MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES

CLINICAL GUIDE IN OBSTETRICS AND GYNECOLOGY

AUTHOR; ELTON ROMAN, MD (2013-2018)

Email; ellierolland@gmail.com

PREPARED DURING OBS AND GYN ROTATION MAY 2018.

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 A SHORT INTRODUCTION
These are just summaries of different clerkships in obstetrics and gynecology department and
some important aspects of discussion about the particular diagnosis. They are common clinical
cases that one might encounter in obstetrics and gynecology department. I found this worthy
during my ample time to leave behind something that others can quickly refer especially when it
is their first exposure to clinical rotation.

Contents in this document are for use among clinical students if it pleases them. It has been my
pleasure sharing moments with so many people during my stay at MUHAS and I would love to
recognize their untiring support and encouragement during my stay. I dedicate this to my
beautiful classmates and teachers.

Special thanks to my lovely friends Francis Kazoba, Humphrey, Cornel Sizimwe, and Davis Amani for their
unconditional support. A Special recognition to our lovely CR Eveline Ngoli for making obstetrics and
gynecology a smooth eight weeks of learning. Life is always beautiful, with good people around, and I
have always been grateful to my golden girl Victoria for her charming company.

How can I be so rude not to mention TAMSA and JKM for they have made me grow both academically
and spiritually.

I would like to share a story called “kiss” which means a lot to me. Sometimes simple things mean a lot in
life and they last long. if you happen to hear a song by Kenny Rogers called “buy me a rose” you would
appreciate this. The story goes by the name kiss.

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 THE KISS
Getting late for a meeting, need to run, he said as he slung his white coat over the shoulder, and
bounded out of the house. As he drove away, she came back running down the stairs two at a time and
screamed “wait, wait, she said but he had already left’’. Her mouth crumpled like used wrapping paper.
‘he forgot to give me a good bye kiss, she whispered in the voice that trembled under the weight of her
hurt. She called him ‘you left without giving me a kiss’, she said accusingly. ‘iam sorry sweet heart’ he
said humbly. ‘its okay’ she said trying to be grown up as she cut the call.

She gulped down her breakfast, wore her shoes, picked up her school bag and started to walk out of the
door, her shoulders slumped. As she climbed down the steps, the car glided to a stop outside the house.
He got out of the car. She ran to him, her all face lit up like christmass tree.

‘I am sorry I forgot’ he said, as he picked her up and hugged her. She said nothing. Her jaw ached from
smiling.

Fifteen years later no one would remember he was late for a meeting, but this little girl would never ever
forget that her father drove all the way back home to kiss her goodbye.

The end of the story….

So maybe someday someone will remember I wrote this after he or she has finished his or her medical
school.. Good deeds will save me a seat in heaven I believe.

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Contents
A SHORT INTRODUCTION.............................................................................................................................. 2
THE KISS ........................................................................................................................................................ 3
HISTORY TAKING ........................................................................................................................................... 5
PHYSICAL EXAMINATION .............................................................................................................................. 8
1. GENERAL EXAMINATION ................................................................................................................... 8
2. LOCAL EXAMINATION ....................................................................................................................... 8
3. SYSTEMIC EXAMINATION .................................................................................................................. 8
CASE ON PRE LABOR RUPTURE OF MEMBRANES ....................................................................................... 12
DISCUSSION ON THE CASE ...................................................................................................................... 14
CASE ON CERVICAL CANCER ....................................................................................................................... 17
DISCUSSION............................................................................................................................................. 19
CASE ON HEMMORHAGE IN EARLY PREGNANCY ....................................................................................... 22
DISCUSSION............................................................................................................................................. 24
CASE ON ANTEPARTUM BLEEDING ............................................................................................................. 28
DISCUSION .............................................................................................................................................. 30
PRE ECLAMPSIA AND ECLAMPSIA ............................................................................................................... 32
INDICATIONS OF CAESARIAN DELIVERY ...................................................................................................... 36
ANEMIA IN PREGNANCY ............................................................................................................................. 36
POSTPARTUM HEMMORHAGE ................................................................................................................... 37

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HISTORY TAKING
1. Particulars of a patient

 Name of the patient- introduce the patient by three names.

 Age of the patient- in years. For pediatric patients can be in months, weeks or years as
well.

 Sex- do not ignore as some patients are trans gender or hermaphrodites. Some disease
are more prevalent in certain sex, example breast cancer is common in females.

 Residence – It’s important to know where the patient comes from because it can tell the
diagnosis also. Some diseases are common in certain areas, example Schistosomiasis is
common in lake zone.

 Religion- this is not so much important but if one asks its best to mention. It could help
in some diagnosis. Possibly not to think of pig tape worm among Muslims.

 Hospital registration number is also important and the ward the patient is residing for
easy allocation. If possible with the bed number. ( but this is not so important for you as
a student in your clinical exams presentation)

 Parity and gravidity-gravidity referring to the number of times this woman has been
pregnant. If it is her second pregnancy then you report gravid 2. Parity is the number of
live births. If this is her third pregnancy and had previous two live births you report as
gravid 3 para 2. (G3P2). If this is her third pregnancy and she had one live birth and one
abortion you write (G3P1+1) that means one live birth plus an abortion.

 Last normal menstrual period- is important to estimate the expected the date of
delivery for pregnant women. So you ask when was her last menstrual period. Example
it was 3/1/2017. To get the expected date of delivery (EDD) we use naegele’s rule by
adding one year, substracting three months and add seven days to the LNMP. So when
we add one year there we get 2018, substracting three months it becomes October and
adding seven days to date it becomes 10. So EDD is 10/oct/2018.

 Expected date of delivery.

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2. A short introduction of a patient/an opening statement- this includes mentioning the number of
days the patient has stayed in the ward, if referred where is he or she referred from and a referral
diagnosis if possible. ( In an exam setting you may not be able to see the file or see the referral letter
so its best you end up mentioning from where he or she is referred otherwise examiners will poke
your eyes). In the introduction remember mentioning if it’s a re-admission at that hospital or it’s the
first one. If it’s a re-admission remember to ask for the reason of previous admission and the
condition at discharge if possible get a look at the discharge summary at the file. Mention if there is
any chronic illness that is known of the patient. Example known patient with HIV on
regular/irregular medication for 3years now.

3. Main complains- this is what brought the patient to hospital. So ask the patient, what made you
seek health care today? It could be that the patient has pain for the past six months, but why didn’t
he come last month? So did it worsen to necessitate him or her to attend the hospital? Remember
to put complains in an order from the one which begun first to the recent one. If all complains
started at the same time then arrange them in the order of severity, beginning with the most severe
symptom.

4. History of presenting illness- this is the story of the current illness. How it started, when, anything
that gives a relief of the condition, anything that worsens the condition and whether there are
accompanying symptoms. This helps you arrive at the diagnosis. Take an example of a patient having
a swelling at the forehead. He tells you it has been there for the past two hours, grew up slowly,
painful, nothing worsens it but has been massaging it and it is fading away.

It was preceded by a fist from an angry loyal citizen that hit his forehead. There you definitely know the
diagnosis. The rule here is DONPARA

 D- DURATION

 O-ONSET

 N-NATURE OF THE CONDITION

 P-PERIODICITY

 A-AGGREVIATING FACTORS

 R-RELIEVING FACTORS

 A-ASSOCIATED SYMPTOMS

In the history of presenting illness we also ask for risk factors regarding the diagnosis you are thinking
about, complications of the disease you are suspecting, and ask for symptoms of the disease that may
mimic the disease you are suspecting to just be sure it’s not some other disease, and this is what we call
ruling out other conditions. Mention if there are any efforts the patient has done regarding his illness
along the course and if any interventions were done and lastly ask for the progress in the ward.

