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GESTATIONAL AGE & FETAL STRUCTURES ƒƒ Increased risk of maternal and perinatal morbidity or mortality
IDENTIFIED BY TVS
due to complications in the antenatal, intranatal or postnatal
period P
ƒƒ Should be monitored, managed and delivered at a tertiary care
centre for a good fetomaternal outcome
Gestational age Fetal structures
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(wks) ƒƒ Risk factors (according to Park’s 24th/e pg. 561) –
○○ Elderly primi (>30 yrs)
4 Choriodecidual thickness, chorionic sac ○○ Short statured primi (<140 cm)
5 Gestation sac, yolk sac ○○ Malpresentations, viz breech,transverse lie
○○ APH, threatened abortion
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6 Fetal pole, cardiac activity
○○ Pre-eclampsia and eclampsia
7 Lower limb buds, midgut herniation ○○ Anemia
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(physiological) ○○ Twins, hydramnios
8 Upper limb buds, stomach ○○ Previous stillbirth, IUD, manual removal of placenta
○○ Elderly grandmultipara
9 Spine, choroid plexus
ƒƒ Embryonic movements are identified as early as by 7 weeks
○○ Prolonged pregnancy (14 days after EDD)
○○ H/o previous CS or instrumental delivery
E
ƒƒ The formation of 4 chambered primitive heart & the appearance ○○ Pregnancy a/w general diseases like cardiovascular diseases,
of first heart beat occurs by 21-28 days post conception i.e. by renal disease, diabetes, liver disease, malaria, convulsions,
35-42 days (or 5-6 wks) of menstrual age.
GE asthma,HIV,RTI,STI,etc.
ƒƒ Hence, the fetal cardiac activity can be detected by TVS as early
as 6 weeks.
○○ Treatment for infertility
○○ 3 spontaneous consecutive abortions
S
ƒƒ The “Risk approach” is managerial tool for improved MCH care.
DETERMINATION OF TYPE OF TWIN PREGNANCY ƒƒ However in books of obstetrics obesity is also considered as high
risk factor in pregnancy. As the other options are straight away U
ED
ƒƒ Twin gestational sacs may be seen sonographically by as early from Park’s. So the best answer here is “b”.
as 6-7 weeks
ƒƒ Two separate fetuses can be identified 12th week onwards
ƒƒ Best time to determine chorionicity of placenta is 10-13 weeks
SECONDARY POST-PARTUM HEMORRHAGE P
ƒƒ Also known as delayed or late PPH
Features Dichorionic placenta Monochorionic
placenta
ƒƒ Uterine bleeding 24 hours to 12 weeks after delivery (ACOG -
2013b)
P
ƒƒ Common causes –
Thickness of ≥ 2 mm ≤ 2 mm
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○○ Retained products of conception (bits of placenta and

inter-twin
membranes)
membrane
○○ Infection of genital tract
No. of layers Two layers of amnion Two layers of amnion ○○ Trauma to genital tract (lacerations and haematomas)
with intervening
chorion
only ○○ Uterine artery pseudoaneurysm
○○ Placental polyp
E
Specific USG “Lambda or twin peak” “ T “ sign – ○○ Submucous myomas
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sign sign - due to triangular due to 2 layers of amnion ○○ Chronic inversion of uterus
projection of chorionic being at right angle with ○○ Trophoblastic disease
tissue between 2 the placenta, without ○○ Coagulopathies (including von Willebrand’s disease)
EX

