OSCE

GESTATIONAL TROPHOBLASTIC DISEASE

 Snow storm appearance on US (Molar

pregnancy – Hydatidiform mole).
 Diagnosis : Gestational trophoblastic
disease (Hydatidiform mole).
 Types : Hydatidiform mole (Complete
mole, Partial mole), Invasive mole,
Choriocarcinoma, Placental site
trophoblastic tumor.
 Genetic composition :

Complete Mole  Diploid, androgenic in

origin, No fetal tissue.

Duplication of Single sperm following

fertilization of an empty ovum / Dispermic
fertilization of an empty ovum.

Partial mole :
Triploid / tetraploid in origin, with two sets
of paternal haploid genes and one set of
maternal haploid genes, Fetal tissue present.

Dispermic fertilisation of an ovum.

 Clinical manifestations :

Irregular vaginal bleeding

Hyperemesis

Excessive uterine enlargement

Early failed pregnancy

 Serum hCG >100,000 mlU/ml

 Treatment :

Suction D & C to evacuate uterine

contents.
  Baseline quantitative beta hcg titer
 Supportive therapy

 Counselling for regular follow up –

If hCG has reverted to normal within 56 days of the pregnancy event then follow
up will be for 6 months from the date of uterine evacuation.

If hCG has not reverted to normal within 56 days of the pregnancy event then
follow-up will be for 6 months from normalisation of the hCG level.

hCG levels are measured 6-8 weeks after the end of the pregnancy to exclude
disease recurrence.

Advice the patient not t get pregnant for atleast 6 months, following negative hcg
titer. Can use combined OCP.

 Risk factors :

Asian

Advanced / very young maternal age

Previous molar pregnancy

Increased risk of malignant transformation of CHM/PHM if using combined oral

contraceptive pill while hCG levels remain elevated

Familial/sporadic clusters of biparental complete hydatidiform mole

 Complications :

Hemorrhage & shock

Sepsis

Perforation of uterus

Pre eclampsia
  Differential diagnosis :

Threatened abortion

Fibroid or ovarian tumor in pregnancy

Multiple pregnancy

ECTOPIC PREGNANCY

Decidual cast
  Etiology / Risk factors :
 Clinical features :
Pelvic inflammatory disease
Unruptured :
Congenital factors
Unilateral pelvic Abdominal pain
Salpingitis isthmica nodosa
Amenorrhea
Previous tubal surgery
Vaginal bleeding
Assisted reproductive techniques.
Ruptured :
Intra uterine devices
Patient will be shock
Cigarette smoking
Inra peritoneal bleeding ( Cullen sign) &
Previous ectopic Irritation

Hypotension & tachycardia

 Diagnosis :
 Management :
Beta Hcg titer > 1500 mIU
Unruptured ectopic :
No intra uterine pregnancy with vaginal
sonogram Medical :
Unruptured ectopic : Methotrexate
Transvaginal ultrasound  single dose 50mg/m2
Empty uterus Criteria for giving methotrexate :
Adnexal mass with free fluid Beta hCG < 6000 mIU
Bagel sign-- gestational sac in the adnexa No FHR
surrounded by a ring or halo
Pregnancy mass < 3.5 cm
Ring of fire appearance by color doppler
 Repeat beta hcg on day 4 and day
5
 There should be a fall of serum
beta hcg 15% by day 7 or else
repeat the dose.
 If fall is more than 15% do
weekly till negative
 Follow up
Surgical : if any sign of rupture, FHR +ve, size of sac > 3 cm, serum beta Hcg
>5000 mIU

● Laproscopy

Conservative : Linear salpingostomy

Management : Ruptured ectopic :

H/O amenorrhea + Vaginal bleeding + abdominal pain + hemodynamically

unstable  laparoscopy + Salpingectomy

Rh –ve woman should be given RhoGAM

RUPTURED ECTOPIC

UNRUPTURED ECTOPIC
Conservative surgery for ectopic pregnancy Linear salpingostomy

Heterotopic pregnancy

 Ectopic pregnancy co exists with

intrauterine pregnancy.