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5. Review of other systems- there could be coexistence of other conditions despite the illness the
patient has. If you have more than one pathologies, sometimes one is primary the others are
secondary. So you might be dealing with renal failure only to forget this patient may have
secondarily hyper parathyroidism.

6. Pre natal history, natal and post natal history follows incase it’s a pediatric case. Pre natal history
involves asking how many times the mother attended clinic while carrying this particular baby in her
womb, what was the gestation age at her first visit and ask for any drugs given during the visits and
if there was any illness like skin rash during pregnancy to just be sure she never suffered things like
rubella. Natal history involves asking for mode of delivery, time of labor, was it at term or not as
some conditions are common among pre term such as necrotizing enterocolitis, ask for the birth
weight too in the natal history and if the baby cried and sucked immediately. Postnatal events
involves the events afterwards, so ask if the baby ever got ill, jaundice or anything. These only
appear in pediatric cases and are written under separate headings, don’t include all at once as I did
in this paragraph.

7. Immunization history- this is important in pediatric cases. This can be obtained from the RCH card.
Conclude if at all they are appropriate for the child’s age. If the child missed the vaccine we conclude
it as “missed opportunity for vaccination”

8. Developmental milestones- report what the child can do and conclude if appropriate for his or her
age. Example for a 9months old baby not be able to sit unsupported is delayed milestones.

9. In obstetrics and gynecology we don’t include the parts no. 6, 7 and 8 instead follows past
gynecology and obstetrics history immediately after history of index pregnancy.

10. Past medical history- this follows review of other systems in an adult male case, otherwise it follows
after pre natal, natal, post natal, immunization and milestones history in pediatric case. For a female
adult case it follows after past gynecological history and obstetric history and if pregnant history of
index pregnancy. Past medical history includes any history of surgery, blood transfusion or any
chronic illness. Report any illness of relevance the patient suffered in the past. Example past history
of recurrent schistosomiasis could explain the bladder ca the patient has now. Any allergy to drugs
or foods should be mentioned.

11. Family and social history- here we are interested of the conditions that run in families, if there is
any social activity that is related to the patient’s illness. Example a long distance driver is at risk of
HIV, smokers have a risk of lung cancer. Alcohol is a risk to liver cirrhosis.

12. Dietary history- mention number of meals, what he eats and amount. And has it changed since he
or she became ill.

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13. Summary of the history- remember summary is the mini skirt of the history. It should be short
enough and contains important information. It should have important positives and important
negatives. If one had a history of bleeding, mentioning in the summary that so and so with history of
bleeding and symptoms of anemia not in failure, symptoms of anemia are important positives here.
One is interested to hear did this patient bleed so much? And saying not in failure is an important
negative, atleast one wants to hear has this patient gone to failure.

PHYSICAL EXAMINATION
1. GENERAL EXAMINATION- a head to toe. Report whatever you see. Example normal
hair distribution, conjunctiva pallor, conjunctiva hemorrhage, any oral lesions such as
candidiasis, ulceration, examine the hands for stigmatas of liver or heart diseases such as
duptreyn contracture, finger clubbing, mention if there is any palpable lymph nodes and
finally lower limb edema. Lymph nodes to palpate are pre and post auricular, sub
mandibular, mental, along the borders of sterno cleido mastoid, supra and infra clavicular,
axillary and inguinal nodes.

2. LOCAL EXAMINATION- in cases of local pathologies.

3. SYSTEMIC EXAMINATION. Begin with inspection, then palpation, percussion and

finally auscultate.

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM-on inspection report respiratory rate then look for the appearance of the chest
and movement. In appearance look for scars if present, shape of the chest which normally is elliptical
with antero-posterior diameter being shorter. Observe the chest movements. Are the movements
symmetrical? Then palpate for lymph nodes (though most of the times it is covered in general
examination and therefore not reported in respiratory examination), palpate for the trachea if its central
and chest expansion. Percussion is done while comparing the two sides of the chest, start with infra
clavicular then mammary and infra mammary, then percussion of the axial and finally three areas at the
back. Normal percussion is resonant. Ascultate same areas you did percussion and finish with
auscultation of the lung basis. Normal breath sounds are reported as vesicular. (more details refer
Hutchson text book)

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CARDIOVASCULAR SYSTEM- Patient should be at lying on bed inclined at 45 degrees.

We follow an inverted J and more palatable we mention it as hockey stick approach. Begin with the
radial pulse, say the rate rhythm, synchronicity, is it of good volume and whether its collapsing or not.

Then measure the blood pressure. See if there are distended neck veins, and you may need two rulers to
measure the jugular venous pressure- with one ruler at sternal angle and the other at the highest point
of jugular pulse and the rulers perpendicular to each other. Normal jugular venous pressure is 6-8 cm of
H20 from right atrium. Then inspect precordium if there is any hyper activity, locate the apex beat in
relation to mid clavicular line, palpate for heaves and thrills and finally auscultate four areas- apex,
lower left sternal border, upper left sternal edge and upper right sternal edge and these correspond to
mitral , tricuspid, pulmonary, and aortic valves. (details are in Hutchison)

PER ABDOMEN- inspect for any scars, therapeutic marks. Report if the abdomen is distended, does it
move with respiration. Palpate to see if there is any tenderness and report according to the nine
abdominal regions eg tender at hypogastric region. Palpate for the liver, spleen and kidneys( hutchson
demonstrates well). Percussion note normally is tympanic, if dull then there is fluid or something else.
Auscultate bowel sounds. Hutchson mentions just to the right of the umbilicus is best and stethoscope
should be kept for one minute. Auscultate for vascular bruits particularly renal bruits 2cm above and
2cm lateral to umbilicus. Then finish abdominal exam with digital rectal examination.

Remember to examine the gravid uterus- that is Leopold maneuver. Leopold maneuver includes fundal
palpation to know what occupies the fundus, lateral palpation to know the lie and finally pelvic grip to
know if the baby is engaged or not.

In gynecology cases remember the per vaginal digital examination and speculum.

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CENTRAL NERVOUS SYSTEM EXAMINATION

This is the most interesting per say. So begin the higher centres. Is the patient oriented to time, place
and person. Ask him whether he is aware if its day time or night to know his orientation to time as it is
difficult one to say the exact clock time like its 1245hrs. Ask him or her of where he or she is to know the
orientation to place and finally identify if can recognize people. While talking to him you must have
known the speech so report it if its slurred, normal or mute. Report memory both long and short term
memory.

You can ask him or her if he or she recalls her forexample when his or her first child was born to assess
long term memory, you can ask her your name if you introduced yourself before you begun taking
history to see if he or she remembers and that could assess short term memory. Then examine cranial
nerves

Cranial nerve examination

We know the cranial nerves and we report their functions only. Forexample

Cranial nerve 1- can smell

Cranial nerve 2- can read from a 6metre distance, has no color blindness (if at all you had ishihara plates
to test), pupils equally in size, reactive to light and measure 2-3mm, fundoscopy not done- obviously for
a medical student to not do fundoscope.

Cranial nerve 3,4 and 6- can move eyes in all directions

Cranial nerve 5- has intact facial sensations, good contraction of the temporalis and masseters.

Cranial nerve 7- it’s the facial nerve. Report if there is any facial symmetry, can blow out the cheeks?

Cranial nerve 8- can hear

Cranial nerve 9 and 10- uvula centrally located, positive gag reflex.

Cranial nerve 11- can shrug shoulders, turn neck against resistance.

Cranial nerve 12- can protrude tongue, no fasciculations, no muscle atrophy

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MOTOR EXAMINATION

Mnemonic is BIG TPR.

