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    GYNAECOLOGY : LAST MOMENT REVISION


    THE MENSTRUAL CYCLE

    It is the cyclical bleeding from the female genital tract which is due to the cyclical changes during endometrium due to the secretion of ovarian hormones. A cycle is counted from the first day of the menstrual bleeding to the first day of next menstrual bleeding.



    Menstrual cycle can be divided into four phases.

    Menstrual Phase- if the ovum is not fertilized, then menstrual bleeding occurs which lasts for about 3-5 days. There is bleeding and shedding of uterine endometrium. An average of 50-200 ml of blood is lost during each menstrual bleeding.

    Proliferative phase - here damaged endometrial lining is restored. From day 5 to 14, the endometrium thickens and proliferates. Proliferation occurs in the glands, stroma , blood vessels and superficial epithelium. Thickness of uterine endometrium reaches about 4 mm by about 14th day.

    Ovulatory phase - ovulation occurs about the 14th day. Cervical mucus secretion increases and it becomes thinner which helps the penetration of sperms.

    Secretory phase / Luteal phase/ progestational phase – in this phase, the uterine endometrium further thickens,glands increase in length, spiral arteries become coiled and dilated, cervical secretions become thick and tenacious in preparation for implantation of fertilized ovum. These changes end about 28th day of the cycle with the onset of menstruation if the ovum is not fertilized.



    Hormonal Control of the Menstrual cycle

    The menstrual cycle is regulated by the hormones from the hypothalamus, pituitary and ovaries. The hypothalamus releases gonadotropin releasing hormone which stmulates the synthesis and release of gonadotropins ,FSH and LH. Increase FSH helps in the development of ovarian follicles and stimulates the secretion of oestrogen from ovarian follicles. Increase oestrogen levels causes the changes in the proliferative phase. Serum oestrogen levels becomes peak at about 12 to 13th day. (oestrogen surge) which has a positive feedback on the hypothalamus resulting in increased gonadotropin releasing hormone. This in turn induces a burst of LH secretion (LH surge) from the anterior pituitary which is the cause of rupture of mature graffian follicles to cause ovulation. After ovulation serum LH and FSH decreases in concentration.



    The corpus luteum formed from the ruptured follicle secretes progesterone. During the secretory phase, the serum progesterone and oestrogen level rises which reduces the secretion of FSH and LH from the anterior pituitary. Progesterone causes the main changes during secretory phase. If pregnancy occurs, corpus luteum persists and continue to secrete progesterone and oestrogen. But if fertilization does not occur, the corpus luteum regresses into corpus albicans and serum oestrogen and progesterone level decreases which causes the menstrual bleeding.



    MENSTRUAL DISORDERS

    1. Amenorrhoea – is the absence of menstruation which may be primary or secondary.PRIMARY amenorrhoea is the condition where menstruation fails to begin by the age of 16 years. Seconday amenorrhoea is the amenorrhoea in a woman after menstruation has been established.(cryptomenorrhoea is where menstrual bleeding occurs but remains concealed due to vaginal occlusion by a congenital septum or atresia)

    amenorrhoea can also be classified as physiological and pathological.



    Physiological amenorrhoea

    1. Amenorrhoea before puberty

    2. Amenorrhoea during pregnancy

    3. During lactation

    4. After menopause



    Pathological Amenorrhoea

    A. Defects in the genital tract

    1. Vaginal atresia

    2. Imperforate hymen

    3. Transverse vaginal septum

    4. Cervical atresia

    5. Genital tuberculosis

    6. Ashermann’s syndrome(amenorrhoea secondary to the trauma of the endometrium due to vigorous curettage during procedures like abortion and MTP.

    B. Defects in the ovaries

    1. Ovarian dysgenesis

    2. PCOD (Stein –Leventhal syndrome)

    3. Premature menopause

    4. Surgical removal of both ovaries

    C. Chromosomal defects

    1. Turner’s syndrome



    D. Pituitory disorders

    1. Pituitory tumors

    2. pituitary infantilism

    3. Hyper prolactinoma

    4. Sheehan’s syndrome(post partal pituitary necrosis due to thrombosis of pituitary blood vessels following post partum haemorrhage)

    E. Gonadotropin releasing hormone deficiency causes hypothalamic amenorrhoea.

    F. Disorders of adrenal glands

    1. Adrenogenital syndrome (caused by a tumor or hyperplasia of adrenal cortex resulting in excessive androgen production. )

    2. Cushing’s syndrome (Cortico steroid hormones are in excess which causes osteoporosis, hirsutism, obesity and amenorrhoea.

    3. Addison’s disease.

    G. Thyroid disorders

    H. Nutritional factors

    1. Starvation,

    2. Extreme obesity

    3. Anorexia nervosa

    I. Drugs

    1. Oral contraceptives

    2. Prostaglandin inhibitors



    Management:

    Depends upon the underlying causes



    DYSMENORRHOEA

    It is the painful menstruation incapacitating the women in day today activities.

    1. Spasmodic dysmenorrhoea (primary dysmenorrhoea)

    here there is no identifiable pelvic pathology. May be due to cervical obstruction, psychological factors like low pain threshold, endocrine factors like low progesterone level, intrauterine contraceptive devices and muscular spasms. The pain begins a few hours before or just after the onset of menstruation may last upto 12 hours and accompanied by constitutional symptoms like chills nausea, vomiting and fainting.



    2. Congestive dysmenorrhoea (secondary dysmenorrhoea)

    Causes:

    1. Uterine fibroid

    2. Chocolate cyst of ovary

    3. Pelvic endometriosis

    4. Adenomyosis

    5. PID

    6. Salpingoophrites

    Here the pain starts 3 to 5 days before menstruation and is relived by the flow..

    3. Membraneous dysmenorrhoea

    It is a variety of primary dysmenorrhoea characterized by shedding of large endometrial casts during menses.



    PMT

    It is a condition where women suffer from excessive premenstrual symptoms which are experienced for 7 to 10 days before the onset of menstruation.

