1-complication of P.P and accidental hage?

Pp: During pregnancy :-

1. hemorrhage
2. Malpresentations and Non engagement of the head
3. CMF
4. IUGR
2-what are the causes of accidental hemorrhage or placenta previa?
Pp:
1. Advancing maternal age
2. High parity
3. Multiple gestation
4. Prior uterine scar (e.g. CS, myomectomy).
5. large sized placenta
6. Smokers
7. Rh incompatibility
3-causes of DIC in obstetric:
1- Concealed accidental hge
2- Severe PET
3- Missed and septic abortion
4- IUFD
5- Excess stored blood transfusion
6- Amniotic fluid embolism

Hypercoagulable state (WHY PREGNANT WOMEN ARE MORE LIABLE TO DVT):

due to :
1- smooth muscle relaxing effect of progesterone on blood vessels (stasis)
2- increased production of coagulation factors (2,5,7,8,9,10,12)
3- decrease in fibrinolytic activity
4- compression of gravid uterus on vessels
 2- Mention selection criteria for ttt with MTX
1. Ectopic sac < 3 cm
2. B HCG level < 3000 mlU/ml
3. No active bleeding
4. No fetal heart pulsation

Hyperemesis :

High bhcg

Vit. B deficiency

Psychological factors

Assess through dehydration or starvation

Source of Infection

• Endogenous: 75%
– GIT
– Deep layers of vagina where yeast penetrates and is
impervious to topical treatment.
• Exogenous: 25%
– Male partner
– Instrumental contamination

Treatment

Azole Compounds:

Nystatin
Fluconazole
Ketoconazole

Itraconazole
Estrogen
1. Breast: Proliferation of duct system and Increase vascularity
2. Bone & Joints: Increase bone mineraliztaion
3. GIT: Increase GIT motility
4. Clotting: Increase clotting
(Inc. factors 2,7,9,10)
(Dec. fibrinolytic activity)

5. Metabolic:
• Protein: Anabolic
• CHO: Diabetogenic activity
• Fat: Increase HDL
Decrease LDL

6. H2O: salt and water retention

Vaginal Supports

• Ligaments attached to the upper vagina:

Pubocervical ligament anteriorly,

Mackenrodt’s ligament laterally,

Uterosacral ligament posteriorly.

• Levator ani muscles : pubo-vaginalis part

• Triangular ligament, and the Perineal membrane.

• Vaginal fascia: Connective tissue fascia that condenses anteriorly

forming the vesico-vaginal fascia and posteriorly forming the recto-
vaginal fascia.

1.
Mention 8 criteria to diagnose ovulation
• Investigations:
1. TVF Transvaginal folliculometry
2. Laparoscope: stigmata of ovulation
3. Basal body temperature
4. Premenstrual endometrial biopsy
 5. Vaginal cytology
6. Cervical mucous study
7. Midluteal progesterone (most accurate test)
8. Midcycle LH
9. Mid cycle E2

1. Mention 8 Non contraceptive use of COCs

1. DUB
2. Spasmodic dysmenorrhea
3. Hirsutism
4. Functioning ovarian cyst
5. Endometriosis
6. PMS
7. Acne
8. To postpone menstruation
2. Causes leading to Inability to feel the threads
1. Difficulty to feel the threads due to deep vagina + short fingers
2. The threads is adherent to the vaginal walls or cervix
3. Cut threads
4. Pregnancy
5. Perforation
6. Expulsion
7. Abnormal position of IUD in uterus

fallopian tube 4 parts

1. Interstitial part (1 cm): pierces the uterine wall, very narrow, no

peritoneal covering, no outer longitudinal muscles
2. Isthmus (2 cm): straight, narrow, thick walled portion lateral to
uterus.
3. Ampulla (5 cm): the widest, tortuous, thin walled outer part.
3. Infundibulum (2 cm):

9-What are the results of uterine contractions?

1)Dilation of cervix
2)Formation of bag of forewater
3)Descent of fetus & delivery
4)Delivery of placenta
5)Stoppage of postpartum bleeding

10-What are the durations of the 3 stages of labor?

Stage I
Primi: 12 hrs, Multi: 6 hrs
Stage II
Primi: 1-2 hrs, Multi: 0.5-1 hr
Stage III
5-10 mins (less than 30 mins)
11-What are the steps of head delivery?
1)Descent
2)Engagement (with definition)
3)Increased flexion (to achieve 9.5 cm)
4)Internal Rotation
5)Extension (Ritgen’s maneuver)
6)Restitution
7)External Rotation

12-What are the steps of placental separation?

3 uterus:-

1)Increase in fundal lvl

2)Body of uterus becomes smaller, harder, globular, mobile
3)Suprapubic bulge due to presence of placenta in the lower uterine
segment

2 Umbilical Cord
1)Apparent elongation of cord
2)Absence of pulsation in umbilical stump

1 blood:-
Vaginal gush of blood
13-Biochemical changes of Hyperemesis
1 - Electrolytes disturbance
2 - Vitamin deficiency ( B1 , B6 )
3 – acidosis
4 – starvation , ketonemia , ketourea and increased urinary area
5 – hypovolemia , oliguria and hemoconcentration
1-What is quickening?
a) 1st perception of pregnancy
b)1st perception of breast fullness
c)1st perception of fetal movements
d)false labor pain
e)true labor pain
Answer: C

2-What is lightening?
a)engagement
b)pelvic pressure symptoms
c)relieved upper abdominal pressure symptoms
d)1st perception of labor pain
e)decreased fetal movement
Answer: C

3-What is attitude?
a)relationship between fetal head & pelvic inlet
b)Relationship between longitudinal axis of fetus to that of the mother
(aka “Lie”)
c)Relationship between fetal parts to each other
d)relationship between the two parietal bones
e)none of the above
Answer: C

4-All are criteria of false labor pain except

a)Regular
b)No effect on cervical dilatation
c)Painless
d)Involuntary
e)Intermittent
f)Relieved by analgesics
Answer: C

5-What is the occipitofrontal diameter?

a)Diameter between the occiput and root of the nose
b)Diameter between the bregma and the root of the nose
c)The longest anteroposterior diameter of the fetal head
Answer: A

6-What is crowning?
a)Passage of biparietal diameter through the ischial spine
b)Passage of biparietal diameter through the vulvar ring
c)Delivery of fetal head
d)Vertex at vulvar ring
Answer: B

7-Average duration of labor in primigravidas are best expressed by

which of the following
a)Stage I: 12 hrs, Stage II: 1.5 hrs, Stage III: 30 mins
b)1.5 hrs, 20 mins, 5 mins
c)2 hrs, 1 hr, 5 mins
d)1.5 hrs, 20 mins, 20 mins
e)12 hrs, 1.5 hrs, 5 mins
 Answer: E

8-What are the causes of failure of engagement in primigravidas

a)Cephalopelvic disproportion
b)Malpresentation & malposition
c)Fetal macrosomia or hydrocephalus
d)Multiple pregnancy
e)All of the above
Answer: E

Dr.Shimaa Belal
➢ Ectopic Pregnancy
• MCQ Questions:

1. The following features suggest diagnosis of ectopic pregnancy EXCEPT .

a. Amenorrhea
b. Normal size uterus
c. Pain
d. Normal pattern of rising B HCG
e. No intrauterine preg by Ultrasound

2. Treatment of ectopic pregnancy include all of the following EXCEPT

a. Laparotomy
b. Laparoscopy
c. MTX
d. Expectant management
e. Hysterectomy

3. The most common site of ectopic pregnancy ...

a. Cervical
b. Ampullary
c. Isthmus
d. Fimbrae

4. Causes of ectopic tubal pregnancy include all of the following EXCEPT ..

a. Chronic salpingitis
b. IUD
c. Anovulation
 d. Endometriosis
e. Tubal hypoplasia

5. Mifiprostone ...
a. Anti prostaglandin
b. Cytotoxic drug
c. Anti progesterone
d. Anti estrogen
e. Non of the above

6. Incidence of Ectopic
a. 2% (1:66)
b. 1/20 %
c. 1/2000 %
d. 1/20 000 %

7. D&C of the uterus in case of Ectopic made of ..

a. Highly vascularised villi
b. Blood and normal villi
c. Decidua
d. All of the above
e. Non of the above

8. All are advantage of medical ttt with MTX EXCEPT ...

a. Minimal hospitalization usually outdoor management
b. Quick recovery
c. May preserve fertility in case of cervical pregnancy
d. 90% success rate if cases are properly selected
e. Monitoring is not essential

9. Salpingostomy or salpingotomy is only indicated when

a. The patient desire to preserve fertility
b. Patient is haemodynamically stable
c. Unruptured and less than 5 cm
d. All of the above

10. Trophotoxic substance used ..

1. MTX
2. Potassium chloride
3. Mifiprostone
4. PG F2 alpha
5. All of the above
 • Give short note:

1. Mention 5 tests to diagnose ectopic pregnancy

1. CBC
2. Serial Quantitative B HCG
3. Ultrasound
4. Progesterone level
5. Culdocentesis
6. D&C Endometrial biopsy
7. laproscopy
8. History and physical examination

2. Mention selection criteria for ttt with MTX

1. Ectopic sac < 3 cm
2. B HCG level < 3000 mlU/ml
3. No active bleeding
4. No fetal heart pulsation

3. Mention Spiegelberg criteria

1. The gestational sac occupies the ovarian site
2. Connected to the uterus by ovarian ligament
3. The wall of the sac contains ovarian tissue
4. The tubes are normal

4. Mention risk factors of Ectopic pregnancy

1. PID
2. Previous Ectopic Pregnancy.
3. Peritubal adhesions (pelvic Surgery, endometriosis).
4. Infertility.
5. Contraception (COCs - progesterone only pills)
(IUD Use (Probably Not)
6. ART (heterotopic pregnancy)
7. Tubal developmental abnormalities,.
8. Broad ligament tumors.
5. Sites of Ectopic pregnancy
1. Ampulla. (70-80%)
2. Isthmus. (10-12%)
3. Fimbria . (3-5%)
4. Interstitial (<2%)
5. Cornual-rudimentery (< 2%)
6. Ovary (< 2%)
7. Abdomen (< 2%)
8. Cervix (< 2%)
9. Secondary abdominal
10.
11. Primary abdominal

6. Mention the different clinical types of Ectopic Pregnancy

1. Undisturbed tubal pregnancy.
2. Subacute tubal pregnancy.
3. Acutely disturbed tubal pregnancy.
4. Chronic type with pelvic heamatocele.
5. Abdominal pregnancy.

7. Differential diagnosis of Ectopic pregnancy

1. Intra uterine pregnancy.
2. PID.
3. Complicated ovarian cyst.
4. Appendicitis.
5. Causes of internal heamorrhage.

7. Treatment of Ectopic pregnancy

1. Observation Expectant treatment.
2. MTX.
3. Laparoscopy.
4. Laparotomy.
5. Trophotoxic substances used:
• Methtrexate
 • Potassium Chloride
• Mifiprostone
• PGF2
• Hyper osmolar glucose solution
• Actinomycin D

➢ DM with Pregnancy
• MCQ Questions:

1. Indication of OGTT with pregnancy:

a. History of gestational diabetes in previous pregnancy
b. History of recurrent abortion
c. History of macrosomic baby
d. Poly hydramnios
e. All of the above

2. Screening for gestational diabetes by GTT is recommended in the following

EXCEPT:
a. Persistent glucosuria
b. A strong family history of diabetes
c. Prior still birth infant
d. Prior large for gestational age infant
e. Prior premature delivery

3. Insulin requirement for pregnant diabetic woman are greatest during:

a. First half of pregnancy
b. Second half of pregnancy
c. Labour and delivery
d. Immediate postpartum period
e. None of the above

4. Which of the following procedures would be most helpful in managing a pregnant

diabetic:
a. Serum cholesterol
b. Urinary lactose
c. Non stress test NST
d. Amniocentesis
e. Fetal scalp ph

5. Which of the following is the most significant in the management of a pregnant

diabetic:
a. Complete bed rest after 38 weeks
b. Adding oral hypoglycemic agent to the insulin therapy
c. Delivering infant before 35 weeks
 d. Avoiding ketoacidosis
e. All of the above

6. Which of the following statements about the management of class A diabetic patient
during pregnancy is TRUE:
a. Normal GTT result in early pregnancy doesn’t require repeating later in gestation
b. Macrosomic fetus are less common than in general population of pregnant women
c. The pregnancy should be carried even bewild the estimated date of gestational age
d. A patient with a prior still birth infant requires more frequent examination
e. None of the above

7. Morbidly obese pregnant patient often experiences ALL of the following

complications EXCEPT:
a. Hypertension
b. Diabetes
c. Thromboembolism
d. Fetal growth retardation
e. Aspiration of gastric content

8. In diabetic pregnancy which of the following carries the WOREST prognosis for the
fetus:
a. 24 hr of estriol 36mg at 38 weeks
b. Amniotic creatinine of 2 at 37 weeks
c. Repeated episodes of maternal ketoacidosis
d. Caesarean section at 37 weeks
e. Oxytocin induction at 37 weeks

9. Diabetic patient on 56 unit of insulin goes to labour at 36 weeks gestation, her insulin
dose should be:
a- Maintained
b- Increased
c- Decreased
d- Decreased and at least in parts switched to regular insulin
 • Give short note:

1. Mention risk factors for diabetes

1- Glycosuria at the first prenatal visit
2- Previous GDM
3- Family history of DM (1st degree relatives)
4- Advanced maternal age and BMI > or = 30`
5- Previous macrosomic infant
6- Previous unexplained fetal death or malformations
7- Medical disorder associated with development of DM as (Metabolic syndrome,
PCO, current use of glucocorticoids, HTN

2. Mention obstetric complications (effect of diabetes on pregnancy)

1. Abortions
2. Infections
3. HTN
4. Preeclampsia
5. Polyhydramnios
6. Preterm delivery
7. Increased risk of prolonged labour, injuries, PPH, CS delivery
8. Puerperal sepsis
9. Development of DM after pregnancy

3. Mention Neonatal complications in diabetic mother

1. Birth injury (shoulder dystocia and brachial plexus trauma)
2. Neonatal respiratory distress syndrome RDS
3. Polycythemia
4. Post Hyperbilirubenemia
5. Hypocalcemia
6. Hypoglycemia

4. Mention Fetal complications in diabetic mother

1. Abortion
2. Congenital fetal malformations
3. Macrosomia
4. IUGR
5. IUFD

Dr.Hossam Abdelmegeed
Physiology of menstruation.

1. Mention the function of FSH and LH

FSH LH
• Growth, ripening, maturation of the • (with FSH) ripening of the ovarian
ovarian follicle follicle
• (+) aromatase activity of granulosa cells • (+) androgen synthesis by theca cells
= E2 production (for E2 production)
• (with LH) = ovulation • LH surge = ovulation
• (+) formation of LH receptors • (+) corpus luteum = estrogen &
progesterone

2. Mention sources of Estrogen with corresponding type

• Ovary: E2 (Estradiol)
• Syncitiotrophoblast of the placenta: E3 (Esstriol)
• Adrenal cortex – small amount: E1 (Estrone)
• Peripheral adipose tissue – small amount: E1 (Estrone)

3. Mention sources of Progesterone

• Corpus luteum
• Syncitiotrophoblast of the placenta
• Adrenal cortex – small amount
• Stroma cells of ovary – small amount

4. Mention general action of Estrogen and Progesterone

Estrogen Progesterone
 7. Breast: Proliferation of duct system and 1. Breast: development of Acini
Increase vascularity
8. Bone & Joints: Increase bone 2. Bone & Joints: Relaxation of joints
mineraliztaion & Ligaments
9. GIT: Increase GIT motility 3. GIT: Decrease GIT motility
10. Clotting: Increase clotting 4. Thermogenic effect: Increase 0.5%
(Inc. factors 2,7,9,10)
(Dec. fibrinolytic activity)

11. Metabolic: 5. Metabolic:

• Protein: Anabolic • Fat: Decrease HDL
• CHO: Diabetogenic activity Increase LDL
• Fat: Increase HDL
Decrease LDL

12. H2O: salt and water retention 6. H2O: salt and water excretion
5. Luteal phase defect and luteal support
Luteal Phase Support: Progesterone
Luteal Phase Defect: Deficiency of progesterone secretion from the corpus luteum
Clinically: Recurrent Abortion (most imp)
Infertility
DUB - Dysfunctional uterine bleeding

6. 3 peaks for ovulation to occur (Not imp Q)

• LH peak: (with Estrogen and progesterone)
• FSH peak: (with Progesterone only)
• E2 peak: (spontaneous)
 Infertility

2. Mention 4 investigations for male factor

1. Semen analysis
2. Testicular biopsy
3. Culture and sensitivity test
4. Hormonal Assay
5. Doppler US
6. Karyotyping
7. Sperm antibodies in plasma

3. Main causes of tubal factor

1. Previous laparotomy
2. PID
3. Endometriosis

4. Mention 4 tubal patency test

1. HSG- Hysterosalpingography
2. Laparoscopy
3. Sonohystrography
4. Hysteroscopy
5. Falloscopy

5. Mention 8 values / advantages of HSG

 Diagnostic
Tubal factor Uterine factor Cervical factor
1. Hydrosalpnix 1. Congenital Anomalies of uterus 1. Cervical Stenosis
2. Salpingitis isthmica nodosa 2. RVF 2. Incompetence
3. Tubal Patency 3. Fibroids 3. Polyps
4. Tubal Obstruction 4. Intrauterine Adhesions
5. Tubal Stenosis 5. Polyps
6. Peritubal Adhesion 6. Missed IUD (not used)

Therapeutic
1. Overcome fimbrial stenosis
2. Overcome tubal spasm
3. Breakdown of thin tubal adhesions
4. Breakdown of mucous plug
5. Straightening of tortous kinked tube
6. Psychological factor

6. Polycystic ovary syndrome definition and Health Hazards (not an imp. Q)

Definition: Rotterdam criteria: 2 of the following 3 characters
1. Hyperandrogenemia
2. Polycystic ovary by US
3. Oligoovulation or anovulation
Health Hazards:
▪ Hyperinsulinemia: Increase risk of DM
▪ Hyperandrogenic state: Increase risk of Hypertension and Arterial disease
▪ Hyperestrogenemia: Increase risk of endometrial hyperplasia and carcinoma

7. Mention 4 investigations of PCO

1. TVS: necklace appearance
2. Laparoscope: PCO
3. Hormonal Assay:
• Increase LH/FSH ratio
• Increase Androgens
• Increase free Estrogen
• Increased Insulin

8. Mention 4 diagnostic hormonal assay for PCO

1. Increase LH/FSH ratio
2. Increase Androgens
3. Increase free Estrogen
4. Increased Insulin
9. Mention 8 criteria to diagnose ovulation
• Investigations:
10. TVF Transvaginal folliculometry
11. Laparoscope: stigmata of ovulation
12. Basal body temperature
13. Premenstrual endometrial biopsy
14. Vaginal cytology
15. Cervical mucous study
16. Midluteal progesterone (most accurate test)
17. Midcycle LH
18. Mid cycle E2

1. Note: clinically
Pregnancy (surest sign)
Regular cyclic menstruation
Midcyclic spotting + midcyclic pain (Mittelschmerz) + premenstrual mastalgia

10. Drugs of Ovulation Induction

1. Clomiphene citrate (Clomid)
2. Cyclophenil
3. Tamoxifen
4. Human Menopausal Gonadotropins (HMG)
5. GnRH Analogue in a pulsatile manner
6. Combined Therapy
7. Surgical Induction (Laparascopic Ovarian Drilling)

11. Mention 8 side effects of clomid

3 GHAD
GIT upset Galactorrhea Multiple Gestations
Headache Hot flushes Hyperstimulation Syndrome
Alopecia Increase risk of Abortion Antiestrogenic effect on cervix
Dysmenorrhea Depression Defect in CL (LPD)

12. 4 basic investigations to approach an infertile couple

1. Semen Analysis
2. HSG
3. Documentation of Ovulation: Midluteal progesterone, Folliculometry
4. Laparascope

13. Mention 4 indications of ICSI

2. Tubal factors of Infertility
3. Immunologic Infertility
4. Unexplained Infertility
 5. Male factor Infertility
6. Ovulatory Dysfunction not responding to ovulatory drugs
7. Endometriosis not responding to the standard treatment

Contraception

4. Mention 8 Non contraceptive use of COCs

9. DUB 13. Endometriosis
10. Spasmodic dysmenorrhea 14. PMS
11. Hirsutism 15. Acne
12. Functioning ovarian cyst 16. To postpone menstruation

5. Mention 8 Advantages of COCs

➢ Generally:
(Remove: Safe and Not need medical supervision )
1. Effective 5. Reliable
2. Easy to use 6. Reversible
3. Available 7. Cheap
4. Accepted by the couple 8. Not affect sexual relationship
➢ Reduce risk of:
1. Ovarian and endometrial 4. Benign breast diseases
cancers 5. PID
2. Ectopic pregnancy 6. Menstrual irregularities
3. Anemia
➢ Non contraceptive use
 6. Mention 4 Non contraceptive use of long acting injectables
1. DUB 4. Endometriosis
2. Hirsutism 5. Endometrial carcinoma
3. Fibroid 6. Precocious puberty

7. Mention 7 hormonal contraception

Combined (Estrogen & Progesterone) Gestagens
1. COCs 4. Long acting injectables
2. Combined Injectables 5. POPs
3. Vaginal Ring 6. Subdermal implants
7. Progesterone IUD

8. Mention 8 Advantages of IUD

➢ Generally:
(Remove: Effective and Easy to use)
1. Reliable
2. Available
3. Safe
4. Accepted by the couple
5. Reversible
6. Cheap
7. Not need medical supervision
8. Not Affect sexual relationship
➢ Durable and can return at anytime with rapid return of fertility
➢ Suitable for lactating women and when COCs are contraindicated
➢ Non contraceptive use

9. Mention 8 S.E. of IUD

5P 2I 2E 2D
Pregnancy
PID
Perforation
Pain
Bleeding and missed period
Inability to feel the threads
Insertion complication (vasovagal attack, perforation, failure of insertion)
Expulsion
Extraction difficulties
Discharge serous, serosanguinous, or mucous
Discomfort of male

10.Causes leading to Inability to feel the threads

8. Difficulty to feel the threads due to deep vagina + short fingers
9. The threads is adherent to the vaginal walls or cervix
10. Cut threads
11. Pregnancy
12. Perforation
13. Expulsion
14. Abnormal position of IUD in uterus

11.Enumerate 4 methods for tubal sterilization

1. Laparoscopic method:
• Bipolar diathermy
• Application of clips
• Application of ring
2. Laparotomy or mini laparotomy
• Madlener’s operation
• