction associated with effacement and

dilatation of the Cervix) 37 Weeks स ह ह , स Preterm Labor ह ह Risk Factor of Preterm Labor (PTL)

Previous H/O Pre Term Labor

Most Common Cause of Preterm Labor is Idiopathic followed by Infection.

Low Socioeconomic Status

Smoking

Congenital Anomallies of Uterus

Pregnancy complication like Antepartum Haemorrhage, PROM, Polyhydroamnios,

Twins

Genital tract Infection

Bacterial Vaginosis

Gardnerella Vaginalis

Ureaplasma Urealyticum

Mycoplasma Hominis

Fusobacterium

Incompetent OS

Prophylactic Measures to decrease Preterm Labor :

Stop Smoking

Progesterone : Progesterone decrease Uterine Contraction by suppressing cytokine

Activity.

Diagnosis of Preterm Labor :

1. Symptoms & sign of PTL :

Uterine Contraction Frequency 4 in 20 min. or 8 in 60 minutes.

Lower Back Pain

Passage of Blood Stained Vaginal discharge (Show)

Sensation of Pelvic Pressure

Bulging/Rupture of Membrane.

2. On TVS :

Length of Cervix : < 2.5 cm (2.5 cm is cut off value for length of cervix to predict PTL)

Dilatation of Cervix : > 2 cm

Effacement of Cervix : U-shaped (80%)




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3.Level of Fibronectin Protein :

Presence of fibronectin Glycoprotein produced by Fetal Amnion in the cervico- vaginal

discharge between 24-34 weeks is a predictor of pretern Labor. When the test is Negative it

Reassure that delivery will not occur with in next 7 days.

Management of Preterm Labor :

General Principles : Preterm Labor स स Important Risk ह Fetus Lung Mature ह ह ह सस Fetus Respiratory Distress Syndrone ह Possibility ह ह Fetus Lung Maturity

Enhance Corticosteroid य ह

Dose of Corticosteroid :

1. Two dose of Betamethasone (12 mg) IM 24 hourly.

2. Four Dose of Dexamethasone (6 mg) IM 12 hourly.

Use of Corticosteroids :

Decrease chances of Respiratory distress Syndrome.

Decrease chances of Intraventricular Haemorrhage

Decrease chances of Necrotising enterocolitis.

Weekly repeat courses are not recommended as it can lead to cerebral palsy in fetus.

Contraindication for corticosteroid : Chorioamnionitis

Tocolytic Therapy : Corticosteroid गभग 24-48 स Best Effect ह

स स 24-48 Uterine Contraction Stop य ह स Short

Term Tocolytic Drug Use ह

Tocolytic Drugs :

Prostaglandin Synthatase Inhibitor : Indomethacin

Calcium Channel Blockers : Nifedipine

Oxytocin Antagonist : Atosiban

Mangnesium Sulfate

Nitric Oxide Donor : Glyceryl Trinitrate

β-Agonist : Ritodrine, Terbutaline, Isoxsuprine, Salbutamol.

Important Points :

Tocolytic of Choice Nifedipine

Tocolytic of Choice in Heart Patient Atosiban

Tocolytic with Maximum Maternal side effect β-Agonist

side effect of β-Agonist

Tremor,

Hyperglycemia

Hypokalemia

Pulmonary edema

Tocolytic with Maximum fetal side effect Indomethacin




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Side Effect of Indomethacin

premature Closure of Ductus Arteriosus

Oligohydroamnios

Neonatal Pulmonary Hypertension

Tocolytic Contraindicated in Diabetes β-Agonist

Long Term MgSo4 Tocolytic ह Use स Neonatal Osteopenia स भ ह

MgSo4 Preterm Labor 24-32 Weeks Use स Cerebral Palsy स भ

ह ह

Preterm Labor Antibiotics Role ह ह Membrane Rupture ह ह ग ह Progesterone Uterine contraction Suppress ह स Preterm Labor Tocolytic

ह Use ह य

Contraindicatron of Tocolytics : chorioamnionitis

Advanced Labor

Preeclampsia/Eclampsia

Abruptio Placenta

congenital Anomally of Fetus not Compatible with life.

Management of Pre term Labor

If corticosteroid was not given earlier it has to be given

Tocolytics

MgSo4 (For neuroprotection)

Send Rectal & vaginal swab for group B Streptcoccal infection (Causes neonatal meningitis)

PROM (Premature Rupture of Membrane) : Premature Rupture of Membrane is defined as

spontaneous rupture of membrane before the onset of Labor.

PROM

Term PROM Preterm PROM

य Membrane Rupture य Membrane Rupture 37

37 Week ह Week स ह ह




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Etiology :

Multifactorial

Infection Chlamydia-Trachomatis

Group B Streptococci

Bacterial Vaginosis

Presentation : Patient Present with Typical History of sudden gush of clear or pale yellow fluid

leaking from vegina. However many women may present with history of Intermittent or constant

leaking of small amount of fluid or just sensation of fluid or just sensation of wetness within the

Vagina.

Test for PROM :

1. Nitrazine Test :

Principle :

PH of Amniotic Fluid = 7-7.5

PH of Vaginal discharge = 3.5-4.5

Yellow Nitrazine Paper introduced into Vagina

If it turns Blue If it Remains Yellow

PH is Alkaline PH is Acidic

Amniotic Fluid is Present (PROM confirmed) Amniotic Fluid is not Present

2. Fern Test :

Fluid from the posterior vaginal fornix is swabbed on a glass.

Slide and allowed to dry for 10 minutes if on drying

Fern Pattern Seen No Ferning Seen

Amniotic Fluid Present (PROM) Amniotic fluid is not Present

It is Vaginal Discharge




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3. USG : In case of PROM in USG decrease amount of Amniotic Fluid or Anhydroamnios.

4. Fetal Fibronectin Protein : If present in Vaginal cervix dischage it shows PROM.

Diagnosis :

Per Speculum Examination : PROM Diagnosis Sterile per Speculum

Examination य ह

PROM Per Vaginal Examination ह ह य सस intrauterine Infection Preterm Labor स भ ह

Effect of Preterm Premature Rupture of Membrane :

Preterm Labor & Birth

Pulmonary Hypoplasia due to severe oligohydroamnios

Skeltal & Joint deformities of the Fetus due to compression.

Chorioamnionitis

General Principle for management of PROM :

1. Bed Rest.

2. Sterile Pads for inspection & Monitor Sign of Infection

3. Observed sign of clinical chorioamnionitis

Maintain temperature chart 4-8 hourly.

Auscultate Fetal heart rate 4-8 hourly

Observe for offensive vaginal discharge.

4. High Vaginal swab examination

5. Maternal CBC & C-Reactive Protein

6. Cardiotocography: Useful for monitor Fetal tachycardia due to Chorioamnionitis

7. Use of Prophylactic Antibiotics Erythromycin can be given for 10 days.

8. Antenatal corticosteroid

9. Tocolysis

9. Delivery at 34 Weeks.

Post Term Pregnancy : य Preganancy 42 Weeks भ Continue ह ह , स Postmaturity य Post Term Pregnancy ह ह

Cause :

1. Wrong Dates : Due to wrong LMP date (Most common)

2. Hereditory

3. Maternal Factor : Primipara, Elderly Multipara, Sedentary Habit

4. Fetal Factors : Congenital Anomallies like Anencephaly, Adrenal Hypoplasia

5. Placental Factor : Sulphatase Deficiency (Low estrogen)




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Fetal Complication in Post Dated Pregnancy

Post-dated pregnancy

Aging of placenta Liquor decreases Increase weight gain by fetus

Placental insufficiency Oligohydramnios Fetal macrosomia

Fetal hypoxia and acidosis

Stillbirth Increase chances Increase chances of

of cord compression meconium aspiration

Increase chances of Increase chances of Increase chances of

shoulder dystocia birth trauma (Intracranial Operative delivery

hemorrhage due to

nonmoulding of head

Chorioamnionitis :

Fetal Membrane Inflammation य Intrauterine Infection Chorioamnionitis ह ह

WBC cell counts Increase ह ह य WBC materel Origin ह ह य WBC Amniotic Fluid

ह , Amnionitis ह ह य WBC Umbilical Cord ह , स Funicultis ह ह Causes :

PROM

Prenatal diagnostic Procedures like Amniocentesis, CVS

Bacterial Vaginosis

H/O Amnio Acid Infusion, Cerclage Surgery

Cases Handled by dais

Diagnosis :

Fever (>100.4°F)

Maternal Tachycardia

Fetal Tachycardia

Uterine Tenderness

Foul Smelling Amniotic Fluid

Maternal Leucocytosis (>16000/cc)

Raised C- Reactive protein >2.5

High Vaginal Swab Culture and Stain Positive




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Management :

Antibiotic : Ampicillin 500 gram 6 hours

Removal of Cerclage

Delivery as soon as possible regardless of Gestational age.

Abortion & MTP

Abortion/Misscarriage : Abortion य Misscarriage ह Process ह Fetus/Embryo 20 Weeks स ह (Wt < 500 gm) Terminate ह

Period of Viability depends on Medical Facilities of a country.

Period of Viability ह Time Period ह Fetus Independent Survive स ह WHO स

Period of Viability is 22 weeks

In India Period of Viability is 28 Weeks.

Incidence of Abortion : गभग 10-20% Pregnancies Misscarriage ह ह 75% Abortion

16 Weeks स ह ह ह औ स Abortions स 75% Abortion 8th

Weeks स ह ह ह Blighted Ovum : Early Pregnancy Uterus Gestation Sac ह ह ,

Fetal Part Development ह ह (Yolk Sac May or may not be present)

Recurrent Abortion : 3 य 3 स य 20 Weeks स ह Spontaneous Abortion ह ह , स Recurrent Abortion ह ह

Causes of Abortion :

Fetal Causes :

Chromosomal Abnormalities (Most Common)

Hydropic Degeneration of villi

Multiple Pregnancy.

Maternal Causes :

Trauma

Infection/Immunological Causes

Maternal Medical Disease

Environmental Factor/Endocrine Problem

Developmental/Anatomical Problem

Most Common Cause of Ist Trimester Abortion : Chromosomal Abnormalities.

Most Common cause of 2nd

Trimester Recurrent Abortion : Cervical Incompetence.




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Classification of Abortion :

Abortion

Spontaneous (Miscarriage) Induced

Isolated (Sporadic) Recurrent Legal (MTP) Illegal (unsafe)

Septic-common

Threatened Inevitable Complete Incomplete Missed Septic

(Less common)

Type of Abortion :

1. Threatened Abortion : स Abortion Abortion Process Start ह ह ह , Recovery Possible ह ह

Internal OS Closed ह ह

Spotting Present, Bright Bleeding

Abdominal Pain

USG Live Intrauterine Pregnancy ह Management : Bed Rest, pad Counting, Activity Limitation, Avoid Intercourse, Progesterone

2. Inevitable Abortion : स Abortion Recovery Impossible ह ह

Internal OS Open ह ह

Bleeding + Pain Abdomen

USG : Live/Dead Fetus

Management :Vaginal Misoprost

3. Incomplete Abortion : स Abortion Fetal Part ह ह

Uterine Cavity ह ह

Internal OS Open ह ह

Pain + Bleeding + Product of Conception coming out from Internal Os

USG — RPOC

Management : If No Infection : Conservative Management.

If Bleeding Persist — D&E, Medical Management




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4. Complete Abortion : स Abortion Patient Initially bleeding Complaint

ह Pain ह ह Product of Conception ह ह स Bleeding Stop

ह ह

Internal OS Closed ह ह

USG – Empty Uterus

5. Missed Abortion : स Abortion Fetus Uterine Cavity Dead ह ह

Dark Brown Vaginal Bleed ह ह

OS Closed ह ह

USG – Dead Fetus (No Fetal Heart Beat)

Management : Dilatation & Evacuation, Misoprostol

6. Septic Abortion : स Abortion Mainly Uterine Infection ह स ह ह स

Abortion Mainly Illegal Abortion Untrained Person य ह स ह ह

Temp. > 100.4° F

Purulent discharge, pelvic Infection

य Infection Uterus स ह Ist degree

Fallopian Tube, Ovary 2nd

degree

Peritonitis 3rd

degree

Management : Antibiotic, Fluid, Oxytocin, Evacuation, Hysterectomy

Recurrent Abortion : 20 Weeks स ह 3 य 3 स य Abortion ह , स Recurrent

Abortion ह ह

1st Trimester — chromosomal Defect (< 12 Weeks)

2nd

Trimester — Cervical Incompetence (> 14 Weeks)

Cervical Incompetence Cervical Repair Mc Donald य Shirodkar Surgery य ह

S.

No.

Type Bleeding Utere size OS USG

1 Threatened Spotting Height of Uters

= POG

Closed Live

2 Inevitable Severe Height of Uterus

= POG

Open Live/Dead

3 Incomplete Severe Small Open RPOC

4 Complete Stop Small Closed Empty

5 Missed Absent/Dirty Brown

Discharge

Small Closed Dead




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Chapter 10

ANTIPHOSPHOLIPID ANTIBODY SYNDROME

यह Autoimmune Disorder ह , सस 2nd Trimester Recurrent Abortion ह ह

Antiphospholipid Antibody Acquired Antibody ह ह β2 Glycoprotein Prothrombin Against ह य Mainly IgM, IgG IgA Type ह ह

Most important Antiphospholipid Antibodies are :

(a) Lupus Anticoagulant (LAC) : यह Antibody स स ह SLE Patient ग स ह स Partial Thromboplastin Time Prolong ह ह Partial Thromboplastin Time भ यह Thrombosis Develop ह ह

(b) Anticardiolipin Antibody(ACL) : स Antibodies ह स Recurrent Abortion ह ह

(c) Anti β2 Glycoprotein Antibodies : स Antibody ह स Syphilis Test False Positive ह ह

Most Common antiphospholipid Antibody is Lupus Anticoagulant.

Most Specific Antiphospholipid Antibody is β2 Glycoprotein.

Antiphospholipid antibodies

Placental thrombosis Decrease hCG Inhibits trophoblastic invasion

Decrease blood supply Small size of placenta PIH

Fetal loss can be IUGR Oligohydramnios Preterm birth due to

In the form of Placental insufficiency

Abortion IUD Stillbirth

(M/C in 2nd

trimester)

Clinical Features

Vascular Thrombosis Pregnancy Complications

Recurrent Arterial/Venous thrombosis Recurrent Abortion

DVT most Common Pregnancy induced Hypertension

(Eclampsia, Preeclampsia)

Pulmonay Embolism Placental Insufficiency/ Abruption

IUGR




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DIAGNOSIS :

Clinical Criteria :

Unexplained one or more clinical episode of arterial,venous or small vessel thrombosis.

One or more Unexplained death of Morphologically normal fetus beyond 10th

week of

Gestation.

One or more premature birth before 34th

week of Gestation due to Eclampsia or preeclampsia

and placental Insufficiency.

Three or more unexplained consecutive spontaneous abortion before the 10th

week of

Gestation.

Laboratory Criteria :

Lupus Anticoagulant present in plasma on two or more occasion at least 12 week apart.

Anticardiolipin antibodiy of IgG/IgM isotype present in plasma on two or more occasion at

least 12 weeks apart.

Anti β2 Glycoprotein-1 antibodies present in plasma twice at least 12 weeks apart.

Management : 2 durgs are used.

1. Heparin : Regular or low molecular weight Heparin can be used. It should be started as soon

as Intrauterine pregnancy is diagnosed on USG. The drug has to be continued throughout

pregnancy and stopped at the onset of labor.

2. Aspirin : Should be started as soon as UPT become positive. It should be continued

throughout pregnancy and stopped 7 days before labor.

3. 2nd

Line therapy : Immunoglobulin therapy.

MTP (MEDICAL TERMINATION OF PREGNANCY ACT, 1971) :

India MTP Act स स ह ग , 1971 स ह 1972 स यह ग ह 1975 यह

ह

Indication :

(a) Therapeutic : Pregnancy Continue स Mother Physical Mental Health ह (b) Eugenic : ह Serious Physical Mental Abnormalities ह स भ ह

(c) Humanitarian : Pregnancy Rape ह ह

(d) Social : Married Woman Pregnancy Contraceptive Failure ह स ह ह Rules :

Who can do MTP : (i) Who has degree or diploma in OBS & Gynae.

(ii) Who has done 6 months house job in OBS & Gynae.

(iii) Who has assisted in 25 MTP‘s in an authorized center.




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Where can do MTP : (i) Government Hospitals.

(ii) Hospitals recongized by Government.

Non Government Hospital has to obtain Licence from Chief Medical Officer of the district.

Consent of woman is required before conducting Abortion.

Consent of Husband is not necessary.

Written consent of Guardian is Required if the woman is Minor (<18 Years).

Abortion can not be performed on the request of husband, if the woman herself is not willing.

Woman need not produce proof of her age.

It is enough for the woman to state that she was raped and it is not necessary that a complaint

was lodged with the police.

If the period of pregnancy is below 12 weeks it can be termitnated on the opinion of single

doctor.

If the period of pregnancy is between 12-20 weeks, opinion of two doctor is must.

Termination is permitted upto 20 weeks of pregnancy.

If termination of pregnancy found illegal there shall be punishment with rigorous imprisonment

for a term which shall not be less than two years,but which may be extended to seven years.

Methods of performing MTP :

Methods of performing Medical Termination of Pregnancy

First trimester (Up to 12 weeks) Second trimester (13-20 weeks)

Medical

Mifepristone

Mifepristone and Misoprostol

(PGE1)

Methotrexate & Misoprostol

Tamoxifen and Misoprostol

Surgical

Manual Vacuum Aspiration

Suction evacuation

Dilation and curettage

Prostaglandins PGE1 (Misoprostol), 15 methyl PGF2α

(Carboprost) and their analogues (used- intravaginally,

intramuscularly or intra- amniotically)

Suction and evacuation using ovum forceps uptill

15 weeks

Intrauterine instillation of hyperosmotic solutions Intra-amniotic hypertonic urea (40%), saline (20%)

Extra-amniotic – Ethacrydine lactate, Postaglandins

(PGE2, PGF2α,)

Oxytocin infusion- High dose used along with either

of the above two methods

Hysterotomy (Abdominal) Less commonly done

Important Points :

Best Method of Abortion upto 7 weeks :- Medical Abortion

Best Method of Abortion between 7-12 weeks :- Suction & Evacuation

Best Method of Abortion > 12 Weeks : Prostaglandin

ECTOPIC PREGNANCY : Blastocyst Development Implantation Uterine Cavity Endometrial Lining य ह ह , स Ectopic Pregnancy ह ह Important Points :

Most Common Site of Ectopic Pregnancy : Fallopian Tube




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Least Common site of Ectopic Pregnancy : Ectopic in cesarean scar (<1%) < cervical ectopic

(1%)

In Fallopian Tube chances of Ectopic Pregnancy

Ampulla > Isthmus > Infundibulum > Interstitium.