    Symptoms:

    Irritability, lassitude, sleepiness, headache, nausea, constipation, frequency of micturition , weight gain, oedema of legs, fullness and tenderness of breast etc. though the exact aetiology is not known, the PMT is said to be due to excess of oestrogen in relation to the progesterone.



    MENORRHAGIA

    Is excessive menstrual blood loss both in amount and duration.



    Casuses:

    Pelvic causes:

    1. Uterine fibroid

    2. Adenomyosis

    3. Ovarian tumors

    4. Pelvic endometriosis

    5. PID

    6. Genital TB

    Endocrine causes:

    1. Hypo and hyper thyroidism

    2. General diseases

    3. Chronic HTN

    4. CCF

    5. Leukaemia and purpureas

    6. Liver dysfunction

    IUCD (Intra Uterine Contraceptive Devices)



    METRORRHAGIA

    It is acyclical intermenstrual irregular uterine bleeding.

    Causes:

    Uterine fibroid

    Uterine polyps

    Ca cervix

    Ca endometrium

    Cervical erosion

    Cervical polyp



    POLYMENORRHOEA (EPIMENORRHOEA)

    It is the frequent menstruation at regular intervals of 2 or 3 weeks due to the shortening of the cycle. If it is associated with prolonged bleeding, it is called Epimenorrhagia.



    Dysfunctional Uterine Bleeding

    This is abnormal uterine bleeding where no organic cause can be detected and occur at any age between menarche and menopause.



    Metropathica haemorrhagica- it is irregualar anovulatory prolonged bleeding which may last for many weeks and is painless due to the failure of ovarian response to gonadotropins.



    VAGINAL DISCHARGE

    A. Physiological :

    In healthy women the vagina contains a small amount of watery secretion which contains mucus, desquamated epithelial cells, doderllains bacilli and lactic acid. It is usually colorless.

    B .Pathological”

    To investigate the pathology behind the vaginal discharge, it is necessary to know the colour, quantity, duration of time it has been present,smell, irritating or not and if it is blood stained or not. An irritating discharge may be due to infection by the trichomonas vaginalis or candida albicans. Yellow discharge may be due to bacterial infections, infected cervical polyp or erosion, acute gonorrhoea, puerperal sepsis or pyometra.Offensive vaginal discharge is characteristic of necrotic lesion of genital tract, carcinoma of vagina, foreign bodies retained in the vagina. Blood stained discharges occur with oestrogen deficiency, carcinoma of cervix, any ulcerated lesions and in intra uterine pregnancies.



    INFERTILITY

    Is defined as failure to conceive even after one year of regular unprotected intercourse. (Sterility is an absolute state of inability to conceive where as infertility is only a relative state)

    Infertility can be primary and secondary.



    Causes of infertility

    Faults in the Male

    1. Defective spermatogenesis

    2. Obstruction in the efferent duct

    3. Sperm motility

    4. Failure in depositing the sperm.



    Faults in the Female:

    1. Vaginal factors

    a. Vaginal atresia

    b. Narrow introitus

    c. Transverse vaginal septum

    d. Vaginal stenosis

    e. Vaginismus

    2. Cervical factors

    1. Elongation of cervical canal

    2. Obstruction of cervical canal

    3. Uterine prolapse

    4. Thick cervical mucus

    5. Chronic cervicitis

    6. Presence of antisperm antibody in cervical mucus

    3. UTERINE FACTORS

    1. Congenital malformations of uterus

    2. Uterine fibroid

    3. Adenomyosis

    4. Uterine tuberculosis

    5. Tubal factors

    1. Tubal occlusion

    2. Tubal additions

    3. Loss of celia

    4. Congenital tubal defects

    5. Tuberculosis

    6. Salpingitis

    6. Ovarian factors

    1. Anovulatory cycles

    2. Ovarian tumors

    3. PCOD

    7. Endocrinal factors

    1. Thyroid disturbances

    2. Hypogonadotrophism

    3. Corpus luteum insufficiency

    4. Hyperprolactinaemia



    INVESTIGATIONS OF INFERTILITY

    MALE

    1. Local examinations of genitals

    2. Semen analysis

    3. Serum hormone levels

    4. Testicular biopsy

    5. Chromosomal test

    6. Immunological test



    FEMALE

    1. Detailed history taking

    2. General systemic and gynaecological examinations

    3. Special investigations to assess tubal, cervical, peritoneal and ovarian functions.



    URINARY PROBLEMS IN GYNAECOLOGY

    Retention of Urine:- the condition where urine collects in the urinary bladder but fails to be voided out leading to stasis of urine in the bladder.

    Causes:

    Postoperative retention

    it may be due to oedema, reflex spasm of bladder sphincter, or denervation of bladder.

    Obstructive conditions like stenosis, cancer of bladder neck retention durine Puerperal period.

    Pelvic tumors

    Retroverted gravid uterus

    DYSURIA

    Causes:

    Cystitis

    Urethritis

    Urethral caruncle

    Carcinoma of urethral meatus

    Trauma to the urethra

    Postoperative

    Vesical calculi

    Following catheterization

    Radiation cystitis



    INCREASED FREQUENCY OF MICTURITION

    Causes:

    Cystitits

    Pregnancy

    Ca Cervix or Vagina

    Trauma during catheterization

    Diabetes



    STRESS INCONTINENCE

    It is the involuntary escape of urine when there is sudden increase in the Intraandominal pressure

    Causes:

    Incompetent urinary sphincter

    Post menopausal atrophy

    Lowered urethral pressure

    Neurological causes

    Trauma to the pelvic floor



    URGE INCONTINENCE

    In this condition , the women experience a sudden desire to pass urine which is unable to control.

    Causes

    Cystitis

    Trigonitis

    Bladder stone or foreign body

    Pelvic tumor

    Neurological causes



    UTI

    It is more common in female because of the shorter urethra, proximity of the external urethral meatus to the vaginal and anal openings, sexual intercourse, stasis or urine during pregnancy and peurperium.

    e-coli is the most common causative agent



    UTERINE FIBROIDS (FIBROMYOMA/LEIOMYOMA)

    Causes:

    Exact aetiology is not known. But there is substantial evidence that oestrogen plays an important role in myomas.