B-Bulkiness of all groups of muscles in upper and lower limbs

I-see if there are any Involuntary movements

G-observe the GATE

T-mucle Tone

P-Power in all groups of muscle

R- Reflexes both superficial and deep tendon reflexes ie knee, ankle, elbow and wrist places you hit with
patella.

COORDINATION

Assess coordination- finger to nose test, or heel to shin test.

SENSATION

Then test for sensation following the dermatomes.

GO THROUGH THIS LINK FOR MORE ON CNS EXAMINATIONS OR HUTCHSON-

https://googleweblight.com/i?u=https://meded.ucsd.edu/clinicalmed/neuro2.htm&hl=en-

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CASE ON PRE LABOR RUPTURE OF MEMBRANES
NAME: PATIENT MMM

AGE: 24 YEARS

SEX: FEMALE

RESIDENCE:VIJIBWENI

OCCUPATION: HOUSEWIFE

CLERKED ON 2018.

LAST NORMAL MENSTRUAL PERIOD (LNMP) -17/11/2017.

EXPECTED DATE OF DELIVERY 24/08/2018

GESTATION AGE: 32 WEEKS

PARITY: GRAVIDA 2 PARA 1 LIVING 1 (G2P1L1).

Referred from Vijibweni Hospital for further management.

Chief complain: watery discharge per vaginum

HISTORY OF PRESENTING ILLNESS

The patient was well until 2 weeks ago when she presented with an acute onset of abnormal vaginal
watery discharge, not stained or mixed with blood, non foul smelling, it started as a gush of clear fluid
and as time went on she reports that it trickles along the thigh up to the legs. Currently she reports
changing up to 3pads per day not fully soaked. Its not periodic, aggravated by standing and walking and
relived by rest.

There is no history of abdominal pain prior to the onset of the discharge, and no reported history of
abdominal pain since she was discharged.

No history of fever prior to the onset of discharge, neither does she have it now. She has no history of
increased frequency of voiding, painful voiding or passage of urine mixed with pus. No history of
abnormal foul smelling discharge per vaginum prior to this.

No history of previous pregnancy losses or similar history in the previous pregnancy. Not known to have
cervical incompetency and has never delivered pre term baby.

There is no history of trauma.

The mother reports the fetal kicks are present and have not been reduced since the onset of the illness.

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History of index pregnancy- she booked at 24 weeks of gestation age and she made two visits and she
has received hematenics, folic acid, 1 dose of TT, mebendazole, SP (malaria prophylaxis). VDRL was non
reactive, HIV negative and normotensive in all visits. Her last hemoglobin was 11.

REVIEW OF OTHER SYSTEMS

RESPIRATORY SYSTEM- no history of difficulty in breathing, chest pain or cough.

CARDIOVASCULAR SYSTEM- no history of awareness of heart beats, syncope or chest pain

CNS- no history of headache, loss of consciousness or seizure

GYNAECOLOGICAL HISTORY

Attained menarche at 14 years of age, she has a cycle of 28days and period of 3-4 days. She changes the
pad thrice once in her periods, not fully soaked. No pain during menstrual period that could interfere
her daily activities.

OBSTETRIC HISTORY

Her previous delivery she delivered by caesarian section due to cord prolapsed, it was at term and the
baby weighed 3.8kg. it was 2015. This is her second pregnancy.

PAST MEDICAL HISTORY

This is the second admission, the first was in 2015 due to caesarian section. No history of blood
transfusion. No known allergy to food or drugs. No history of chronic illness such as hypertension or
diabetes.

FAMILY AND SOCIAL HISTORY

She is married with 1 child, lives with the husband in a single rented room. She is a housewife and the
husband is a bus driver. She doesn’t smoke or take alcohol. No family history of hypertension or
diabetes.

DIETARY HISTORY

She is a fan of fried fish, meat, vegetables and rice plus stiff porridge have been their usual foods. She
takes fruits occasionally.

SUMMARY

MMM 24 years old female, 13 days post admission, she is G2P1L1, referred from Vijibweni with
complains of a gush of watery discharge per vaginum at 32weeks gestation age. No prior history of
fever, pregnancy loss or preterm delivery,

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PHYSICAL EXAMINATION

GENERAL EXAMINATION- conscious, afebrile, not pale, not jaundiced, no palpable peripheral
lymphadenopathy and has no lower limb edema.

BP=110/70mmhg, PR=84beats/min and RR=17breaths/min

SYSTEMIC EXAMINATION

PER ABDOMEN- uniformly distended abdomen, moves with respiration and there is a surgical scar
(pfannesteil incisional scar), presence of striae, but no visible distended veins.

Not tender on both superficial and deep palpation. No palpable organ, dull on percussion and bowel
sounds not appreciable.

Fundal height-34 cm= 34 weeks gestation age.

Leopold manuvre- on fundal grip it’s the buttocks that occupy, the lie is longitudinal, cephalic
presentation, not yet engaged and the fetal heart rate is 150beats/min.

Speculum examination- fluid leaking from cervix, cervix was mid positioned, firm, cervical os closed and
there is clear fluid pooling at posterior fornices. Detection of PH using litmus or nitrazine papper was not
done.

OTHER SYSTEMS WERE ESSENTIALLY NORMAL

SUMMARY

MMM 24 years old from Vijibweni, 13 days post admission, at gestation age of 32 weeks, with lnmp on
17 november last year, G2P1L1 presented with a gush of watery discharge per vaginum which begun
two weeks ago. On speculum there is pooling of fluid at the posterior fornices.

Provisional diagnosis- premature pre labor rupture of membranes.

DISCUSSION ON THE CASE

Pre labor rupture of membrane (PROM) is rupture of membranes any time beyond 28weeks but before
the onset of labor. If it occurs before term it is premature pre labor rupture of membranes (PPROM), if it
occurs at term it is term pre labor rupture of membranes.

It affects 10% of pregnancies. So if you have 100 women chances are 10 might get PROM, not must but
might get.

The complain is always watery discharge per vaginum, could be a slow leak or a gush.

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The risk factors are

1. Increased friability of the membranes – making them easily rupture

2. Decreased tensile strength of membranes
3. Polyhydramnios
4. Cervical incompetency
5. Multiple pregnancy
6. Infections – like UTI, chorioamnionitis
7. Cervical length less than 2.5cm
8. Prior pre term labor or rupture of membranes
9. Low BMI less than 19kg/m2

The bolded ones are the ones you can easily ask in history.

INFECTIONS- this is why in our history we had to ask of any history of fever. To exclude UTI one has to
ask urinary tract symptoms such as increased frequency, painful urination. To exclude STI too you ask for
any fowl smelling discharge.

PRIOR PRE TERM LABOR- this you ask of previous pregnancies.

MULTIPLE PREGNANCY AND BMI- this is hard for a patient to know unless she was told during the clinic,
or by a healthy worker. If you happen to get a learned person and happens to know her BMI well and
good.

CERVICAL INCOMPETENCY- ask if she has ever had pregnancy losses previously or if she was ever told
she has cervical incompetency.

CONFIRMING IF IT IS PROM

One needs to use speculum (cuscos speculum). And you will see fluid escape the cervix some pooling at
the posterior fornices. If you check the PH of this fluid by either nitrazine paper or litmus it will help.

Normal vaginal PH in pregnancy is acidic (4.5-5.5) this is to kill germs that want to go up harm the baby.
But the fluid surrounding the baby which is the one that leaks once membranes rupture can’t be acidic
just logic. The PH of the fluid that leaks is around 7-7.5. its around neutral, kind of slightly alkaline. So
now you know how litmus will react here.

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Investigations- its about finding whether infections caused and see how the baby is doing.