Most Common site of Ectopic Pregnancy in Fallopian Tube : Ampulla ( य Fertilization

Ampulla Part ह ह ह )

Least Common Site of Ectopic Pregnancy in Fallopian Tube : Interstitium

Heterotopic Pregnancy : यह Twin Pregnancy ह ह स Pregnancy Ectopic स Pregnancy Intrauterine ह ह

Risk Factors of Ectopic Pregnancy :

य Previous Pregnancy Ectopic Pregnancy ह ह , Next Pregnancy Ectopic ह Risk

Maximum ह ह

य Previous Tubal Surgery ह ह , Ectopic Risk Increase ह ह

Ectopic Pregnancy Most Common Risk Factor Infection ह ह (STI & PID) Mainly due

to chlamydia Trachomatis & Mycoplasma hominis. Congenital Factor – Tubal Tuberosity, Accessory Ostia, Diverticula.

Salpingitis Isthmica Nodosa – TB Infection ह स Fallopian Tube - स Constrict ह ह

Failed Contraception – Contraception Use ह स Ectopic Pregnancy Chances ह ह , य Contraceptions ह स Overall Chances of Pregnancy ह ह , Contraception

Failure ह स Ectopic Pregnancy Chances Increase ह ह

Maximum Chances of Ectopic Pregnancy with contraceptive agents

Sterlization procedure > IUCD > Progesterone only pill.

Endometriosis

Assisted Reproductive Technology.

Smokers, IV/Drug Abusers.

In Utero Exposure of DES (Diethyl Stilbestrol)

Fate of Ectopic Pregnancy :




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(i) Tubal Abortion : Ectopic Pregnancy Fallopian Tube Ampulla Infundibulum Part ह ह , Tube ह Abortion ह ह

(ii) Rupture of the Tube : Ectopic Pregnancy Fallopian tube Isthmus Interstitial Part ह ह , Tube Rupture ह स भ स स य ह ह

Most Common site of Tubal Abortion - Ampulla

Most Common Site of Tubal Rupture - Isthmus

Fallopian tube Ectopic Pregnancy end स स ह Isthmus Part ह ह (6 Week)

Fallopian Tube Ectopic Pregnancy Maximum Survival Interstitum Part ह ह , य यह स Uterine Myometrium स Support ह ह स Ectopic Pregnancy Most Dangerous site

Interstitium ह

Overall Ectopic Pregnancy Longest Survival Abdomen ह ह यह Ectopic pregnancy Term

Continue ह स ह

Symptoms and Sign :

Classical Triad : Amenorrhoea, Abdominal Pain, Vaginal Bleeding.

Ruptured Ectopic Pregnancy Pain Mainly Hemoperitoneum ह स ह ह blood Diaphragmatic Irritation ह ह स Pain Shoulder Referred ह स ह स Danforth Sign

ह ह

Unruptured Ectopic Pregnancy Pain Fallopian Tube Stretching ह स ह ह

Sign :

Ruptured Ectopic Pregnancy Patient Shock ह ग (BP-Decrease, HR-Increase)

P/A examination-Tenderness, Rigidity, Guarding in Lower Abdomen

Hemoperitoneum ह स Periumbilical Region Bluish Discoloration ह ह स Cullen Sign

ह ह

P/V Examination : Cervical Movement Tender,

Bulging of Post Vaginal Fornix due to Blood Collection in POD

Tender Boggy Mass may be felt on one side of uterus.

Ruptured Ectopic : भ Female 6-10 Weeks Amenorrhoea, Lower Abdominal Pain स य

Urine Pregnancy Test Positive ह , Patient Shock ह , ह Ectopic Pregnancy Possibility स स ह स ह

Management of Ruptured Ectopic Pregnancy :

Simultaneous Resuscitation & Laparotomy.

Ruptured Ectopic Pregnancy ह Salpingectomy ह ह Female Primiparous ह Multiparous.

Salpingectomy Ruptured Ectopic Gold Standard Treatment ह ह

Ruptured Ectopic Expectant/Medical management ह य

Unruptured Ectopic Pregnancy :




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Diagnosis :

Look at the adnexa

Note : Presence of gestational sac in adnexa surround

By a hyperechoic ring is called as bagel sign

Management :

Medical Management : Drug of Choice-Methotrexate. Dose 50 mg/m2 Body Surface area IM Single

Dose.

Chapter 11

Urine pregnancy test +ve

Investigation of choice : Transvaginal ultrasound

(TVS)

βHCG (Critical titre : The level of βHCG at which gestational sac is definitely visible in intrauterine pregnancy.

On Ultrasound critical value of βHCG for TVS = 1500 IU. Critical value of βHCG for TAS = 5000-6000 IU)

βHCG > 1500 IU + empty uterus βHCG < 1500 IU

Repeat HCG levels after 48 hours

If gestational sac is present

inside the uterus

If uterus is empty- raises the suspicion of ectopic

pregnancy

Intrauterine

pregnancy In adnexa : If gestational sac is not seen or

cardiac activity is not seen

In adnexa if gestational

sac or cardiac activity

Present

It confirms ectopic pregnancy. This can further be confirmed by doing Doppler which shows increased

vascularity (Called as Ring of fire appearance)

3 differential diagnosis of

empty uterus with UPT +ve

To differentiate between them measure βHCG levels

Early intrauterine

pregnancy Ectopic

pregnancy

Abortion

After 48 hours if βHCG levels

Diagnosis of ectopic pregnancy confirmed

Decrease Approximately Double (≥66%) Increases but < 66%

Ectopic pregnancy Intrauterine pregnancy Abortion




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TROPHOBLASTIC DISEASE

Hydatiform Mole :

यह Most Common Gestational Trophoblastic Disease ह

यह Placenta Abnormal Condition ह , स Chorionic villi partly Degenerative Partly Proliferative Changes ह ह

Hydatiform Mole Benign Neoplasm of Chorion ह स Malignant Potential ह ह

ह Choriocarcinoma Convert ह स ह

Uterine Cavity Multiple Grapes Like Vesicles ह Fetus Normally Absent ह ह

Vesicles Interstitial Fluid ह ह स hCG ह ह

Microscopically :

(a) Marked Proliferation of Syncytio & Cytotrophoblastic epithelium.

(b) Thinning of Stromal tissue due to hydropic degeneration.

(c) Avascular Vill

Risk Factor :

Maximum Incidence Asia South America & Least in USA.

Maximum Incidence in Philippines (1 in 80), in India (1 in 400 Pregnancies)

य Woman Age > 35 Year स य ह < 18 Year स ह , Risk य ह ह

Low Socioeconomic Status

History of Molar Pregnancy

Diet Deficient in Protein, Folic Acid and Vitamin A

Blood Group A woman married to group O Man.

Pathophysiology of H.Mole :

H. Mole Blastocyts Trophoblast Excessive Proliferation ह स Develop ह ह

Proliferating Trophoblast Fluid Secret ह Chorionic Villi ह ह औ Grapes

Like Vesicles ह Hydropic Degeneration ह ह

Uterus Grapes Like Vesicles भ ह सस Blastocyst Inner Cell Mass Grow Space

ह

य Fetal Part Develop ह ह , य Fetal Part Develop ह ह ह Partial Mole ह Complete Mole ह




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USG –Hydatiform mole

Partial Mole :

Partial Mole Karyotype Triploid ह ह (90%)

Chromosome No.--> 69 (69 XXY or 69 XXX)

Extra Haploid Set of Chromosome derived from Father.

Complete Mole :

Complete Mole Karyotype Diploid ह ह

46 XX (90%) or 46 XY (10%) Paternal Origin स ह ह Father Chromosome ह ह ह

यह Empty Ova Single Sperm स Fertilize ह ह Sperm Chromosome duplication ह ह स यह सभ Chromosome Paternal Origin ह ह स Process

Androgenesis ह ह

Complication :

Thyrotoxicosis

Preeclampsia

Hyperemesis Gravidarum

Theca Leutin Cyst

Investigation of Choice = USG

USG Snow-Storm Appearance ह

Tumor Marker for H.Mole/Choriocarcinoma hCG

Management :

Suction & Evacuation.

Follow up of β-hCG upto 6 months.

Choriocarcinoma : यह Most Malignant Tumor of Uterus ह




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Causes :

50% develop following H.Mole.

25% develop following on Abortion.

20% develop following full term pregnancy.

5% develop following Ectopic Pregnancy.

Most common mode of spread : Hematogenous.

Most Common site of Metastasis of Choriocarcinoma

Lung 80% > Vagina (30%) > Pelvis (20%) Liver & Brain (10%)

Symptoms : Irregular Bleeding

Snow Storm appearance in Uterus (USG) : H.Mole

Snow Storm apperance in Lungs (X-Ray) : Choriocarcinoma

Tumor Marker for Choriocarcinoma : β hCG

Tumor Marker for placental site trophoblastic tumor : hPL (Human Placental Lactogen)

Management : Chemotherapy

Methotrexate is drug of choice




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Chapter 12

ANTEPARTUM HAEMORRHAGE(APH) :

Fetal viability period (22 Weeks) Delivery स ह Genital Tract स य bleeding ह ह , स Antepartum Haemorrhage ह ह

Causes :

Maternal Causes :

Placenta Previa

Abruptio Placenta

Fetal Causes :

Vasa Previa

Unclassified

Placenta Previa : Placenta Previa Situation Placenta Uterus Lower Uterine cavity Partly य Completely Attach ह ह Placenta Localization 3

rd Trimester Ultrasound

य ह

Types of Placenta Previa :

(i) Type 1 : Low Lying or Lateral : स Placenta Previa Placenta Lower Uterine

Segment ह ह , Internal OS स गभग 2 cm away ह ह

(ii) Type 2 or Marginal : स Placenta Previa Placenta Internal OS Margin

Anteriorly य Posteriorly Attach ह ह

(iii) Type 3 or Incomplete : स Placenta Previa Placenta Internal OS Fully Cover

ह , Cervix Dilate ह ह Cervix Dilation Condition ह , यह Partially Cover

ह

(iv) Type 4 Complete : Cervix full Dilation Condition भ Placenta Internal OS Fully

Cover ह




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Placenta Previa Condition Placenta Fetus OS Compress ह ह सस Bleeding स भ ह ह

Type 1 Type 2 Placenta OS ह Cover ह स Bleeding ह ह

Type 3 Type 4 Placenta OS Cover ह स Bleeding य ह ह

Minor Degree : Type 1, Type 2 Anterior.

Major Degree : Type 2 Posterior, Type 3 & Type 4

Type 2 Posterior Placenta Previa Dangerous Type ह ह , य यह Pelvis Ischial Spine Level Attach ह ह सस Fetal Head Engagement ह ह ह स Cord

Compression स भ स स य ह ह सस Fetal Asphyxia भ - भ Fetal Death भ ह स ह

Stallworthy Sign : Fetal Head Pelvis Push ह ह , स स य Fetal Heart Rate Decrease

ह ह स Stallworthy sign ह ह Mainly Posterior Placenta Previa Stallworthy Sign Present

ह ह

Risk Factor :

Previous H/O Placenta Previa.

Multiparity & Increased Maternal Age.

H/O any Previous Uterine Surgery : Like Cesarean section (Risk Increase as No. of cesarean

Increases), Myomectomy.

Previous Uterine Curettage.

Increased placental size seen in Multifetal pregnancy.

Succenturiate Lobe.

Smoking

Increased Maternal serum AFP

Clincial Features :

Symptoms : In Placenta Previa Bleeding is :

Painless

Recurrent

Revealed

Sign :

Pallor :Proportionate to the amount of Bleeding.

Size of Uterus corresponds to the period of Amenorrhoea.

Uterus is soft and Nontender.

Malpresentations are common and if it is in cephalic presentation, head is usually floating.




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Fetal Heart sound Heard.

Note : Suspected Placenta Previa Vaginal Examination ह य ह

Management :

Placenta Previa Vaginal Examination ह ह

Investigation of Choice : TVS Ultrasound

Double set up examination : Placenta Previa Situation Per vaginal Examination

Operation Theatre य ह ह Cesarean Facility availabe ह ह

(i) Expectant Management (Macafee Regime)

Indication :

No Active Bleeding Present.

Hemodynamically Stable.

Gestation age < 37 Weeks.

CTG – should be Reactive

No Fetal Anomally incompatible with life.

Steps :

Hospitalize the Patient.

Arrange for Blood.

If patient is Rh (–), give her Anti D.

Give Injection corticosteroid to hasten lung maturity of Fetus.

If contraction present give short term tocolytic (Nifedipine)

Expectant Management 37 Week ह य Expectant Management

patient स भ स य Rebleed ह , Pregnancy Immediate Terminate ह (ii) Active Management : Active Management Pregnancy Immediate Terminate य ह ह Fetus Gestational Age भ ह

Indication :

If active Bleeding Present.

Haemodynamically Unstable/Shock.

Gestational Age > 37 Weeks.

Fetal Distress Present.

FHS absent.

USG Shows fetal anomally incompatible with life.




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Mode of Delivery :

USG localization of placenta or

double set up examination in OT

Indication of Cesarean Section in Placenta Previa :

Major degree of Placenta Previa.

Dangerous Variety (Type 2 Posterior) of Placenta Previa.

Severe Bleeding Irrespective of Placenta Previa.

Fetal Age < 32 Weeks.

Fetal Distress.

Most Common Fetal Complication of Placenta Previa : Low birth weight baby.

Abruptio Placenta : Normally situated Placenta Premature Separation ह स Antepartum Haemorrhage ह , स Abruptio Placenta ह ह

Risk Factor :

Increased Maternal Age.

Pre eclampsia

Preterm Rupture of Membranes

Cigarette Smoking

External Trauma

Uterine Fibroid

Increased Parity

Chronic Hypertension

Polyhydroamnios

Twin Pregnancy

Previous H/O Abruption

Folic Acid Deficiency

Grading of Abruptio Placentae :

Depends on the type of placenta previa

Dangerous variety of

placenta previa, i.e.

Type II posterior

Try vaginal delivery

Minor degrees of placenta

previa,

Type I Anterior or posterior

Type II Anterior

Major degrees of

placenta previa, i.e.

Type III or type IV

Cesarean section done




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Grade Bleeding Uterus B.P. or Pulse Heart rate Separation

0 No No change No change No change <10%

1 Mild No change No change No change 10-20%

2 Moderate Tender Altered Distress 20-30%

3 Severe Titanic contraction Shock Death >50%

Types of Abruptio Placenta :

(i) Concealed : स Variety Placenta स Separate ह ह Blood Placenta ह ह ह Vagina ह ह ह Collected Blood Uterus Wall Middle Outer Muscle Layer Intravasate ह ह सस Muscle Layer Separate ह ह

स Couvelaire Uterus (Uteroplacental Apoplexy) ह ह couvelaire Uterus Hysterectomy ह ह

(ii) Revealed : स Variety Placenta स Separate ह ह Blood Vagina ह ह

(iii) Mixed : Blood Placenta ह ह , Vagina ह ह (Most Common Variety)

Clincical Features :

Symptoms :

Severe and constant Abdominal pain (More in concealed and less in Revealed)

Bleeding : Absent in concealed type present in revealed & Mixed type.

Abruptio Placenta Bleeding Placenta Previa Different ह ह

Associated with pain in Abdomen.

Non-Recurrent in same pregnancy.

No warning Haemorrhage.

Never without any reason.

Sign :

General condition of patient is usually out of proportion to the extent of Bleeding.

Hypertension may present (Preeclampsia)

Uterus will be larger than period of amenorrhoea (In concealed variety)

Uterus may be tender, tense, rigid (woddy hard)

Difficulty in palpating the underlying fetal part.

Fetal distress absent FHS.

Management :




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Abruptio Diagnosed ह ह , स Actively Management य ह

ह Fetus Gestational Age भ ह

Abruptio भ भ Wait & Watch ह ह

भ भ Tocolytics ह ह

Abruption Case Delivery Interval Important ह ह यह Time Period Prolong ह ह ह य DIC औ Renal Failure ह Chance ह ह

Abruption Management Pritchard Rule Follow ह

Keep Hematocrit atleast 30%.

Maintain Urine output : 30 ml/hr.

Abruption Case Preferred Mode of Delivery Vaginal delivery.

Indication of Cesarean delivery--- Fetal disress

---Fetal age < 32 Weeks.

Most Common Fetal complication of Abruptio Prematurity.

Placenta previa Abruptio placenta

Symptoms Bleeding and pain

Signs Pallor

Fundal hight

Palpation

Fetal parts

Head

Malpresentations

Fetal heart sounds

Pre-eclampsia

Coagulopathy

IUGR

Sudden, painless and recurrent

Always revealed

Bright red in colour

Proportionate to loss

Corresponds to gestation

Soft and relaxed uterus

Easily palpated

High and floating head

Common

Usually normal

Normal incidence

Rare

Not seen

Severe abdominal pain Revealed or

concealed

May be out of proportion

May be more

Tense, tender and rigid

Difficult to palpate

Head usually fixed

Uncommon

Distress or absent

Increased

Frequent

May be seen as it is associated with PIH

Vasa Previa : यह Mainly Umbilical Cord Velamentous Insertion ह स ह ह स Insertion Umbilical Cord Placenta Margin Fetal Membrance Attach ह ह

Risk Factor :

Bilobate or Succenturiate Placenta.

Placent Previa.




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Blood Loss mainly fetal Origin ह ह स Fetal Mortality Chances Increase ह ह Maternal Mortality Chance ह ह ह

Bleeding ह ह , Fetal Anaemia ह स FHS Sinusoidal Pattern ह Diagnosis ,Bleeding स य Singers Alkali Denaturation/Apt Test स य ह

Management : Emergency Cesarean Section

Chapter 13




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MULTIFETAL PREGNANCY

Zygosity : Twins Monozygotic य Dizygotic ह स ह

Zygosity : Refers to the type of conception.

Dizygotic (75%) dizygotic Twins Ova ग- ग Spermatozoa Fertilization स ह

Monozygotic (25%) : Monozygotic Twin Single Zygote Divide ह स ह स Sex Same ह ह स ह

Dizygotic Twins :

More Common (70%)

Incidence of Dizygotic Twins Increases with.

Increased Maternal Age.

Increased parity.

Maternal Family H/O Twining.

Ovulution Induction drugs like clomiphine or gonadotropin.

Dizygotic Twin ग- ग Zygote ह स स Twins Baby Sex

Same Different ह स ह

Dizygotic Twins ह 2 Chorion 2 Amnion ह ह (Dichorionic & Diamniotic)

Dizygotic Twins Genetic Feature, Finger Prints भ ग- ग ह ह Skin Graft भ स Reject ह ह

Monozygotic Twins :

Less Common (30%)

स Twins य ह Zygote Split ह स ह स Fetus Sex ह स ह ह

Chorion Amnion स य Zygote Split ह Time Depend ह

स Twins Genetic Feature, DNA imprints Same ह ह Skin Grafts स Accept ह ह

Fingerprints स Different ह ह Important Points :

Incidence of Twins Highest in Nigeria (1 in 20)

Incidence of Twins lowest in Japan.

Incidence of Twins in India : 1 in 80




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Ovulution Induce Drugs स Clomiphine, Gonadotropin IVF Procedures ह स India भ Twins Incidence Increase ह ह ह

Hellin’s Rule : Hellin‘s स Frequency of Multiple Pregnancy

Twins 1 in 80

Triplet 1 in (80)2

Quadruplets 1 in (80)3 and so on.

Gemellology : Scientific study of Twins and twinning.

