OBG Revision E6.5 PDF

Obstetrics Revision 1 01 1 OBSTETRICS REVISION 1 ----- Active space ----- Fertilization 00:00:37 Fertilizatio...

Obstetrics Revision 1 01 1 OBSTETRICS REVISION 1 ----- Active space ----- Fertilization 00:00:37 Fertilization occurs in Ampulla of Fallopian tube. Day after fertilization Events Day 1- Day3 8-16 celled zygote is called as Morula. Day 4 16 celled Morula enters uterine cavity Day 5 Zona pellucida lost, Blastocyst formation begins. Day 6-10 Implantation window. Day 11 Implantation ends (Day 25 of cycle). Total duration of pregnancy 00:02:20 Type of pregnancy Weeks of gestation Total duration of pregnancy : Pre-term pregnancy < 37 wks 9 months + 7 days /40 weeks/280 days. Early-term pregnancy 37-38 wks + 6 days. POG (Period of gestation)/ PO (Period of) amenorrhoea/ Full-term pregnancy 39-40 wks + 6 days. PO pregnancy : Calculated from the first day of LMP. Late-term pregnancy 41-41 wks + 6 days. ACOG recommendation : Post-term pregnancy ≥ 42 wks. Termination of pregnancy done at ≥ 41 wks (Induction of labour is done). Obstetrical score 00:04:05 1st method 2nd method GTPAL system Gravidity and parity Parity represented by G : Gravida, Total no of times represened by one number. two numbers. a female has conceived (twin Gravidity : Total no times First number is parity. considered as single conception). a female has conceived Second number is no. T : No. of term deliveries (≥ 37 → Past + present. of abortions : Preg- wks). Parity : Total of no nancy loss at < 20 wks P : No. of preterm deliveries of past-pregnancies (includes ectopic and (20–36 wks + 6 days) (Not which crossed period of molar pregnancy). parity). viability (India : 28 wks). Grand multipara: 4 or A : No. of abortion (pregnancy Twins and triplets more previous births. ending < 20 wks → ectopic, counted as 1 pregnancy. Multipara: 2 or more molar, abortion). previous births. L : No. of living children at pres- ent (here twins taken as 2). Obstetrics Revision v1.0 Marrow 6.5 2023  2 01 Obstetrics ----- Active space ----- EDD (Estimated Date of Delivery) 00:07:35 For regular cycles : In all cases presume pregnant female had 28 day cycle before pregnancy. Presumptive EDD (Naegele’s formula) : 1st day of LMP + 9 months & 7 days. Always 7 days added first, (Except if LMP was in month of Feb). If cycle length is not 28 days : Expected EDD = Presumptive EDD + (Cycle length - 28). In case of IVF cycles : For fresh cycles : Day of oocyte retrival/fertilization + 266 days. For frozen cycle with D3 transfer : Date of D3 transfer + 263 days. For frozen cycle with D5 transfer : Date of D5 transfer + 261 days. If cycles are irregular or patient is lactating/on OCP/unsure about LMP : Best method for dating pregnancy : USG. Parameter used is→ Crown-Rump Length (CRL). The earlier USG done → More accurately it predicts gestational age. Signs of pregnancy 00:13:04 Early pregnancy signs : Signs Description POG Goodell’s sign Softening of cervix 6 weeks Chadwick/Jacquemier sign. Bluish discoloration of cervix/vagina. 8 weeks Osiander sign Lateral vaginal wall pulsation 8 weeks Palmer’s sign Rhythmic uterine contraction 8 weeks Piskacek sign Unequal growth of uterus 8 weeks Softening of isthmus such that 6-10 Hegar sign on bimanual palpation, vaginal & weeks abdominal fingers touch each other. Placental/Hartman sign Bleeding at the time of implantation. - Height of uterus : POG Level of uterus At 12 weeks At pubic symphysis. At 22 weeks At the level of umbilicus. Just below umbilicus (corresponds to 20 weeks). Immediately after delivery Remains same till 24 hrs. 24 hrs after delivery Decreases by 1 finger breath / day. (D2 after delivery) Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 1 01 3 Quickening : Mother feels fetal movement for the first time in that pregnancy. ----- Active space ----- In primi-gravida : 18-20 weeks. Multi-gravida : 16-18 weeks. Lightening/welcome sign : At 36 weeks → Uterus at xiphisternum (mother → Respiratory discomfort). At 40 weeks → Height of uterus↓ to the level of 32 weeks (Head of fetus enter pelvis) → mother relieved of discomfort. Absolute signs of pregnancy : Fetal Heart Sounds (FHS) : By Doppler at 10 weeks, stethoscope at 20 weeks. Fetal parts : Palpated or movements felt. USG evidence of pregnancy. Fetal skeleton on X-ray at 16 weeks (C/I in pregnancy). Signs of pregnancy on USG : Gestational sac 1st sign : Intradecidual Sign Double Decidual Sac Sign Double Bleb Sign : (Interstitial implantation). Inner ring : Decidua capsularis. 2 Bubbles : Yolk sac and 1st structure seen : Outer ring : Desidua parietalis. amniotic sac. Gestational sac. Double decidual sac sign and double bubble sign : Intra-uterine pregnancy. Decidua capsularis + decidua parietalis = Decidua vera (Fuse at 14-16 weeks). USG in pregnancy 00:20:46 Scans POG Dating/viability scan 6-8 weeks Nuchal translucency scan 11-13 weeks + 6 days Anomaly scan/target scan 18-20 weeks (extend till 22 weeks) Growth scan 32-34 weeks Placental localization (Best time) 3rd trimester. In all pregnant females : Target or anomaly scan should be done. Obstetrics Revision v1.0 Marrow 6.5 2023  4 01 Obstetrics ----- Active space ----- Fetal Echo : Only done if fetal congenital heart defect is suspected (TTTS, Rubella infection, pre-gestational DM), time → 22-24 weeks. Nuchal transluency (NT) scan : Causes of NT ≥ 3 mm : M/C cause is Aneuploidy (Downs syndrome > Turners syndrome) others : Trisomy 18 and 13. Congenital heart disease. Early marker for TTTS (Twin to twin transfusion syndrome). Next step : 1. Karyotyping/FISH. 2. Fetal Echo. Increased NT can be confused with cystic hygroma : The differentiating features include : More generalised fluid collection with presence of septa. Cystic hygroma is a better marker of aneuploidy. NT Scan USG showing cystic hygroma Estimation of gestational age by USG : Trimester Parameter T1 Before CRL can be measure → MSD (mean sac diameter) used. CRL : Best parameter over all. Used till 11 weeks + 6 days (till CRL < 84 mm). Most accurate gestational age determined between : 7-9 weeks. CRL in mm + 42 = Gestational age in days. Smallest CRl measured : 5 mm. T2/CRL>84mm BPD > HC T3 Best : FL + BPD + HC, single best : FL. In the table above, BPD : Biparietal diameter ; HC : Head circumference ; FL : Femur length. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 1 01 5 Estimation of fetal growth by USG : ----- Active space ----- Single best USG parameter for fetal growth : AC (Abdominal circumference). Hockey Stick Sign Ribs & vertebral column Fetal kidney and cord insertion should not be visible. Estimation of weight of fetus : Best clinical formula : Johnson formula. On USG best way : Hadlock formula/Shepard formula. Single best parameter : AC. Macrosomia : Definition : weight of the fetus ≥ 4 kgs. Risk factors : Post-term pregnancy. Diabetic mother. Male fetus. Maternal obesity. Diagnosis : Abdominal circumference ≥ 35 cm on USG. Mode of delivery : Vaginal delivery. Indications of c-section : In diabetic female if weight of fetus ≥ 4.5 kg or in non-diabetic patient if weight of fetus is ≥ 5 kgs. If patient has macrosomic baby in this pregnancy and H/O c-section : VBAC is a relative contraindication. Obstetrics Revision v1.0 Marrow 6.5 2023  6 01 Obstetrics ----- Active space ----- Structures seen on USG in pregnancy : Structure Seen on TVS 4 1/2-5 weeks (4 weeks + Gestational sac 3 days). Yolk sac 5 weeks Fetal pole 5-5 1/2 weeks (CRL) Cardiac activity 5 1/2-6 weeks (M mode) All these structures are seen on TAS (Trans abdominal sonography) only 1 week after when it’s seen on TVS (Transvaginal sonography). Best test to differentiate ectopic and IU pregnancy : β HCG titres. Presence of gestational sac : Pregnancy confirmed. True gestational sac Psuedo-gestational sac In Intra uterine (IU) In ectopic pregnancy pregnancy Eccentric Central Grows Does not grow Yolk sac forms inside later No yolk sac formed Presence of gestational sac and yolk sac inside uterus : Confirms IU pregnancy. Presence of gestational sac and yolk sac in tube : Confirms ectopic pregnancy. Important cut-off’s : MSD to measure CRL : 25 mm. CRL to get cardiac activity : 7 mm. Critical HCG titre at which gestational sac is seen on TVS : 1500 IU. Minimum value of HCG at which gestational sac is seen : 1000 IU. Important scenarios : 1. If MSD is ≥ 25 mm and CRL cannot be measured /fetal pole not seen. Indicates missed abortion (anembryonic pregnancy loss /blighted ovum). Next step MTP (medical abortion). 2. If MSD < 25 mm and CRL not seen → Wait and watch Next step Repeat USG after 1 week. 3. If CRL is ≥ 7 mm and cardiac activity not seen → Missed abortion Next step MTP. 4. If CRL is < 7 mm and cardiac activity not seen Next step repeat USG after 1 week. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 1 01 7 Congenital anomalies seen on Ultrasound : ----- Active space ----- Best method : Target scan. 1. Anencephaly : Earliest anomaly detected : 10 week (T1). Best time to detect : 14 weeks. (T2). IOC : TVs. ↑ AFP. Best biochemical marker in NTD : Acetylcholine esterase. Shower cap sign : Brain tissue exposed. Mickey mouse sign. Absent skull and deep eye sockets Frog eye sign. 2. Spina bifida : Meningocoele : Protrusion of meninges. Lemon sign : Bossing of frontal bones. Meningomyelocoele : Protrution of Banana sign : Downward displacement of meninges + Spinal cord. cerebellum 3. Duodenal atresia : On USG : Double bubble sign. Leads to polyhydramnios. Associated with Trisomy 21. 4. Posterior urethral valve : Duodenal atresia Posterior Urethral valve On USG : Key hole sign. Associated with : Oligohydramnios. Obstetrics Revision v1.0 Marrow 6.5 2023  8 01 Obstetrics ----- Active space ----- Preconceptional advice 00:43:05 Folic acid supplementation : In all females In female with previous H/O of NTD Role To prevent NTD To prevent recurrence of NTD. Dose 400 mcg /day 4 mg /day. 3 months before conception/ As soon Started 1 month before conception as patient plans about conceiving. Stopped 3 months after conception 3 months after conception Other indications : Folic acid deficiency : 1 mg /day. In diabetic patients : 400 mcg /day. In patients on antiepileptic drugs : Before conception → 400 mcg /day, af- ter conception → 4 mg /day. Sickel cell anemia : 5 mg /day. Antenatal visits : Ideally : POG No. of visits Till 28 weeks 1 visit /4 weeks 28-36 weeks 1 visit /2 weeks ≥ 36 weeks 1 visit /week According to WHO (min) : 8 visits. According to GOI (min) : 4 visits. Weight gain in pregnancy : Recommended : 11-12.5 kg. In females with low BMI : 12.5-18 kg. In females with BMI > 30 (obese) : 7 (5-9) kg. Additional caloric requirement in pregnancy : Trimester PARK National guidelines International guidelines T1 + 350 kcal + 85 kcal + 0 kcal T2 + 350 kcal + 280 kcal + 350 kcal T3 + 350 kcal + 470 kcal + 450 kcal Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 1 01 9 RDA in pregnancy : ----- Active space ----- Iodine requirement : 250 mcg/day. Calcium requirement : 1000 mg/day. BMR in pregnancy ↑ by 10-20 %. Fluid retention in pregnancy : 6.5 L. Vaccines in pregnancy : C/I in pregnancy : Mumps, Measels, Rubella, Smallpox, Chicken pox, BCG, HPV. Min gap between live vaccine and pregnancy : 1 month. If given < 1 month : Not an indication for MTP. Td vaccine : Given to all pregnant females. 1st dose at 1st antenatal visit after 4 weeks 2nd dose. If patient was immunized in past 3 years and had received 2 doses : Booster dose only. TDap vaccine : one dose, between 27-36 weeks to all pregnant females. Amniotic fluid 00:48:57 Gestational age Main contribution T1 Maternal plasma 12-20 weeks Fetal skin ≥ 2o weeks Fetal urine (overall most important) Amniotic fluid is 98-99 % water. Colour at term :Straw coloured / colourless (pre-term). PH : 7-7.5 (7.1-7.3). Max amniotic fluid at : 32-34 weeks. Normal amniotic fluid index (AFI) : 5-24 cms. Normal deepest vertical pocket (SDP)/Single largest vertical pocket (SVP) : 2-8 cm. SVP /SDP Ratio : a. More sensitive. b. Used in multifetal pregnancy. Obstetrics Revision v1.0 Marrow 6.5 2023  10 01 Obstetrics ----- Active space ----- Oligohydramnios : AFI : < 5 cms. Definition : SVP : < 2cm Causes : M/C cause of mild oligohydramnios : Idiopathic M/C cause of severe oligohydramnios : Congenital renal anomalies of fetus. Ex : Renal agenesis, posterior urethral valve. (Exception : Barter’s syndrome → Polyuria → polyhydramnios). ↓ transudation across placenta → Small placenta : PIH (Pregnancy induced hypertension), UPI (Uteroplacental insufficiency), IUGR (intra uterine growth restriction). ↓ Volume of amniotic fluid (other than renal anomalies) : a. ↓ urine output → Indomethacin or ACE inhibitors. b. Post-term pregnancy. c. PPROM /PROM. M/C cause of oligo in T2 (early T2) : Renal anomalies. M/C cause of oligo in T3 : UPI/PROM. Management : Severe Oligo/Severe polyhydromnios 1st step : Check USG If USG is normal If USG shows gross congenital anomalies Next step Next step P/S exam (To rule out ruptured Karyotyping. membranes) + Umbilical Artery doppler (To rule out UPI) Note : P/V is C/I in Ruptured membranes. Moderate/severe oligo and polyhydramnios is a high risk pregnancy → Fetal monitoring done from 32 weeks : a. NST : Weekly. b. BPS : Weekly. c. USG for fetal growth : 3 weekly. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 1 01 11 Complications : ----- Active space ----- T1 T2/T3 Associations Pulmonary Cord compression (On D/T UPI : IUGR, (On CTG hypoplasia CTG → Variable → Late deceleration). Limb reduction deceleration). D/T PROM : Amniotic defects Meconium aspiration band syndrome/ Potter’s syndrome : syndrome streeter syndrome/ Renal agenesis + Limb deformities : CTEV constriction ring → Pulmonary hypoplasia /club foot. Digital amputation, distal + Typical flat faces. limb amputation. Note : In Phocomelia (proximal limb amputation) → d/t thalidomide ingestion. Polyhydromnios : AFI : ≥ 25 cms. Definition : Digital amputation SVP : ≥ 8 cm Causes : 1. M/C cause of mild polyhydramnios : Idiopathic. 2. M/C cause of severe polyhydramnios : Congenital anomalies of fetus. M/C : GIT anomalies. 2nd M/c : NTD → Swallowing defect and Abdominal wall defects. GIT defects Abdominal defects Duodenal atresia. Omphalocoele : Smooth appearance in USG. Esophageal atresia. Gastrochisis : Cauliflower like appearance Intestinal obstruction. in USG. Cleft lip and palate. NTD → Swallowing defects. 3. ↑Urine output : Twin/multifetal pregnancy. Maternal diabetes. 4. Fetal ↑ cardiac output : Anemia. Parvovirus infection. Mainly d/t polyuria Syphilis. Rh -ve pregnancy /Rh incompatibility. Obstetrics Revision v1.0 Marrow 6.5 2023  12 01 Obstetrics ----- Active space ----- Note : Causes which can lead to either oligohydromnios or polyhydramnios : TORCH infection : Oligo > poly, M/c in T2. Chromosomal anomalies : Trisomy and triploidy. Twin to twin transfusion syndrome. Drug used to treat polyhydramnios : Indomethacin (Should not be taken beyond 32 weeks of pregnancy as it leads to premature closure of Ductus arteriosis). Placenta 01:03:43 Weight : 500 gms. 350 ml : Villi (fetal blood) volume : 500 ml 150 ml : Intervillous space (Maternal blood) Gestational age at which wt of placenta = Fetal wt : 17 weeks. Diameter : 15-20 cms (22 cms). Central thickness : 2.5-4 cms (Placentomegaly : ≥ 4cm). Maternal side formed by : Decidua basalis (forms 1/5th of placenta). Fetal side formed by : Chorion frondosum (forms 4/5th of placenta). In early IU life, placental cord has 4 vessels → RUA, LUA, LUV, RUV, later on becomes 3 vessels → RUA, LUA and LUV. Human placenta is discoid, deciduate and hemochorial. Hormones secreted by placenta : HCG, HPL, Progesterone, Estriol (E3). HCG : Alpha : Similar in LH, FSH and TSH a. 2 subunits b. Functionally similar to LH. Beta : Specific subunit. c. Produced by : Syncytiotrophoblast. d. Doubling time : 48 hrs. 8-9 days of fertilization (D 22 of cycle) e. Appearance in blood : Peaks : 9-10 weeks. Plateau : 16-20 weeks. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 1 01 13 ↑ HCG ↓ HCG ----- Active space ----- Downs syndrome Abortions Twin pregnancy Ectopic pregnancy Molar pregnancy Trisomies other than T 21. Gestational trophoblastic neoplasia Type of placenta Images 1. Marginal insertion of cord/battledore placenta 2. Succenturiate lobe 3. Placenta bilobata 4. Extrachorial placenta : Maternal side of placenta is larger & surrounds the fetal side. A. Circumvallate placenta : Valve like thickening between fetal & maternal side. B. Circummarginate placenta : No valve like thickening between. Obstetrics Revision v1.0 Marrow 6.5 2023  14 01 Obstetrics ----- Active space ----- Antenatal care (ANC) 01:11:46 Investigations on first visit : ABO, Rh typing. Hb (National guidelines : Repeated min 4 times in pregnancy), HCT. VDRL. HBS Ag. Rubella susceptibility screening. Urine routine and microscopy (every trimester). In case if DM and sickle cell anemia : Urine culture & sensitivity (↑ risk of asymptomatic bacteuria). HIV testing → Opt-out approach. DIPSI test → Repeat 24-28 weeks. Investigations done if patient can afford : TSH Aneuploidy screening. Investigations done if female is Rh -ve: Husband’s Rh status. ICT (Indirect Coomb’s test) at 1st visit and 28 weeks. At 35-37 weeks : Group B streptococci screening (recto-vaginal swab). Discrepancy in height of uterus : Height of uterus > POG Height of uterus < POG Full bladder Oligohydromnios Twin pregnancy PIH Polyhydramnios IUGR Molar pregnancy UPI Macrosomia IUD (Intra uterine death) Concealed hemorhhage Transverse lie Fibroid uterus Mistaken dates Mistaken dates If discrepancy in height of uterus and POG by ≥ 3 weeks : Pathological cause > mistaken dates Next step USG. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 2 02 15 OBSTETRICS REVISION 2 ----- Active space ----- Bleeding during pregnancy : 1st or 2nd trimester (early pregnancy) 3rd trimester (T3) DD : Abortion, ectopic pregnancy, molar K/a Antepartum hemorrhage. pregnancy. DD : Placenta previa, abruptio placenta, uterine rupture, vasa previa. Per speculum, per vaginal examination : Per speculum, per vaginal examination : Not Mandatory. done unless contraindications are r/o on USG. Abortion 00:01:58 Abortion : Spontaneous pregnancy loss upto 20 weeks (m/c in Trisomy > Monosomy X > Trisomy 16). Infections can lead to spontaneous abortions (Except HIV). Medical disorder which usually does not cause (T1) abortion : Thrombophilia. Recurrent abortion : Recurrent pregnancy loss (RPL) : ≥3 consecutive spontaneous pregnancy loss. Investigations should begin after ≥ 2 RPL. According to American society for reproductive medicine (ASRM) : New definition for RPL → ≥ 2 pregnancy losses confirmed by either USG or HPE (Histopatholog- ical examination). M/c group of causes leading to RPL : Endocrinopathies (hypothyroidism, uncontrolled DM, ↑prolactin, luteal phase defect). Infections do not lead to RPL (Including syphilis). Four Established causes of RPL : 1. APLA (Antiphospholipid antibody) syndrome (single most common cause) : 16% 2. Uterine structural abnormalities : Congenital like septate uterus & acquired like cervical incompetence, fibroid, polyp. 3. Chromosomal abnormalities (Balanced translocation of chromosome) are responsible for RPL in 4% cases. 4. Hypothyroidism. Obstetrics Revision v1.0 Marrow 6.5 2023  16 02 Obstetrics ----- Active space ----- Uterine anomalies : 2nd M/C group leading to RPL. M/c during : T2 > T1. M/c congenital anomaly leading to RPL : Septate uterus (T2 > T1). But it can also lead to T1 abortions. M/c acquired anomaly leading to RPL : Cervical incompetence (only T2). leads to painless abortions. Investigations done for RPL : Investigations not done for RPL : Ultrasound uterus. TORCH test. APLA Antibodies. VDRL test. TSH. Testing for thrombophilia. Parental karyotype. Cervical incompetence : As no. of abortions ↑, period of gestation at which abortion occurs ↓. IOC to measure cervical length is TVS. 1. Length of cervix decreases to ≤ 25 mm. 2. Dilatation : ≥ 2 cms. 3. Shape of cervix changes from : T-Y-V-U shaped cervix. 