 Incidence more with ART

Cervical pregnancy

Pregnancy implants in endocervical canal below the internal os

● An empty uterus,

● A barrel-shaped cervix,

● A gestational sac present below the

level of the internal cervical os,

The absence of the ‘sliding sign’ and

blood flow around the gestational sac
using colour Doppler.

 Med managmnt with Methotrexate /

Uterine artery embolization /
hysterectomy (last option)

Ovarian pregnancy

● Ipsilateral tube is intact

● Ectopic pregnancy should occupy the ovary

 ● Ectopic pregnancy is connected by the uteroovarian ligament to the uterus

● Ovarian tissue can be demonstrated histologically amid the placental tissue

Management :

Laparoscopic --- enucleation or wedge resection .

Methotrexate

Cessarian Scar pregnancy

TWIN PREGNANCY

DETERMINATION OF CHORIONICITY BY ULTRASOUND

 Division takes place within 72 hours after fertilization  Diamniotic
Dichorionic ( Lambda / Peak sign )

 4-8 days  monochorionic diamniotic ( T sign on US)

  Division takes place after 8th day of fertilization.  monoamniotic-
monochorionic ( 8-13 )

 Division occurs after the development of embryonic disc

 - conjoined twin – Siamese twins

Symptoms :

 exaggerated symptoms of pregnancy

 Unusual rate of abdominal enlargement

 Excessive fetal movements by mother.

Differential diagnosis :

 Hydramnios

 Big baby

 Pregnancy with fibroid or ovarian tumors

 Pregnancy with Ascitis

Complications :

Fetal :

 Growth restriction
 Congenital anomalies
 Preterm deliveries
 Monoamniotic twin pregnancy  Inter twin cord entanglement, Conjoined
twins , TTTS

Maternal :

Anemia, pre eclampsia, Hydramnios, APH, GDM, Thromboembolic disease

Early Rupture of membrane, Cord prolapse, Prolonged labourPPH

Failig lactation, Sub involution, Infection

Twin to Twin transfusion Syndrome

Treatment :

by giving Blood transfusion to anemic baby and removal of blood at the rate of 5
ml per 30min till the venous pressure comes to normal from plethoric baby.

Management :

ANTENATAL :

 Diagnose at the earliest

 Diet advice

 Supplementary therapy like Iron, FA, Calcium

 More Frequent antenatal visits

 Avoid physical & mental strain

 May need hospitalization if developing complicating factors.

LABOUR – 1st stage

  Well equipped hospital with intensive neonatal care unit.

 Kept in bed, withheld enema to prevent early rupture of membrane

 Careful fetal monitoring

 Internal examination, soon after rupture of membrane to exclude cord

prolapse

 Bottle of blood cross matched should be preserved.

2nd stage

 Not to give ergometrine with birth of first baby

 For 2nd baby look for lie ,presentation,fetal size & heart rate. May be
artificial rupture of membrane after fixing the presenting part

3rd stage

 Ergometrine after birth of 2nd baby

 Removal of placenta

 Watched for 2 hours postpartum

Indications for C section :

 Contracted Pelvis

 Placenta previa

 Severe Toxemia

 Previous Cesarean section

 Cord Prolapse

 Abnormal uterine actions

  First baby with non cephalic presentation

 Conjoined twins

LILEY’S CHART
To check for hemolytic disease in fetus in case of Rh isoimmunization

PLACENTAL ABRUPTION

Clinical symptoms :

Late trimester painful bleeding

Risk factors :

Previous abruption, HT, Maternal blunt trauma, PROM, Smoking

Managemnt :

Emergency C section – if maternal / fetal jeopardy is present

Vaginal delivery - If bleeding is heavy but controlled / pregnancy > 36wks.

Perform amniotomy & induce labour.

Complications :
DIC , Acute tubular necrosis, Couvelaire uterus.

PLACENTA PREVIA

Clinical features :

Common in early pregnancy but not associated with bleeding.

Painless ;ate trimester bleeding can happen

Uterus is non tender, non irritable

Risk fact :

Prev placenta previa, multiple gestation, Advanced maternal age, multiparity

Manangement :

Emergency C sec – if maternal / fetal jeopardy present

Conservative in hospital observation

Complications :

Sheehan syndrome
Acute tubular necrosis

VASA PREVIA

 Rarely confirmed before delivery

 Clinical presentation : Rupture of membrane , painless vaginal bleeding,
bradycardia
 Risks : Velamentous insertion of umbilical cord, accessory placental lobes,
multiple gestation.
 Managemnt : immediate C sec

SCREENING FOR CONGENITAL ANOMALIES

Nuchal translucency  11 -13 weeks

Ultrasound – 2D
Amniocentesis :

 performed between 15-20 weeks of pregnancy.

 To diagnose fetal chromosomal anomalies after ultrasound or biophysical
markers have determined significant likelihood that the fetus will be
affected.
 Advance maternal age
 Previous baby with chromosomal abnormality

Risks : fetal loss and maternal Rh sensitization.

Chorionic villus sampling

 performed very early in gestation between 9-12 weeks, ideally at 10 weeks'

gestation.

Advantage of CVS over amniocentesis :

 getting quick results and its use in early pregnancy.

 Abnormalities can be identified at an early stage.

Disadvantages of CVS
  2- 3 % risk of miscarriage
 Rarely limb defects in the fetus
 Maternal sensitization


Percutaneous umbilical blood sampling ( cordocentesis)

 method for fetal blood sampling and is performed after 16 weeks' gestation

ABNORMAL UTERIN BLEEDING

PCOS

Fibroid

Polyp
 Normal uterus

Hysteroscopy – To diagnose Abnormal uterine bleeding

High risk patient who had a failed Pipelle ( endometrial biopsy)

Negative Pipelle but continuing symptoms

Ultrasound findings inconclusive for endometrial pathology

Failure of primary treatment

Prior to endometrial ablation

POLYHYDRAMNIOS

Causes :

 Idiopathic

 Fetal Anomalies – Anencephaly, spina bifida,

 Diabetes

 Multifetal gestation

 Immune/Non-immune hydrops

 Fetal infection

 Placental haemangiomas

Symptoms :

 Dyspnea

 Abdominal pain

 Venous stasis
  Contractions  preterm labor

 Decreased Perception of Fetal

Movements

Diagnosis :

 Fundal height > gestational age

 Difficulty palpating fetal parts/hearing

heart tones

 Tense uterine wall

 ***Sonography

Treament :

 Mild to Moderate hydramnios: rarely requires treatment

 Hospitalization, bed rest

 Amniocentesis

 Non-steroidal anti-inflammatory analgesia

 Blood sugar control

OLIGOHYDRAMNIOS
Etiology :

 Postdate

 Fetal Anomalies: obstruction of fetal

urinary tract/renal agenesis

 IUGR

 ROM

 Twin/Twin transfusion

 Exposure to ACE inhibitors, and

 Non-steroidal anti-inflammatory

Signs / Symptoms :

 Fundal height < gestational age

 Decreased fetal movement

 Fetal Heart Rate tracing abnormality

 Diagnosis: Ultrasound

Complications :

 Extremely poor fetal prognosis, especially in early pregnancy

 Adhesions between amnion and fetal parts ---malformations and

amputations

 Musculoskeletal deformities

 Pulmonary hypoplasia

 Cord Compression -- >fetal hypoxia

 Passage of meconium into low AF volume: thick particulate suspension --

>respiratory compromise
Treatment :

 Delivery
 Amnioinfusion


IUGR
INDUCTION OF LABOUR

Atad Ripener Device

NORMAL LABOUR
Delivery of shoulders

Downward traction Delivery of anterior shoulder

Upward traction

Delivery of the posterior shoulder

Diameter in vertex presentation : Sub occipito bregmatic (9.5cm)

Diameter in Brow presentation : Mento vertical (13 cm)

Diameter in face presentation : submento bregmatic (9.5cm)

PID

C. trachomatis Infection (PID)

COMPLICATION OF 3rd STAGE OF LABOUR

UTEROVAGINAL PROLAPSE
Stages :

Normal – external os lies at the level of ischial spine.

Grade 1 – cervix descends halfway to hymen

Grade 2 – cervix descends to hymen

Grade 3 – cervix extends halfway past the hymen

Grade 4 / Procedentia – entire uterus , anterior , posterior vaginal walls extend

outside introitus.

OR

POPQ system of staging

Stage 0 – No prolapse

Stage 1 – leading edge descends to 1cm above hymen

Stage 2 - leading edge descends to within 1 cm of hymen

Stage 3 – leading edge extend s > 1 cm beyond hymen byt <2cm of total vaginal
length

Stage 4 – complete eversion, leading edge >2cm of total vaginal length

Nonsurgical Therapy

▪ Life style modifications

▪ Pelvic floor exercises – kegal exercise

● Vaginal support device(pessary)

supportive(ring)

space occupying(doughnut, cube,inflatoball)

Surgical :

Sacral colpopexy –

complications : intraoperative bleeding from sacral vessels

bowel obstruction due to mesh (1.1%) mesh erosion rate

Vaginal hysterectomy repairs uterine prolapse

Anterior vaginal repair repairs cystocele

Posterior vaginal repair for rectocele

Anterior and posterior colporraphy

➢ Uterosacral ligament suspension  complicaton : Ureteric injury

11%, usually kinking rather than transection

Pre disposing factors :

Vaginal child birth

Aging

Decresed estrogen
Following pelvic surgery

Ethnicity

Collagen disorders

Procidentia uterus

Degrees of pelvic organ prolapse. A. Stage 2. This stage is defined by

the most distal edge of the prolapse lying within 1 cm of the hymenal ring.

B. Stage 3. This stage is defined by the most distal portion of the prolapse
being >1 cm below the plane of the hymen, but protruding no farther than 2
cm less than the total vaginal length in centimeters.

C. Stage 4. This stage is defined as complete or near complete eversion.

Colpoclesis

( Step 1, 2, 3 Resp)

Step 4, 5, 6

Step 7, 8, 9
SHOULDER DYSTOCIA

McRoberts Position
Supra pubic pressure

Shoulder dystocia

Risk factors :

• Previous shoulder dystocia.

• Prolonged first stage of labour

 • Macrosomia > 4.5 kg

• Diabetes mellitus

• Prolonged second stage of labour

• Maternal body mass index > 30 kg/m2

• Oxytocin augmentation, induction of labour

• Assisted vaginal delivery.

Management :

• Immediately after recognition of shoulder dystocia, additional help should

be called.

• The problem should be stated clearly as ‘this is shoulder dystocia’ to the

arriving team.

• Fundal pressure should not be used.

• McRoberts’ manoeuvre is a simple, rapid and effective intervention and

should be performed first.

• Suprapubic pressure should be used to improve the effectiveness of the

McRoberts’ manoeuvre.

Complications :

Baby :-

– Brachial Plexus injury

– Humerus and clavicle fracture

– Pneumothorax

– Hypoxic acidosis

– Hypoxic brain damage

Mother :-
PPH

3rd or 4th degree perineal tear (Vaginal lacerations, cervical tear)

Bladder rupture

Uterine rupture

Lateral femoral cutaneous nerve neuropathy.

AMENORRHEA

PCOS
 Hirsuitism

DIAGNOSTIC CRITERIA :

• Oligomenorrhea / menstrual dysfunction

• USG - ovarian volume > 10 mm 3, 12 or more follicles 2- 9 mm in

diameter.

• Clinical or biochemical features of hyperandrogenism

Mnagement :
Irregular bleeing – give OCPs

Hirsuitism – Spirinolactone

If infertility – Clomiphene citrate

CONTRACEPTION

OC pills

 Combined pills – Estrogen + progestin

 Progestin only mini pills – side effects  bleeding

Implants

 Side effect – breakthrough bleeding

 Uses etonogestrel as active ingredient
IUCDs

Lippes loop

Risk factors

 recent chlamidia infection

 Leiomyomas ( C/I)
 Ectopic pregnancy
 Septic abortion

Sterlization methods

Tubal ligation

Vasectomy
Hysteroscopic sterilization
Pregnancy with IUCD in situ
CIN

Cervical cancer

A macroscopically apparent squamous cell

carcinoma of the cervix stage IB2 seen on a posthysterectomy specimen
Lesion : Carcinoma of cervix

Method of prevention : 9 Valent HPV recombinant vaccine ( Gardasil 9) , 3 doses

– initial, 2 months later, 6 months later for all females age 9-26

Screening programme : cervical smear test as a screening tool for detecting pre-
malignant disease of the cervix.

• women between 25 and 49 years every 3 years

• women between 49 and 64 years every 5 years.

• Women whose smear results report borderline changes (of squamous or

endocervical type) or low-grade dyskaryosis are given a HR-HPV test.

• When the woman is determined to be high-risk HPV positive, she is

referred for a colposcopy, and women who are high-risk HPV negative are
returned to routine recall.

Risk factors :

 The major risk factors for cervical cancer are early onset of sexual
activity and multiple sexual partners.

• low socioeconomic class (see NCIN press release, 2008)

• cigarette smoking

• oral contraceptive pill

• sexually transmitted diseases, particularly human papillomaviruses

(HPV)

Clinical features :

• postcoital or intermenstrual bleeding

• persistent vaginal discharge, which may be bloodstained

• postmenopausal bleeding.
 In these patients, a speculum examination may reveal an obvious cervical
tumour but an appropriate biopsy is still required to confirm the diagnosis.

• backache, leg pain (due to nerve involvement), haematuria (due to extension

of tumour into bladder), bowel symptoms, malaise and renal failure (ureteric
involvement).

Treatment :

• For stage IA1 cancer, a loop excision may be adequate as long as the
excision margins are clear.

• For stage IA2 cancer the standard treatment is radical hysterectomy with
bilateral pelvic lymphadenectomy.

• For stage IB or IIA disease, treatment is guided by suitability for major

surgery and the patient’s preference.

• Options include radical surgery or radiotherapy.

• Management of stage IIB to IVA cancer is by radical chemo–radiotherapy.

• Management of stage IVB cancer is usually by palliative radiotherapy.

Stages of Carcinoma cervix :
ADNEXAL MASS

Endometrioma

Ovarian cyst
Fibroids

Submucosal fibroid cause heavy bleeding

Intramural fibroid

Subserosal fibroid – no bleeding

Fibroids in pregnancy :

• Pressure symptoms like on the bladder (retention of urine) and on the

rectum (constipation)

• Malpresentation

• Interfere with enlargement of the uterus, initiate abnormal

contractions

• Abortion

• Preterm labor

• Red degeneration

• Placental abruption
INSTRUMENTS

Vaginal swab

Cusco’s speculum

 In pap smear, to check cervical

abnormalities
 No assistance needed
 To visualize cervix and vaginal foenices
to check polyp, ectopy.

\
Sim’s speculum

 Used for curettage &

evacuation
 For retracting vaginal wall
 To clean vagina following
delivery

Vulsellum
  To pinch anterior lip of cervix
 Used in curettage

Uterine sound

 Introduce into cervix

 To know position f uterus and length
of uterine cavity
 To sound uterine cavity to detect
foreign body
Hegars dialator

 Dialatation of cervix prior to

evacuation.
 To diagnose cervical weakness

Suction curettage

 Used for S + E
Sponge holding forceps

 Used in curettage
 To catch/hold cervix in cervical
cerclage

More chance of perforation

Von Wilkinson’s cannula

  Used in hysterosalpingography to
check for tubal patency

Uterine curette

Forceps

 For instrumental delivery

 To shorten 2nd stage of labour
 Extraction of head of baby
Cervical cytobrush Liqid base dcytology/ative medium

Used in pap smear

Vaccum ( ventouse cup)

 For vaccum extraction of head

during delivery

MEDICATIONS

Oxytocin

Methergine

Misoprostol( PGE1)

Carboprost ( PGE2alpha)

Mg Sulfate

Monitoring parameters : Toxicities :

RR > 12/MIN Resp depression

Urine output > 30ml/hr Neuromuscular paralysis

Presence of deep tendon reflex Renal suppression

Antidote : Ca gluconate
Serum level of mg should be <10mEq/L