Chorionicity : Denotes the type of placentation.

(i) In Dizygotic Twins : स Twins य Fetus placenta, Amnion chorion

Separate ह ह Dizygotic twins ह Dichorionic Diamniotic (2 Chorion & 2 Amnion) ह ह (ii) In Monozygotic Twins : स Twins Chorionicity स Depend ह

Zygote ह स य Split ह ह

Monozygotic Twins

[Division of Single Fertilized OVUM]

< 3 Days 4-7 Days > 8 Days > 14 Days

Dichorionic Monochorionic Monochorionic Conjoined

Diamniotic Diamniotic Monoamniotic Twins

(Most Common)

Dichorionic Twins ह Dizygotic ह Monozygotic य Complication ह ह ह

Monochorionic Twins Vascular Anastomosis ह ह स Complication स भ य ह ह

Chorionicity 10-14 Week पर Detect (Best Time)

Ultrasound differentiation of Chorionicity :

Criterion Monochorionic Dichorionic

Placenta Single Double

Fetal sex Concordant Discordant/ Concordant

Membrane <2 mm thick >2 mm thick

Number of layers in membrane Two (2 amnion) Four (2 amnion, 2 chorion)

Twin peak sign Absent Present

(i) No. of Sacs : यह 10 Weeks स ह Applicable ह ह य 2 Sac ह , Dichorionic

औ 1 Sac ह , Monochorionic.

(ii) Placenta : Dichorionic Pregnancy ग- ग Placenta ह

Monochorionic Single Placenta ह ह




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(iii) Fetal Sex : Dichorionic Pregnancy Fetal Sex स ग ह स ह

Monochorionic Pregnancy Sex स ह ह

(iv) Intertwin Membrane : Dichorionic Twins यह Membrane Thick ह ह (> 2mm)

Monochorionic Twins यह Membrance Thin ह ह (< 2 mm)

(v) No. of Layer in Membrane : Dichorionic Twins 4 Layer ह ह (2 Amnion, 2 chorion)

Monochorionic Twins 2 Layer ह ह (Only 2 Amnion)

(vi) Twin Peak Sign or Lambda Sign : यह Mainly Dichorionic Pregnancy Characteristic

Feature ह यह Mainly Intertwin Membrane Chorionic Tissue ह स ह ह

Monochorionic Twins Twin Peak Sign or Lambda Sign Absent ह ह

सभ Monochorionic Pregnancy ह Monozygotic ह ह

Dichorionic Pregnancy Monozygotic य Dizygotic ह स ह

Monozygotic Twins Monochorionic य Dichorionic ह स ह

य Twins Sex Different ह , ह Dizygotic ह ग य Sex Same ह , Dizygotic Monozygotic ह स ह

Complications of Twin Pregnancy :

Maternal Complications

Antepartum Intrapartum

Hyperemesis Dysfunctional labour

Hydramnios Malpresentations

Pre-eclampsia Increased chance of operative delivery

Pressure symptoms

Anaemia Postpartum hemorrhage

Antepartum hemorrhage Retained placenta

Most common cause of maternal mortality in twins is PPH > Anaemia > Pre- eclampsia

Fetal Complications

Antepartum Intrapartum




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Prematurity PROM and cord prolapse

IUGR

Single fetal demise Abruption in the second twin

Monochorionic monoamniotic twins

Twin-twin transfusion syndrome Interlocking of twins (extremely rare)

Vanishing twin and abortion

Congenital anomalies including acardiac fetus

and conjoined twins

Most Commmon cause of perinatal death in twins is pre-maturity > IUGR > Infection

Complications specific to monochorionic twins

Twin-twin transfusion syndrome

Conjoined twining

Acardiac fetus

Selective IUGR

Single fetus demise

Complications specific to monoamniotic twins

Cord entanglement

Conjoint Twins Siamese Twins भ ह ह Different type of conjoined twins.

(a) Thoracopagus : Fusion at Chest. Most Common (40%)

(b) Omphalopagus (Xiphopagus) : Fuision at Anterior Abdominal wall (33%)

(c) Pyopagus : Fusion at buttocks (18%)

(d) Ischiopagus : Fusion at Ischium (6%)

(e) Craniopagus : Fusion at Head (2%) Least Common.

Mode of delivery of Conjoint twins : Cesarean section.

Monoamniotic Twin Pregnancies :

Monoamniotic twin pregnancies Rare ह ह (Only 1% of Monozygotic Twins).

Main Complication : Umbilical Cord entanglement

Congenital Malformation

Preterm Delivery.

Sonographic Diagnosis : Single Amniotic Membrane

Twins of Same Sex

Presence of Single Placenta




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Best Criteria to Diagnose Monochorionic Monoamniotic twins is single Amniotic Cavity.

Color Doppler Examination : Variable Deceleration seen in cord entanglement.

Mode of Delivery : Cesarean section after 2 dose of betamethasone between 32-34 weeks.

Twin to twin transfusion syndrone (TTTS) :

यह ह Monochorionic Twins ह

यह Deep Arteriovenous Malformation ह ह स Donor Twin Umbilical Artery Recipient Twin Umbilical Vein स Abnormal Communication ह ह

Donor Twin : IUGR, Hypovolemia, Oligohydroamnios, Anaemia.

Recipient Twin : Macrosomia, Hypervolemia, Polycythemia, Polyhydroamnios, Plethoric

Twin to twin transfusion female fetus य Common ह ह

Fetus Heart Failure ह स ह Recipient Fetus Cardiac complication ह स Death य Chance ह ह

Important Points :

Twin Pregnancy Fetus Most Common lie Longitudinal ह ह

Twin Pregnancy Most Common Presentation Fetus Vertex Presentation ह ह

Both Vertex (Most Common) : 60%

Vertex (Ist) Breech (IInd) : 20%

Breech (Ist) Vertex (IInd) : 10%

Both Breech : 8-10%

Management of Labor

Time of Delivery :

Monochorionic Monoamniotic Twins: Cesarean section at 32-34 weeks after giving

corticosteroid.

Monochorionic Diamniotic : elective delivery at 36-37 weeks.

Dichorionic Twins : elective cesarean 37-38 weeks.

Triplet Pregnancy : elective cesarean at 35 weeks after giving corticosteroid.

Mode of Delivery :

If Ist twin is Cephalic than Vaginal delivery is possible.

If Ist twin is Breech/Transverse than cesarean section should be done.

Condition 1 :

If Ist twin is cephalic Vaginal delivery

If 2nd

Twin is cephalic Vaginal delivery.




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Condition 2 :

If 1st Twin is cephalic Normal vaginal delivery.

2nd

Twin breech Assisted breech delivery.

Condition 3 :

If 1st twin cephalic Normal vaginal delivery.

2nd

twin transverse lie. Internal podalic version

under GA in OT

Make it breech

Do breech extraction.

Condition 4 :

If 1st twin breech/Transverse lie always do cesarean section.




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Chapter 14

PREGNANCY IN Rh- NEGATIVE WOMEN

Rh-Antigen

Rh-System स स ह Carl Landsteiner 1940 Rhesus Blood Group Antigen ह Antigens ह ह Eg. C, c, D, E, e य antigens

Chromosome 1 Short Arm Present ह ह

सभ Antigens स D Antigen स स य Immunogenic ह ह Rh (D) स Antigen Presence य Absence स Person ह Denote ह ह Rh Positive ह Rh Negative

Fetal Rh Antigen Fertilization 38 Appear ह ह

New Born Babies ABO (Major Blood Group Antigen A and B) Incompatibility

Haemolytic Disease Main Cause ह ह , स ह स ह Anaemia Mild

Anaemia ह ह

Anti A Anti B Antibodies IgM Type Immunoglobulin ह ह Placenta Cross

ह स

Rh-Negative Pregnancy :

Mother Rh Negative ह ह , Fetus Blood Group Rh Positive ह ह Delivery Time Placental Seperation ह ह स स य Maternal Blood Fetal Blood Contact ह सस Rh Antigen Mother Blood Enter ह Rh Isoimmunization ह ह

Condition Predisposing to Isoimmunization in Rh Negative Female/Fetomaternal/

Hemorrhage/Indication of giving Anti D

Abortion, Ectopic Pregnancy, Molar Pregnancy

Cordocentesis

Amniocentesis

Chorionic Villous Sampling

Attempted Version

Manual Removal of Placenta

Trauma

Antepartum Hemorrhage

Vaginal Delivery

Cesarean Section

Forceps Delivery

Placental Abruption

Blood Transfusion




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Rh Antigen Mother Blood स Mother Blood Rh Antigen

Antibodies ह IgM IgG Type ह ह

IgM Antibody Placenta Cross ह स IgG Type Antibody Placenta Cross Fetal Circulation ह ह

Rh Antigen Fetal Red Cell Membrance Present ह ह ह Antibody, Antigen स

Antigen - Antibody Complex ह औ RBC Destroy ह ह

Clinical Manifestation of Hemolytic Disease of the Fetus and Neonates are :

Hydrops Fetalis

Icterus Gravis Neonatorum

Congenital Anaemia of the Newborn

Hydrops Fetalis :

Hydrops Fetalis, Rh negative hemolytic Disease Most Serious Form ह

Rh-Incompatibility ह स Fetal RBC Excessive Destruction ह ह सस Severe

Anaemia, Tissue Anoxemia Metabolic Acidosis Develop ह ह

Fetal RBC Destruction ह स O2 Transport Affected ह ह Oxygen Transport Increase Placental Tissue Hyperplasia ह ह

Rh Incompatibility ह स Hypoproteinemia ह ह सस Generalized Edema, Ascites Hydrothorax Develop ह ह

IgG antibodies against Rh-antigen

Cross the placenta

Fetal RBCs have Rh- antigen

Antigen – antibody reaction

occurs and fetal RBC destroyed

Placentomegaly

Hepatosplenomegaly

Jaundice

e

Anaemia in

fetus

i. Results in sinusoidal heart rate pattern.

ii. Increased Peak systolic velocity in middle

cerebral artery on Doppler study




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Hydrops Fetalis ह Situation ह स स Two Fetal Compartment Fluid

Accumulation Edema ह ह Hydrops Fetalis Situation Cardiac Failure ह स Fetal Death ह ह

Antenatal Investigation Protocol of Rh-Negative Mothers :

य Woman Rh Negative ह , Husband भ Rh-Grouping ह य Husband भ Rh-Negative ह ह Problem ह ह ह , य Husband Rh-Positive ह , Further

Investigation ह

Methods of know whether Antibodies have been formed or not.

Indirect Coombs Test : यह Test Maternal Blood स य ह

य Test Positive ह , स ह Mother Rh Antigen Antibodies ह ह

य Test Negative ह , स ह Mother भ Antibodies ह ह ह

Primigravida Case य 12th

Week ICT Negative ह 20 28 week Test Repeat

य ह

Multigravida Case 24 Weeks य ह Test Repeat य ह

Pregnant Rh Negative Mother Anti D Injection ह य य स भ

ह स य Fetal Blood स Rh Antigen Present ह , Mother Blood ह , Anti D Antibodies, Rh Antigen स Reaction Antigen -Antibody complex ह औ

स Antigen ह य Antigen ह ह ग Mother Immune System Antibodies

Produce ह ग

य Mother ह स ह Antibodies ग ह , Anti D य ह ह य

Indirect Coomb‘s Test Negative ह , ह Anti D Injection ह य Indirect Coombs

Test Positive ह , Anti D Injection ह ह

ICT Test Antibodies Concentration Dilution Method स Check स ह : Antibody Titre > 1 : 4 : Isoimmunization

Antibody Titre > 1 : 16 : Severe Hemolysis (Critical Titre)

Direct Coomb’s Test : यह Test Delivery Newborn Baby Blood Rh Antibody Titre Check य ह

Middle Crebral Artery Doppler : Antenatally Fetal Anaemia Detect Middle

Crebral Artery Doppler Test य ह यह Noninvasive Test ह




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MCA (Middle Cerebral Artery) PSV (Peak Systolic Velocity) Measure य ह

य PSV > 1.5 MoM ह , IUT (Intra Uterine Transfusion) य Delivery Prefer ह

य Fetal Age < 34 Week IUT

Fetal Age > 34 Week Delivery.

य PSV-MCA > 1.5 MoM ह Period of Gestation < 34 Weeks ह , Next Step

Cordocentesis य ह Haematocrit Check य ह य Haematocrit < 30% ह , IUT (Intra Uterine Transfusion) य ह

Cordocentesis Most Common Complication Bleeding ह

Management of Rh-Negative Pregnancies :

(i) Rh-Negative Nonimmunized Women.

(ii) Rh-Negative Immunized Women.

(i) Mangement of Rh-Negative Nonimmunized Women :

यह Basic य Mother Rh Isoimmunization ह

Antenatal Period Rh Isoimmunization Possibility ह ह ह

Anti D Immunization स ह 28 Weeks Mother Blood Indirect Coomb‘s Test

य ह य antibody titre > 1 : 4 ह , स ह Mother Rh Isoimm-

unization ह ह

Rh-Negative mother

Father blood group/ Indirect Coombs test (12 weeks/booking visit)

ICT-Negative

Primi/no history of transfusion Multi/ history of transfusion

Repeat ICT at 28 weeks Repeat ICT every month starting

Give anti D at 28 weeks (Antipartum) from 12 weeks and after 20 weeks do

it biweekly till 28 weeks

300 mcg ICT remains negative (Give anti D at 28 weeks)

Delivery at 40 weeks

If baby is Rh-positive and Coombs test is negative

Anti D immunoglobulin within 72 hours of delivery




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(ii)Management of Rh-Negative Immunized Pregnant Woman

(First Affected Pregnancy)

Critical Titre = 1 : 16 or 10 IU/L

Rh negative mother

Fathor blood group/ ICT

(Indirect coombs test)

ICT- Positive, (i.e. mother immunised)

Do antibody titer

Rise above critical Remaines below

level, i.e. > 10 IU/L critical level

Monitor every 4 weeks

Do amniocentesis Induced labors at

or measure MCA-PSV 38-40 weeks

Anti D :

यह IgG antibody ह IM route स ह

यह Antibody Fetal RBC स Bind ह ह औ Maternal Immune System Stimulation Prevent ह

सभ Rh-Negative Mother Indirect Coombs Test Negative ह , 28 Weeks 300 mcg य 1500 IU Anti D य ह Delivery 72 Anti D ह य Baby

Blood Group Rh Positive ह Direct Coombs Test Positive ह Anti D Mainly Delivery 72 ह Delivery 28 य

स ह

300 mcg of Anti D = 1500 IU Anti D




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Chapter 15

MEDICAL COMPLICATIONS IN PREGNANCY

Heart disease in Pregnancy

Normal finding in CVS During Pregnancy

(i) Pulse Rate Increases.

(ii) Diastolic BP Decreases (Peripheral Vascular Resistance Decrease)

(iii) First Heart Sound is Prominent & split.

(iv) Second Heart Sound : Normal

(v) Third Heart Sound : Normally not heard but in Pregnancy it is prominent.

(vi) Slight Cardiomegaly on X-Ray.

(vii) ECG-Left Axis deviation.

Most Common Heart Disease :

Acquired Valvular disease : Mitral Stenosis

Congenital Heart Disease : Atrial Septal Defect

Cyanotic Congenital Heart Disease : Fallot‘s Tetralogy.

Heart Disease in which termination of Pregnancy is advised/pregnancy is contraindicated.

(i) Marfan Syndrome with Aorta involvement (> 45 mm)

(ii) Coarctation of Aorta

(iii) Eisenmenger Syndrome

(iv) Severe Mitral Stenosis/severe Symptomatic/ Aortic Stenosis.

(v) Any Heart Disease which belongs to NYHA Class 4 or Class 3

(vi) Ejection Fraction < 45%

(vii) Pulmonary arterial Hypertension due to any cause.

Predictors of cardiac event during pregnancy :

N : New York Heart Associatron (NYHA) Class > 2

O : Obstructive lesion of left heart (Mitral valve area < 2 cm2 or Aortic valve area < 1.5 cm

2,

Peak LV outflow tract gradient > 30 mm of Hg.

P : Prior Cardiac event before pregnancy eg. Heart Failure, Arrythmia, Transient Ischemic

attack, stroke.

E : Ejection Fraction < 40%

NYHA Classification (Revised 1979)

Class I : No limitation of Physical Activity.

Class II : Slight limitation of Physical Activity.




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Class III : Marked limitation of Physical Activity.

Class IV : Severely compromised -inability to perform any physical activity without discomfort.

Important Points :

Heart disease with maximum risk of maternal mortality : Eisenmenger‘s Syndrome.

Most Common time of Heart failure during pregnancy-

Immediate Postpartum > 2nd

stage of labor > late 1st stage of labor > 28-32 Weeks of pregnancy

> early 1st stage of labor.

Management of Heart Disease in Pregnancy : Antepartum Management time of

Hospitalization

Class I : 36 Weeks

Class II : 28 Week

Class III & IV : If seen in 1st trimester MTP should be advised ideally. if patient want to

continue pregnancy than the woman are hospitalized for the remainder of pregnancy.

India MTP Legally 20 Weeks य स ह Heart Disease Patient MTP 12

Weeks ह ह य 12 Weeks Delivery Abortion Same Risk

ह ह

MTP Suction & Evacuation ह

Heart Diseased Patient Pregnancy ह स Heart Work Load Patient

Activity Restricted ह

Sodium Water Retention Moderetely Sodium Dietry Restriction

ह

य sodium Restriction भ Intra vascular volume Increase ह ह , diuretics

(Furoseuide) Use ह

Intrapartum Management :

Patient Spontaneous Labor ह

य Labor Induction य ह , Vaginal PGE2 Use ह

Note : Induction is safe in case of Heart Desease.

Heart diseased Patient Trial of Labor Contraindicated ह ह

Patient Propped up Position ह

I/V Fluid Restrict ह




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Vaginal Delivery Preferred ह य 2nd

Stage of Labor 30 Minute स य ह , Head

Delivery Outlet Forceps Vaccum Use ह (Vacuum is more better

than Forceps)

Labor pain Relief Epidural Analgesia Use ह

Heart Disease Patient LSCS Anaesthesia Epidural Anaesthesia

Post Partum Management :

Immediately Delivery Heart Failure Chances ह ह , : स Stage Pulmonary

Edema Prevent Placenta delivery I/V furosemide य ह

Heart Diseased Patient Delivery Bleeding Ergometrine Methylergo-

metrine Contraindicated ह ह Bleeding Oxytocin य स ह

Condition where Methylergometrine is Contraindicated-

Twin Pregnancy

Organic Cardiac Disease

Severe Preeclampsia & Eclampsia

Rh Negative Mother

Contraception in Heart Disease :

Heart Diseased Patient OCP Use ह ह य OCP Use ह स Thromboembolism स भ ह

Contraception may be used Temporary IUCD, Progesterone only Pills, Implants, Barrier

Contraceptives (condoms)

Contraception of Choice Permanent Sterlization.