4. Funneling of the os. Condition Investigations/ next step Management A non pregnant female gives Pass number 8 Hegar’s Cerclages : h/o ≥3 painless second trimes- dilator easily through Vaginal → LASH & LASH ter abortion. internal os (premenstru- technique. al phase) OR If you can Abdominal : Laparoscopic pull out number 16 foleys cerclage. catheter filled with 1 ml of water easily. H/o ≥2 T2 painless abortion : No investigation needed Progesterone + Pregnant female at 8 weeks History based diagnosis. cervical cerclage (or) (12-14 wks). Pregnant female at 16 weeks cervical length >25 mm Pregnant female with h/o one TVS for cervical length. Length >2.5 cms : Progesterone T2 abortion/ Preterm labour. Measurement between Present at 16 wks of pregnan- 16-24 wk Length ≤2.5 cms : Progesterone cy. + cervical cerclage Pregnant female with Progesterone. no H/O T2 abortion but length of cervix POG. POG. Fetal parts not easily felt. Fetal parts palpable superficially. Placenta previa : New classification : Low lying Placenta : Placental edge < 2 cm from internal os (old = Type 1). Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 2 02 27 Placenta Previa : Type 2, 3 & 4 of older classification i.e., placental edge ----- Active space ----- either reaching uptil the os or covering it. P/S & P/V examination are C/I in placenta previa but not in abruptio. Screening USG to differentiate between placenta previa to abruption : TAS. IOC : TVS. USG is important in placenta previa : To confirm diagnosis. To detect malpresentation (M/c : Transverse lie > Breech). To rule out placenta accreta spectrum. Note : M/c cause of transverse lie : Prematurity. M/c cause of transverse lie at term : Placenta previa. Best time to do USG to rule out previa : T3. Mx of a case of bleeding ≥ 28 wks - diagnosis not known Next step Resuscitation : 2 large bore iv cannula (14G, 16G), O2 by mask, start iv (crystalloids), Urine input output chart. Vitals stable/ Vitals unstable/ FHS = Normal/ Fetal distress/ No DIC DIC Next step TAS (screening test) C-section If placenta previa (irrespective of diagnosis) TVS (IOC) Mx of placenta previa : 1. Expected Mx : Continuing prenancy with McAfee and Johnson regimen. Done if all following conditions McAffe and Johnson regime : fulfilled : Admit the patient. Vitals - stable. Give corticosteroids (for lung maturity). No active bleeding. Tocolytics (only if 11g/dL → Normocytic normochromic type. M/c pathological anemia in pregnancy : Iron Deficiency Anemia (IDA). M/c indirect cause of maternal mortality in India : Anemia. Iron deficiency anemia Thalassemia Microcytic, hypochromic anemia NESTROF test -ve NESTROF test +ve MENTZER index > 13 MENTZER index < 13 Rx : Oral or parenteral Iron or blood transfusion Rx : Blood transfusion Anemia Mukt Bharat program : Aim : To prevent anemia (not treat it). Interventions : 1. Digital hemoglobinometer (PHCs) 2. Iron-folic acid (IFA) pills 3. Deworming 4. Food fortification with iron 5. Delayed cord clamping (to prevent neonatal anemia) 6. Addressing other causes. To prevent anemia : All reproductive age females : 1 IFA pill/ week (red in color) + deworming with tab albendazole 400 mg (twice a year). Pregnancy plans : Upto 3 months of pregnancy : Folic acid (FA) Pills. 4th month onwards : Iron & folic acid (IFA) Pills. IFA : Iron (60 mg) + Folic acid (500 mcg) WHO criteria : Severe : Hb 2nd stage of labor > Late 1st stage of labor > 28-32 weeks of pregnancy. Back to normal : 10 days post delivery. Obstetrics Revision v1.0 Marrow 6.5 2023  32 03 Obstetrics ----- Active space ----- Supine hypotension syndrome : Dizziness on lying down, corrects when lying on left side. Seen from T3. Occurs d/t compression of IVC. Rx : Lying in left lateral position. Normal in pregnancy Signs of heart disease HR Abnormal BP Abnormal JVP N S1 Loud, prominent split S2 loud & prominent. S2 N S4 heard S3 Easily heard. Ejection systolic Grade < 3/6 Grade ≥ 3/6 murmur Continuous / N Diastolic murmur + mammary murmur Chest X-ray Slight cardiomegaly Marked cardiomegaly ECG LAD < 150 Abnormal Normal signs/symptoms in pregnancy Abnormal sign/symptoms Dyspnea on exertion. Progressive dyspnea, Easy fatiguability orthopnea. Decreased exercise tolerance PND Peripheral dependent edema Clubbing & cyanosis Management of heart diseases in labor : Induction of labor : Not C/I (Spontaneous preferred). Mode of delivery : Vaginal delivery with prophylactic use of forceps > vacuum. Mandatory pain relief Restrict IV Fluids Position : Semi-recumbent. Active Management Of Third Stage Of Labor (AMTSL) can be done. Methylergometrine : C/I. Oxytocin : Can be given. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 3 03 33 M/c in heart diseases : ----- Active space ----- M/c heart disease (HD) in pregnancy : Mitral stenosis. M/c congenital HD in pregnancy : Atrial septal defect (ASD). HD with maximum maternal mortality : Eisenmenger’s syndrome. HD where cesarean section is indicated : HD with aorta involvement (aortic aneurysm/ coarctation of aorta/ Marfan syndrome with aortic involvement or patient on warfarin at the time of delivery). Mitral stenosis with Rheumatic etiology : Surgery should be done before conception (if not, 1st symptom of MS in pregnancy : Dyspnea, mimics a normal pregnancy symptom). Mx of Symptomatic MS (area of valve NTD Most specific malformation Caudal regression syndrome (sacral agenesis) Most specific cardiac malformation TGA M/c lesion (reversible after delivery). HOCM Risk of congenital malformations ∝ Values of HbA1C (Congenital malformations may be present if HbA1c >6.5%). Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 3 03 35 Radiation exposure in pregnancy : ----- Active space ----- Maximum permissible radiation during pregnancy : 5 Rads. Exposure leads to anomalies such as : Microcephaly (M/c). Growth retardation. Neurological impairment. Leukemia (M/c cancer). Fetal loss (if exposure ≥ 10 rads). X-ray done accidentally : Not an indication for MTP. In 1st 2 weeks after fertilization : All or none law (either conceptus escapes injury or fetal loss). Teratogenic drugs : Teratogenic drugs Alcohol Growth Restriction Abnormal facial features (smooth philtrum, thin vermilion border, small epicanthal folds). Microcephaly, abnormal brain development Abnormal behavioral development Phenytoin Fetal hydantoin syndrome : Midfacial hypoplasia. Upturned nose. Distal digital hypoplasia (Hypoplastic phalanges) ± cardiac defects. ACEi / ARBs Renal hypoplasia/Renal agenesis. Oligohydramnios in T2. Lithium Ebstein anomaly (Apical displacement of Tricuspid valve → Tricuspid Regurgitation + Right atrial enlargement). Neonates : Floppy infant syndrome, diabetes insipidus & hypoglycemia. Isotretinoin Microtia/ Anotia. Thalidomide Phocomelia (Proximal limb amputation). Stillbirth. Warfarin DI SALA syndrome : Stippled Epiphysis Chondrodysplasia Nasal hypoplasia CNS : Agenesis of corpus callosum/microcephaly/cataracts. Methotrexate Craniosynostosis or cloverleaf skull. Tamoxifen Vaginal adenosis. A minimum gap of 3 months (similar to Craniofacial defects. required between pregnancy and DES) Ambiguous genitalia. stopping tamoxifen. Mother : Endometrial cancer. Misoprost Mobius syndrome Indomethacin Premature closure of ductus arteriosus (when used > 32 weeks). Obstetrics Revision v1.0 Marrow 6.5 2023  36 03 Obstetrics ----- Active space ----- Warfarin exposure Phocomelia Fetal alcohol syndrome Maternal teratogenic infections : Syphilis : Congenital syphilis follows Kassowitz’s law (with subsequent pregnancy the outcome gets better). Not a/w recurrent abortions. A/w : Still birth Polyhydramnios Preterm labor Hydrops fetalis Single episode of abortion Fetal anemia & hepatosplenomegaly Varicella Zoster : Teratogenic period : 12-20 weeks. Congenital Varicella syndrome : Microcephaly + cataract + cicatricial skin lesions + limb hypoplasia. Indication for MTP. Neonatal VZ syndrome : Infection 5 days before Congenital varicella syndrome delivery or 2 days after delivery (hepatitis + pneumonitis + typical chicken pox lesions + meningoen- cephalitis). Congenital Rubella : Most teratogenic infection. Neonatal varicella syndrome Congenital Rubella syndrome (CRS) : Heart disease (PDA > pulmonary steno- sis) + cataracts + sensorineural hearing loss + blue-berry muffin rash CRS is an indication for MTP. Zika virus (Vector - Aedes mosquito) : Linked to receptors TIM-1/ TAM-XL → Microcephaly + increased limb tone + clubfoot. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 3 03 37 Other physiological changes in pregnancy 00:49:16 ----- Active space ----- Thyroid gland : Size : Goiter : Pathological Free T3 & T4 : Normal (Euthyroid state). T3/T4 : TSH : Normal (0.1 - 2.5). TBG : Mc cause of hyperthyroidism in pregnancy : Grave’s disease. DOC for hyperthyroidism in T1 : Propylthiouracil. DOC for hyperthyroidism in T2 & T3 : Methimazole/Carbimazole (can cause aplasia cutis if used in T1). Mc cause of hypothyroidism in pregnancy : Hashimoto’s thyroiditis. K/C/O hypothyroidism pre-pregnancy : dose of thyroxine by 30-50%. Metabolic changes in pregnancy : Diabetogenic state (Significant : 24 - 28 weeks → Gestational DM). Insulin resistance (d/t HPL, estrogen, progesterone, cortisol - HCG is not responsible). Insulin secretion : Oncotic pressure : Fluid retention : ~ 6.5 L Physiological anemia Glycosuria : Normal Renal changes in pregnancy : Size of kidney : slightly (~ 1cm). Renal Blood Flow, Glomerular filtration rate : S. urea, S. uric acid : Asymptomatic bacteriuria (more common in Sickle cell anemia/ DM patients) : Type of specimen No of samples Minimum CFU/ml required required for diagnosis of UTI Mid-stream clean catch urine 2 consecutive 10 of the same bacterial 5 specimen samples species Catheterized urine specimen 100 for asymptomatic Single sample bacteriuria (CA-ASB). Suprapubic aspirate Any growth of microorgan- isms in the culture Obstetrics Revision v1.0 Marrow 6.5 2023  38 03 Obstetrics ----- Active space ----- Respiratory changes in pregnancy : Chest diameter : by 2 cm. Diaphragm : by 4 cm. Chest circumference : by 6 cm. Inspiratory reserve volume, Respiratory rate, Vital capacity : Unchanged. I see (Inspiratory capacity), TV (Tidal volume), Movie (Minute ventilation) : All other respiratory parameters : Diabetes in pregnancy 00:56:06 Pre-gestational diabetes (PGDM) : Type non-A diabetes (according to Priscilla White classification) : Pregnancy with K/C/O DM : Blood sugar level raised from day 1 of pregnancy → Hyperglycemia → Fetotoxic → Congenital malformations Diabetes that does not resolve after pregnancy/ delivery. Diagnosis of PGDM : Other required investigations : FBS ≥ 126 mg/dL Check BP at every visit. RBS ≥ 200 mg/dL Proteinuria (dipstick method) 2hr PP ≥ 200 mg/dL Urine culture & sensitivity (for asymptomatic HbA1C ≥ 6.5% bacteriuria). Fetal monitoring (NST weekly, BPS weekly, Growth scans - atleast 2). Above investigations are also done for GDM. Congenital malformations in PGDM : Risk assessment tool : HbA1c. IOC : TIFFA (Targeted imaging for fetal anomalies/ target scan/ level 2 scan) (done in all pregnant females). Screening USG : Trans-abdominal USG. Test for PGDM to detect congenital malformations : Fetal Echo (22-24 weeks). Measures to reduce chances of congenital malformations : Strict glucose control, to reduce HbA1c. Preconceptionally, switch to insulin + start 1 FA tablet (400 mcg)/ day. Rx of PGDM : Insulin (DOC for DM in pregnancy). Low dose aspirin (to prevent PIH) Weight + diet counselling Terminate at ≥ 39 weeks. Mode of delivery : Vaginal delivery (C-section if weight of fetus ≥ 4.5 kgs). Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 3 03 39 Gestational diabetes (GDM) : ----- Active space ----- Type A diabetes (according to Priscilla White classification) : A1 : Well controlled with diet A2 : Controlled with insulin/ oral hypoglycemic agents. Patient not a K/C/O of DM before pregnancy. Detected at 24-28 weeks. No risk of congenital malformations. Diagnosis (DIPSI guidelines) : Non fasting OGTT done twice (1st antenatal visit & 24-28 weeks of pregnancy with a minimum of 4 weeks gap). If the first test is done after 28 weeks, second test is not required. 