1. Check out if it’s the infection that brought this quietly- so do urine analysis, full blood picture
and high vaginal swab for culture. This is because some infections can come silently.
2. Ultrasonography for fetal biophysical profile. To just be sure what is happening doesn’t harm
the baby. In fetal biophysical profile things checked are fetal breathing, fetal movements, fetal
tone, and the amniotic fluid volume. It has a score called manning score. If all the things that is
breathing, movements, tone and amniotic fluid is adequate then the score is high
3. Cardiotocography for non stress test

Complications include

1. Dry labor. Once all fluid escapes she will have a dry labor.
2. Ascending infections. bacteria can ascend to the baby once membranes have ruptured
3. The cord can prolapse after membranes have ruptured.
4. Neonatal sepsis
5. Placenta abruption
6. Fetal pulmonary hypoplasia if it occurs in pre term.

MANAGEMENT

To make it simple we divide into whether it occurs at pre term or at term

AT TERM- jus wait for normal labor to come. 90% of patients with PROM at term labor sets in within
24hrs. if it doesn’t give oxytocin to induce

PRE TERM- if beyond 34 weeks wait for labor to come. In majority it sets in within 48hrs if it doesn’t
induce. Less than 34 weeks conservative give dexamethasone for lung maturation, prophylactic
antibiotics then you can think of delivering after completing dexamethasone.

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CASE ON CERVICAL CANCER
PATIENT YYY

48 YEARS

CHANIKA

FARMER

CLERKED ON 2018

P4L4

Referred from Amana hospital for further management.

Main complain is per vaginal bleeding on for 4months (4/12)

HISTORY OF PRESENTING ILLNESS

The patient was apparently well until 4months ago when she presented with abnormal bleeding per
vagina, which she initially noticed following cleaning herself. It was sudden on onset and it was fresh
blood. As time went on she experienced bleeding without any prior provocating event like sex or
cleaning herself, it was sometimes mixed with clots. Not period specific, and aggravated by contact. No
relieving factor. No associated symptoms.

No history of easy fatigability, awareness of heart beats, difficulty in breathing on lying flat or lower limb
swelling.

She reports to have unintentional weight loss as her clothes don’t fit her well.

She voids normally, with no pain or change in frequency. She has no abdominal pain.

She doesn’t cough or have any chest pain. No difficulty in breathing. She has not noticed any mass per
vagina. She opens her bowel normally though she has lost apetite. She doesn’t have bone pain.

She doesn’t have any abnormal per vagina discharge, no foul smelling discharge or itching per vagina.

Her first sexual contact was while she was 18 years old. She denied history of multiple sexual patners
and she says the patner is faithful too. She is HIV negative and has never had organ transplant.

She doesn’t prefer so much vegetables and fruits in her diet on regular basis though she takes
occasionally. She doesn’t smoke neither the husband does. She has had four deliveries as previously
mentioned she is P4. She doesn’t have any history of irradiation and has never run fevers.

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She has never used oral contraceptive pills. she attained menarche at 16 years of age, her cycle has been
regular with periods of 3-5days with no pain or heavy bleeding. She denies doing exercises and she is
just a house wife.

Not known to have any bleeding disorders and she doesn’t report any bleeding from any other part of
the body. Not on any medications such as warfarin.

There is no history of instrumentation per vagina or any surgery recently.

REVIEW OF OTHER SYSTEMS

CNS- no complain of headache, loss of consciousness or seizure.

GYNAECOLOGICAL HISTORY

She attained menarche at 16. She has regular cycle of 28 days and period of 3-5 days with no heavy
bleeding or pain. She exchanges the pad thrice not fully soaked.

OBSTETRIC HISTORY

Has four children all born by SVD, and all pregnancies were un eventiful.

PAST MEDICAL HISTORY

No history of surgery, but has history of blood transfusion in her first delivery.

No known allergy to drugs or food. No known chronic illness.

FAMILY SOCIAL HISTORY

She is divorced living with her four children.

Not smoking. Not taking alcohol.

No family history of similar presentation.

SUMMARY

48yrs lady from Chanika referred from Amana, who is P4L4 presents with 4months history of contact
bleeding with positive history of first sexual encounter at 18years.

ON EXAMINATION

PER ABDOMEN- everything was okay except she had supra pubic tenderness.

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Pelvic examination

Digital exploration no mass protruding.

Speculum- a mass at the cervix, fungating, measuring about 2 by 3 cm and bleeds on touch. The vaginal
walls are free.

Bimanual exam- the parametrium is free

Digital rectal- free rectal mucosa.

Provisional diagnosis: cervical carcinoma.

Investigations

1. Biopsy
2. Abdominal pelvic ultrasound
3. Liver function test
4. Renal function test
5. Full blod picture

DISCUSSION
Most of the times it begin with bleeding because it ulcerates. The bleeding may be post coital or after
douching (cleaning herself).

Then later the lesion undergoes necrosis and sloughs off so the next presentation is abnormal vaginal
discharge, if it gets infected one finds the discharge foul smelling and will have itching per vagina.

So the sequence is contact bleedingdischarge per vaginalater foul smelling dischargeitching.

It may grow to affect the near by structures to cervix such as bladder and ureters leading to
hydronephrosis and later uremia. So its necessary to ask of urination and symptoms of uremia. It may
grow to affect rectum too and bring bowel habits change. It can metastasize to bones, lungs and liver.

Risk factors- all are about getting HPV

1. Early sexual contact

2. Multiple sex patners
3. Having a high risk patner
4. Smoking
5. High parity
6. Early marriage
7. Lack of vegetable or fruit rich diet

19 | P a g e
For any case of bleeding consider the causes that can be put in a mnemonic PALMCOEIN

P- Polyps.

A-Adenomyosis. Patients with this they have heavy bleeding and heavy abdominal cramps during
menstruation which this patient does not have.

L- leiomyoma. risk factors for leiomyoma include low parity or nulliparity, obesity, lack of exercise and
early menarche. Our patient has only lack of exercise which doesn’t strongly support this as a diagnosis

M- malignancy. Most likely probably. Could not be endometrial though due to age, and endometrial is
high in women with no children and our patient had 4 deliveries.

C-Coagulopathy. Diseases like hemophilia can present with bleeding. Our patient doesn’t have.

O- ovarian dysfunction

E- endometrial causes.

I-Iatrogenic such as instrumentation such as speculum. It could be blood thinning drugs such as warfarin

N-not classified.

STAGING CERVICAL CANCER

Stage 1

It’s within the cervix. We have 1a and 1b.

1a- not seen by naked eyes and 1b seen by naked eyes.

1a1- not seen by naked eyes and has invaded less than 3mm, with horizontal extension of not more than
7mm. 1a2 its invasion more than 3mm but not more than 5mm with horizontal extension of 7mm.

1b1- seen by eyes but less than 4cm. and 1b2 its more than 4cm.

Stage 2

2a- involvement of upper two third of vagina without parametrial involvement.

2b- involvement of parametrium present.

Stage 3

3a- lower third of vagina involved.

3b- pelvic side walls involved where ureters cross- a result is hydronephrosis, and renal failure and high
creatinine. Once you find raised creatinine and evidence of renal shut down you are likely dealing with
stage 3b

20 | P a g e
Stage 4

4a- extension to adjacent organs like bladder and rectum.

4b- distant metastasis.

During pelvic exam in case of cervical cancer begin with digital exploration before speculum because if
the mass is protruding and you introduce your speculum directly one may bleed a lot. After you have
explored with your digit and you are sure there is no mass protruding introduce the speculum and see If
there is any mass, report if it is fungating, ulcerating or anything. Its size and whether it bleeds to touch
or not. You can take biopsy for histology. After that bimanual should be done one hand in vagina the
other on abdomen. Lastly DRE to see if rectal mucosa is free.