य Female Heart Compensated ह ह , Male Vasectomy Advise ह

य Female Heart compensated ह , Tubal Sterlization Delivery गभग 1 Week

Under Local anaesthesia ह (Procedure preferred –Minilap technique by Abdominal

route)

Prognosis of Heart Disease in Pregnancy

General Concpet :

Highest mortality associated with Eisenmengar syndrome

Stenotic lesions have a higher mortality than regurgitant lesions

Aortic stenosis > Mitral > Pulmonary (in alphabetical order)

Congenital heart disease and mitral valve prolapse have least mortality

Most Common Fetal complication in Heart Disease : IUGR

Best Tocolytic in Heart Disease : Atosiban




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Cardiovasculer drug safety profile in Pregnancy :

Safe Drug :

Adenosine

Lidocaine

Procainamide

Quinidine

Digoxin

Drug which should be used Judiciously :

Diuretics

Calcium antagonist

Unsafe Drugs :

ACE Inhibitor

Amiodarone.

Chapter 16

Hypertensive Disorders in Pregnancy




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PIH (Pregnancy Induced Hypertension)

Definition : Hypertension in pregnancy is defined as systolic BP >140mm of Hg or diastolic BP

> 90mm of Hg on two occasions atleast 4 hours apart.

Pregnancy induced Hypertension chronic Hypertension in Pregnancy

य Normal Female Conceive BP

Increase ह

य Female Conceive स ह ह Hypertensive ह

No Past H/O Hypertension Past H/O Hypertension present.

Increase in BP is seen after 20 weeks of

Pregnancy.

Increase in BP seen before 20 weeks of

Pregnancy.

BP comes back to normal within 12 weeks of

delivery.

BP does not come back normal with in 12

weeks of delivery.

No Proteinurea

Types of PIH :

S. No. Pre Eclampsia S. No. Gestational Hypertension

1 Proteinurea & sign of end organ

damage are present.

1. Proteinurea & sign of end organ

damage are absent.

Proteinurea :

Excreation of Protein > 300 mg/24 hours urine.

Proteinurea of preeclampsia is non selective.

Sign of End organ damage :

Platelet count < 1 lacs.

Raised serum creatinine > 1.1 mg/dl

Elevated liver enzymes more than 2 times.

Evidence of pulmonary edema.

Onset of visual/cerebral symptoms.

Risk factor for preeclampsia :

Previous H/O Pre-eclampsia.

Primigravida

Obesity BMI > 35 kg/m2

Diabetes

Chronic Renal Failure

Extreme of Maternal age

Molar Pregnancy

Twin Pregnancy

Rh Negative Pregnancy

Antiphospholipid antibody syndrome

Pathophysiology of PIH




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PIH Placental Pathology ह

Normally Placenta Villi Intervillous Space ह ह Villi trophoblast य ह ह Fetal Blood Capillaries Open ह ह Intervillous space Maternal Blood Open ह ह (Via Spiral Arteriole)

Endovascular Trophoblast maternal Spiral Artery Lining ह सस य blood Vessels, Low

Resistance, Low Pressure & High Flow Vessels ह ह स Trophoblastic Invasion ह ह

PIH Condition यह Trophoblastic Invasion Incomplete ह ह सस Maternal Blood

Vessels High Resistance Develop ह ह PIH Develop ह ह

In PIH tropoblastic invasion incomplete

Blood Supply to placenta is decreased

Placental ischaemia

Releases inflammatory mediators and vasoactive substance

Endothelial injury

Capillaries become leaky

Movement of fluid into the extravascular space

Collection of fluid in third space Hemoconcentration

+

Edema Platelet number and function is defective

End organ failure/ End organ damage

Concept Box :

PIH ए Multisystem Disorder End Organ Damage

Main Culprit in PIH – Placenta

लए PIH Definitive Management – Termination of Pregnancy

Most Common Hematological Finding in PIH – Decreased Platelet Count.

Symptoms of Preeclampsia :

Headache

Visual Problem

Most common visual symptom in preeclampsia – scotoma

Blindness occurs due to vasospasm or due to pathology in occipital cortex or

Retina.




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Occipital cortex edema – Amaurosis

Retinal Ischemia – Purtscher‘s Retinopathy.

Disturbed Sleep

Oligourea (<400 ml/day) : PIH Renal blood Flow Decrease ह ह सस GFR Decrease

ह ह

Sign :

Hypertension (> 140/90 mm of Hg)

Pitting Edema

Weight gain (Due to Edema)

Pulmonary Edema

IUGR (Due to decrease Blood Supply to Placenta)

Oligohydroamnios

Grades of Pre-eclampsia :

Mild Preeclampsia Severe Preeclampsia

BP is more than 140/90 but less than 160/110 BP is more than equal to 160/110.

Sign of end organ damage absent. Sign of end organ damage present.

Diagnosis : Urine Analysis (Proteinurea)

Low Platelet Count (<1 Lacs)

Opthalmoscopic Examination

Liver Function Test

Coagulation Profile

Ultrasound Examination (IUGR Seen)

Absent Biceps or Patellar Reflex.

Uterine Artery Doppler : Normally 24 weeks Uterine artery Diastolic Notch ह 24 Weeks Disappear ह ह य diastolic Notch 24 Weeks भ ह ह , यह PIH ह (Uteroplacental Insufficiency)

Giants Roll over Test : Late 3rd

Trimester Pregnant Female Supine Position ह , IVC Compression ह स BP Decrease ह ह , य Female PIH Develop ह ह ,




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ह BP decrease ह य गभग 20 mm of Hg Increase ह ह यह Test 28-32 Week य ह

Management :

Drugs to Prevent Pre-eclampsia :

(i) Aspirin : (75 mg/day)--To be given after 1st trimester & continued throughout pregnancy

and stopped 7 days before delivery.

(ii) calcium Supplementation : स Female Calcium ह , Pre-eclampsia Prevent Calcium supplementation ह य Female ह स Calcium Normal ह , Pre Eclampsia Prevent Calcium Role ह ह ह

Measures proven to have no role in pregnancy Pre eclampsia :

Salt Restriction

Supplementation of Antioxidants

Supplementation of fish oil

Supplementation of Vit C, D, E

Progesterone

Low dose Heparin

Management Principles :

Pregnancy Induced Hypertension (Pre-eclampsia/Gestational Hypertension) Placental

Pathology ह स BP Increase ह ह , : स Condition ह Definitive Treatment

Termination of Pregnancy ह ह

Chronic Hypertension ह Antihypertensive Drug of Choice Methyldopa ह ,

Labetalol Use ह

Pregnancy Induced Hypertension (Preeclampsia/Gestational Hypertension) Drug of

Choice Labetalol > Alpha-Methyldopa

Antihypertensive of choice for hypertensive crisis – Labetalol > Hydralazine

Antihypertensive in Pregnancy

Safe Contraindicated

Labetalol ACE Inhibitor

Calcium Channel Blockers—Nifedipine Diuretics

Hydralazine Diazoxide

Alpha Methyl dopa Losartan

Nitroglycerine

Sodium Nitropruside

Preeclampsia Antihypertensive भ Use ह BP > 160/110 mm of Hg ह

Target BP in Preeclampsia is




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Systolic : 130-140 mm of Hg

Diastolic : 80-90 mm of Hg

Target BP in chronic Hypertension is Systolic : 140-150 mm of Hg

Diastolic : 90-100 mm of Hg

Management of Mild Preeclampsia :

Role of Antihypertensive is +/–

Definitive Management – Termination of Pregnancy at 37 Weeks.

Mode of Delivery – Vaginal Delivery

Eclampsia : Severe Preeclampsia Condition Tonic Clonic Convulsion Coma ह , स Eclampsia ह ह यह Convulsion Coma Definitive (Metabolic,

Neurological) Cause ह ह Eclampsia Severe Pre eclampsia Advance Stage ह

Sign/Symptoms of Impending Eclampsia :

Epigastric Pain (Due to Stretching of Glisson Capsule of Liver), Nausea, Vomitting.

Headache, Dizziness (Due to Cerebral Hypoxia)

Visual Symptoms – Blurring/diplopia/scotoma/Blindness

Oligurea.

Severe Pre eclampsia Eclampsia Condition BP ह य Increase ह ह

Pressure ह य Increase ह ह स Brain Blood ह ह सस Cerebral

Hypoxia ह ह औ Convulsion Develop ह ह Important Points :

Most Common Type of Eclampsia : Antepartum Eclampsia

Eclampsia with worst prognosis : Antepartum Eclampsia

Most Common MRI Finding in Eclampsia : subcortical white matter edema

Most Common cause of death in Eclampsia & Preeclampsia : Intracranial Bleeding

There are four stage of convulsion in Eclampsia.

Pre-monitory TONIC CLONIC COMA

30 sec 15-20 sec 1 to 4 min Brief

Invasion stage Contraction stage Sizure stage Short period

Unconsciousness Respiration ceases Muscle contraction Sleepy

Muscle twisting Body spasm Tounge biting

Eye ball turn & fix Opisthotonus position Frothy secretion

Management of Eclampsia :

First line Management in eclampsia : Airway Management

Drug of choice to control convulsion : MgSO4




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Antihypertensive should be given to control BP.

Drug of choice in Hypertensive crisis :- I/V Labetalol.

Definitive Management : Termination of Pregnancy Irrespective of Gestational age.

Mode of Delivery : Try vaginal delivery.

य Last convulsion 24 भ Spontaneous Labor Start ह ह ह , Cesarean ह

Indication for Cesarean in Eclampsia :

Prolonged Fetal Bradycardia

Unripe Cervix

Gestational Age < 32 Weeks

Poor Progress in Labor

IUGR

Uncontrolled BP

Prevention & Treatment of Convulsion with MgSO4 :

Eclampsia condition Convulsion Treat Drug of Choice : MgSO4

Mechanism of Action :

It Blocks NMDA Receptors in Brain.

It causes Cerebral Vasodilatation.

Block Calcium Channel and decrease intracranial edema.

Therapeutic range of MgSO4 : 4-7 mEq/L

Mg Therepeutic Range ह Short ह ह , : MgSO4 Maintenence Dose स य

Magnesium Toxicity Monitoring य ह

Urine output should be atleast : 30 ml/hr

Deep Tendon Reflex (Patellar Reflex) should be present.

Respiration Rate should be more than 14/min

Pulse Oximetry should be > 96%

Absolute Contraindication of MgSO4 :

Myasthenia Gravis

Deranged Renal Function.

Important Points :

1st sign of impending toxicity of MgSO4 : Disappearance of pateller Reflex.

Mg++ concentratron 10 mEq/L स य ह ह pateller reflex lost ह ह य Mg++ concentration

> 12 mEq/L : Respiratory Depression

> 15 mEq/L : Respiratory Arrest

> 30 mEq/L : Cardiac Arrest




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Mg Toxicity Best Marker Pulse Oximetry ह ह य Mg Toxicity ह स respiratory

Depression Start ह स ह O2 Saturation ह ग ह

MgSO4 Calcium Channel Blocker स Cautiously य ह य य ह Drug

Neuro Muscular Blockage ह Antidote of MgSO4 Toxicity : 10 ml injection of 10% Calcium gluconate

Uses of MgSO4 : Prophylactic use in Severe Preeclampsia.

Prophylactic use in Severe HELLP syndrome.

Prophylactic use in Severe impending eclampsia.

Therepeutic use in Eclampsia.

Use as a short term tocolytic.

Neuroprotective Action :- It protect cerebral palsy in Neonate.

HELLP Syndrome :

Weinstein 1985 स स ह HELLP Syndrome य

यह Severe Pre-eclampsia Most Severe Hematological Complication ह

The acronym HELLP Stands for :

H = Evidence of Hemolysis

EL = Elevated Liver Enzyme

LP = Low Platelet Count.

Haemolysis Mainfested by :

1) LDH > 600 IU/L

2) Elevated Billirubin > 1.3 mg/dL

3) Low Serum Haptoglobin (Most Specefic Marker)

4) Abnormal peipheral Blood smear : Showing Schistocytes, Burr cell and helmet cells.

Elevated liver enzymes : AST and ALT > 70 IU/L

Low Platelet Count (< 1 Lac/mm3)

HELLP syndrome सभ Coagulation Parameter ( स PT, aPTT, Fibrinogen) Normal ह ह

Management :

If Pregnancy is > 34 Weeks = give prophylactically MgSO4 and Immediate deliver.

If Pregnancy is between 24 and 34 weeks give MgSO4 and corticosteroid (Betamethasone 12

mg I/M 2 dose 24 hrs. apart) & deliver.

Mode of Delivery :

If Cervix is Ripe, Gestational age > 32 weeks & FHR Reactive : Vaginal Delivery.

Otherwise Cesarean Section.

Chapter 17




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DIABETES & THYROID IN PREGNANCY

Carbohydrate Metabolism in Pregnancy :

Pregnancy Diabetogenic State ह स Hyperinsulinemia Insulin Resistance Develop ह स ह

Insulin Resistance Placental Hormones ह स Develop ह ह , Anti Insulin ह ह

Human Placental Lactogen (Mainly)

Estrogen

Progesterone

Cortisol

Pregnancy 24-28 Weeks Maximum Insulin Resistance ह ह

Maternal Insulin Placenta Cross ह स

Fetus 12 Weeks Insulin Secretion Start ह

Effect of Maternal Hyperglycenia on Fetal Physiology :

Important Point :

Due to maternal hyperglycemia

Insulin decreases

surfactant production

Increased glucose transfer to fetus

Fetal hyperglycemia

Hyperglycemia and hypertophy

of β cells of fetal pancreas

Insulin secretion by fetus

After birth the connection

between mother and child is

lost, so source of high glucose

is lost in neonate but insulin

levels are high. This leads to

hypoglycemia in new born

Increased incidence

of respiratory distress

syndrome

Insulin is required for

growth of fetus increase

insulin leads to increased

growth i.e. Macrosomia.

This is called as

Penderson hypothesis




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Maternal Hyperglycemia ह स Placenta Hydropic Degeneration ह ह सस Placenta - स Non Functional ह ह Fetus Size Increase ह ह स O2

Demand ह Supply Decrease ह ह (due to Hydropic Degeneration

of Placenta) स ह स Hypoxia Develop ह ह सस Sudden Fetus Death ह स ह

स ह स Diabetic Mother Fetus Hypertrophic Cardiomyopathy Develop ह स ह

Diabetes in Pregnancy :

Gestational Diabetes :

स Female ह Normal , स Pregnancy Insulin Resistance Develop ह ह स Diabetes ह ह स Gestational Diabetes ह ह

Pregnancy Insulin Resistance Maximum 24-28 Weeks Develop ह ह

(Mainly due to human placental Lactogen Hormone)

Diabetic patient High Blood Sugar Level ह ह स Free Redicals ग ह ह स Fetus Congenital Malformation Develop ह ग ह , Gestational Diabetes 24 Weeks Free Radicals ह स स य Fetus Organogenesis ह ह ह , : Gestational Diabetes Congenital Malformation ह ह ह

Overt Diabetes : Overt Diabetes ह स Female स ह स ह Type-I य Type-II

diabetes ह औ ह Pregnant ह ह

Pregnancy Overt Diabetes Female Oral Hypoglycemic Drugs Insulin

य ह य Oral Hypoglycemic Drugs Placenta Cross स ह

Overt Diabetes Condition ह स ह Sugar Level य ह ह , : Pregnancy Day-1 स ह Free Redicals ह ह स Fetus Congenital Malformation ह ह

Diagnostic Criteria for Diabetes during Pregnancy :

1) Random Plasma Glucose > 200 mg/dL

2) Fasting blood Glucose > 126 mg/dL

3) HbA1c > 6.5%

4) Two or More Abnormal Values on 100 gram oral Glucose tolerance test during pregnancy

5) Classical Symptoms of Diabetes

Gestational Diabetes Congenital Malformation ह ह ह Overt Diabetes congenital Malformation ह ह

Congenital malformation in Infant of Diabetic Mother




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Overt Diabetic Female Fetus Congenital Malformation Risk Predict स स Best Parameter : Estimation of HbA1c Level

HbA1c Level < 6.5% --No Increased Risk

6.5-8.5% -- 5% Risk

> 10% -- 22 % Risk

Diabetic Female Fetus Antenatally congenital Malformation Detect Best

Test = Level II /TIFFA Scan at 18-20 Weeks

Most Common System involved in Congenital malformation = CVS > CNS

Most Common Congenital Anomally = Ventricular Septal defect (VSD > Neural Tube

Defect)

Most Specefic Anomally = Caudal Regression Syndrome (Sacral Agenesis) यह

Anomally ह Rare ह ह

Most Common Cardiac Anomally in Infant of Diabetic Mother = VSD

Most Common CVS Finding in Infant of Diabetic Mother = HOCM (Hypertrophic

Cardiomyopathy)

Most Specific Cardiac Anomally : Transposition of Great Aorta (TGA)

Meausures to Decrease the risk of congenital Malformation in Overt diabetic Females :

Periconceptional Period Early Pregnancy स य Strict Blood Sugar Control Insulin ह

स ह Diabetic Female Pregnancy Diagnose ह ह , Oral Hypoglycemic Agent

Rapid/Intermediate Acting Insulin Start ह

Prepregnancy HbA1c Level < 6.0% ह ह

Folic Acid Supplementation Dose = 4 mg स Therepeutic Dose of Folic Acid भ ह ह यह

Conception स ह Start ह conception ह Continue ह

Protocol for Diagnosis of Congenital Malformation :

HbA1c level estimation before 14 Weeks of Pregnancy

TVS in 1st Trimester to detect Anencephaly (11-14 Weeks)

β-hCG & PAPP-A to Detect Down Syndrome

Targated Anomally Scan at 18-20 Weeks

Fetal Echocardiography done between 22-24 Weeks.

Diagnosis of Gestational Diabetes :




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1. Two Step Approach :

(i) 1st Step (Screening Test) : Glucose challange Test.

Performed by giving 50 gram Glucose.

No Fasting Required

Plasma Glucose level are measured after 1 hour.

Cutoff value < 140 mg%

य Plasma Glucose value > 140 mg% स य ह Confirmatory Test (2nd

Step) य ह

य Plasma Glucose Value > 200 mg% स य ह , ग औ Test य ह ह स Confirmed Diabets Category ह

(ii) 2nd

Step (confirmatory Test) : Glucose Tolerance Test

Performed by giving 100 gram Glucose

8 hours Overnight Fasting Required

Total 4 blood samples are taken

1st Sample : Fasting Sample

Than give 100 gram Glucose and Collect

2nd

Sample : After 1 Hour

3rd

Sample : After 2 Hours

4th

Sample : After 3 Hours

Time 100 Gram Glucose Load

Fasting 105 mg/dL

1 Hour 190 mg/dL

2 Hours 165 mg/dL

3 Hours 145 mg/dL

य भ 2 Value Abnormal ह , स Confirmed Diabetes ह ह 2. One Step Approach :

यह Test Screening Diagnostic Purpose य ह

Patient is advised Unrestricted diet for 72 hours followed by overnight fasting and then 75

gram of glucose is given.

Total 3 Samples are taken :

1st Sample = Fasting Sample

2nd

Sample = After 1 Hours




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3rd

Sample = After 2 Hours

75 Gram OGTT

Time mg/dL

Fasting 92

1 Hour 180

2 Hour 153

य Samples स भ Value Abnormal ह , स Gestational Diabetes ह ह

Management of Diabetes in Pregnancy :

Antepartum Management :

(i) Diet & Exercise : First line therapy recommended colorie intake as per BMI

BMI Calorie Intake

< 25 kg/m2 3000 kcal/day

25-30 kg/m2 2500 kcal/day

> 30 kg/m2 1250-1500 kcal/day

Total Calorie requirement should consist of

< 45% Carbohydrate

30% Protein

25% Fat (Unsaturated Fat)

(ii) Pharmacotherephy : Insulin

Drug of choice for diabetes during pregnancy = Insulin.

Dose = 0.6-1 U/kg/day

Short Acting/intermediate Acting Insulin used.

Oral Hypoglycemic agent are not used during pregnancy except for metformin.

(iii) Fetal surveillence : from 3rd

trimester

Kick count

Weekly BPP

Biweekly NST

(iv) Obstetric Management :

Induction of Labor is safe in diabetic Female.

Mode of delivery – Vaginal Delivery.

य Fetus Weight > 4.5 kg स य ह , Cesarean य ह

Complication of Gestational Diabetes :




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(i) Maternal Complication :

Maternal Hyperglycemia

Fetal Hyperglycemia

Polyurea by Fetus

Polyhydroamnios

Preterm Labor & PROM Postpartum Hemorrhage

Increased Incidence of Infection like UTI, asymptomatic Bacterurea, Vaginal Candidiasis

In 40-50% cases, female develop type 2 diabetes in future life.

(ii) Fetal Complications :

-Fetal Hyperglycemia

-Macrosomia

य Fetal Weight > 4000 gram स य ह , स Macrosomia ह ह

Shoulder Dystocia : य Head Delivery Shoulder Delivery > 1 Miniute स य

स य ग ह , स Shoulder Dystocia ह ह Increased Incidence of Abortion/IUD/Still Birth.

(iii) Neonatal Complication :

Neonatal Hypoglycemia

Prematurity leading to RDS

Hypocalcemia

Hypomagnesemia

Hypokalemia

Polycythemia

Hyperbillirubinemia

(iv) Long Term Complication :

Obesity

Type 2 Diabetes

Cardiovascular Disease

Important Points :




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Anaemia is not complication of Diabetes.

Mental Retardation is not seen in babies of diabetic mother.

IUGR seen in babies of overt type II diabetic female with vasculopathy.

Best Investigation to access lung maturity in fetus of diabetic mother – Presence of

phosphotidyl glycerol in Amniotic fluid.

Thyroid disorder in Pregnancy

Hypothyroidism in Pregnancy :

Commonest thyroid dysfunction in Pregnancy.

Majority of Hypothyroidism case are due to Autoimmune disease Hashimoto thyroiditis.

Effect of Hypothyroidism on Pregnancy

Anaemia

Preterm Labor/Prematurity

Preeclampsia

Recurrent Abortion

IUGR

Still Birth

Mental Retardation

Diagnosis & Management :

Diagnosis is made by T3, T4, TSH level

Treatment : Levothyroxine

Hyperthyroidism in Pregnancy :

Most common cause of Hyperthyroidism during pregnancy is Autoimmune Hyperthyroidism

Grave‘s disease.

Complication

Maternal :

Miscarriage

Preterm Labor

Preeclampsia

Congestive cardiac Failure

Placental Abruption

Thyroid Storm & Infection.

Fetal/Neonatal :




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IUGR

Prematurity

Stillbirth

Management :

Medical Management is the management of Choice.

Propylthiouracil/Methimazole/Carbimazole are effective & Safe in Pregnancy.

Side effect of Propylthiouracil.

Transient Leucopenia

Agranulocytosis

Fetal Hypothyroidism

Side effect of Methimazole/Carbimazole

Aplasia cutis of Neonate

Esophageal atresia

Choanal Atresia

Drug of choice in Hyperthyroidism during pregnancy

Propylthiouracil > Methimazole

Radio Active Iodine is an Absolute Contraindication in the treatment of thyrotoxicosis in

Pregnancy.

Beta Blocker like propranolol are used for management of tremors and Tachycardia. They

are safe in Pregnancy.

Maternal Hormone which do not cross placenta.

Insulin

TSH

Parathyroid Hormone

Calcitonin

Erythropoitin

Chapter 18




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ANAEMIA IN PREGNANCY

Anaemia in Pregnancy : WHO स Pregnancy Hb Concentration 11 gm % स

ह Hematocrit Value 33% स ह , स Anaemia ह ह Severity of Anaemia :

Mild : 10-10.9 gm%

Moderate : 7-10 gm%

Severe : Less than 7 gm%

Very Severe : Less than 4 gm%

Physiological Anaemia during Pregnancy : Pregnancy Red Cell Mass (10-15%) Plasma Volume (30-40%) य Increase ह ह सस Hemodilution ह ह औ Hb

concentration Decrease ह ह स Physiological Anaemia of Pregnancy ह ह

Cause of Anaemia during Pregnancy :

Acquired Hereditary

Iron Deficiency anaemia

Dimorphic anaemia- Anaemia due to iron and folic acid

deficiency

Anaemia caused by acute blood loss

Anaemia of inflammation or malignancy

Megaloblastic anaemia

Acquired hemolytic anaemia

Aplastic or hypoplastic anaemia

Thalassemias

Sickle-cell hemoglobinopathies

Other hemoglobinopathies

Hereditary hemolytic anaemia

Complication of Anaemia :

Maternal :

Preeclampsia

Infection

Heart Failure

PPH

Shock

Subinvolution

Pulmonary embolism during Puerperium

Fetal :




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Low Birth Weight

Intra Uterine Death

Iron deficiency Anaemia :

यह Pregnancy Most Common Anaemia ह

Pregnancy Total Iron Requirement गभग 1000mg ह ह 4-6 mg Iron

Daily Required ह ह

Pregnancy Iron Deficiency Anaemia Serum Iron, Serum ferritin ह ह TIBC Serum Transferrin Increase ह ह

Iron स भ Form य ह Only 10% ह Absorb ह ह , : 4-6 mg/daily

requirement 40-60 mg Daily Iron य ह Diet स भ ह ह स Pegnancy गभग ह ह Iron Supplementation

य ह

Ministry of Health & Family National Anaemia Control Programme ह सभ Pregnant Females Iron Folic Acid Tablet ह

100 mg elemental Iron + 500 mcg Folic Acid Tablets 100 Days ह

Earliest Indicator of Iron deficiency Anaemia decrease serum ferritin.

Normal S. Ferritin 50-300 μg/L

S. Ferritin < 30 μg/L Iron deficiency Anaemia

Most Sensitive Blood Index of Iron deficiency MCHC

Diagnosis of Iron deficiency Anaemia :

(i) PBF : Microcytic Hypochromic anaemia, Reticulocyte count slightly raised.

(ii) Decrease MCV, MCH, MCHC, Seme Ferritin

(iii) TIBC & Serum Transferrin increased.

(iv) Most Accurate method of measuring Hb : Cyanomethemoglobin method.

Management of Iron deficiency Anaemia :

(i) Prophylactic Therapy :

Avoid Frequent child Birth.

Supplementory Iron Tablets.

Early detection of Anaemia

(ii) Curative Therapy (Oral Iron Therapy)

180-200 mg elemental Iron orally + 1 mg Folic Acid




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Oral Iron Therapy Parameter स स ह ह Reticulocyte Count (With in 7-

10 Days)

Parenteral Iron Therapy :

स Patient Hemo/Peritoneal Dialysis, Malabsorption Syndrome य Pregnant Female

with severe Anaemia ह , स Parenteral Iron य ह

Parenteral Oral Iron Therapy स गभग 0.7-1.0 gram% per week Haemoglobin

Concentration Increase ह ह Parenteral Iron स स Iron Increase ह ह ह

Types of Parenteral Iron :

Iron Dextran

Iron Sucrose

Iron Sorbitol

Iron Carboxymaltose

Dose of parenteral Iron :

Total iron requirement is calculated by the following formulae

a. 4.4 x body weight (kg) x Hb deficit (g/dL) – This formula includes iron needed for

replenishment of stores

b. 0.3 x weight (lb) x (Hb deficit) = iron req in mg. add 500 mg for stores

c. 250 mg of elemental iron for each gm% of Hb deficit

d. 2.21 x body weight (kg) x Hb deficit (g/dL) + 1000 mg (replenishment of stores)

Note : Weight in kg = wt in lb x 2.2

Normal Hb is taken as 14 g/dl

(iii) Blood Transfusion :

1 unit Blood 0.8-1 gram% Hb level ह (Within 24 Hours)

Delivery Time Hb Level स 7 Gram% ह ह

Dimorphic Anaemia :

स Anaemia Iron Folic Acid य Vit B12 स ह ह

PBF Shows : Macrocytic or Normocytic

Hypochromic or Normochromic

Treatment : Iron & Folic Acid (Therapeutic Dose)




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Sickle Cell Anaemia :

Pregnancy Haemolytic Anaemia Most Common Cause Intravascular Microangi-

opathic Hemolysis ह HELLP Syndrome Part ह

Sickle Cell Disease Pregnancy ह Most Common Hemoglobinopathy ह

Sickle Cell Anaemia Hereditory Disorder ह स Chromosome 11 β-Globin chain Point Mutation ह ह

β -chain Point Mutation ह स 6th Position Glutamic Acid Valine amino

acid ह ह

Gene Mutation Homozygous Condition ह ह , Sickle Cell Anaemia disease ह ह

(HB-SS) (Small Quantity of HbF but No HbA)

य यह Heterozygons State ह ह , स Sickle Cell Trait (HbAS) ह ह स Person 55-60% HbA ह ह 35-40% HbS ह ह

Normal RBC Life Span 90-120 Days ह ह Sickle Cell Life Span only 5-10

Days ह ह

Sickle Cell Crisis :

Characterized by intense bone pain due to sequestration of sickled erythrocyte & Infarction

in various organ.

Management :

IV Fluid

O2

Epidural Analgesia

Antibiotic

Thromboprophylaxis

Red Cell Transfusion

Complication during Pregnancy :

Preterm Labor

IUGR

Fetal Death

Abortion

Increased Incidence of

(i) Preeclampsia

(ii) PPH

(iii) Infection

Management during Pregnancy :




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Folic Acid supplementation 4-5 mg daily (Folic Acid increase blood cell Turnover)

Prophylactic Penicillin (Penicillin V 250 mg BD Daily)

Prophylactic Blood Transfusion during pregnancy to maintain Hematocrit above 25% and

HbS below 60%

Hydroxyurea not recommended in Pregnancy.

य Antenatal visit Hb, hematocrit, Platelet Count, Billirubin, Transaminase Lactate dehydrogenase (LDH) Level Check ह (Fortnightly)

Vaginal Delivery is Preferred

Epidural Analgesia is given during labor to Relieve pain.

Postnatal thromboprophylaxis upto 6 weeks.

Contraception :

Low Dose Oral Progestins or DMPA or Progesterone implant are Ideal Contraceptive

choice in sickle cell female.

Thalassemia :

Thalassemia Group of Inherited blood Disorder ह स Severe Microcytic Hypochromic

Anaemia ह स ह यह स ह स ह

α- Thalassemia

β- Thalassemia

Thalassemia Hemoglobin α β Chain Structurally Normal ह ह , स Production ह ह

Thalassemia : Autosomal Recessive Trait

Alpha Thalassemia :

यह Disease Southeast Asia, Africa,Carribbean Mediterranean Region ह ह

यह Disease Chromosome 16p Deletion ह स ह ह

यह α-Chain Absent ह ह excess β chain ह सस β -Globin Tetramer ह

स HbH ह ह

स Disease Fetus भ Affected ह ह य Fetal Hb (HbF) भ α -Chain

Required ह ह

β -Thalassemia :




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यह Disease Mainly Mediterranean, Asia ,Middle East, Caribbean Region ह ह

यह Disease Chromosome 11 Point Mutation ह स ह ह सस β –Globin Chain Synthesis य ह ह ह

स Condition α -Chain य ह ह Red Cell Membrance स bind ह ह औ स Damage ह

Haematological Finding in Thalassemia :

Low MCV, Low MCH but normal MCHC

Serm Iron & TIBC : Normal or Elevated

Hemoglobin electrophoresis Shows

Increase HbA2 (α2 + δ2) > 3.5%

Increase or normal HbF (α2 + γ2)

Serm Billirubin Raised 2-3 mg%

NESTROFT Test : Naked eye single tube Red cell osmotic Fragility test. यह Thalassemia Screening Test ह ह

Chapter 19

INFECTION IN PREGNANCY




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Fetal Cell Mediated Humoral Immunity Intrauterine Life 9-15 Weeks of Gestation

Start ह ह

स भ Infection Against स स ह Immunoglobulin IgM Type ह ह

Passive Immunity Mother स Fetus Placenta Transfer ह ह , IgG Type Immunoglobulin ह ह

Vertical Transmission : Infectious agent Placenta, Labor, Delivery Breast Feeding

Mother स Fetus Transmission ह Vertical Transmission ह ह

Chickenpox (Vericella Zoster)

Chickenpox vericella zoster virus ह

Route of Transmission : Respiratory Route

यह Infection Placenta Mother स Fetus Transmit ह स ह

Incubation Period = 11 Days

Most Common cause of Maternal Mortality in chickenpoxPneumonia

Drug of choice for vericella in pregnant woman Acyclovir

Acyclovir 20 Weeks स ह (Due to Organogenesis) Avoid ह

य Pregnancy 20 Week स य ह , Rash Start ह 24 Hours Acyclovir Start

ह

Pregnant Female य स Chickenpox Patient contact ह Exposure 96

Hours Varicella Immunoglobulins Prophylaxis ह यह contact स भ य स ह

Varicella Zoster Vaccine Pregnancy Contraindicated ह ह य यह Live Attenuated

Vaccine ह ह

Varicella Zoster Vaccine Breast Feeding Contraindicated ह ह ह

य Varicella Infection Pregnancy 1st Trimester ह ह (Time of Organogenesis)

Fetus congenital Varicella Syndrome ह स ह

Congenital Varicella Syndrome

Chorioretinitis

Micro-opthalmia

Cerebral Cortical Atrophy

IUGR

Hydronephrosis

Skin/Bone Defect

य Congenital Varicella Syndrome Antenatally Diagnose ह ह , MTP ह

Neonatal Varicella : Pneumonitis




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Hepatitis

DIC

Influenza :

Influenza Virus RNA Virus ह

Hemagglutinin (H) Neuraminidase (N) Antigen Surface ह Influenza Virus Strain Genus, Species H N Subtype ह

ह

Effects on Pregnancy due to H1-N1 infection (Swine Flu)

Miscarriage

Preterm Labor

PROM

Pneumonia

ARDS

Renal Failure

DIC

Pregnancy Influenza Infection स Teratogenic Effect ह ह ह Infection 1st

Trimester (Time of Organogenesis) ह ह ह

Influenza (Inactivated) Vaccine Pregnancy Breast Feeding Safe ह ह Diagnosis – Immunoassay, RT-PCR

Management – Supportive Care

Measles :

o Measles Virus Paramyxovirus Family Belong ह यह RNA Virus ह

o Measles infection Teratogenic ह ह ह

o Measles Infection High Fever ह स Miscarriage, IUGR, Microcephaly,

Oligohydramnios, Still Birth Premature Delivery ह स ह

o Incubation Period = 10 Days from Exposure to onset of Fever

14 days to appearance of Rashes (Avg. 7-21 days)

o Diagnosis – assay of IgM – Detection of Viral RNA (RT-PCR)

o Management – Supportive Care

o Ribavirin may be given for viral pneumonia

o Measles vaccine live attenuated vaccine ह ह स यह Pregnancy Containdicated ह ह

Rubella (German Measles)

Rubella Vaccine RNA Virus ह Togavirus Family Belong ह




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Incubation Period 2-3 Weeks (18 Days Avg.)

Route of Transmission – Droplet Infection

यह Infection Pregnancy Fetus Most Severe Congenital Malformation Produce

ह

Mother Rubella Infection ह स Rash, Malaise, Fever, Lymphadenopathy Polyarthritis ह ह

य Mother Rubella Infection 2nd

Trimester ह ह Fetus Transmission Possibility Negligible ह ह

Congenital Rubella Syndrome : (i) Mental Retardation (Most Common)

(ii) Sensorineural Deafness

(iii) Cataract /Glaucoma

(iv) Congenital Heart Disease – PDA, PS

(v) CNS Defect-Microcephaly, MR

(vi) Thrombocytopenia

(vii) Hepatosplenomegaly

य Infection Late 2nd

Trimester 3rd Trimester ह ह , Fetal Malformation ह ह ह ,

Mental Retardation Hearing Loss ह स ह

Maternal Diagnosis :

Maternal IgM and IgG should be done within 7-10 days of exposure and repeated after 3

week.

IgM & IgG Negative – No Infection

IgM – Negative, IgG – Rise [Infection may Occur but reduced Risk]

IgM – Positive in any sample – Acute Infection Do MTP

Fetal Diagnosis : PCR by CVS, Amniocentesis, Cordocentesis

Management : य Pregnant Female Ist Trinmester य Early 2nd

Trimester Infection ह ह , MTP ह

Prevention : Vaccine – MMR Vaccine/Rubella Vaccine

MMR Vaccine live attenuated Vaccine ह ह स स Pregnancy ह ह Cytomegalo Virus (CMV)

यह Herpesvirales Family Virus ह यह ds DNA Virus ह

Maternal Infection usually Asymptomatic ह ह

Patient Mononucleosis स Symptons ह ह :Like : Malaise, Fever, Generalized

Lymphadenopathy, Hepatosplenomegaly




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Menifestation of Congenital CMV Infection :

Still Birth

Mental Retardation

Microcephaly

IUGR

Chorioretinitis

Hepatosplenomegaly

Deafness

Haemolytic Anaemia

Intracranial calcification seen in periventricular zone while in toxoplasma, calcification is

scattered throughout brain.

CMV ह स Fetus भ भ Heart Defect ह ह ह , Most Commonly Brain Defect ह ह

Childhood Age CMV, Sensorineural Hearing Loss Most Common Cause ह

Diagnosis : CMV – IgM antibody

CMV – PCR of Amniotic Fluid

Management :

Symptomatic Treatment

Passive Immunization

No Vaccine Available till Date

Herpes Infection :

Maternal HSV : U/L or B/L vesicular lesion along the dermatome.

Management : Acyclovir 200 mg 5 times a day for 5 days.

Mode of Delivery : Cesarean Section

Toxoplasmosis :

यह Toxoplasma Gondii ह Obligate Intracellular Parasite ह

Cat is Definitive Host

Mother Infection undercooked Meat स ह

Toxoplasma Infection Maximum 3rd

Trimester ह ह

य Toxoplasma Infection 1st Trimester ह ह , य Severe Infection ह ह

Symptoms – Posterior Cervical Lymphadenopathy, Fever, Fatigue, Rash

Drug of choice for toxoplasma during pregnancy – spiramycin (1 g every 8 hourly)

Triad of congenital Toxoplasma

Intracranial calcification

Hydrocephalus

Chorioretinitis




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य Non Pregnant Woman Toxoplasma diagnosed ह ह , 6 Months Pregnancy

Avoid ह

HIV in Pregnancy :

Pregnancy Least Teratogenic Infection - HIV

Most Common Time Period of Vertical Transmission

Peripartum Period

During Delivery

Risk depends on following factors.

Maternal Viral Loads

CD4+ Cell count

Vit A deficiency

Chorioamnionitis

Screening Test – ELISA

Confirmatory Test : Western Blot Test

CD4 + Cell Count < 200 cells/mm3 स ह , Pneumocystic Jiroveci य

Opportunistic Infection Prevent Prophylaxis ह

Anti Retroviral Therapy is highly effective in Reducing Viral Load & Perinatal

Transmission.

HAART (Highly Active Anti Retro Viral Therapy) : यह Perinatal Transmission Best Regimen ह ह , यह Expensive Treatment ह ह

य Female HIV Positive ह , Tripple Drug Therapy as soon as Start ह औ

Throughout Pregnancy, Labor & Post Partum Period Contiune ह

Care during Labor :

य Female HIV Positive ह , 38 Weeks Elective Cesarean ह Elective Cesarean Delivery Vertical Transmission Reduce ह

HIV Positive Females ARM (Artificial Rupture of Membrane) ह ह

Post Exposure Prophylaxis :

Zidovudine 200 mg TDS

Lamivudine 150 mg BD x (4 Weeks)

Nelfinavir 750 mg TDS

य Mother HIV Positive ह , Breast Feeding Avoid ह Navirapine Therapy : Mother स Fetus HIV Vertical Transmission Prevent

Navirapive ह यह Cost Effective ह ह 200 mg orally 4 hours before cesarean section

& Single dose to baby (2 mg/kg) with in 72 hours of birth.

Key Concept




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Most common infection CMV

Most teratogenic infection Rubella

In rubella –Most common single defect which occurs is –Sensorineural hearing loss.

Heart defects seen in rubella Patent ductus arteriosus and pulmonary artery stenosis.

After rubella vaccine, pregnancy is contraindicated for 1 month.

CMV –Transmission can occur in any trimester

CMV never leads to heart defects in fetus

Most common time for toxoplasma infection—3rd

Trimester

Triad of toxoplasma infection –Intracerebral calcification, chorioretinitis and hydrocephalus.

Treatment—Spiramycin (Prevents fetal transmission but it cannot treat fetal infection if it is

present).

Spiramycin + Pyrimethamine and sulfonamide combination is given to treat fetal infection

and prevent further transmission.

Infection DOC in pregnancy

Bacterial vaginosis Metronidazole to patient only 1st trimester-clindamycin

Pneumocystis carinii Sulphamethozole –trimethoprim

Typhoid Third gen. cephalosporins/ azithromycin

Syphilis < 1 year > 1

year

Benzathine penicillin 2.4 million U IM single dose Benzathine penicillin

2.4 million U IM weekly x 3 doses

Gonorrhoea Inj. Ceftriaxone 125 mg IM single dose or Tab cefixime 400 mg single

dose or inj. Spectinomycin 2 g i.m. single dose

Chlamydia Azithromycin single dose or Amoxicillin 500 mg TDS * 7 days, 2nd

choice- Erythromycin

Group B streptococci Pencillin, 2nd

best –Ampicillin. In patients who are pencillin-resistant-

Cefazolin

Malaria-Prophylaxis Chloroquine

Malaria -Treatment Chloroquine. For radical cure primaquine is advised after delivery. In

resistant cases (Mostly d/t P. falciparum) – Quinine + Clindamycin or

mefloquine

Appendicits Immediate appendicectomy

Red degeneration Conservative management (no termination of pregnancy and no

myomectomy)

Viral Hepatitis in Pregnancy :

Tropical Countries Pregnancy Jaundice Most Common Cause Viral hepatitis ह

Hepatitis A (HAV) : Picorna Virus (RNA Virus)

Hepatitis A Feco oral Route स ह




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Diagnosis Anti HAV IgM antibody

Perinatal Transmission is Rare.

Chronic carrier stage not exist.

Pregnant women HAV Infection ह ह Immunoglobulin 0.02 ml/kg exposure 2

Weeks ह

Hepatitis B (HBV) :

यह DNA Virus ह ह

Route of Transmission : Parenteral

Sexual Contact

Vertical Transmission

Hepatitis B Transmission Risk 1st Trimester 10% 3rd

Trimester 90%

ह ह

HBV is not Teratogenic

Clinicial Feature : Malaise, Anorexia, Nausea, Vomitting, Cirrhosis, HCC

Chronic Carrier stage present

Diagnosis :

Serological detection of HBSAg, HBCAg (Denote high Infectivity) Antibody to hepatitis

B core Antigen (HBcAg) & Viral load HBV DNA titre.

Management:

HBsAg Positive mother स fetus Hepatitis Transmission Active

Passive ह Immunization ह

Hepatitis Immunoglobulin (0.5 ml IM) within 12 hours after birth

+

1st Dose of Hepatitis B recombinant vaccine followed by Hepatitis B vaccine at 1 & 6

Month.

Hepatitis B is not a contraindication for breast feeding.

Hepatitis C (HCV) : RNA Virus

Major cause of Non-A, Non-B Hepatitis worldwide & leading cause of Transfusion

associated Hepatitis.

Route of Transmission Blood Borne.




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Perinatal Transmission is high if coinfected with HIV & HBV

Chronic Carrier stage Present.

Breast Feeding is not Contraindicated.

Hepatitis D (HDV) : RNA Virus

यह Infection ह Hepatitis B infection स ह

Hepatitis E (HEV) : RNA Virus

Most important cause of Non A, Non-B Hepatitis in developing country like India.

Chronic Carrier stage present.

Maternal Mortality is very High.

Important Points :

Maximum Risk of Maternal Mortality : Hepatitis E

Maimum Risk of Hepatic Encephalopathy :Hepatitis E

Maximum Risk of Perinatal transmission: Hepatitis B

Maximum Risk of Transmission of Hepatitis: at the time of delivery.

Breast Feeding is not contraindicated in case of Hepatitis.

Tuberculosis in pregnancy :

Caused by : Mycobactrium Tuberculosis.

Effect of Pregnancy on TB : TB Relapse Maximum Puerperium Period ह स ह TB

Flare up भ Puerperium Period ह स ह

Effect of TB on pregnancy :

Decrease Fertility

Abortion

IUD

Preterm Delivery

IUGR

Low Birth Weight

Mode of Infection in Fetus :

Hematogenous : Through umbilical vein

Ingestion of infected Amniotic Fluid during delivery

Post partum Infection

TB is not an Indication for termination of Pregnancy.

ATT Pregnancy स भ Trimester स ह




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First Line Drug for TB

Isoniazid

Rifampicin

Pyrazinamide

Ethambutol

Pregnancy Streptomycin contraindicated ह ह यह Drug Fetus Oto-toxicity

Develop ह

Breast Feeding is not contraindicated if the woman is on treatment but contraindicated if

active lesion is present.

Delivery Baby ह INH (Isoniazid) Prophylaxis ह य ह

Montoux Test Negative ह Prophylaxis ह BCG Vaccination ह

Antitubercular Drugs contraindicated in Pregnancy :

K = Kanamycin

F = Fluro-quinolones

C = Capreomycin

A = Amikacin

S = Streptomycin

Mnenonic = KFC always surprising

TB is not a Indication for Termination of Pregnancy.

Epilepsy in Pregnancy :

Pregnancy Most Common Neurological Disorder Epilepsy ह

Pregnancy Epilepsy Most Common Cause Idiopathic ह

Pregnancy सभ Anticonvulsant Drug Congenital Anomally ह (Due to

defective folic Acid Metabolism)

Malformation due to Anticonvulsant drugs :

Cleft Lip/Palate

Mental Retardation

Limb Defect

Hypoplasia of Terminal Phalanges

Sodium valproate is associated with neual tube defect.

Chances of Neonatal Hemorrhage Increased due to Anticonvulsant induced vitamin K

dependent coagulopathy.

Antepartum Management :

Mono drug therapy preferred.

Lowest possible dose should be given.

Therapeutic dose Monitoring




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सभ Females Anticonvulsant Drug ह , ह Conception स ह ह 4 mg/day

Folic Acid Start ह Pregnancy ह

Prenatal Screening :

MSAFP (Maternal Serum Alpha Fetoprotein) at 16 weeks + Level IInd USG

Vitamin K 10 mg/day orally from 36 weeks onward to prevent Hemorrhagic disease of

New born.

Post partum management : Newborn is given Vitamin K (1mg IM)

Breast Feeding is not contraindicated.

Drugs in pregnancy :

Food and drug administration (FDA) charted out categories for drugs, taking into account the possible

fetal adverse effects.

Category A Drugs which have no fetal risks as demonstrated by well-controlled studies in

humans, e.g. pencillin.

Category B Drugs which have shown no risk in animal studies but human studies do not

exist, or also if any adverse effects have been seen in animal studies with no

such effect in well-controlled human trails, e.g., paracetamol, ranitidine

Category C Drugs for which there are no studies either animal or human, or drugs in which

there are adverse fetal effects in animal studies but no such data exists in

human trials, e.g. chloroquine, acyclovir, zidovudine.

Category D Drugs which have proven risks but their use in essential and the benefits

outweigh the risks, e.g. phenytoin, warfarin, propylthiouracil.

Category X Drugs which are clearly teratogenic and the risks outweigh the benefits and

hence should be avoided.

CNS anomaly (NTD) + CVS anomaly + facial defects are seen with the use of isotretinoin

Drug Teratogenicity

Alcohol Fetal alcohol syndrome (dose related) Pre and postnatal growth restriction

Facial abnormalities like shortened palpebral fissure, low set ears, smooth philtrum,

thinned upper lip and midfacial hypoplasia.

CNS defects like microcephaly, mental retardation and behavioral disorders

Warfarin Fetal warfarin syndrome

Chondrodysplasia punctata, epiphyseal stippling, nasal hypoplasia, optic atrophy

and microcephaly

Phenytoin Fetal hydantoin syndrome Hypertelorism, broad nasal bridge, low set ears, hypoplastic nails and digits.

Sodium

valproate

Fetal valporate syndrome Brachycephaly with a high forehead, hypertelorism, small nose and mouth, shallow

orbits, overlapping long fingers and toes and hyperconvex nails.




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Diethyl

stilbesterol

Neural tube defects

Vaginal and cervical adenosis, clear cell adenocarcinoma, uterine anomalies,

cryptorchidism and testicular hypoplasia

Isotretinoin Cleft palate, neural tube defect, microcephaly, deafness, blindness, cardiac defects

like atrial septal defect and great vessel defects.(CNS +CVS + facial defect)

ACE

inhibitors

Renal tubular dysgenesis, anuria and oligohydramnios

Androgens

and danazol

Masculinisation of a female fetus

Antineoplastic

agents

IUGR, craniosynostosis, micrognathia, severe limb abnormalities

Tetracyclines Discoloration of deciduous teeth

Cocaine Microcephaly, limb reduction defects and genitourinary malformations due to

cerebral infraction

Chapter 20

PUERPERIUM & ITS ABNORMALITIES Puerperium Delivery 6 Weeks Time Period ह ह स Pelvic Organs Anatomically

Physiologically Pre-Pregnant State ह

Involution ह Process ह स Genital Organs स Pre-Pregnant Stage ह




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Duration : Normal Puerperium expulsion of Placenta स Start ह 6 Weeks (42 days ) ह ह स य भ ग गय ह : 1. Immediate Puerperium : 1

st 24 Hours after delivery.

2. Early Puerperium : 1st

7 days after delivery.

3. Remote Puerperium : 2nd

Week to 6th

Week after delivery.

Physiological Changes :

Uterine Changes :

Involution of the Uterus :

Delivery Just Contracted Uterus Fundal Height Pubic symphysis स 13 cm ह ह , Umbilicus Just Feel ह ह

48 Uterus 1.25-1.5 cm per day हस स Shrink ह Start ह ह औ गभग स ह Uterus Intrapelvic Organ ह ह

Delivery गभग स ह Uterus Pre-Pregnant Stage ह

Uterus Weight

At the time of Delivery : 1000 Gram

After One Week : 500 Gram

After Three Week : 100 Gram

After Six Week : 60 Gram

Pregnancy Uterus स ह , स स य Uterine Muscles Hypertrophy Hyperplasia ह ह , Uterus Pre-Pregnant Stage ह , स स य No. of Cells Decrease ह ह ह , Only Cells Size Decrease ह ह

Delivery Puerperium period estrogen Progesterone hormone Withdrawl स Uterus Collagenase Proteolytic Enzyme Release ह ह सस Uterine Cell Size

Decrease ह ह

Uterus Delayed Involution Subinvolution ह ह

Cervix :

Labor Cervix 10 cm Dilate ह ह स Prepregnant Stage ह

Delivery Cervix 5 cm स Close ह ह 1 Week Complete

Close ह ह (Pre Pregnant Stage)

Delivery Internal os ह स Close ह ह , External os स भ ह ह

Endometrium :

Delivery Decidua Superficial Part Necrotic ह Lochia Shred ह ह




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Endometrium Basal Layer Myometrium ह ह ह Intact ह ह औ स Regeneration Start ह ह

Endometrium Regeneration ह Fast Process ह ह Delivery स ह Endometrium Complete Regeneration ह ह

Placental Site Regeneration slowest ह ह (Approx-6 Weeks)

Vaginal Changes :

Vagina स Prepregnant Stage य स य ग ह यह Slow Process ह

Size & Elasticity never revert back.

Delivery Puerperium period 1st 15 days Vagina स fluid Discharge ह ह स

Lochia ह ह Lochia Uterine Body, Cervix Vagina स Originate ह ह स Fishy Smell ह ह

Initially Lochia Alkaline ह ह - Acidic ह ह

Lochia Colour स ग- ग य गय ह : (i) Lochia Rubra [1-4 Days] :(Red Colour). It consist Blood, shred of fetal membrane, decidua,

vernix caseosa, Lanugo and Meconium.

(ii) Lochia Serosa [5-9 Days] : (Yellow colour) serosa meansserum (yellowish discharge). It

consist of leucocyte, wound exudate ,Mucus from cervix and Micro- Organism.

(iii) Lochia Alba [10-15 Days] : (Pale White). It consist decidual cells, leucocytes, Mucus,

Fatty & granular epithelial cells & Micro -Organism.

5-6 Average Dischange गभग 250 ml ह ह

Post partum Period Average Blood Loss गभग 200 ml ह ह

Total 15 Complete Fluid Loss गभग 400 ml ह ह

Clinical Importance :

Discharge Premature Labor Infection Condition Scanty ह स ह Twin

Delivery, Polyhydroamnios, Subinvolution RPOC Condition Excessive ह स ह

य Discharge स Fishy Smell गह ग ग ह , यह Infection Show ह

य Lochia Red Color Normal time period भ Continue ह ह यह Subinvolution

य RPOC ह स ह स ह

Breast Changes :

Postpartum Period Breast Milk Secretion ह ह




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(i) Mamogenesis : Growth of Alveolar Tissue.

(ii) Lactogenesis : Synthesis and Secretion of Milk from Alveoli.

(iii) Galactokinesis :Ejection of Milk from Breast.

Milk Ejection Oxytocin Hormone Responsible ह ह , Posterior Pitutory स Release

ह ह

(iv) Galactopoiesis : Maintenence of Lactation. यह Prolactin Dependent ह ह

Milk Synthesis Mainly Prolactin Hormone Responsible ह Anterior Pitutory स Release ह ह

Prolactin Level Increase ह ह , यह Hypothalamus Suppress ह सस Gonadotropin Releasing Hormone Release ह ह सस Pitutory स Gonadotropin FSH LH Release ह ह Ovulution ह ह स Lactational Amenorrhoea ह ह

Urinary Tract : Delivery Urinary Bladder Trauma ह स Nerve Plexus Injury ह स ह सस Intravesicle Pressure Increase ह भ Micturation Feeling ह ह ह औ Urinary Bladder overdistended ह ह Bladder Incomplete empty ह ह सस Puerperium Period UTI ह स भ य ह ह

Gestrointestinal Tract : Puerperium Period Intestinal Paresis ह स Constipation ह ह

Loss of Weight : Delivery of Fetus, Placenta, Amniotic Fluid Blood Loss ह स Puerperium Period Immediately 5 kg Weight Loss ह ह

6 Weeks Extra 4 kg Weight भ Loss ह ह (Due to excreation of Fluid & electrolytes)

Fluid Loss : Delivery First Week 2 Litre Fluid Loss ह ह ग 5 Weeks गभग 1.5 Litre Fluid Loss ह ह

Haematocrit Changes : Early puerperium period Platetlet Coagulation Factor Increase

ह ह स Hypercoagulable State ह ह सस Puerperium Period Thromboembolism ह स भ ह

Temperature :

Delivery Slight Reactionary Temperature (0.5°F) Increase ह ह गभग 12

Hours Normal ह ह

Temperature First 24 Hours 37.2° C स य ह ह ह

Delivery Breast Engorgement ह स 3rd Day slight Temperature Increase ह ह

24 Normal ह ह




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Important Points :

Rule of 3 : Delivery Nonlactating Female 3 Weeks Lactating Female 3 Month Contraceptives Use ह

Abnormal Puerperium :

Puerperal sepsis : Delivery First 10 Days य Oral Temperature. 38°C स य ह , स Hyperpyrexia ह ह

Sepsis : Delivery स 42 Genital Tract Infection ह स य Pelvic Pain, >

38.5°C Temp, Subinvolution य Vaginal Discharge ह ह

Mode of Infection : Direct Spread (Endogenous/Exogeous)

Micro Organism : Streptococcus

Clinical Manifestation : Endometritis

Risk Factor :

(i) Patient Related : Unhygiene, Anaemia, Malnutrition.

(ii) Delivery Related : Frequent examination, Prolonged/Obstructed Labor, Instrument

Delivery.

(iii) Health Care Person Related : Untrained Staff, Use of unsterlized Instruments.

Prevention :

Antenatal : Hb > 11%, treat local infection.

Intranatal : Aseptic Method, Perineal Hygiene

Post Natal : Clean Pad, early detection & treatment of infection.