75g oral glucose given in 300 ml water → 2 hour plasma glucose value measured. Result : < 140 mg/dL : Repeat test between 24-28 weeks. ≥ 140 mg/dL : Manage as GDML ≥ 200 mg/dL : Manage as PGDM. Other investigations : Same as PGDM. Rx of GDM : First 2 weeks : MNT (Medical nutrition therapy)/ diet control + weight modi- fication. If metabolic goals are met : FHS < 96 2 hour PP < 120 Continue with MNT + Check 1 hour PP < 140 HbA1c < 6g% 2 hour PP levels every week Average capillary glucose < 100) (T3) or every 2 weeks (T2). If metabolic goals not met : Start insulin Oral hypoglycemic agents (OHAs) metformin/ glyburide, used if patient refuses insulin. Note : OHAs are C/I on PGDM Terminate : Type A1 : ≥ 39 weeks. Type A2 : Well controlled with insulin/ OHA : ≥ 39 weeks. Not well controlled with insulin/ OHA : 36 - 37 weeks + 6 days. Mode of delivery : Vaginal delivery (C/S if weight of fetus ≥ 4.5 kgs). Obstetrics Revision v1.0 Marrow 6.5 2023  40 03 Obstetrics ----- Active space ----- Complications of diabetes : 01:08:18 Maternal Fetal Neonatal ed chances Fetal hyperglycemia. Neonatal hypoglycemia. of infection Macrosomia (M/C) Hypocalcemia , (asymptomatic (weight ≥ 4 kg) → hypokalemia, bacteriuria, Shoulder dystocia hypomagnesemia candidiasis ). Placentomegaly → ed chances of abortion, Surfactant → Risk PIH/ polyhydramnios. IUD, still-birth of respiratory distress Polyhydramnios Diabetic vasculopathy → syndrome & Necrotiz- → PPH/ Abruptio/ Oligohydramnios & IUGR ing enterocolitis PROM/ PTL/ Hyperviscosity, Cord prolapse/ Hyperbilirubinemia Malpresentation Polycythemia → Risk of developing No anemia. diabetes in future No mental retardation. IADPSG/ ADA guidelines for GDM : Test : 24 - 28 weeks Fasting : 8 hours → FBS measured → Give 75g oral glucose. Test Upper limit (mg/dL) FBS 92 1 hour PP 180 → ≥ 1 test abnormal → GDM diagnosed. 2 hour PP 152 Shoulder dystocia : 01:12:16 Delay in delivery of shoulder by ≥ 1 minute after delivery of fetal head. Obstetric emergency. Turtle sign seen. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 3 03 41 Algorithm of Rx (each step for 30 seconds) (HELPERR) : ----- Active space ----- H : Call for Help E : Give Liberal Episiotomy L : Legs maneuver (Mc Robert’s maneuver) : Flex & abduct the thighs → Straightens sacrum & increases available space M/c nerve injured by this : Lateral cutaneous nerve of thigh → Meralgia paresthetica P : Apply suprapubic pressure + attempt McRobert’s maneuver again. E : Enter hand in pelvis & rotate shoulder (Woods cork screw maneuver). R : Remove posterior arm (deliver posterior arm) : Jacquemier maneuver. R : Rollover patient on all 4 limbs (Gaskin maneuver/ All-4 maneuver) Zavaneilli maneuver : If everything else fails, Push baby back into uterus C/S. Applying fundal pressure is C/I in shoulder dystocia. M/c fetal complication : Brachial plexus/ Erb’s palsy (C5, C6 nerve roots). M/C maternal complication : PPH. McRobert’s maneuver Woods cork screw maneuver Gaskin maneuver/ All-4 maneuver Obstetrics Revision v1.0 Marrow 6.5 2023  42 04 Obstetrics ----- Active space ----- OBSTETRICS REVISION 4 Pregnancy induced hypertension 00:00:23 Definition : BP > 140/90 on 2 occasions 4 hours apart. BP > 160/110 → Still high after 15 mins → Start anti-hypertensives. BP seen < 20 weeks BP seen > 20 weeks Pregnancy induced HTN (PIH) (BP normal within 12 weeks post-delivery). Chronic HTN in If > 20 weeks, BP → pregnancy uncontrolled /proteinuria/ ( BP even 12 signs of end organ damage No proteinuria Proteinuria (or) weeks post- (or) signs of end signs of end organ delivery). Chronic HTN + organ damage damage seen superimposed pre-eclampsia Gestational HTN Pre-eclampsia Proteinuria : Signs of end organ damage (any 1) : Excretion of ≥ 0.3g (300mg) of protein Platelet < 1 lakh in 24 hours Liver enzymes (2x normal) Protein : Creatinine ratio ≥ 0.3 Serum creatinine ≥ 1.1 Urine dipstick protein ≥ +1 Pulmonary edema Screening test : Dipstick Visual symptoms/cerebral Gold standard : 24 hours protein estimation edema Classification of pre-eclampsia : Criteria PE without severe features (Mild PE) Severe PE BP 140-160/90-110 ≥ 160/110 Signs of end organ damage Signs of impending eclampsia Absent Present Note : Extent of proteinuria, oliguria, IUGR → Cannot be used to differentiate Signs & symptoms of impending eclampsia : 1. Severe headache (not relieved by medications). 2. Visual disturbances. 3. Epigastric pain. 4. Clonus. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 4 04 43 Eclampsia : 00:07:09 ----- Active space ----- Severe preeclampsia + Generalized tonic-clonic seizures. Type of eclampsia Description Postpartum eclampsia Eclampsia < 48 hours of delivery, for the first time Intrapartum eclampsia Eclampsia at the time of labour Antenatal (antepartum) eclampsia Eclampsia before the onset of labour (M/C & with worst prognosis) Risk factors for PIH : 1. Exposure to placenta for first time (Primigravida, new paternity, long interpregnancy interval). 2. Big placenta (Twin pregnancy, diabetes, molar pregnancy (PIH at 24 weeks (disappears by 22-24 weeks of pregnancy). pulsatality index. Management of pre-eclampsia : PIH Management All patients Admitted at first (Irrespective of BP) → Proper history + all lab tests + fun- dal examination Mild PE (OPD) No need of admission, bed rest, aspirin & salt restriction. MgSO4 & antihypertensives not given. Fetal monitoring started at 32 weeks (NST & biophysical score weekly, USG for fetal growth + umbilical artery doppler Definitive management : TOP at ≥37 weeks (Induction of labor). Severe PE Admission (IPD) MgSO4 (To prevent seizures) & anti-hypertensives (To prevent intracranial hemorrhage). 1st dose of corticosteroid (28-34 weeks) : a. Abruptio/ DIC/ HELLP syndrome/ fetal distress/ impending eclampsia/ pulmonary edema → Emergency delivery, even without giving 2nd dose of corticosteroids. b. PROM (Premature rupture of membranes/ Renal dysfunction/ Oligohydramnios/ uMblical artery doppler showing reverse diastolic flow) → Deliver after 2nd dose of corticosteroids. Definitive management : TOP at ≥34 weeks. TOP : Termination of pregnancy Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 4 04 45 Umbilical artery doppler : ----- Active space ----- Normal S/D ratio in pregnancy : Thoracophagus Least common variety : Rachiphagus > Craniophagus Prognosis of twins (Depends on chorionicity) : Best with DCDA twins. IOC to detect chorionicity : TVS at 11-13 weeks + 6 days (Earliest at 10 weeks). / Twin peak sign/Lambda sign positive (DCDA) Inverted T-sign positive (MCDA) Differences between DCDA, MCDA & MCMA : DCDA MCDA MCMA Number of layers 4 2 0 of membrane Thickness of ≥ 2mm < 2 mm No membrane membrane Vascular Absent Deep vascular Superficial vascular connections b/w twins Sex Same/ different Same Same Number of pla- 2 placentas Single Single centas (may/may not fuse) USG findings Twin peak sign +ve T-sign +ve - Prognosis Good Bad d/t risk of TTTS Bad d/t risk of cord entanglement Delivery 38 weeks If TTTS present : 34 wks. C/s at 32-34 weeks If TTTS absent : 37 wks. after steroid cover. Obstetrics Revision v1.0 Marrow 6.5 2023  48 04 Obstetrics ----- Active space ----- DCDA (Thick membrane) MCDA (thin membrane) MCMA (no membrane) Complications in Monochorionic twins : Twin to twin transfusion syndrome (TTTS) Twin anemia polycythemia sequence (TAPS) Twin reversed arterial perfusion (TRAP) Selective