What kills cervical cancer patient mostly is UREMIA, the other being hemorrhage, and metastasis.

Management

It depends with stage but treatment is either surgery, using chemotherapy or radiation.

Early stage (1a-1b1)- primary surgery- radical hysterectomy. Or primary chemotherapy of radiotherapy
(brachytherapy)

Advanced stage but hasn’t metastasize- primary chemo or radio with chemo.

Disseminated – palliative. Palliative surgeries include pelvic exenteration

21 | P a g e
CASE ON HEMMORHAGE IN EARLY PREGNANCY
PATIENT XXX

37YEARS

FEMALE

KINYEREZI

PO+1

LNMP 26/2/2018

EDD 3/12/2018

MAIN COMPLAINS ARE; lower abdominal pain for 3days and vaginal bleeding for 3hours

HISTORY OF PRESENTING ILLNESS

The patient was progressing well until 3days ago when she started experiencing sudden onset of on and
off abdominal pain that is not period specific, colicky in nature radiating to the back and there are no
identified aggravating or relieving factors.

Three hours prior to admission she noticed blood coming per vagina, sudden on onset, the blood is dark
in color mixed with clots. She changed the pad once not fully soaked.

She has no awareness of heart beats or difficulty in breathing on lying flat.

No history of fever, change of urination frequency, painful micturition or change of urine color. No
history of passing foul smelling discharge prior to the onset of this illness.

She denies having cold intolerance or heat intolerance. She doesn’t have increased apetite or weight
loss. She is diabetic and she is on metformin. She has never had intentional attempt to terminate
pregnancy.

No history of trauma. She has a previous history of pregnancy loss at around 15 weeks gestation age. No
history of using any medications prior to the onset of these problems.

She reports no passage of tissues per vagina.

No history of using intra uterine device as means of contraception. No history of pelvic surgery but has
had abdominal surgery. Has history of using oral contraceptive pills, or history of using assisted
reproductive therapy. However she agrees to a history of failure to conceive for about 10years despite
regular unprotected sexual intercourse with the partner.

She heard the fetal kicks once in the past 12 hours.

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History of index pregnancy- she booked antenatal clinic for the first time at 13 weeks gestation age and
made two visits. Received hematenics, TT dose and was given SP. She is PMTCT 2. Booking HB was
13.5g/dl and normal tensive in all visits. In the ward blood has been taken for investigation, was kept on
IV fluids and antibiotics. She was then augmented with oxytocin and expelled a male fetus. Abdominal
pain subsided together with the bleeding following that.

REVIEW OF OTHER SYSTEMS

RESPIRATORY SYSTEM- doesn’t cough or have difficulty in breathing

MUSCULOSKELETAL- no history of joint pain.

GYNAECOLOGICAL HISTORY

Attained menarche at 18years of age, her cycles have been irregular until 3months prior to her last
normal menstrual period. She could have periods of 5-7days and changes pads thrice not fully soaked.
No history of painful menses. She has history of using oral contraceptive pills for 1year, about 10years
ago.

PAST MEDICAL HISTORY

This is the second admission the first being ten years ago. Not hypertensive and has no known allergy.

No history of blood transfusion.

FAMILY AND SOCIAL HISTORY

She is married for 10years living with the husband and they have no child.

She is a secondary school drop out. The husband is a business man and smokes cigarette.

DIETARY HISTORY

Adequate in quality and quantity.

SUMMARY

37 years old female from Kinyerezi, presented with colicky abdominal pain for three days and vaginal
bleeding three hours prior to admission. She is diabetic and married to a husband who smokes and has a
previous history of second trimester abortion.

impression- inevitable abortion

EXAMINATION FINDINGS

Aler, afebrile, not pale, not jaundiced, not tachypnoeic, has no palpable peripheral lymphadenopathy
and has no lower limb edema.

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Speculum exam done on admission revealed internal OS dilated with products of conception felt (copied
from the file).

Systemic examinations were all normal.

SUMMARY

37 years old XXX female patient from Kinyerezi, presented with colicky abdominal pain for three days
and vaginal bleeding for 3hrs prior to admission. She is diabetic, and married to a husband who smokes
and has previous history of second trimester abortion. On examination internal cervical os dilated with
products of conception felt

Provisional diagnosis- inevitable abortion

DISCUSSION
Inevitable abortion is among the causes of hemorrhage or bleeding in early pregnancy. So the topic of
discussion is bleeding in early pregnancy.

HEMMORHAGE IN EARLY PREGNANCY

According to the American college of Obstetrics and gynecology bleeding in early pregnancy is common
and may not signal a major problem. Bleeding in late pregnancy is serious because it’s always a major
problem.

Bleeding in first trimester occurs in 15-25% of pregnant women. Light bleeding can occur 1-2 weeks
after fertilization as the fertilized egg tries to implant and it’s called implantation bleeding.

The cervix itself bleeds easily during pregnancy because blood vessels develop more in this area during
pregnancy. So its common to have bleeding after coitus.

However there are dangerous causes of bleeding in early pregnancy such as abortion, ectopic pregnancy
and molar pregnancy (referred to as pregnancy related causes). Sometimes it could be a problem that
was there before only that the bleeding came while someone is already pregnant (pregnancy associated
causes, not related to pregnancy), such causes are like polyps, malignancy etc. maybe someone had
cervical malignancy and got pregnant she could still bleed.

24 | P a g e
ABORTION

Its when a baby comes out of the mother’s womb while it still cant survive alone in the outer world. If it
comes out at a stage it can survive then its premature delivery.

Standard definition- expulsion of a fetus from the mother weighing 500g or less and is not capable of
independent survival. 500g or less is put believing at that weight its around 22weeks of pregnancy and
the fetus is not well developed and cant survive at all outside.

80% of pregnancy losses occur in first trimester and they are referred to as early pregnancy loss.

Early pregnancy loss, spontaneous abortion and miscarriage are terms used interchangeably during first
trimester but beyond first trimester only spontaneous abortion and miscarriage apply and its no longer
early pregnancy loss.

Early pregnancy loss according to American college of obstetrics and gynecology its defined as loss of
non viable intra uterine pregnancy with either an empty gestational sac or gestational sac containing
embryo or fetus without fetal heart activity within 1st trimester. So this definition is simply loss of a fetus
that is not able to live out with it inside the sac or comes out then the sac and there is no fetal heart
activity and its within first trimester.

ABORTION can be spontaneous or induced.

Spontaneous abortion can be

1. Threatened – it is threatening to happen. It is just an abortion that has not progressed to a state
where recovery is impossible. They usually have painless bleeding per vagina (light bleeding,
bright red or brown in color) and speculum will show closed external OS meaning nothing has
come out only it is threatening. The only way to treat this is make a woman rest. On discharge
tell her to not do any activities for two weeks, no sex and repeated sonography every 1month to
check the status.
2. Inevitable-it’s the one that by any means will occur. There is abdominal contractions and pain,
cervix dilated and bleeding per vagina. All you have to do is to help the woman expel the fetus
safely because you can’t prevent it. So give oxytocin if more than 12weeks, if less than 12 weeks
pregnancy remove the products at theatre by dilating the cervix and curettage.
3. Complete abortion- is the one in which everything has been expelled out already. They will
come reporting they passed tissues and there is no longer pain or bleeding. The cervix closed.
4. Incomplete abortion- when still some products of conception are left inside. They will report
passing fleshy mass per vagina but still will have abdominal pain and bleeding. Rescusitate the
patientA (airway) B(breathing) C(circulation- if in shock give fluids/blood) etc. Then help the
woman by removing the left products by dilating the cervix then curettage.

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 5. Septic abortion- its abortion with clinical signs of infection. Three things of importance are
abortion followed by fever, offensive purulent vaginal discharge plus any other evidence of
infection such as lower abdominal pain and tenderness. Majority are a result of incomplete
abortion and illegally induced done under aseptic conditions. Most of the times (80%) the
infection is in the conceptus and hasn’t gone to the muscle layer of uterus. Sometimes it may
spread to cause inflammation of both the inner lining and muscle layer referred to as
endomyometritis. Clinical grading includes grade 1- localized in uterus, if it involves
parametrium, tubes and ovaries its grade 2 and later one may have generalized peritonitis which
is grade 3
6. Missed abortion- its when a fetus is dead inside the mothers womb and retained for some
period of time. If the dead fetus was able to survive alone outside it is no longer abortion but
intrauterine fetal death. A woman will report she doesn’t hear fetal kicks if she had started
hearing them. Pregnancy symptoms will go away like morning sickness, breast changes will go
away and uterus doesn’t grow plus she may have brownish discharge per vagina.

Causes of abortion

1. Genetics-chromosomal abnormalities. And are the majority. And usually cause loss in first
trimester. This you cant ask in history
2. Endocrine causes- diabetes, hypo or hyper thyroidism and luteal phase defect. Atleast history of
diabetes can be picked in history, about thyroid diseases you can ask of symptoms such as cold
intolerance(hypothyroidism) or heat intolerance (in hyperthyroidism).
3. Infections- parasitic such as TOXO, viral such as HIV. So its necessary to know if she ever had
fever, any history suggestive of infection like increased frequency of urination or pain in
urination.
4. Anatomical – cervical incompetence which is why we ask if one has ever lost pregnancy
previously, issues of fibroids which are associated with risk factors such as nulliparity, cigarette
smoking should be asked in history. Anatomical factors usually cause second trimester losses.
5. Blood group incompactibility
6. Cigarette smoking- be it second hand or first hand. She stays with a husband who smokes which
is a risk factor.

You need to rule out possibility of ectopic pregnancy whose risk factors are

1. Previous history of pelvic inflammatory infections that could have impaired cilia motility. If cilia
motility is impaired cant propel the egg forward and it gets fertilized and implants on fallopian
tubes.
2. Tubal surgeries- which is why we ask of pelvic surgeries or tubal surgery. Surgery can end up
with adhesions on healing that can kink the tube and make passage of fertilized embryo to
implant normally hard
3. Presence of intra uterine device that prevents implantation at normal site. Which is why we
need to ask this to just be sure its not ectopic that we are dealing with.

26 | P a g e
In our case its even not molar pregnancy since molar pregnancy they will present with passage of grape
like vesicles per vagina. Easy way to remember is they present with exaggerated symptoms of
pregnancy. Everything is exaggerated, if its vomiting it is severe which is hyperemesis gravidarum, if its
uterus size it will be big than the normal appropriate for gestation age. They can have gestational
hypertension and very high HCG. The ultrasound for molar pregnancy shows snow storm appearance.

27 | P a g e
CASE ON ANTEPARTUM BLEEDING
PATIENT MMM

32 YEARS OLD

FEMALE from,

BOKO

Clerked on 2018.

Referred from Mwananyamala. She is P3L3. LNMP= 22/12/2018. EDD= 29/9/2018.

Its 16days post caesarian section (the outcome was a live baby 1.7kg with apgar score of 7 and 10 at first
and fifth minute) and subtotal abdominal hysterectomy due to placenta acreta.

Main complaints- vaginal bleeding and vomiting for one day

HISTORY OF PRESENT ILLNESS

The patient was well until 16days ago when she she started experiencing sudden onset of bleeding per
vagina, bright red in nature and changed a piece of cloth twice fully soaked. No associated abdominal
pain or passage of tissues. Inspite of the bleeding she could still feel the fetal kicks.

She had history of awareness of heart beats and and difficulty in breathing on lying flat. She also had
dizziness. No history of interrupted sleep due to air hunger. She also reduced urine frequency and she
could pass deep yellow concentrated urine reduced in amount.

She has not been told if she has twins in all her visits she made to clinic, she does not smoke. No history
of prior curettage.

No history of trauma prior to this. She has been normal tensive through out pregnancy. No history of
fever prior to this and she denies using any illegal drugs such as cocaine. No history of watery discharge
per vagina.

Prior to this she ever noticed light bleeding per vagina that came and went away. She denies having
attempted to terminate the pregnancy.

Prior to referral caesarian section was done where they found placenta is abnormally adhered to uterus
hence the part of uterus was removed however the bleeding could not be arrested ad they had to
remove the uterus and leave the cervix (subtotal abdominal hysterectomy).

She also has history of acute onset of non period specific, non meal related non projectile vomiting with
odorless non bilious vomitus. She vomited 7times from morning to evening. Doesn’t have fever, painful
micturition, headache, or joint pain. she doesn’t sleep in insect treated nets.

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Booked clinic at 18weeks gestation age, made three visits and received anti malarias, deworming agents,
AND completed TT already. The booking HB was 11.1 and the last one was 9. Blood pressure normal in
all visits.

Was admitted at ICU for five days then transferred to general ward. She has received 4 units of blood, IV
fluids, iron tablets and antibiotics.

Currently no more awareness of heart beats. While in the ward she reports to have developed lower
abdominal pain dull with no known aggravating or relieving factors and not period specific.

REVIEW OF OTHER SYSTEMS

Nothing came up.

RESPIRATORY SYSTEM- No cough or chest pain.

GYNECOLOGY HISTORY

Attained menarche at 14 years. Has regular cycles with period of 3 -4 days and exchanges 3pads not fully
soaked. No pain during menses. Never used contraceptives

OBSTETRIC HISTORY

Has two previous pregnancies. The first was eight years ago delivered by caesarian section due to a big
baby and the birth weight was 5kg. The second four years ago and delivered by caesarian section due to
previous scar and birth weight was 4.8kg.

PAST MEDICAL HISTORY

This is the third admission. First and second were all pregnancy related conditions. Has history of two
caesarian section. no known allergy to food or drugs.

FAMILY AND SOCIAL HISTORY

She is married living with the husband and their two children.

No one smokes in the family. She used to be a social drinker.

No family history of hypertension.

DIETARY HISTORY

Adequate in quantity and quality.

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SUMMARY

32 yrs old female from Boko referred from Mwananyamala presented with painless bleeding per vagina,
causeless and recurrent for 1 day before admission with symptoms of anemia not in failure. She also
presented with vomiting, with no associated fever or diarrhea and in the ward she developed
hypogastric pain. caesarian section was done and subtotal abdominal hysterectomy due to placenta
acreta which was an intra operative finding.

Impression- 1.placenta previa with features of anemia not in failure. 2. Malaria in pregnancy (she
doesn’t use insect treated nets) 3. UTI in pregnancy.

EXAMINATION FINDINGS- normal

DISCUSION
PLACENTA PREVIA- is a diagnosis that falls under the heading ante partum hemorrhage.

ANTEPARTUM BLEEDING

Bleeding from or into genital tract after 28weeks of pregnancy. The bleeding could be due to placenta
causes (which are majority 70%), extra placental causes (polyps, cervical cancer) or undetermined.

Placental causes are placenta previa and abruption.

PLACENTA PREVIA

Its when placenta is lowly implanted. When implanted at lower uterine segment. The lower segment
usually dilates as pregnancy grows and as it stretches the in elastic placenta vessels are sheared off
leading to bleeding.

Risk factors include

1. Multiparity- our patient this was her third pregnancy so she is multipara.
2. Increased maternal age- they usually say above 35, but then this woman was around 32, almost
there. But diseases don’t read books.
3. Smoking –she doesn’t smoke
4. Prior curettage- she has no such history.
5. Size of the placenta- as in polyhydramnios where its too big until some of it implants at lower
segment (Just thinking out loud easy way to remember)

They present as vaginal bleeding, apparently causeless and painless and can be recurrent with initial
episodes light and worsening on progressive episodes. On examination fetal heart sounds heard, uterus
size is appropriate for gestation. Uterus feels soft and relaxed.

Remember DON’T DO VAGINAL EXAMINATION.

30 | P a g e
COMPLICATIONS

TO FETUS- low birth weight as this baby had 1.7kg, birth asphyxia, intra uterine death.

TO THE MOTHER- increased incidences of operative deliveries as this woman underwent operation.
Other complication are cord prolapse as placenta is low implanted near cervix opening cord can
prolapsed, membranes can easily rupture before labor, premature labor can set in. also the lower
segment no enough space so the baby wont be lying well so another complication is malpresentation.

Management- if gestation age is less than 37, the mother’s health is good, no more active bleeding and
fetal heart rate is re assuring and you have facilities to do Caesar incase anything goes wrong you can do
expectant management. Expectant management means you just do nothing, give a woman a bed rest,
give hematenics because has been bleeding, and drugs to lower uterine contractions (tocolytics) if there
are contractions and let the woman wait for term delivery at 37 weeks.

If things ain’t good like there is active bleeding not stopping, or the woman is at term just deliver the
woman by either caesarian or vaginal delivery. Vaginal delivery is impossible if placenta is within 2cm
from internal OS. To be safe Caesar is the best in previa.

PLACENTA ABRUPTIO

It’s the bleeding due to premature separation of normally implanted placenta. As placenta separates
vessels shear off and bleeding occurs. The blood may collect between the separated placenta and uterus
and doesn’t come out we call it concealed type of abruption, or it can separate and blood comes out and
this is revealed type of placenta abruption, or you can have mixed.

Risk factors include

1. Trauma to abdomen- our patient didn’t have trauma prior to this and it is mentioned
2. Drug abuse like cocaine- our patient has never abused drugs.
3. Smoking- our patient doesn’t smoke
4. High order parity gravid 5 and above- she is just para 3
5. PROM- no history of watery discharge in our patient
6. Chorioamnionitis- which is why we ask of fever.
7. Increase maternal age

The presentation is usually vaginal bleeding with abdominal pain. so it is painful bleeding. And in our
patient it is painless. In abruption the fundal height is usually larger than gestation age since blood
collects inside making it look bigger than the gestation age. Fetal heart rate may not be heard.

Management is immediate delivery.

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PRE ECLAMPSIA AND ECLAMPSIA
It’s simply gestational hypertension (pressure during pregnancy) plus protein in urine (proteinuria).
When do we say this hypertension is due to pregnancy (gestational) its when it occurs after 20 weeks of
pregnancy.

And make sure this woman has never had hypertension or protein in urine before to call it pre
eclampsia.

Up to date tells, even if a woman gets gestational hypertension plus end organ dysfunction its pre
eclampsia regardless she has protein in urine or not, and it should be either in the last half of pregnancy
or post partum.

So to say a woman has pre eclampsia simply she should have

- Blood pressure of 140/90 and above and it should be after 20 weeks of pregnancy and this
pressure should be measured twice atleast four hours apart to just be sure if really its high. Plus
- Protein in urine confirmed by dipstick.

We can still make a diagnosis without protein in urine only if one has blood pressure high and signs of
end organ dysfunction. One would ask what are these symptoms of end organ dysfunction?

Symptoms of end organ dysfunction include

1. Cerebral or visual symptoms- such as headache usually occipital headache, altered mental
status, blurry vision and disturbed sleep.
2. Pulmonary edema signs- pinky frothy sputum
3. Progressive renal insufficiency- one would have reduced urine
4. Low platelets below 100000. So one can have petechiae which are pin point bleeding under the
skin. Platelet control clotting so if they are low one will have petechiae.
5. Severe persistent right upper quadrant pain or epigastric pain.

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Risk factors that can lead to develop pre eclampsia that you need to ask in history are bolded

1. Previous history of pre eclampsia. Ask her how was your blood pressure in previous
pregnancies. She will tell you. If she had fits/ seizure in any pregnancy? Ask all that.
2. Family history of pre eclampsia. Ask if any of her sisters ever told her they had high blood
pressure in their pregnancies.
3. Change of paternity. Ask if is this pregnancy of the same man or a different patner. Ask it
politely.
4. Obesity this you can observe. or ask how her weight trends.
5. Polyhydramnios- this cant be asked in history but it is a risk factor.
6. Twin pregnancy- this maybe can be asked if she has been told in her clinical visits that she is
carrying twins.
7. First pregnancy- this you can get from history by asking if this is her first pregnancy
8. Pre existing hypertension- so ask if she has ever been diagnosed with hypertension before
getting pregnancy.
9. Pre existing diabetes
10. Use of assisted reproductive technology- can be asked in history. Not common in our setting.
11. Extremes of age

Chief complain

Most patients wont have a chief complain, they will tell you I went to the clinic and they found my blood
pressure was high and protein in urine and they admitted me. So you simply say this is so and so, 35
years old, female from Pangani, lnmp so and so, g1p0, admitted from clinic after being incidentally
found with high blood pressure of this value dash dash and protein in urine. So it is not a must to have
chief complain.

Clinical signs and symptoms that you need to ask someone if he or she has

1. Headache
2. Disturbed sleep
3. Epigastric pain
4. Visual symptoms- blurred vision, photopsia (if she is seeing flash lights or sparks), scotoma (if
she sees dark areas in her visual field)
5. Lower limb edema
6. Difficulty in breathing because of pulmonary edema. Pulmonary edema patients can cough out
sputum that is pinky and frothy.
7. Oliguria-reduced urine output
8. Stroke
9. Seizure- and if this occurs it is called eclampsia

Alarming symptoms-diminished urine output, epigastric pain, disturbed sleep, headache and eye
symptoms which you need to ask in history.

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Complications that can ask in the HPI are bolded

1. heart failure symptoms- such as paroxysmal nocturnal dyspnoea, difficulty in breathing on lying
flat.
2. seizures- eclampsia
3. renal failure symptoms- reduced urine output, symptoms of uremia like loss of taste as urea
enters saliva, abdominal pain in uremic gastritis and other symptoms
4. abruption placenta
5. recurrent pre eclampsia in coming pregnancies
6. chronic hypertension- she may remain hypertensive after there.
7. a baby might end up dead which is why you need to ask the woman if she still feels the fetal
kicks.
8. Intra uterine growth retardation

Patients with pre eclampsia can develop HELLP syndrome which is Hemolysis, Elevated liver enzymes
and Low platelet count

Investigations

1. Urine analysis- protein

2. Renal function tests- serum creatinine and blood urea nitrogen
3. Liver function test- AST, ALT
4. Full blood picture- to check platelets count and hemoglobin. Can tell if its HELLP.
5. Ultrasound, non stress test and biophysical profile to check if the baby is fine

Management

Basically follow the following principles

1. Control blood pressure- drugs are methyldopa, nifedipine, labetalol and hydralazine. Muhimbili
they prefer methyldopa. Diuretics can be given if the patient has heart failure, pulmonary edema
or massive edema.
2. Control seizure/ fits-if they have fits. if its severe pre eclampsia blood pressure above 160/110
one can give prophylactic magnesium sulphate. 4g of 20% mgs04 stat if given IV, then followed
by 1gm/hr
3. Plan to deliver- if its term then deliver. Delivery is by SVD unless there are indications for
surgery.