Chapter 21

Practice Questions

1. How many primary spermatocytes formed by one spermatogonia ?

(A). 4 (B). 16 (C). 64 (D). 8

2. Time taken in spermiogenesis is ?

(A). 14 days (B). 74 days (C). 61 days (D). 46 days

3. Capacitation occurs in ?

(A). Vas deferns (B). Seminal vesicle (C). Ejaculatory ducts (D). Female genital tract

4. SRY gene present at ?

(A). Short arm of ―Y‖ chromosome (B). Long arm of ―Y‖ chromosome

(C). Short arm of ―X‖ chromosome (D). Long arm of ―X‖ chromosome

5. Which of the following statement is wrong ?




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(A). time taken in sperm capacitation is 7 hrs (B). Life span of sperms 48-72 hrs

(C). Main hormone responsible for spermatogenesis is testesterone(D). Testesterone is secreted by sertoli cell

6. At birth all oogonia present at which stage of development ?

(A). Primary oocyte (B). Secondary oocyte (C). Polar body (D). Ovum

7. The process of ovulation is known as ?

(A). Release of secondary oocyte from primary oocyte (B). Release of ovum from secondary oocyte

(C). Release of primary oocyte from oogonia (D). Release of 2nd

polar body from secondary oocyte

8. Which of the following statements is false ?

(A). Maximum no of oogonia during intra uterine life present at 5th

month of intrauterine life

(B). At birth secondary oocyte division arrested at diplotene stage of meiosis-I

(C). Size of mature ovum is 120-130 micron, which is largest cell of the body

(D). Life span of ovum is 12-24 hrs

9. Morula is 16 cell stage structure, sorrounded by a layer which prevent polyspermy known as ?

(A). Zona pellucida (B). Corona radiata (C). Amnion (D). Chorion

10. Zygote enters the uterine cavity after how many days of fertilization ?


11. Which structure of the blastocyst developed into embryo proper ?

(A). Trophoblast (B). Inner cell mass (C). External cell mass (D). Zona pellucida

12. True statement is ?

(A). Fertilization occurs in isthmus part of fallopian tube (B). Implantation occurs 6-7 days after fertilization

(C). Zona hatching occurs 8th

day after fertilization (D). hCG hormone secreted mainly by cytotrophoblast

13. 1st meiotic division of oogenesis gets arrested at ?

(A). Pachytene stage of prophase (B). Diplotene stage of prophase

(C). Leptotene stage of prophase (D). Metaphase stage of prophase

14. Fertilisation is said to be complete if ?

(A). 1st polar body formed (B). 2

nd polar body formed

(C). Primary oocyte is formed (D). Secondary oocyte is formed

15. Match the following ?

Color of amniotic fluid Disease

P. Greenish yellow (Saffron) W.Rh incompatibility

Q. Golden yellow X. Postmaturity

R. Green Y. IUD

S. Tobacco juice Z. Fetal distress

(A). P (X) Q (W) R (Y) S (Z) (B). P (X) Q (Y) R (Z) S (W)

(C). P (X) Q (Y) R (W) S (Z) (D). P (X) Q (W) R (Z) S (Y)

16. Uteroplacental blood flow at term is ?

(A). 400-600 ml/min (B). 100-200 ml/min (C). 200-400 ml/min (D). 800-1000 ml/min

17. Which of the followig is /are charecteristic of human placenta ?

(A). Discoid (B). Hemochorial (C). Deciduate (D). All of the above

18. Placental barrier is formed by all, Except ?

(A). Syncytiotrophoblast(B). Cytotrophoblast (C). Endothelium of fetal capilleries (D). Decidua parietalis

19. Fetoplacental circulation is established after fertilization ?

(A). 10-12 days (B). 17-21 days (C). 7-10 days (D). 25-28 days

20. Identify the wrong statement ?




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(A). At 17 week of gestation the weight of placenta & fetus are equal

(B). The ratio of weight of placenta to the weight of the baby at term is 1:6

(C). Hoffbauer cells are macrophage cells which are present in fallopian tube

(D). In placenta villi contain 350 ml fetal blood & intervillous space contain 150 ml maternal blood at term

21. Which of the folowing limits the invasion of decidua by trophoblast ?

(A). Nitabuch‘s membrane(B). Amnion (C). Chorion (D). Cytotrophoblast

22. Small placenta seen in all except ?

(A). Postdatism (B). IUGR (C). Placental infract (D). Gestational diabetes

23. Identify the anomally of placenta in given diagram ?

(A). Placenta succenturiata (B). Placenta Bilobata(C). Placenta Spuria (D). Battledore Placenta

24. After 8-10 weeks of pregnancy main source of progesterone is ?

(A). Syncytiotrophoblast(B). Cytotrophoblast (C). Corpus luteum (D). Ovary

25. Doubling time of hCG is ?

(A). 1.4-2 days (B). 3-4 days (C). 5-7 days (D). 8-10 days

26. A 30-year-old-female H/O Rt adnexal ectopic pregnancy 1 year back coming in OPD with pain in Lt

Adnexa with UPT-positive. Doctor advised her to test spot β-hCG test which value is 20 IU/L, For the

diagnosis of Ectopic pregnancy β-hCG value after 48 hrs should be ?

(A). 45 IU/L (B). 30 IU/L (C). 50 IU/L (D). 55 IU/L

27. Single umbilical artery (SUA) is a significant finding, it is associated with all complications, Except ?

(A). Congenital malformation (B). Prematurity(C). IUGR (D). Post partum haemorrhage

28. Which of the following statement is/are true regarding amniotic fluid ?

(i) Specific gravity of amniotic fluid is 1.008-1.010

(ii) Volume of amniotic fluid is maximum at 24-28 weeks

(iii) Fetal urine is main contributor of amniotic fluid

(iv) Normal color of amniotic fluid is green

(A). (i) & (iii) (B). (i), (ii) & (iii) (C). (i), (ii), (iii) & (iv) (D). (i), (iii) & (iv)

29. Function of amniotic fluid are all except ?

(A). Act as a shock absorber & protect fetus from trauma (B). Give nutrition to fetus

(C). Maintain temperature (D). Prevent adhesion of fetal parts

30. During fetal life maximum growth occurs due to ?

(A). GH (B). Cortisol (C). Thyroxin (D). insulin

31. Wrong statement is ?

(A). Amnion is inner most fetal membrane and it is highly vascular

(B). Chorion is outer most fetal membrane

(C). Amnion is derivative of fetal ectoderm (D). Formation of chorion occurs after 8 day of fertilization




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32. Umbilical cord contains ?

(A). 2 arteries & 2 vein (B). 2 arteries & 1 vein (C). 1 artery & 2 vein (D). Only 2 arteries

33. When the umbilical cord attached to margin of the placenta is called ?

(A). Battledore placenta (B). Velamentons cord insertion

(C). Furcate cord insertion (D). None

34. Complication of placenta succenturita may all, Except ?

(A). Preterm delivery (B). PPH (C). Sepsis & subinvolution(D). Missing lobe

35. Wharton’s Jelly of umbilical cord is derived from ?

(A). Ectoderum (B). Mesoderm (C). Endoderm (D). Trophoblast

36. Oligohydroamnios is considerd when AFI is ?

(A). Below 5 (B). Below 10 (C). Beow 7 (D). Below 15

37. Cause of oligohydroamnios are all, Except ?

(A). Preeclampsia (B). B/L multicystic dysplastic kideny

(C). Maternal DM (D). Posterior urethral valve

38. Complication of oligohydroamnios are all except ?

(A). Malpresentation (B). IUGR (C). Limb deformilies (D). Unstable lie

39. A pregnant women is found to have excessive accumulation of amniotic fluid. Such polyhydroamnios is

likely to be associated with all of the following condition except ?

(A). Oesophageal atretia (B). Cleft lip (C). Anencephaly (D). B/L Renal agenesis

40. All are the indication of amnioinfusion, Except ?

(A). Oligohydroamnios (B). Suspected renal anommalies

(C). To facilitate labour (D). In case of fetal distress

41. A pregnant female goes to doctor and ask for expected date of delivery. Doctor tell her that EDD will be 25

July 2016. According to EDD the patient LMP was ?

(A). 19 Oct 2015 (B). 18 Oct 2015 (C). 02 May 2017 (D). 01 May 2017

42. Life span of fetal RBC is ?


43. Ligamentum teres is formed after ?

(A). Obliteration of the umbilical vein (B). Obliteration of the ductus venosus

(C). Obliteration of the ductus arteriosus (D). Obliteration of the umbilical arteries

44. During fetal circulation arrange in descending order according to concentration of oxygen ?

(A). Umbilical vein > RA > IVC > LV> Umbilical artery

(B). Umbilical vein > IVC > RA > LV > Umbilical artery

(C). Umbilical artery > LV > IVC > RA > Umbilical vein

(D). Umbilical artery > IVC > LV > RA > Umbilical vein

45. HbA2 contains ?

(A). 2α + 2β chain (B). 2α + 2γ chain (C). 2α + 2δ chain (D). 2α + 2θ chain

46. Which of the following test differentiate maternal blood from fetal blood ?

(A). Kleihauer- batke test(B). Bubble test (C). Lily‘s test (D). Shake test

47. Fetal sex can be identified on USG by ?

(A). 14 weeks (B). 16 weeks (C). 9 weeks (D). 10 weeks

48. Fetal kidney’s start producing urine by ?

(A). 5 months (B). 3 months (C). 4 months (D). 6 months

49. Estrogen and progesterone is first two months of pregnancy are produced by ?




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(A). Fetal ovaries (B). Fetal adrenal (C). Placenta (D). Corpus luteum

50. Primigravida with full term, complains of faintness on lying down and she feels well when turns to side or

sitting position. This is due to ?

(A). Increased abdominal pressure (B). IVC compression

(C). Increased intracranial pressure (D). After heavy lunch

51. Which of the following is the least likely physiological change in pregnancy ?

(A). Increase in intravascular volume (B). Increase in cardiac output

(C). Increase in stroke volume (D). Increase in peripheral vascular resistance

52. Which is not feature of pseudocyesis ?

(A). Amenorrhea (B). Abdominal distension

(C). Fetal heart sounds are audible (D). None of the above

53. Extra calories requirement during pregnancy & lactation is ?

(A). 350, 600 K. Cal. (B). 300, 550 K. Cal. (C). 600, 350 K. Cal. (D). 550, 300 K. Cal.

54. Total weight gain during pregnancy ?

(A). 6-8 kg (B). 11-12 kg (C). 15-16 kg (D). 18-20 kg

55. Which of the following parameter not decrease during pregnancy ?

(A). Platelet count (B). WBC count (C). Cotting factor 11 & 13 (D). Haematocrit level

56. Maximum cardiac output during pregnancy at ?

(A). Immediately after delivery (B). 2nd

stage of labour

(C). 1st stage of labour (D). 28-32 weeks

57. Which of the following parameter of respiratory system unaffected during pregnancy ?

(A). Tidal volume (B). Total lung capacity

(C). Vital capacity (D). Expiratory reserve volume

58. Which of the following statement is false regarding iron metabolism during pregnancy ?

(A). Decrease serum iron concentration (B). Decrease serum ferritin

(C). Increased total iron binding capacity (D). Decrease serum transferrin

59. NESTROFT test is used for detection of ?

(A). β-Thalassemia (B). Down syndrome (C). Cystic fibrosis (D). Sickle cell anemia


Test Time

(i)Double marker test (P)16-18 week

(ii)Tripple marker test (Q)11-14 weeks

(iii)Quadruple marker test (R)18-22 weeks

(A). (i) Q (ii) P (iii) R (B). (i) P (ii) Q (iii) R (C). (i) Q (ii) R (iii) P (D). (i) R (ii) Q (iii) P


(i)Early deceleration(P)Uteroplacental insufficiency

(ii)Late deceleration (Q)Umbilical cord compressor

(iii)Variable deceleration (R)Head compression

(A). (i) R (ii) Q (iii) P (B). (i) R (ii) P (iii) Q (C). (i) P (ii) Q (iii) R (D). (i) Q (ii) P (iii) R

62. Manning score is done for ?

(A). Fetal well being (B). Progression of labour(C). Induction of labour (D). Cervical dilation

63. Early CVS procedure (before 9 weeks) cause which of the following complication ?

(A). Rh isoimmunization (B). Oromandibular limb defects

(C). Rupture of membrane (D). Vaginal bleeding




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64. Early amniocentesis can be done at ?

(A). 9-11 weeks (B). 11-14 weeks (C). 14-16 weeks (D). 7-9 weeks

65. All of the following test are used for detection of down syndrome except ?

(A). NT scan (B). Double marker test(C). Karyotyping (D). NESTROFT test

66. Triple test includes all except ?

(A). hCG (B). AFP (C). Unconjugated estriol(D). Inhibin-A

67. Which of the following is not seen in down syndrome ?

(A). Trisomy at 21 chromosome (B). Clinodactyly(C). Nasal bone hypoplasia (D). Cystic mass in neck

68. During 1st trimester best parameter to detect fetal age ?

(A). CRL (B). BPD (C). FL (D). AC

69. Targeted anomally scan by ultrasound should be done at ?

(A). 12 weeks (B). 20 weeks (C). 28 weeks (D). 32 weeks

70. Which of the following anomally can be detect earliest on USG ?

(A). Anencephaly (B). Omphalocele (C). Cystic hygroma (D). Diaphragmatic hernia

71. All of the following are included in neural tube defect except ?

(A). Anencephaly (B). Spina bifida (C). Encephalocele (D). Gastroschiasis


Test Time

(i)Chorionic villi sampling (P)15-20 weeks

(ii)Amniocentesis (Q)10-13 weeks

(iii)Cordocentesis (R)20-22 weeks

(A). (i) P (ii) Q (iii) R (B). (i) Q (ii) R (iii) P (C). (i) Q (ii) P (iii) R (D). (i) R (ii) P (iii) Q

73. In india 1st dose of tetanus toxoid during pregnancy should be given at ?

(A). 2nd

trimester (B). As early pregnancy is diagnosed

(C). Before labour pain (D). 3rd

trimester

74. All of the following vaccine are contraindicated during pregnancy, Except ?

(A). BCG (B). MMR (C). Chickenpox (D). IPV

75. A 12 weeks pregnant female with previous history of twin delivery at 38 weeks denotes ?

(A). G2P1 (B). G3P1 (C). G2P2 (D). G2P3

76. At 16 weeks fundal height of uterus is ?

(A). At umbilicus (B). At pubic symphysis

(C). Midway between pubic symphysis & Umbilicus(D). Midway between Umbilicus & Xiphoid process

77. Calcium requirement during pregnancy ?

(A). 600 mg (B). 800 mg (C). 1200 mg (D). 1500 mg

78. Calculation of EDD is done by ?

(A). Naegele‘s formula (B). Shirodkar formula (C). Robin‘s formula (D). Chadwick formula

79. Absolute sign of pregnancy are all, Except ?

(A). Auscultation of fetal heart sound (B). USG evidence of embryo

(C). Radiological demonstration of fetal skelton (D). Amenorrhoea

80. WHO recommends how many antenatal visits ?

(A). 3 visits (B). 12-14 visits (C). 4 visits (D). 6 visits

81. Which of the following statement false regarding folic acid supplementation during pregnancy ?

(A). Folic acid supplementation prevents neural tube defects

(B). Prophylactic dose of folic acid should be start in 1st trimester of pregnancy




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(C). Folic acid dose is 500 μg (D). All are true

82. Total amount of iron required during pregnancy is ?

(A). 500 mg (B). 1000 mg (C). 300 mg (D). 700 mg


Sign Feature

(i)Chadwick sign (P)Softening of cervix

(ii)Osiander’s sign (Q)Bluish discoloration of vagina

(iii)Goodell’s sign (R)Increased pulsation in lateral fornix

(iv)Hegar sign (S)Softening of isthms

(A). (i) Q (ii) R (iii) S (iv) P (B). (i) Q (ii) P (iii) R (iv) S

(C). (i) Q (ii) R (iii) P (iv) S (D). (i) Q (ii) S (iii) P (iv) R

84. Which of the following statement are wrong ?

(A). Palmer‘s sign is regular & Rhythmic uterine contraction which seen at 4-8 weeks of pregnancy

(B). Braxton hicks contraction is nonrhythmic sporadic painless contraction which starts in 2nd

trimester

(C). Quickening is perception of active fetal movement felt by 24 weeks of GA

(D). Lightening seen at 36 weeks of GA

85. Which of the following is not a presumptive sign of pregnancy ?

(A). Amenorrhoea (B). Palpation of fetal part (C). Quickening (D). Breast discomfort

86. Most conclusive sign of pregnancy is ?

(A). Auscultation of fetal heart sound (B). Quickening

(C). Breast discomfort (D). Ballottement

87. During pregnancy PH of vagina is decreased due to ?

(A). Doderlein bacilli (B). Proteus bacilli (C). Klobs-loffler bacilli (D). Klebseilla bacilli

88. Braxton hick contraction starts at ?

(A). 1st trimester (B). 2

nd trimester (C). 3

rd trimester (D). At term

89. Montogomery’s tubercle seen at ?

(A). Vagina (B). Abdonem (C). Breast (D). Face

90. Skin changes during pregnancy are all, Except ?

(A). Chloasma (B). Linea nigra (C). Stria gravidarum (D). Necrobiosis lipodica

91. Colostrum has all component in high amount compared to breast milk except ?

(A). Immunoglobulin (B). Protein (C). Potassium (D). Sodium

92. Best time to test for gestational diabetes during pregnancy ?

(A). 24-28 weeks (B). 10-12 weeks (C). 32-34 weeks (D). 6-8 weeks

93. Supine hypotension syndrome (Mengerts syndrome) occur due to compression of ?

(A). Aorta (B). IVC (C). Carotid artery (D). Iliac vain

94. All of the following statements are true for parity Except ?

(A). Parity refers to number of pregnancies reaching viability (B). In twin pregnancy, parity remains same

(C). If a female has still birth her parity decreases (D). Parity is to affected by number of fetuses delivered

95. Kegels exercise should begin ?

(A). Immediately after delivery (B). 24 hours after delivery

(C). 3 weeks after delivery (D). 6 weeks after delivery

96. Which is most significant finding in cardiotocography for detection of fetal hypoxia ?

(A). Late deacceleration (B). Variable deacceleration

(C). Sinusoidal deacceleration (D). Early deacceleration




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97. Consider the following

(i)Reactive NST

(ii)Absence of deacceleration

(iii)Sinusoidal pattern

Which of the above findings in an antepartum CTG indicate fetal well-being ?

(A). (i) and (ii) only (B). (ii) and (iii) only (C). (i) and (iii) only (D). (i),(ii),(iii)

98. Best confirmation for pregnancy at six weeks ?

(A). USG for cardiac activity (B). Doppler(C). Estimation of serum beta-hCG in urine(D). Bimanual palpation

99. Which of the following is the investigation of choice in a pregnant lady at 18 weeks of pregnancy with past

history of delivering a baby with Down’s syndrome ?

(A). Triple screen test (B). Amniocentesis (C). Chorionic villous biopsy (D). Ultrasonography

100. Most important diameter of pelvis during labour is ?

(A). Interspinous diameter (B). Oblique diameter of inlet

(C). AP diameter of outlet (D). Intertuberous diameter

101. The shortest diameter of fetal head is ?

(A). Biparietal diameter (B). Suboccipitofrontal diameter

(C). Occipitofrontal diameter (D). Bitemporal diameter

102. AP diameter is maximum in which type of pelvis ?

(A). Platypelloid (B). Android (C). Anthropoid (D). Gynecoid

103. The characteristics of caput succedaneum include all of the following except ?

(A). Crosses midline (B). Crosses the suture line

(C). It does not disappear within 2-3 days(D).It is diffuse edematous swelling of the soft tissues of the scalp

104. All of the following are included in first stage of labour except ?

(A). Effacement of Cervix (B). Dilatation of Cervix

(C). Crowning of fetal head (D). Descent of head

105. The perineal injury can be prevented in normal labour by all except ?

(A). Maintaining flexion of the head (B). Timely episiotomy as a routine

(C).Slow delivery of the head in between contractions (D). Effective perineal guard

106. Ritgen maneuver is done in ?

(A). Shoulder dystocia (B). For delivery of head in breech presentation

(C). For delivery of legs in breech (D). For delivery of head in normal labour

107. Cardinal movements of labour are ?

(A). Engagement descent flexion internal rotation extension restitution external rotation

expulsion

(B). Engagement flexion descent internal rotation extension expulsion

(C). Engagement flexion descent external rotation expulsion

(D). Engagement extension internal rotation external rotation expulsion

108. In bishop score all are included except ?

(A). Effacement of cervix(B). Dilatation of cervix(C). Station of head (D). Interspinal diameter

109. All are signs of placental separation except ?

(A). Lengthening of cord(B). Gushing of blood (C). Suprapubic bulge (D). Increase of BP

110. Most common cause of maternal death immediately after delivery ?

(A). Amniotic fluid embolism (B). PPH (C). Uterine inversion (D). Pulmonary embolism




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111. A 24-year-old-female reports in the casualty with history of amenorrhoea for two and half months and

abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other

systems are normal. On speculum examination, bleeding is found to come from Os. On bimanual

examination, uterus is of 10 weeks size, soft and Os admits one finger. The most likely diagnosis is ?