IUGR Complications in Monoamniotic twins : Cord entanglement Conjoint twins → C/s between 32-34 weeks TTTS (Twin-Twin Transfusion Syndrome): Criteria for diagnosis : Monochorionic diamniotic twins USG : One twin with oligohydramnios + other twin with polyhydramnios. Complications in donor twin : Complications in recipient twin : Oligohydramnios Polyhydramnios Anemia Polycythemia → Thrombosis Renal failure Congestive heart failure (M/c) : Need to do Less growth fetal Echo. Heart failure Prognosis : Depends on recipient twin Staging : QUINTERO staging : Stage 3 : Abnormal doppler (Peak systolic velocity of middle cerebral artery : PSV-MCA). ≥ 1.5 MOM → Fetal anemia PSV-MCA ≤ 0.8MOM → Fetal Polycythemia. Stage 4 : Hydrops fetalis in one or both fetus Stage 5 : Death of one or both fetus. Management : a. < 28 weeks : In utero laser ablation of passage b. ≥ 28 weeks : Amniocentesis of larger twin Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 4 04 49 TAPS : Anemia/ polycythemia without oligohydramnios/ polyhydramnios ----- Active space ----- TRAP : One twin : Heart present (donor) Other twin : Acardiac (recipient) → receives deoxygenated blood via umbilical artery of donor twin → Formation of lower limbs → Acardius acephalus / Acardiac amorphus. Acardius, acephalus Acardius amorphus (Formation of lower limbs) (Growth of no part of recipient twin) Delivery of twins : Twins Timing of TOP MCMA 32-34 weeks Conjoint twins (Always C/S) DCDA 38 weeks MCDA without TTTS 37 weeks MCDA with TTTS 34 weeks Presentation Mode of delivery First twin : Vaginal delivery Cephalic presentation First twin : C/s Breech/ transverse lie First twin in Cephalic position Post delivery of 1st twin → Internal podalic + version under GA (Risk : Uterine rupture, C/I Second twin in Transverse lie in previous C/s) → Make twin Breech f/b position Breech extraction. AMSTL in twin pregnancy : Can be done. Injection methergine : C/I after delivery of first twin, not after delivery of second twin. Injection oxytocin : Can be given. VBAC : Can be done Cerclage : Not done. Progesterone : Not useful. M/c fetal complication in twin pregnancy : Prematurity. Obstetrics Revision v1.0 Marrow 6.5 2023  50 04 Obstetrics ----- Active space ----- Note : Hellen’s rule : Incidence of twins is 1 in 80 pregnancy →Incidence of triplets is 1 in 802 & Incidence of quadruplets is 1 in 803. Superfecundation : Two ova released at two different times in the same cycle → Fertilized by two different acts of coitus (Rare in humans). Superfetation : Two ova released in two different cycles. Not seen in humans. Theoretically, possible only till 14-16 weeks of pregnancy. Rh negative pregnancy 01:03:29 Rh negative patient → Check Rh status of husband Both Rh -ve → Not High risk Husband : Rh +ve, wife : Rh -ve → High risk Indirect Coomb’s test (at first antenatal visit) Negative Positive Rh non isoimmunized pregnancy Rh isoimmunized pregnancy No role of anti-D Repeat ICT at 28 weeks No role of early cord clamping. Negative Antibodies titre (Critical = 1 : 16) Anti D (antepartum prophylaxis) - 300 mcg/ 1500 IU at 28 weeks Less More (1:16, 1:32, 1:64) Repeat titres every 4 weeks. Peak systolic velocity of MCA Delivery between 39-40 weeks Fetal monitoring at 32 weeks Vaginal delivery at 37-38 weeks. 32 weeks d/t increased risk of premature closure of ductus arteriosus). 32-34 weeks : Nifedipine Heart disease : Atosiban Tocolytic of choice in India : Nifedipine. Absolute contraindications of tocolytics : PTL ≥34 weeks IUD of fetus Fetal anomaly Chorioamnionitis → Immediate TOP (IOL). No corticosteroids, no tocolytics, no C/s. Maternal hemodynamic unstability Relative C/I : Dilatation of cervix ≥3 cm. Obstetrics Revision v1.0 Marrow 6.5 2023  54 05 Obstetrics ----- Active space ----- OBSTETRICS REVISION 5 Pelvis 00:01:24 True pelvis : Has inlet, cavity, outlet. Anatomy of Pelvis a) Inlet : Lies at level of pelvic brim. Inlet AP diameters Inlet other diameters True conjugate 11 cm Transverse diameter 13 cm Obstetric conjugate 10-10.5 cm Oblique diameter 12 cm Diagonal conjugate 12 cm b) Cavity : Has 2 planes. Features Plane of greatest pelvic Plane of least pelvic dimension dimension Anterior boundary Pubic symphysis Pubic symphysis Posterior boundary Junction of S2 & S3 Junction of S4 & S5 Lateral boundary Obturator foramen Ischial spine AP diameter 12cm 11.5-12 cm Transverse diameter 12 cm 10 cm (interischial/bispinous diameter) Most important diameter during labor : Interischial diameter (since it is the smallest diameter). Midpelvis : Area b/w plane of greatest dimension & least dimension. Plane of greatest pelvic dimension Midpelvis c) Outlet : Plane of least pelvic dimension Anatomical outlet : Present at ischial tuberosity. AP diameter : Distance b/w pubic symphysis & tip of coccyx = 13 cm. Transverse diameter : Distance b/w 2 ischial tuberosities (intertuberous diameter) = 11 cm. Obstetric outlet : Area b/w plane of least pelvic dimension & anatomical outlet. Contracted pelvis : Contracted inlet OC < 10 cm (critical obstetric conjugate) Contracted midpelvis Interischial diameter < 8 cm Contracted outlet Intertuberous diameter < 8 cm Measurement of DC Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 5 05 55 Diagonal conjugate (DC) : AP diameter of inlet which can be measured clinically. ----- Active space ----- Obstetric conjugate (OC) = DC - (1.5 to 2 cm) Mx of contracted pelvis : C-section (C/S) Subpubic angle : Angle b/w 2 descending rami of pubic bone. Acute angle in males. Obtuse angle in females. Angle of inclination : Angle which inlet makes with the floor. =. Types of pelvis : Caldwell Moloy classification : Gynecoid Platypelloid Anthropoid Android M/c (female type) Least common. AP > Tr. Male pelvis. Tr > AP. Tr >>> AP. Tr > AP. Shape of inlet : Flat/bowl shaped. Shape of inlet : Inlet : Heart Round AP oval. shaped. Prominent ischial spine. Face presentation. Persistent OP/ OP position is m/c. Direct OP is m/c. Most favourable Face to pubis Least favourable for delivery. delivery (most for delivery. common). Deep transverse arrest. Tr : Transverse diameter. AP : Anteroposterior diameter. Examples of contracted pelvis : Naegle pelvis : Only one ala of sacrum absent. Both require C-section. Robert pelvis : Both ala of sacrum absent. Terminologies of Labor 00:11:42 M/c lie : Longitudinal lie. M/c presentation : Cephalic. M/c presenting part : Vertex. M/c malpresentation : Breech. Obstetrics Revision v1.0 Marrow 6.5 2023  56 05 Obstetrics ----- Active space ----- Transverse lie : Presentation : Shoulder Denominator : Acromion process Mx : Antenatal → ECV at ≥ 36 weeks. During labor → C/S (whether baby dead/alive). Transverse lie Dead baby in transverse lie is k/a Neglected shoulder presentation. Presenting part : Vertex Brow Face Definition M/c. When head is Head completely extended. Fully flexed/deflexed partially extended. head. AP diameter of SOB : 9.5 cm (fully Mento vertical : Submento vertical/ Submento engagement flexed). 