    Types:

    Intra mural fibroid (interstitial)

    Subserous fibroid

    Submucus fibroid

    Clinical features

    Majority are asymptomatic. Symptoms may depend upon the size of the tumor. Abdominal lump. Pressure symptoms, pain, menstrual abnormalities and infertility may be the presenting features.



    Diseases of the New born

    RDS (Respiratory Distress Syndrome)

    Aetiology : the basic abnormality is deficiency in pulmonary surfactant. In the absence of surfactant, the surface tension increases and alveoli collapse during expiration.

    RDS appears within 6 hours of life characterized by tachyapnoea, chest retraction and cyanosis.

    Diagnosis can be confirmed by X-ray which shows ground glass mottling.

    Meconeum aspiration Syndrome

    Meconeum aspiration causes chemical pneumonitis or blockage of various airways. This is common in small for date and post mature babies. They develop respiratory distress in the first 24 hours of life.



    HAEMOLYTIC DISEASE OF THE NEWBORN

    The disease is characterized by excessive haemolysis of the foetal RBC. It is mostly due to incompatibility of the foetal and maternal blood groups. They include Rh incompatibility, ABO group incompatibility and other antigen incompatibilities.





    CARCINOMAS

    Ca of Female Genital Organs

    Ca of Vulva

    Ca of vulva contributes about 4.8% of total carcinomas of female genital organs. 3 clinical types are there

    The cauliflower growth, the flat indurations and the excavated ulcer. Pruritus is a very common complaint. Diagnosis is made by lump, pruritus and cytology.

    Carcinoma Vagina

    It contributes about 1.9% of all genital carcinomas. Usually seen in the upper 1/3rd of the posterior vaginal wall as cauliflower growth or indurated ulcer.

    Symptoms are pain, bleeding after coitus and later blood stained offensive discharge.



    Ca Cervix

    It is the most frequent of all genital tract cancers (about 30%). Occurs frequently in multiparous women. Average age incidence is between 39 and 57. usually presents as cauliflower like growths or excavated ulcers which causes profuse bleeding on even slightest touch. The four main symptoms of Ca Cervix are

    haemorrhage

    discharge

    cachexia

    pain.



    Ca fallopian tube

    This is the rarest type of gynaecological cancer and can be managed by means of radical surgery.

    Ovarian carcinoma

    This is extremely common and usually metastatic. (Krukenberg tumor- these are bilateral ovarian tumors which have smooth and slightly bossed surfaces and are freely movable in the pelvis.). Ovarian carcinomas usually present with pain and tender swelling.



    MEDICAL TERMINATION OF PREGNANCY (ABORTION ACT OF 1067)

    According to abortion act of 1967, the circumstances in which abortion may be carried out are as follows.

    two registered medical practitioners must form in good faith about the abortion.(section 1(1))

    the continuance of pregnancy would involve risk to the pregnant woman (section 1 (1-a))

    if cause injury to the physical or mental health of the pregnant woman (section 1 (1-a)

    if it would cause injury to the physical or mental health of any existing children of the pregnant woman’s family. (section 1 (1-a)

    the child that is to be born would suffer from severe physical or mental abnormalities. (section 1(1-b)

    Consent:

    A written consent of the patient should be obtained before conducting the MTP. If the patient is an unmarried girl between the ages of 16to18, the patient consent is a must rather than the parent’s consent.

    If the patient is under 16, her parents should always be consulted even if the patient forbids it. Still if the patient’s consent is not obtained MTP should not be carried out.



    CARCINOMAS

    Ca of Female Genital Organs

    Ca of Vulva

    Ca of vulva contributes about 4.8% of total carcinomas of female genital organs. 3 clinical types are there

    The cauliflower growth, the flat indurations and the excavated ulcer. Pruritus is a very common complaint. Diagnosis is made by lump, pruritus and cytology.

    Carcinoma Vagina

    It contributes about 1.9% of all genital carcinomas. Usually seen in the upper 1/3rd of the posterior vaginal wall as cauliflower growth or indurated ulcer.

    Symptoms are pain, bleeding after coitus and later blood stained offensive discharge.



    Ca Cervix

    It is the most frequent of all genital tract cancers (about 30%). Occurs frequently in multiparous women. Average age incidence is between 39 and 57. usually presents as cauliflower like growths or excavated ulcers which causes profuse bleeding on even slightest touch. The four main symptoms of Ca Cervix are

    haemorrhage

    discharge

    cachexia

    pain.



    Ca fallopian tube

    This is the rarest type of gynaecological cancer and can be managed by means of radical surgery.

    Ovarian carcinoma

    This is extremely common and usually metastatic. (Krukenberg tumor- these are bilateral ovarian tumors which have smooth and slightly bossed surfaces and are freely movable in the pelvis.). Ovarian carcinomas usually present with pain and tender swelling.



    MEDICAL TERMINATION OF PREGNANCY (ABORTION ACT OF 1067)

    According to abortion act of 1967, the circumstances in which abortion may be carried out are as follows.

    two registered medical practitioners must form in good faith about the abortion.(section 1(1))

    the continuance of pregnancy would involve risk to the pregnant woman (section 1 (1-a))

    if cause injury to the physical or mental health of the pregnant woman (section 1 (1-a)

    if it would cause injury to the physical or mental health of any existing children of the pregnant woman’s family. (section 1 (1-a)

    the child that is to be born would suffer from severe physical or mental abnormalities. (section 1(1-b)

    Consent:

    A written consent of the patient should be obtained before conducting the MTP. If the patient is an unmarried girl between the ages of 16to18, the patient consent is a must rather than the parent’s consent.

    If the patient is under 16, her parents should always be consulted even if the patient forbids it. Still if the patient’s consent is not obtained MTP should not be carried out.