(A). Threatened abortion(B). Missed abortion (C). Inevitable abortion (D). Incomplete abortion

112. Young lady presents with acute abdominal pain and history of 1.5 months amenorrhoea, on USG

examination there is collection of fluid in the pouch of doughlas and empty gestational sac. Diagnosis is ?

(A). Ectopic pregnancy (B). Pelvic hematocele (C). Threatened abortion (D). Twisted ovarian cyst


(i) True conjugate (P) 10.5 cm

(ii)Obstetric conjugate (Q) 12 cm

(iii)Diagonal conjugate (R) 11 cm

(A). (i) R (ii) Q (iii) P (B). (i) P (ii) Q (iii) R (C). (i) R (ii) P (iii) Q (D). (i) Q (ii) P (iii) R

114. Which of the following statement ia/are true ?

(i) Gynecoid pelvis is most common pelvis

(ii)Anthropoid pelvis is heart shape pelvis

(iii)Face to pubic delivery is most common in anthropoid pelvis

(iv)Anthropoid pelvis AP diameter is more than transverse diameter

(A). (i), (ii), (iii) &(iv) (B). (i), (ii) & (iv) (C). (ii), (iii) & (iv) (D). (i), (iii) & (iv)

115. In which pelvis one Ala of sacral bone is absent ?

(A). Naegele‘s pelvis (B). Robert‘s pelvis (C). Triradiate pelvis (D). Osteomalacic pelvis

116. Most common position during labour is ?

(A). LOT (B). LOA (C). DOA (D). ROA

117. Which of the following statement is false ?

(A). Lambda fuses at 2-3 month (B). Coronal suture seen between frontal & parietal bone

(C). Bregma is triangular shaped & fuses at 18 months (D). Suture are helpful in moulding

118. Vertex presentation seen in which engaging diameter ?

(A). Mentovertical (B). Submentobregmatic(C). Submentovertical (D). Suboccipitobregmatic

119. All of the following statement are true regarding true labour pain except ?

(A). Cervical dilatation & effacement seen (B). Lower abdomen pain radiating to thigh

(C). Absent bag of water (D). Contraction are regular & frequency increases gradually

120. Partograph shows ?

(A). Progression of labour(B). Induction of labour(C). Fetal well being (D). Amount of amniotic fluid

121. Bishop score include all except ?

(A). Cervical dilatation & effacement (B). Cervical position & consistency

(C). Head station (D). Pelvic diameter

122. A primigravida at 37 week of gestation reported to labour room with central placenta previa with heavy

bleeding per vaginum. The fetal heart rate was normal at the time of examination. The best management

option for her is ?

(A). Expectant management (B). Cesarean section

(C). Induction and vaginal delivery (D). Induction and forceps delivery

123. Dose of anti D for antenatal prophylaxis in Rh-negative nonimmunized females ?

(A). Single dose of 1000 IU at 28 weeks (B). Single dose of 1500 IU at 28 weeks

(C). Single dose of 500 IU at 28 weeks (D). Single dose of 1500 IU at 32 weeks




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124. All of the following are used in the treatment of postpartum hemorrhage except ?

(A). Misoprostol (B). Mifepristone (C). Carboprost (D). Methylergometrine

125. Most common type of breech presentation ?

(A). Frank breech (B). Complete breech (C). Footling (D). Knee

126. All of the following are features of obstructed labour except ?

(A). Hot dry vagina (B). Tonic contracted uterus

(C). Bandl‘s ring (D). Unruptured membranes

127. In transverse lie, the presentation is ?

(A). Vertex (B). Breech (C). Brow (D). Shoulder

128. Uterine rupture is least common with ?

(A). LSCS (B). Classical cesarean section (C). Inverted T-shaped incision (D). T-shaped incision

129. An elderly multigravida female presents in labour. She has multiple fibroids in lower uterine segment.

Managemet is ?

(A). Vaginal delivery (B). Trial of labour

(C). LSCS (D). Classical cesarean section followed by hysterectomy

130. A cesarean section was done in the previous pregnancy. All of the following would be indications for

elective cesarean section except ?

(A). Breech (B). Macrosomia (C). Polyhydroamnios (D). Post-term

131. A women at 32 weeks of pregnancy, presents with labour pain. On examination, her cervix is dilated and

uterine contractions are felt. The management is ?

(A). Isoxsuprine hydrochloride (B). Dilatation and evacuation

(C). Termination of pregnancy (D). Wait and watch

132. All of the following drugs have been used for medical abortion except ?

(A). Mifepristone (B). Misoprostol (C). Methotrexate (D). Atosiban

133. A 27-year-old female with a history of 8 weeks amenorrhoea complains of vaginal bleeding and lower

abdominal pain. On USG examination there is gestational sac with absent fetal parts. The diagnosis is ?

(A). Ectopic pregnancy (B). Incarcerated abortion

(C). Threatened abortion (D). Corpus luteum cyst

134. Most valuable diagnostic test in case of suspected ectopic pregnancy ?

(A). Serial β-hCG levels (B). Transvaginal USG

(C). Progesterone measurement (D). Culdocentesis

135. A hypertensive pregnant women at 34 weeks comes with history of pain in abdomen, bleeding per

vaginum and loss of fetal movements. On examination the uterus is contracted with increased uterine tone.

Fetal heart sounds are absent. The most likely diagnosis is ?

(A). Placenta previa (B). Hydramnios (C). Premature labour (D). Abruptio placenta

136. A lady with 38 weeks pregnancy and painless vaginal bleeding comes to casualty. On examination head is

engaged and uterus is non tender and relaxed. The next line of treatment is ?

(A). Perspeculum examination (B). Conservative management

(C). Termination of pregnancy (D). Ultrasonography

137. Best time to give Anti-D to a pregnant patient ?

(A). 12 weeks (B). 28 weeks (C). 36 weeks (D). After delivery

138. Which of the following tests is most sensitive for the detection of iron depletion in pregnancy ?

(A). Serum iron (B). Serum ferritin (C). Serum transferrin (D). Serum iron binding capacity

139. In pregnancy, which type of anemia is not common in India ?




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(A). Vitamin B12 anemia (B). Folic acid anemia

(C). Iron + Folic acid anemia (D). Iron deficiency anemia

140. In which of the following heart diseases is materanl mortality during pregnancy found to be the highest ?

(A). Coarctation of arota (B). Eisenmenger syndrome(C). AS (D). MS

141. The following drug is used in management of thyroid storm during pregnancy ?

(A). Sodium iodide (B). Dexamethasone (C). Propranolol (D). All of the above

142. Most common congenital malformation seen in a diabetic pregnant women amongst the following are ?

(A). Cardiac defect (B). Renal defect (C). Liver defect (D). Lung defect

143. A lady with 12 weeks of pregnancy having fasting blood glucose 170 mg/dl, the antidiabetic drug of choice

is ?

(A). Insulin (B). Metformin (C). Glipizide (D). Glibenclamide

144. Best test for fetal maturity in a diabetic mother is ?

(A). L : S ratio (B). Lecithin-cephalin ratio (C). Phosphatidyl choline(D). Phosphatidyl glycerol

145. Late hyperglycemia in pregnancy is associated with ?

(A). Macrosomia (B). IUGR (C). Postmaturity (D).Congenital malformation

146. All of the following may be used in pregnancy associated hypertension except ?

(A). Nifedipine (B). Captopril (C). Methyldopa (D). Hydralazine

147. Which is not a feature of HELLP syndrome ?

(A). Thrombocytopenia (B). Eosinophilia (C). Raised liver enzyme(D). Hemolytic anemia

148. Earliest sign of Mg toxicity ?

(A). Depression of deep tendon reflexes (B). Respiratory depression

(C). Cardiac arrest (D). Anuria

149. The most important reason to give antihypertensive drug in PIH is to decrease the ?

(A). Incidence of IUGR (B). Incidence of fetal death

(C). Incidence of maternal complication like stroke(D). Incidence of placental abruption

150. Maximum chances of cord prolapse seen in ?

(A). Transverse lie (B). Footling (C). Complete breech (D). Frank breech

151. Diagnostic sign of IUD are all except ?

(A). Robert‘s sign (B). Spalding sign (C). Ball sign (D). Cullen sign

152. Most common type of episiotomy is ?

(A). Median (B). Mediolateral (C). Lateral (D). J-shaped

153. Vertical incision on lower uterine segment ?

(A). Pfannenstiel incision (B). Kronig incision

(C). Classical cesarean section (D). Inverted T incision

154. Indication of classical cesarean section are ?

(A). Cancer cervix (B). Major degree of placenta previa

(C). Previous classical cesarean section (D). All of the above

155. All of the following drugs are tocolytic except ?

(A). Nifedipine (B). Atosiban (C). Ritodrine (D). Misoprostol

156. Which of the following statements are true regarding MTP ?

(i)MTP act came in 1971

(ii)MTP should be done at only govt. hospital

(iii)Consent of women is required

(iv)Abortion can be performed on request of husband




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(A). (i), (ii) & (iii) (B). (i) & (iii) (C). (i), (iii) & (iv) (D). (i), (ii), (iii) & (iv)

157. All of the following statements regarding H. mole are true except ?

(A). H.mole developed due to excessive proliferation of trophoblast (B). Partial H. mole is triploid

(C). Marker for H. mole is Beta-hCG (D). Necklace appearance seen on USG

158. Most common cause of HIV infection in infant is ?

(A). Perinatal transmission (B). Breast milk(C). Transplacental transmission (D).Umbilical cord sepsis

159. Transmission of HIV from mother to child is prevented by all the following except ?

(A). Oral zidovudine to mother at 3rd

trimester along with oral zidovudine to infant for 6 weeks

(B). Vitamin A prophylaxis to mother

(C). Vaginal delivery (D). Stopping breastfeed

160. Which of the following types of viral hepatitis infection in pregnancy, the maternal mortality is the highest

?

(A). Hepatitis A (B). Hepatitis B (C). Hepatitis C (D). Hepatitis E

161. A 21-year-young female presented for antenatal checkup. She was in 1st trimester and was diagnosed to

have ovarian cyst. Treatment of choice ?

(A). Surgical removal in 2nd

trimester (B). Removal after delivery

(C). Termination of pregnancy and cyst removal(D). Observation

162. Best parameter for ultrasound evaluation of IUGR is ?

(A). Placental membrane (B). Length of femur (C). Abdominal circumference (D). BPD

163. Which of the following leopold’s grip is shown in the image ?

(A). Pawlick‘s grip (B). Pelvic (C). Fundal (D). Abdominal

164. In the gynae labour room, the scissor shown in the diagram was used, Identify ?

(A). Episiotomy scissor (B). Dissection scissor (C). Stitch scissor (D). Mayo scissor

165. A midwife at a PHC is monitoring pregnancy and maintaining the partograph of pregnancy progression.

At how much cervical dilation should the partograph plotting be started ?

(A). 2 cm (B). 8 cm (C). 4 cm (D). 6 cm

166. Mechanism by which IUCD does not act ?




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(A). Chronic endometrial inflammation (B). Increase the motility of tubes

(C). Inducing endometrial atrophy (D). Inhibition of ovulation

167. Contraceptive vaginal foam tablet “today” contains ?

(A). Nonoxynol 9 (B). Octoxynol 9 (C). Menfegol (D). None of the above

168. Antihormonal substance used to induce ovulation ?

(A). Mifepristone (B). Clomiphene citrate (C). Tamoxifen (D). Raloxifen

169. Emergency contraceptive of choice is ?

(A). OCP (B). Danazol (C). Levonorgestrol (D). Mifepristone

170. A 24-year-old-female comes to your clinic for evaluation of infertility. A hysterosalpingogram reveals

Asherman’s syndrome. What symptoms will be the patient have ?

(A). Menorrhagia (B). Oligomenorrhea (C). Polymenorrhea (D). Hypomenorrhea

171. Sperms attain maturity in ?

(A). Vas deferens (B). Ejaculatory duct (C). Epididymis (D). Seminal vesicle

172. Ideal contraceptive for lactating mother is ?

(A). Barrier method (B). Combined OCP (C). Lactational amenorrhoea (D). Progesterone only pill

173. CA- 125 is a tumor marker for ?

(A). Carcinoma ovary (B). Alpha fetoprotein (C). β-hCG (D). LDH

174. Intrauterine insemination means implantation of ?

(A). Semen (B). Washed semen (C). Million of sperm (D). Fertilized ova

175. Most common agent responsible for Ca cervix is ?

(A). HPV 16 (B). HPV 18 (C). HPV 31 (D). HPV 36

176. Among the following IUCD’s which has life span for 10 years ?

(A). CuT380 A (B). CuT200 (C). Nova T (D). Multiload

177. Mirena is ?

(A). Used in abortions (B). Antiprogesterone (C). Progesterone IUCD (D). Hormonal implant

178. PID occurs least common with ?

(A). OCPs (B). Condom (C). IUCD (D). Diaphragm

179. The secretion of FSH in a male is inhibited by negative feedback effect of ?

(A). Inhibin secreted by sertoli cells (B). Inhibin secreted by Leydig cells

(C). Testosterone secreted by sertoli cells (D). Testosterone secreted by Leydig cells

180. Spermicidal jelly acts through ?

(A). Acrosomal enzyme (B). Cervical enzyme alteration

(C). Glucose uptake inhibition by sperms (D). Disruption of cell membrane

181. Fallopian tube dysmotility is seen ?

(A). Noonan syndrome (B). Turner syndrome (C). Kartagener syndrome(D). Marfan syndrome

182. A couple semen analysis report shows oligospermia. Which of the following can be given to increase sperm

count ?

(A). FSH (B). LH (C). Estrogen (D). Progesterone

183. A lady with IUCD becomes pregnant with tail of IUCD being seen, next course of action is ?

(A). MTP (B). Remove the IUCD

(C). Continue the pregnancy (D). Remove IUCD and terminate pregnancy

184. A 20-years-old nulliparous women is on oral contraceptive pills. She is currently diagnosed as having

pulmonary tuberculosis. Which anti-tubercular drug decreases the effect of OCP ?

(A). INH (B). Pyrazinamide (C). Ethambutol (D). Rifampicin




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185. Which of the following is the noncontraceptive benefit of OCP’s ?

(A). Decrease incidence of breast CA (B). Decrease incidence of lung CA

(C). Decrease incidence of colorectal CA (D). Decrease incidence of gallbladder CA

186. A 18-year-old girl with amenorrhea, atrophied breast, hypoplastic uterus ?

(A). Turner‘s syndrome (B).Gonadal dysgenesis

(C). Androgen insensitivity syndrome (D). Klienfelter‘s syndrome

187. Clue cells are seen in ?

(A). Bacterial vaginosis (B). Candidiasis (C). Trichomoniasis (D). Gonorrhoea

188. Most common genital prolapse is ?

(A). Cystocoele (B). Procidentia (C). Rectocoele (D). Enterocoele

189. An 18-years-old-girl complains of failure to attain menarche. She does not have secondary sexual

characteristics. FSH & LH levels are high. Karyotype is XO. What is the best management ?

(A). Long term treatment with estrogen (B). Removal of streak gonads

(C). Treatment with growth hormone

(D). Treatment with estrogen for 1 year followed by estrogen and progesterone

190. A 16-year-old-girl presents with rapid onset hirsutism and amenorrhea. Best investigation is ?

(A). Testosterone estimation (B). Dihydroepiandrosterone

(C). Adrenocorticoids (D). LH and FSH estimation

191. A 16-year-old-girl presents with primary amenorrhea. Her secondary sexual characteristics are well

developed with good axillary and pubic hair. Examination of external genitalia reveals absence of vagina.

USG reveals absence of uterus. Most likely diagnosis is ?

(A). Androgen insensitivity syndrome (B). Gonadal agenesis

(C). Mayer-Rokitansky-Kuster-Hauser syndrome(D). True hermaphrodite

192. Anjali devi , a 45 years-old-women, presents with hot flushes after stopping of menstruation.”Hot flush”

can be relieved by administration of following agents ?

(A). Ethinyl estradiol (B). Testosterone (C). Fluoxymesteron (D). Danazol

193. The most serious complication of clomiphene therapy for induction of ovulation is ?

(A). Bone marrow depression (B). Hyperstimulation syndrome

(C). Secondary amenorrhea (D). Multiple pregnancy

194. Protective bacterium in normal vagina is ?

(A). Peptostreptococcus (B). Lactobacillus (C). Gardenella vaginalis (D). E. coli

195. Most common route of transmission of endometrial tuberculosis is ?

(A). Direct local spread (B). Lymphatic spread (C). Retrograde spread (D). Hematogenous

196. Labia minora is homologus to ?

(A). Penis (B). Scrotum (C). Penile urethra (D). Corpus cavernosa

197. Strawberry vagina is seen in ?

(A). Candida albicans (B). H. vaginalis (C). Spyhilis (D). Trichomonas vaginalis

198. Narrowest part of fallopian tube is ?

(A). Interstitial portion (B). Isthmus (C). Infundibulum (D). Ampulla

199. The major contribution to the human seminal fluid is from ?

(A). Testes (B). Seminal vesicles (C). Prostate (D). Bulbourethral and urethral glands

200. A girl present with primary amenorrhea, short stature, widely spaced nipple. Karyotype of the girl would

be ?

(A). 45 XO (B). 46 XXY (C). 46 XY (D). 46 XX




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Ans Key (Practice Questions)

Que 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Ans B A D A D A A B A B B B B B D

Que 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Ans A D D B C A D C A A B D A B D

Que 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

Ans A B A A B A C D D C A B A B C

Que 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Ans A A B D B D C A B B A C D A A

Que 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

Ans B A B B D D D A B A D C B D A

Que 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90

Ans C C A D C B B C C B A A B C D

Que 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105

Ans C A B C B A A A B A D C C C B

Que 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120

Ans D A D D B C A C D A A C D C A

Que 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135

Ans D B B B A D D A D C A D B B D

Que 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150

Ans C B B A B D A A D A B B A C A

Que 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165

Ans D B B D D B D A C D A C A A C

Que 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180

Ans D A B C D C D A B A A C B A D

Que 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195

Ans C A B D C A A A D A C A B B D

Que 196 197 198 199 200

Ans C D A B A

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