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Pathophysiology in simple explanation- I simplified it in my own understanding.

1. Normally the trophoblasts need to penetrate the uterine layer up to myometrial layer to about
16th -18th week inorder to anchor the placenta. As they penetrate they destroy walls of the
blood vessels present in myometrium and as these vessels heal they heal and become weak, low
resistance vessels, easily dilated and this process has an advantage to allow a lot of blood flow
to the placenta. So failure of the trophoblast to reach this myometrial layer these vessels remain
undestroyed, rigid and with high resistance hence low blood flow to placenta. Low blood flow
then ischemia to placenta and placenta releases substances after being ischemic to cause high
blood pressure. In books this theory they call it failure of second wave invasion of
endovascular trophoblasts.
2. The other theory is that in normal pregnancy placenta makes angiotensinase that destroys a
vasoconstrictor angiotensin 2. But in patients with pre eclampsia angiotensinase activity is
reduced.
3. The other theory is the imbalances between the substances that constrict vessels and those that
dilate. There is deficiency of a vasodilator prostaglandin I2 and increased production of a
vasoconstrictor thromboxane A2 from platelets and so.

Eclampsia- is simply pre eclampsia plus seizure. Here treatment is delivery of the baby and the placenta
within 6-8hrs.

Actually management of eclampsia is A B C D. secure airway, put in left lateral, check breathing, rule out
other causes of seizure under the mnemonic A E I O U…

A-Alcohol either sudden withdrawal or overdose

E-Epilepsy so ask if she is epileptic, Electrolyte imbalance

I-infections like meningitis so ask of fever. Intoxication from drugs

O-oxygen deficiency

U- uremia

T-Trauma, tumor. So ask if has had head injury.

I-insulin overdose so probably hypogylcaemia causing seizure. So ask if the patient if is diabetic and if on
insulin and when did she last use

P-psychogenic

S- space occupying lesion like brain abscess, toxoplasma in HIV patients. So ask if is HIV patient could be
toxo you are dealing with man.

35 | P a g e
INDICATIONS OF CAESARIAN DELIVERY
1. Central placenta previa
2. Contracted pelvis/ cephalopelvic disproportion
3. Advanced carcinoma of the cervix
4. Pelvic masses obstructing the pathway
5. Vaginal stenosis or atresia
6. Cord prolapsed
7. Transverse lie

ANEMIA IN PREGNANCY
It can be physiological or pathological.

Physiological anemia is because during pregnancy blood volume increases to fit the demands of the
growing fetus. So increase in blood volume causes dilution of the hemoglobin I can say in a lay way. We
call it hemodilution. The other reason of physiological anemia is the demand of iron is increased by the
growing baby during pregnancy. Same iron that used to satisfy the mother now the growing baby wants
also. Easy to understand it that way.

Pathological anemia- causes are same as anemia in other patients. The following are the causes

1. Infections like Malaria. so a pregnant woman with symptoms of anemia try to ask for fever and
symptoms of malaria. don’t forget to do MRDT.
2. Worm infestations- hookworms can suck up your blood dude same as they can do to a pregnant
woman. So ask her when did she last take deworming drugs in your history if you clerk a case of
anemia in pregnancy
3. Bleeding- could be bleeding from hemmorhoids for long could end up with anemia. Could be
bleeding from cervical cancer. So ask if she is bleeding anywhere.
4. Dietary deficiency- see if she takes vegetables, and other diets that can improve her HB. In
pregnancy women loose apetite so the diet intake could be poor.
5. Could be anemia of chronic illness- so ask if she has any chronic illness like renal issues. If no you
can report no history of chronic illnesses to make your examiner happy that you at least thought
about it as a cause.
6. Hereditary disorder- so ask if she has sickle cell. Has she ever been transfused before maybe it’s
her tendency.

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It is common for our women to have anemia in pregnancy because

1. Dietary habits in Africa. We take diets with phosphates and phytates that hinder iron
absorption.
2. We loose iron from sweat, too hot in the tropics.
3. Repeated pregnancies with poor spacing deplete body iron stores
4. Worm infestations and infections are common here.

Complications of anemia in pregnancy

1. One can end up with heart failure.

2. Pre term labor.
3. Postpartum hemorrhage- because a little bleeding in delivery will cause them symptoms.
Postpartum hemorrhage is defined any bleeding from genital tract following delivery that can
affect adversely the mother’s health. So for a woman who is already anemic, bleeds a little after
delivery fits the definition.

POSTPARTUM HEMMORHAGE
The above definition of PPH is a clinical definition and the simplest to recall. That any bleeding after
delivery that can make one have symptoms of anemia.

PPH can be called primary if it occurs within 24hrs after delivery or can be secondary if it occurs after
24hrs following delivery.

Causes of primary PPH go by the 4T- Tone, Tissue, Trauma and Thrombosis. So the causes of primary
PPH are

1. Uterine atone- this means uterine tone is reduced and cannot contract after the baby is out to
return to normal and contraction is what helps compress vessels and control bleeding. To
understand the causes its simple I summarize them as, tone is reduced either due to
overstretching (even a rubber band once overstretched its tone reduces), tiredness to contract
or something hindering it to contract. Why the tone is reduced- maybe it was overstretched
(twin pregnancy, hydramnios-which is a condition in which there is too much amniotic fluid,
fibroids- these are benign masses that could overstretch the uterus), maybe its tired to contract
each year (grand multipara- has had many pregnancies, prolonged labor- labor has been long
that after delivery the uterus is tired to contract) or maybe something makes it not to contract
(the anesthesia given during Caesar)
2. Retained tissues- examine the placenta and tissues if they are complete. Maybe some tissues
are left inside
3. Trauma –could be cervical tear during the time baby is coming out
4. Thrombosis/ coagulation disorders- patients with hemophilia forexample.

Secondary PPH is when it occurs after 24 hours

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To prevent primary PPH we do active management of the third stage of labor whose steps are after
delivery of the baby make sure there is no other baby inside (could be twins), after you are sure within
one minute after delivery give oxytocin 10IU intramuscular, then apply controlled cord traction with
counter traction above the pubic bone to deliver the placenta and after the placenta is out massage the
uterus every 15mins for 2hrs.

Management of PPH

IT’S AN EMERGENCY. SO ABC PROTOCAL SHOULD BE FOLLOWED. So begin with calling for help, then
airway, breathing etc.

1. Put three large bore canullas. One for running fluid, one blood the one oxytocin. Send blood for
grouping and cross matching and order at least 2units of blood.
2. If its uterine atone do uterine massage until it contracts. If it fails you can give drugs like
oxytocin and misoprostol to make it contract. If drugs fail go for either bi manual compression,
or intra uterine packing or ballooning tamponade. If all fails then surgical means can be applied
like ligating the bleeding vessels or hysterectomy which is the removal of the uterus.
3. If it is traumatic- repair the area
4. If its retained tissues remove the retained tissues.

Secondary PPH could be due to infection, endometritis or bleeding from a caesarian wound.

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A CLOSING NOTE

Materials in this handout are from the textbook of DUTA, up to date and teachings from the ward
rounds. They don’t cover all that a clinical student need to know in obstetrics and gynecology but atleast
they give light to the common clinical scenarios in obs and gyn. If anyone can improve this to be better I
will be glad. In my limited time this is the little I could do for obs and gyn. I hope this would help
somehow some people referring to the story of an old lady and the turtles that I shared in my surgery
handout.

If anyone should be proud of you is yourself. God is great always and gave you the breath to make it
right today and not tomorrow. Be a nice human.

For contact my whatsapp and telegram number is 0713038141. Feel free to give feedback and share
your work incase this motivates you to do a smilar thing.

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