14 cm bregmatic. OF : 11.5 cm (deflexed) Mx Vaginal delivery C/S Mentoanterior → Vaginal Mentoposterior → C/S Image SOB : Suboccipito bregmatic; OF : Occipitofrontal. M/c congenital anomaly a/w face presentation : Anencephaly. In anencephaly, m/c presenting part : Face. Attitude of baby : Relationship b/w different parts of the baby. M/c : Flexion. Face & brow are abnormalities of attitude of baby (not malpresentation). Position : M/c : LOT > LOA. (ROP) M/c during labor : LOT. M/c in active labor : LOA. (LOT) OP is an example of malposition. M/c OA position : LOA. M/c OP position : ROP. (LOA) M/c position in breech : LSA (Left sacroanterior). M/c position in face : LMA (Left mentoanterior). Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 5 05 57 Mx of OP : Wait & watch. ----- Active space ----- Maximum chance of cord prolapse : Transverse lie. Identification of position 00:26:00 1. Identify occiput (triangular posterior fontanelle). 2. Occiput towards pubic symphysis → OA. 3. Midway b/w pubic symphysis & sacral promontory → OT. 4. Occiput towards sacral promontory → OP. 5. Occiput towards examiner’s left → mother’s right. LOP occiput ROA Lie is commented after correction of dextrorotation of uterus. Longitudinal lie Oblique lie Looks oblique but becomes lonitudinal after dextrorotation Compound presentation Hand prolapse in transverse lie : Both hand & head coming out in together Mx is C-section. longitudinal lie : Mx is vaginal delivery. Obstetrics Revision v1.0 Marrow 6.5 2023  58 05 Obstetrics ----- Active space ----- Fetal skull diameters 00:20:06 Bregma (Antr fontanelle) Vertex 9.5 SOF 9.5 11.5 OF 11.5 ) g est Occiput (lon 11.5 m 14 c Brow presentation : MV (longest diameter) = 14 cm. Hence, Mx is always C-section. Transverse diameters : In ascending order : Diameters which are 9.5 cm Miss - Bimastoid = 7.5 cm. Biparietal. Tina - Bitemporal = 8 cm. SOB. So - Super sub parietal = 8.5 cm SMB. Pretty - Biparietal = 9.5 cm (M/c engaging diameter). Caput succedaneum v/s cephalhematoma : Features Caput succedaneum Cephalhematoma Collection of Fluid Blood Mechanism Head stays in one position Traumatic instrumental for a long time during labor. delivery. Location Above periosteum Below periosteum Crosses suture lines Yes No Pits on pressure Yes No # of underlying bone/jaundice No Yes Appearance & disappearance Present at time of birth. Appears hours after birth. Disappears within 2-3 days. Disappears after 2-3 weeks. Image Note : Never drain cephalhematoma. DD : Meningocele. Meningocele has cough impulse. Transillumination is +ve in meningocele. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 5 05 59 Leopold manoeuvres 00:33:03 ----- Active space ----- First 3 → face the face of the pt. Last 1 → face the feet of the pt. First/fundal grip Second/umbilical Third/Pawlik grip Fourth/deep grip pelvic grip. Tells about Lie : Position of fetus. Presentation : Confirms Fundal grip Fetal back : Smooth, Firm, round, findings of empty → regular curved, globular structure Pawlik grip. transverse lie. board like rigidity. : Cephalic Attitude of Presentation : Limbs : Small, Ballotability : fetus. Broad, irregular, multiple knob like Head has entered soft → cephalic. structures. pelvis/ not. Hard, globular Back on left side → → breech. LOA/LOP/LOT. Image Bishop score 00:36:26 Parameter 0 1 2 3 Dilatation of cervix Closed 1-2 cm 3-4 cm > 5 cm Position of cervix Posterior Mid Anterior Effacement of cervix 30% 40-50% 60-70% >80% Station Above -2 Above -2 -1, 0 Below ischial spine Consistency of cervix Firm Medium Soft 6= lOL can be done Score ≥9 Maximim success of IOL Maximum score = 13. Mnemonic : Delhi Police Employed Special Commodity Score +2 score mnemonic : Harry Potter Softly asked (anterior) 3-4 times (cm) 0 or -1 station as he was 60-70% (effacement) confident. Obstetrics Revision v1.0 Marrow 6.5 2023  60 05 Obstetrics ----- Active space ----- Modified Bishop score : Effacement is replaced by length of cervix (measured by TVS). Station : Landmark : Ischial spine. 0 station : Head at ischial spine. Head is engaged. Forceps & vacuum are applied only if station is +2 or below. Methods of induction of labor (IOL) Mechanical Medical methods methods Best for IOL in Misoprost (PGE1) : Tab 25 mcg 4hrly P/V (max 6 doses). previous Dinoprostone (PGE2) : Available as cerviprime gel & C-section. cervidil. Foley’s catheter. - Cerviprime gel (0.5 mg) 6hrly (max 4 doses). Extraamniotic - Cervidil : Slow release formulation (10 mg). saline infusion. Placed in posterior fornix. Stripping of membranes. C/I for IOL : Severe CPD. Contracted pelvis. Changes at onset of labor Transvers lie, brow presentation, Estrogen face (mentoposterior position). Fetal distress. Oxytocin receptors Placenta previa. Gap junctions Classical C/S. Prostaglandins Previous hysterotomy. Functional withdrawal of progesterone. Previous myomectomy. Active genital herpes infection. Obstetrics Revision v1.0 Marrow 6.5 2023  Obstetrics Revision 5 05 61 Labour 00:45:50 ----- Active space ----- True labor pain : Characteristics : Progressive : in intensity/duration/frequency. Leads to dilatation of cervix. Regular & rhythmic (on & off). Felt in lower abdomen, radiating to the back & thigh. A/w show & formation of bag of water. Not relieved by enema/rest/sedation (false labor pain is relieved by these). Adequate contractions : Frequency ≥ 3 in 10 mins. Duration ≥ 45 seconds. Intensity : 65-75 mm Hg (200-250 Montevideo units). Origin : Cornua of uterus. Tachysystole : > 5 contractions in 10 minutes → fetal distress (aka hyperstimulation). D/t augmentation of labor with Oxytocin/Misoprost. On CTG : Prolonged deceleration (deceleration ≥ 2 mins & < 10 mins). Cardinal movements during labor : 1. Engagement. 2. Descent : Due to uterine contractions. 3. Flexion of head. 4. Internal rotation : At level of ischial spine. Occiput moves by 2/8th of a circle. (Crowning occurs after this, but is not a cardinal movement). 5. Extension : Head of baby is delivered. 6. Restitution. 7. External rotation : Shoulder rotates by 1/8th of a circle. 8. Lateral flexion : Body of baby is delivered. In vertex : Head of baby is born by extension. In breech : Head of baby is born by flexion. Obstetrics Revision