    Endometriosis

    Is the presence of ectopic endometrium in any situation other than it normal location. Endometriosis is confirmed when

    - Lining epithelium rescembles, should have typical endometrial stroma, should respond to oestrogen, the contents of endometrial glands is dark altered tarry blood

    - The disease is one adult sexual life- peak 30-40 years of age

    - Divided into internal endometriosis or adenomyosis or external endometriosis .eg. ovaries , uterosacral ligament, abdominal scars, umbilicus, bladder etc

    symptoms of adenomyosis

    Menorrhagia in fairly high degree

    Infertility

    Large uterus

    Feeling of weight in the pelvis



    CYSTS OF OTHE OVARIES

    1. Chocolate cyst of the ovaries – the important site of extra uterine endometriosis, affected ovary enlarge, outer surface white and thickened. Ovary and fallopian tubes prolapsed and fixed to the pelvis. Rupture is common with chocolate sauce like blood as content.

    Symptoms-

    - Pain

    - Dysmenorrhoea

    - Dyspareunia

    - Infertility

    - Bowel and bladder symptoms

    2. Retention cyst of graffian follicle

    Incase of excess hCG

    3. Follicular cyst

    Regarded as pathological if it is more than one inch diameter.



    SCLEROCYSTIC DISEASES OF OVARY (PCOD) Stein-leventhal syndrome

    Virilising syndrome in young women characterized with infertility obesity hirsutism and acne



    Kruckenberg tumour

    May be primary or seconday . invariably bilateral. Smooth bossed surface with additions.

    Clinical features- abdominal swelling pain , alteration in menstrual cycle, ascites, post menopausal bleeding, fixity indicated malignancy.



    ABORTION

    Classification-

    1. degree

    a. threatened

    b. inevitable

    c. incomplete

    d. complete

    e. missed

    2. cause

    a. spontaneous

    b. habitual

    c. criminal- legal and illegal

    3. infections

    a. septic

    b. non septic

    Abortion may occur due to

    a. abnormalities of foetus

    b. abnormalities of placental membrane e.g. hydatidiform mole

    c. disease of the mother. E.g. measles, cholera, syphilis,

    d. chronic disease like HTN, nephritis

    e. local abnormalities in mother.e.g. cervical incompetence, genital hyperplasia

    f. drugs

    g. endocrine factors

    h. psychiatric disturbance

    i. faults in the male like law quality sperm



    HYDATIDIFORM MOLE (vesicular mole)

    Chorionic villi distended with fluid forming translucent vesicles . usually abortion may occur between 4-6th month.

    Symptoms- abdominal pain, vaginal bleeding or watery dirty discharge. Complication may follow as haemorrhage, sepsis, perforations ,chorione epithelioma which is pre malignant.



    PROLAPSE UTERUS

    Normal position of uterus is one of universal anteversion and antiflexion with body of the uterus tilted forward.

    First degree prolapse descent of cervix in vagina

    Second degree to the introitus

    Third degree – out side the introitus

    Fourth degree or procidentia – uterus completely out side



    ASPHYXIA NEONATORUM


    Here heart continues to beat but respiration not established. Diagnosed by APGAR Scoring carried out every one and five minute after birth.


    APGAR scoring

    - heart rate

    - respiratory effort

    - muscle tone

    - reflex irritability

    - pallor of the skin

    cephal haematoma- may not present in birth but develop within two to three days. Limited by a suture to a particular bone. Soft and elastic. Does not pit on pressure. Gradually increases in size and takes week or months to disappear.

    Caput succidenum present at birth not well circumscribed . maximum at birth and gets smaller.



    CARCINOMAS


    Ca of Female Genital Organs

    Ca of Vulva

    Ca of vulva contributes about 4.8% of total carcinomas of female genital organs. 3 clinical types are there

    The cauliflower growth, the flat indurations and the excavated ulcer. Pruritus is a very common complaint. Diagnosis is made by lump, pruritus and cytology.

    Carcinoma Vagina

    It contributes about 1.9% of all genital carcinomas. Usually seen in the upper 1/3rd of the posterior vaginal wall as cauliflower growth or indurated ulcer.

    Symptoms are pain, bleeding after coitus and later blood stained offensive discharge.



    Ca Cervix

    It is the most frequent of all genital tract cancers (about 30%). Occurs frequently in multiparous women. Average age incidence is between 39 and 57. usually presents as cauliflower like growths or excavated ulcers which causes profuse bleeding on even slightest touch. The four main symptoms of Ca Cervix are

    9. haemorrhage

    10. discharge

    11. cachexia

    12. pain.



    Ca fallopian tube

    This is the rarest type of gynaecological cancer and can be managed by means of radical surgery.

    Ovarian carcinoma

    This is extremely common and usually metastatic. (Krukenberg tumor- these are bilateral ovarian tumors which have smooth and slightly bossed surfaces and are freely movable in the pelvis.). Ovarian carcinomas usually present with pain and tender swelling.



    MEDICAL TERMINATION OF PREGNANCY (ABORTION ACT OF 1067)

    According to abortion act of 1967, the circumstances in which abortion may be carried out are as follows.

    11. two registered medical practitioners must form in good faith about the abortion.(section 1(1))

    12. the continuance of pregnancy would involve risk to the pregnant woman (section 1 (1-a))

    13. if cause injury to the physical or mental health of the pregnant woman (section 1 (1-a)

    14. if it would cause injury to the physical or mental health of any existing children of the pregnant woman’s family. (section 1 (1-a)

    15. the child that is to be born would suffer from severe physical or mental abnormalities. (section 1(1-b)

    Consent:

    A written consent of the patient should be obtained before conducting the MTP. If the patient is an unmarried girl between the ages of 16to18, the patient consent is a must rather than the parent’s consent.

    If the patient is under 16, her parents should always be consulted even if the patient forbids it. Still if the patient’s consent is not obtained MTP should not be carried out.