layers of amnion, at
the base of membrane
any placental projection
or intervening chorion
ƒƒ Management – clinical assessment and investigations to establish
the cause of secondary PPH E
○○ Clinical assessment (vital parameters, pallor, uterine tenderness
HIGH RISK PREGNANCY and subinvolution, offensive lochia, lower genital tract
examination for signs of trauma, retained POCs, haematomas,
foreign bodies viz. forgotten sponges)
N
ƒƒ Definition – pregnancy which is complicated by factors that
○○ Investigations (CBC, coagulation profile, vaginal swab c/s,
adversely affect the pregnancy outcome – maternal or perinatal
or both
pelvic USG to detect retained POCs)
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○○ Medical management (with oxytocin, methylergonovine, ƒƒ Liver is small, soft, yellow and greasy with deposition of
prostaglandin analogue along with broad spectrum antibiotic)
preferred in a stable patient with USG showing empty uterine
microvesicular fat droplets that ‘crowds out’ normal hepatocyte
function P
cavity). ƒƒ May be due to deficiency of long chain 3-hydroxyacyl-Co
○○ Surgical management (gentle suction curettage) indicated A dehydrogenase (LCHAD) due to genetic mutations on
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in patients with heavy bleeding, recurrent bleeding, sepsis, chromosome 2 → accumulation of medium and long chain fatty
subinvolution. acids
ƒƒ Autosomal recessive inheritance, heterozygous mothers with
ACUTE FATTY LIVER OF PREGNANCY homozygous fetuses
ƒƒ Clinical features –
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ƒƒ Rare condition (1 in 10,000) occurring in late 3rd trimester of ○○ Non-specific – upper abdominal pain, persistent nausea and
pregnancy vomiting, anorexia, progressive jaundice
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ƒƒ Also called acute fatty metamorphosis or acute yellow atrophy ○○ Specific – rapid deterioration, profound hypoglycemia,
ƒƒ Commonest cause of acute hepatic failure during pregnancy with hepatic encephalopathy, hepatic failure, renal failure, severe
a high maternal and perinatal mortality coagulopathy and haemorrhages, coma and death
ƒƒ Differential diagnosis – E
Parameters Acute viral hepa- Acute fatty liver of pregnancy Intra hepatic cho- HELLP syndrome
titis lestasis of pregnancy
S. transaminases 400-4000 IU/L
GE
200-800 IU/L < 200 IU/L < 300 IU/L
S
S. bilirubin 5-20 mg/dl 4-10 mg/dl 1-5 mg/dl 2-4 mg/dl

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Coagulopathy - + - +

Other specific features Pruritus, elevated bile Hypertension, P

Viral markers Hypoglycemia, renal failure, coma acids proteinuria, edema,
positive thrombocytopenia,
hyperuricemia P
ƒƒ Treatment – early diagnosis and aggressive supportive care

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ƒƒ Definitive treatment – delivery → arrests hepatic function deterioration

PERIPARTUM CARDIOMYOPATHY ○○ Unknown

○○ Potential causes – viral myocarditis, abnormal immune
ƒƒ Diagnostic criteria – response to pregnancy, abnormal response to increased E
○○ Cardiac failure in the last month of pregnancy or within 5 haemodynamic burden of pregnancy, oxidative stress during
months of delivery pregnancy, hormonal interactions, antiangiogenic factors,
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○○ No identifiable cause for cardiac failure malnutrition, inflammation, and apoptosis

○○ No recognizable heart disease prior to last month of pregnancy ƒƒ Clinical features-
○○ Left ventricular systolic dysfunction as evidenced by ○○ Young (20-35 years) multiparous patients
EX

echocardiography-
–  Ejection fraction < 45%
○○ Symptoms – weakness, breathlessness (at night also),
palpitation, cough E
–  Left ventricular dilatation (end diastolic dimension > 2.7 ○○ Signs – tachycardia, arrhythmia, signs of CHF
ƒƒ Treatment – bed rest, digoxin, diuretics, salt restriction, oxygen,
cm/m2 )
ƒƒ Incidence – 1:3500 to 1:5000 deliveries ACE inhibitors and β blockers (postpartum), anticoagulants
ƒƒ Pregnancy poorly tolerated, vaginal delivery preferred
N
ƒƒ Etiology –

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PRE-IMPLANTATION GENETIC TESTING tube is excised. The ligated proximal stump is buried beneath the

ƒƒ The technique requires one or more cells that may be obtained at

serous coat. Distal stump is open in peritoneal cavity.
ƒƒ Irving : the tube is ligated on ethier side and mid ortion of tube P
different stages of development. The chromosomal composition is excised. The free medial end is turned back and buried in
posterior uterine wall creating a myometrial tunnel.
of the oocyte may be inferred from that of the extruded polar
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bodies. One or two blastomeres may be removed from cleavage ƒƒ ESSURE: Hysteroscopic tubal ligation with nickel titanium alloy.
stage embryos. Biopsy of the trophoectoderm can also be
performed at the blastocyst stage. In the most common scenario
(cleavage stage embryo biopsy), a laser or a dilute solution of
acid Tyrode’s solution is used to create a small hole in the zona
i
pellucida and one or two cells are aspirated, typically on the third
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day after oocyte retrieval and fertilization when embryos are at
the 6–8 cell stage.
ƒƒ PGD can be performed on polar bodies removed from oocytes
before fertilization (preconception diagnosis) or on blastomeres
or trophoectoderm removed from embryos before transfer. E
ƒƒ To detect abnormalities in embryos, one or two nucleated cells
are removed, typically on the third day after fertilization (the 6–8
cell stage), before compaction when the blastomeres become
more tightly adherent
GE
NACO GUIDELINES
S
ƒƒ For Prevention of Parent to Child Transmission (PPTCT) of HIV
using Multidrug Anti-retroviral Regimen
U
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ƒƒ Updated in December 2013, effective from 1st January 2014
ƒƒ Time for starting –
○○ ART should be started immediately after detection P
○○ ART should be started irrespective of the following-
– Gestational age
– CD4 count
– WHO clinical stage
P
ƒƒ Eligible candidates for ART- all HIV positive pregnant and
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lactating women requiring ART for –

○○ Their own sake
○○ Prevention of mother to child transmission
ƒƒ Duration of ART – should be continued lifelong
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STERILIZATION TECHNIQUES IN FEMALES
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ƒƒ Fimbriectomy is done in Kroener procedure : ampullary end of

tube is ligated and dissected .
ƒƒ Pomeroy : a loop is made by holding the tube by an allis forceps
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such a way that the major part of loop consist mainly of isthumuns
and ampullary part . about 1-1.5 cm of loop is excised (Loop-
E
ligate-cut)
ƒƒ Modified Pomeroy : Loop-ligate-cut and crush the end.
ƒƒ Uchida : a saline solution is injected subserosaly in the mid N
portion of tube to create bleb. The serous coat is incised along the
antimesentric border to expose the muscular tube about 3-5 cm of
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RETRACTORS IN OBG CALCULATION OF EXPECTED DATE OF DELIVERY
ƒƒ Naegele’s formula
P
○○ Calculated from 1st day of last menstrual period (LMP) in a
woman with regular cycles
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○○ By adding 280 days or 9 calender months and 7 days to the 1st
day of LMP
○○ A quick estimate can be made by adding 7 days to the 1st day
of LMP and subtracting 3 months
○○ Accuracy of prediction 50% within 7 days on either side
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○○ Limitations – irregular cycles, conception during lactational
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amenorrhoea, conception immediately following stoppage of
oral contraceptives
Czerny retractor ƒƒ Pregnancy following single act of fruitful coitus – by adding 266
Jolls retractor
days to the date of coitus
ƒƒ Pregnancy following ovulation induction and infertility treatment E
– add 266 days to date of intrauterine insemination (IUI) or in
vitro fertilization- embryo transfer (IVF-ET)
GE ƒƒ Date of quickening – by adding 22 weeks in a primigravida
and 24 weeks in a multipara to the date 1st appreciating fetal
Morris retractor Deaver’s retractor
movements. Limitation – all women not equally sensitive to
quickening
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These Updates are from Primes Supplement 2018