    MCQs



    1. ------------------ type pelvis is the type with accepted with female sex characteristics
    2. The uterus grows out of the pelvis by --------- week
    3. Alphafoeto proteins are synthesized in the -------------- and ----------- .
    4. The bluish discolouration of the vagina during pregnancy is called ----------- .
    5. Hegar’s sign is --------------
    6. The soft murmur heard rarely synchronous with the foetal heart beat is called ------
    7. Aschheim and zondek test detects ----------
    8. The retention of menstrual fluid in the cavity of uterus leads to ---------------
    9. The most common presentation of the foetus is ---------------
    10. Peurperium is a period following the delivery lasting up to ---------------
    11. Elderly primi is a woman above ----------- years of age
    12. Vagina is lined by --------------- epithelium
    13. Vaginal ph is acidic due to the presence of --------------
    14. Commonest malignancy in women in india is --------------------
    15. Quickening appears at ----------- weeks
    16. The most common cause of postpartum haemorrhage is------------
    17. The weight of non pregnant uterus is -----------
    18. The involution of uterus is completed by ------------ days
    19. Other than pre-eclampsic symptoms, eclampsia is characterized by --------
    20. The disease due to cystic degeneration of chorionic villi is ---------
    21. The normal amount of liquor amni at term is ---------
    22. ---------------- is the placenta in which the cord is attached to the margin of the placenta.
    23. The normal length of the umbilical cord is----------
    24. False knots in the umbilical cord are the result of local increase of the ----------
    25. A woman is said to be habitual aborter if she has undergone ---------consecutive abortions
    26. The overlapping of skull bone seen in the x-ray in intrauterine death of foetus is called -------------- sign
    27. The most common site of ectopic pregnancy is ---------
    28. The most common form of multiple pregnancy is -------------
    29. Excessive traction in the delivery of the shoulder results in ---------------
    30. The characteristic oedema in the haemolytic disease of the new born is called-----
    31. ‘Islands of bones in a sea of membranes’ is a particular feature of ---------
    32. Umbilical cord contains ---------- arteries and ----------- veins
    33. The best speculum for pelvic examination is ------------------- .
    34. The glands of both sexes present in the same individual is called ----------------
    35. The condition , in which the urethra opens below the phallus is -------------
    36. In turner’s syndrome the nucleus has ------- chromosomes
    37. Cyclic recurrent ulceration of vulva and mouth with uveitis is called --------------
    38. Mittelschmers refers to ------------
    39. The usual position of uterus is ----------- and ----------------
    40. The commonest type of fibroid uterus is -------------
    41. Sharp dorsiflexion of the foot which elicit pain in deep phlebothrombosis is called-------
    42. A baby weighing less than ---------- gms at birth is classed as premature according to the international standards
    43. ‘Phlegmasia alba dolans’ is usually associated with -------------------
    44. Snuffles in infants is an important and early sign of ---------------------
    45. Formation of an opaque tissue behind the lens of the eyes, a few months after birth especially in premature babies is called---------------------
    46. The normal foetal heart rate is ------------
    47. The commonest reason for post partem mortality is ------------
    48. The basic cause of placenta accrete is ----------------
    49. The bimanual examination done to assess the cephalopelvic disproportion is called----
    50. The study of nature pf uterine contraction is called ---------------
    51. The most common maternal disease which is associated with hydramnios is --------
    52. The colostrums is rich in immunoglobulin ---------
    53. The most common type of episiotomy applied is -----------------
    54. In cephalic presentation maximum intensity of foetal heart sound is heard ---------
    55. It is estimated that the mature milk flow is about ------------- ml/day
    56. The diameter of engagement in a vertex presentation is ---------------------------
    57. Mac Donald’s rule calculates the EDC from calculating the -----------------
    58. Calculate the EDC by Nagetes rule- LMP July 17th
    59. In a nulliparous woman the external os of the uterus is ----------
    60. Active foetal movements are felt during --------- trimester of pregnancy
    61. The normal ph of vagina during reproductive period is -----------------
    62. The pouch of peritoneum which separates the bladder from the uterus is --------
    63. After ovulation, the ruptured follicle develops in to --------------
    64. The hormone liberated by graffian follicle is -----------
    65. Corpus luteum secretes the hormone ---------------
    66. The menstrual blood does not clot, though it contains calcium, because it does not contain ------------
    67. Excessive menstrual loss with preservation of the normal cycle is --------------
    68. In turner’s syndrome the chromosome structure is -----------
    69. Hyperplasia of adrenal cortex leads to ---------------------
    70. A frothy discharge from vagina is the indication of --------------------
    71. The basophil adenoma of the anterior pituitary leads to ---------------
    72. The most frequent type of all genital tract cancer is ----------
    73. Complete prolapse of the uterus is called--------
    74. Relaxin secreted by the ---------------
    75. Presence of ecto endometrium in any site outside normal location is ------
    -----



    Answers

    [HIDE]
    1. Gynaecoid type

    2. 12th week

    3. foetal liver and yolk sac

    4. Chadwick sign

    5. Softening and

    6. funic soufflé

    7. HCG

    8. Haematoma

    9. Vertex

    10. 6-8 weeks

    11. 40 years

    12. simple squamous

    13. Doderlein’s bacilli

    14. Carcinoma breast

    15. 16th week

    16. Uterine atony

    17. 50 gms

    18. 12 days

    19. Convulsions

    20. Hydatidiform mole

    21. 100 ml

    22. Battle dore placenta

    23. 50-60 cm

    24. Wharton’s jelly

    25. 3 or more

    26. Splading’s sign

    27. Tubal

    28. Twin pregnancy

    29. Erb’s palsy

    30. Hydrops foetalis

    31. Hydrocephalus

    32. 2 arteries and 1 vein

    33. Bivalve speculum of cusco

    34. True hermaphroditism

    35. Hypospadiasis

    36. 45 chromosomes

    37. Behcet’s syndrome

    38. Ovulation pain

    39. Anteversion and anteflexion

    40. Intramural

    41. Homan’s sign

    42. 2500 gms

    43. Thromobophlebitis

    44. Congenital syphillis

    45. Retrocentral fibroplasias

    46. 150/minute

    47. Shock

    48. Decidual deficiency

    49. Munro – Kerr-Muller method

    50. Tocography

    51. Diabetes mellitus

    52. A

    53. Mediolateral

    54. Below the umbilicus

    55.850 ml/day

    56. Subocciputo bregmatic presentation

    57. height of the fundus

    58. April 24

    59. Circular

    60. Last / Third

    61. 4.5

    62. Uterovesical pouch

    63. Corpus luteum

    64. Oestrogen

    65. Progesterone

    66. Prothrombin

    67. Menorrhagia

    68. 44+ X0

    69. Adernogenital syndrome

    70. Trichomoniasis

    71. Cushing’s disease

    72. Ca Cervix

    73. Procidencia

    74. Ovaries

    75. Endometriosis
    [/HIDE]

  2. #2
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    OBSTETRICS : LAST MOMENT REVISION

    The OB and GYN part actually start with the physiological changes of mother during pregnancy. Almost every organ and tissues of a female body undergo physiological changes during pregnancy. The metabolic, chemical and endocrine balances of the body gets altered.


    The important changes


    Changes in UTERUS and CERVIX



    Increase in weight from 50 gms. To 900 gms

    Increase in size from 7.5X 5X 2.5 cms to 30X 23X 20 cms

    Myometrium and endometrium undergo hypertrophy. The endometrium of the pregnant uterus is called deciduas.

    Cervix becomes softer.

    Cervical racemose glands secretes a tenacious mucus forming a plug (operculum) which acts as a barrier against infections

    Uterine contractions increases which are irregular, infrequent and painless(Braxton-Hicks contractions)



    CHANGES in VAGINA

    Vaginal blood supply increases leaving a bluish appearance to mucosa (Jacquemier sign or Chadwick’s sign)

    the action of oestrogen increases the vaginal secretions

    Vaginal pH becomes more acidic which helps to prevent infections



    CHANGES in The BREAST

    Breast changes are more evident in primigravida. The changes are mostly due to oestrogen and progesterone. Oestrogen acts more on glands and ducts and progesterone on the secretory functions of the breast.Breast changes are mostly taking place during second and fifth months.

    During second month,

    Breast increases in size, bluish discolouration and more sensitiveness.errectile nipple, deeply pigmented aerola, and prominent tubercles (Mont Gomery’s tubercles)in the areola are noted.

    During fifth month, secondary areola develops, a sticky yellow fluid may be expressed from the nipple.



    CHANGES IN THE SKIN

    Mostly due to the action of the MSH of the anterior pituitary.

    Depressed pinkish or slightly bluish lines (striae gravidarum) appear on the abdomen and thighs. Sometimes pigmentation may appear on cheeks,foreheads and around eyes which mostly disappear after the pregnancy.



    WEIGHT GAIN DURING PREGNANCY

    The weight gain during pregnancy is contributed by the enlarging uterus, growing foetus, placenta, liquor amnii, acquisition of fat and water reduction. It may vary from person to person. In general the average weight gain is 5 to 9 kg.



    HAEMATOLOGICAL CHANGES

    Plasma volume increases upto 1.2 litres

    RBC volume increases by about 20 to 30 % (upto 350ml)

    Leucocytes increases predominantly neutrophils

    The total plasma proteins increases

    Albumin globulin ratio is decreased to 1:1 (normal 1.7: 1)

    Fibrinogen level raised by 50%

    ESR level increases



    Cardio vascular changes

    1.Cardiac output is raised by 40%.

    2. Femoral venous pressure is increased

    3. The blood flow to the uterus is considerably increased.

    4. Pulmonary and renal blood flow is considerably increased

    5. Due to venous congestion, varicose veins tend to develop more during pregnancy.



    CHANGES IN URINARY SYSTEM

    Increase frequency of micturition due to antiverted uterus during the early weeks of pregnancy and due to descent of the presenting part in the later part of pregnancy

    Glycosuria is common but may not be pathological

    Proteinuria should be investigated thoroughly



    DIAGNOSIS OF PREGNANCY

    Normal duration of pregnancy

    9 months and seven days/ or 280 days or 40 weeks

    First trimester - first twelve weeks

    Second trimester - 13 to 28 weeks

    Third trimester - 29 to 40 weeks



    SIGNS AND SYMPTOMS

    Amenorrhoea

    Frequency of micturition

    Morning sickness

    Breast changes

    Skin changes

    Quickening (usually occurs between 16th and 20th week)



    Probable signs

    Abdominal enlargement

    Changes in uterus

    Braxton Hicks contractions

    Chadwick sign

    Ociander’s sign (increase pulsation felt in the lateral vaginal fornix by about the 8th week of pregnancy)

    Softening of Cervix

    External and internal ballottement

    Detection of hCG in urine and blood



    Positive signs of pregnancy

    Foetal parts and foetal movements (apprectiated by 22nd week)

    Foetal heart sounds. Most conclusive sign of pregnancy heard between 18 – 20th week for the first time.

    Ultra sonic evidence . Gestation sac by 6th week, foetal heart beat -7th week, foetal heart rate -10th week using Doppler.

    Malformations detected by 18th week

    .

    CALCULATION OF THE DATE OF DELIVERY (EDD)

    By adding 7days to the first day of LMP count back 3 months or count 9months forward to reach the EDD.



    Minor disorders of pregnancy

    1.Morning sickness

    Med. - Sepia, Puls, Nux vom, Ignatia, Phosph, Ntrum mur, Cocculus, Colchicum, Ipecac, Symphoricarpus,

    2. Acidity and Heartburn

    Med- Puls, Sepia, Nux vom , Colocynth ,Staphy, Carbo veg, sulphur, Lyco, Ars alb, Robinia



    3.Back ache

    Med- Kali bich , Actea, Ammon mur, Arnica, Rhustox, Bryonia, Phosph

    Constipation

    Varicose veins

    Haemorrhoids

    Fainting



    PHYSIOLOGY OF LABOR



    Defined as the process of expulsion of the foetus along with the placenta and the membranes from the uterus through the birth canal.



    NORMAL LABOR

    A Labor is normal, if it is

    1. Spontaneous in onset

    2. At term

    3. Vertex presentation

    4. Process completed by natural unaided efforts of the mother

    5. Time for first and second stages does not exceed 18 hours

    6. No complications arise



    PROCESS OF LABOR

    The exact process of labor is not certain. But humoral and mechanical factors control labor.

    Humoral control

    Oxytocin from posterior pituitary has a stimulating action on the pregnant uterus. Oxytocin receptors are more in the myometrium.

    Fall in the level of progesterone which changes the oestrogen –progesteron balance produces uterine contractions in greater amplitude.

    Increase in prostaglandins increases the rhythmic uterine activity and the hormonal changes that initiates the parturition.



    MECHANICAL

    1. Uterine distension

    Causes:

    1.Increase in intra uterine pressure and the resultant tension enforced on uterine muscle fibre may initiate labor.

    2. The stretching of lower uterine segment by the foetal head and the pressure exerted by it on the para cervical nerve ganglion may initiate labor.



    SIGNS OF LABOR

    1. Pre labor

    These signs occur 2 or 3 weeks prior to the onset of labor.

    1. Lightening which is the sinking of the presenting part into the pelvis

    2. False pains- irregular dull pains appearing in the lower abdomen and are not associated with uterine hardening.

    3. Frequency of micturition

    4. Cervix become soft and dilated



    Signs of True Labor

    1.True labor pains- the uterine contractions become painful which are cotrolled by the nervous system and endocrine factors.

    2. Dilatation of Cervix and cervical canal. After a dilatation of 3cms has occurred, further dilatation occurs at the rate of 1 cm per hour.

    3. Show- blood stained mucoid discharge due to the detachment of chorion is seen within two hours of starting the labor.

    4. Formation of bag of water- stretching of lower uterine segment causes a detachment of membrane . the presenting part fix into the cervix and divide the amniotic fluid into two. The presenting part forces the bag of membrane during contraction which may lead to early rupture of the membrane.



    STAGES OF LABOR

    STAGE 1

    Onset of true labor pain to full dilatation of cervix.

    STAGE 2

    Full dilatation of cervix and expulsion of foetus

    STAGE 3

    Expulsion of foetus to expulsion of placenta and its membranes



    MECHANISM OF NORMAL LABOR

    Engagement

    Flexion of head

    Internal rotation of head

    Crowning

    Delivery of head by extension

    Restitution of head

    External rotation of head

    Delivery of shoulders and trunk by lateral rotation



    DURATION OF LABOR

    Depends on

    Primigravida or multipara

    Type of pelvis

    Size and presentation of foetus

    Strength and frequency of uterine contractions

    Usually in primigravida first stage last for about 12 hours, second two hours, third one fourth of an hour. In multipara, it is 6 hours, half and hour and one fourth of an hour respectively.



    COMPLICATIONS OF THE THIRD STAGE OF THE LABOR

    POST PARTUM HAEMORRHAGE pph. pph is severe bleeding during the third stage of labor or within 24 hours of expulsion of placenta.

    causes:

    Atonic uterus

    Traumatic causes

    Blood coagulation disorders.

    signs of PPH

    1.Bleeding /vagina

    2. Rapid pulse

    3.Pallor

    4. Collapse

    Management

    1. Stimulation of uterus to contract by massaging

    2. Emptying of uterus fully

    3. Blood transfusion if necessary

    4. Traumatic causes should be repaired

    Homoeopathic Medicines

    Caulophyllum, Actea, Pulse,Arnica, Bell, Phosoph, Ipecac, Sabina, Secale Cor.



    RETAINED PLACENTA

    Placenta is said to be retained, if it is not expelled even after 30 minutes of the birth of the baby.

    Causes:

    Poor bearing down efforts

    Distended uterus

    Prolonged labor

    Uterine atonicity

    Hour glass contraction of uterus

    Adherent placenta



    MANAGEMENT

    Empty the bladder with a catheter

    Retained placenta should be removed

    Adherent Placenta (placenta accuate) it is a rare condition in which the placenta is directly embedded into the uterine muscles . the spongy layer of decidua is absent here.



    COLLAPSE AND SHOCK

    It is due to hypovolumic shock associated with haemorrhage.

    Signs:

    1. Pulse is rapid, soft and thready

    2. Fall in blood pressure

    3. Marked pallor

    4. Shallow respiration

    MANAGEMENT

    1. Restoration of the blood volume

    2. Medicinal management



    PUERPERIUM

    It is the period which begins with the termination of the third stage of labor and last till the genital organs have assumed their pre-pregnancy stage which last for 6-8 weeks.



    CHANGES IN UTERUS

    1.Reduction in weight to 60 gms

    2. Reduction in size

    3. Arteries at the placenta site undergo constriction.

    4. Decidua left after delivery undergoes necrosis and entire endometrium is restored by the third week.



    THE LOCHIA

    The vaginal discharge during puerperium is called lochia which may extend up to 3 weeks. Persistence of red lochia and excessive amount of lochia should be considered seriously.

    The cervix never returns to the non gravid state, the external os is always patulous in a multipara. The vaginal outlet is markedly relaxed , hymen replaced by small tabs of tissue which cicatrise (carunculae myrtiformis) which is a characteristic sign of parity. The perineum is relaxed,pelvic floor regain tone with a certain amount of gaping of vulva.

    The puerperal bladder has a very much increased capacity and there is oedema and hyperaemia of the bladder mucosa. Striae gravidarum appear in the abdominal wall with a certain amount of laxity and flabbiness of the abdominal muscles if proper exercises are not observed.

    Milk is secreted by the mother only by the second or third day of delivery. Breast become larger, fuller, and veins become more prominent. The thin liquid secreted from the breast during the first 48 hours is rich in fat globules, lactalbumin and lactglobulin is called cholestrum.

    Return of menstrual cycle takes place after about 10 weeks of pregnancy in most lactating mothers; whereas in non lactating mothers it may be as early as 4 weeks.



    MANAGEMENT OF NORMAL PUERPERIUM

    Restoration of health of mother

    To prevent infection

    Promotion of breast feeding

    Motivation for adopting contraceptive measures



    COMPLICATION OF PUERPERIUM

    1. Puerperal sepsis:

    It is an infectionof genital tract occurring as a complication or abortion or child birth

    Clinical features:

    1.Pyrexia

    2. Tachycardia

    3. Brownish,profuse,foul smelling lochia

    4. Large and soft uterus which is tender to touch



    Treatment

    Adequate rest and sleep

    Diet should be high in calories and vitamins

    Adequate fluid and electrolyte balance

    Correction of anaemia

    Medicinal Management



    SUBINVOLUTION

    Slowing of the process of involution is known as subinvolution.

    Causes:

    Retained products of conception

    Fibroids

    Overdistension

    Caesarian section

    Prolapse of uterus

    Retroversion of uterus

    Local uterine infections

    Treatment

    Treatment of the underlying cause and medicinal management



    URINARY TRACT INFECTIONS

    Causes:

    Infections due to catheterization during labor or retention of urine

    clinical features:

    Fever with Chills and Rigor, Frequency of micturition, Dysuria, Anorexia, Nausea and Vomiting.

    Treatment:

    1.Increase fluid intake

    Medicinal management



    RETENTION OF URINE

    The causes are bruising and oedema of the urethra and bladder

    Prolonged second stage of labor

    Treatment

    Women should be encouraged to pass urine within 12 hours of delivery

    Medicinal management



    BREAST COMPLICATION

    Acute Mastitis:

    Is the inflammation of the breast which may progress into a breast abcess if not treated.

    Clinical features:

    Fever with general malice and head ache, throbbing pain and tenderness in the breast

    Treatment:

    Frequent feeding of the baby.

    Medicinal management



    VENOUS THROMBOSIS

    This is characterized by formation of thrombi in the veins which may be superficial or deep.



    PULMONARY THROMBO EMBOLISM

    A piece of thrombus may become detached in the veins of the pelvis or lower limbs and travels by the inferior venacava to the right side of the heart and via the pulmonary artery to the lungs.

    Clinical features:

    Sudden chest pain with respiratory distress, haemoptysis, cyanosis, hypotension, collapse, respiratory failure and cardiac arrest. Death may occur from shock or vagal inhibition.



    HYPEREMISIS GRAVIDARUM

    The term hyperemisis gravidarum is applied to the excessive vomiting which persists beyond 4 months and very little nourishment is retained.



    TOXAEMIAS OF PREGNANCY

    1. A/c toxaemia of pregnancy (onset after the 24th week)

    Pre eclampsia which may be mild or severe characterized by oedema, albuminura and hypertension.

    Eclampsia characterized by the above symptoms with convulsion or coma

    2. C/C HYPERTENSIVE DISEASE WITH PREGNANCY

    Without superimposed a/c toxaemia

    i. hypertension known to have antenatal pregnancy

    ii. hypertension observed inpregnancy

    b. c/c hypertensive vascular disease with superimposed toxaemia

    3. Unclassified toxaemia



    A/C MATERNAL VIRAL INFECTIONS

    Influenza

    Variola or small pox

    Rubella



    ABORTION

    Abortion is the termination of pregnancy before the foetus become viable.

    Aetiology

    Foetal factors

    Intrinsic defects of fertilized ovum

    Cystic degenerationof chorionic villli

    Haemorrhage into the deciduas

    Low quality sperm

    Maternal factors

    Infectious fevers

    Hypertension

    c/c nephritis

    Syphilis

    Diabetes

    Trauma

    Stress

    Uterine causes

    Congenital malformation of uterus

    Fibroid tumors of the uterus

    Retroversion of the uterus

    Ovarian tumors

    4. Hormonal causes

    Hormonal imbalance may cause habitual abortion

    Incompatibility of the blood of husband and wife may cause abortion.



    Clinical features

    1. Pain due to uterine contractions

    2. Haemorrhage as a result of separation of ovum

    3. Dilatation of cervix

    4. Expulsion of part or entire ovum

    Treatment

    1. Removal of product of consumption when abortion is confirmed and medicinal Management



    CORD PROLAPSE

    It is a condition where the umbilical cord lies below the presenting part

    Diagnosis:

    Feeling the cord, pulsation on vaginal examination. Sometimes cord can be seen outside the vulva

    Management:

    No management is required when the baby is dead or foeatal survival rates are very less. Otherwise cord compression reduction measures should be done to improve the condition of the foetus.



    MULTIPLE PREGNANCY

    Presence of more than one foetus is refered to as multiple pregnancy.

    Twin pregnancy is the commonest form. Twin pregnancy can be monozygotic or uniovular or dizygotic or biovular. Diagnosis is confirmed by ultra sound examination.



    ECTOPIC PREGNANCY

    Implantation and development of foetus anywhere outside the uterine cavity is called ectopic pregnancy. Tubal pregnancy is the commonest form

    Clinical features:

    Short period of amenorrhoea

    Severe lower abdominal pain with or without vaginal bleeding

    Fainting attacks,pallor,

    Palpation through the fornix and no mass is usually felt.



    PLACENTA PRAEVIA

    Is the condition where the placenta is located partially or wholly within the lower uterine segment.

    Clinical features:

    Sudden painless and causeless bleeding from vagina

    Uterus is relaxed and non tender

    Foetal heart rate is decreases when the head is pushed down into the pelvis due to the embedded placental circulation by the pressure of the foetal head on the low lying placenta (stallworthy’s sign)

    Management:

    After the diagnosis is confirmed by the ultrasound, the women are advised to take complete rest, intercourse is prohibited and medicinal management is given.



    ABRUPTIO PLACENTA

    It is also called as accidental haemorrhage where the cause of bleeding is premature separation of a normally situated placenta.



    PROLONGED LABOR

    Labor is said to be prolonged if the duration exceeds 24 hours. The main causes are inefficient uterine contraction, contrcted pelvis, cervical dystocia. Malposition of foetus, congenital anomalies,uterine inertia, poor bearing down efforts, pelvic tumors.

    Management:

    1. prolonged labor can be prevented by the managing the causes accordingly.suppportive measures, maintenance of hydration, and medicinal management can be done.



    OBSTRUCTED LABOR


    Labor is said to be obstructed when there is no advance of presenting part in spite of strong uterine contractions. It may be due to mechanical obstruction due to some fault in the birth passage or in the foetus or both

  3. #3
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    thanks a lot

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    thanks.

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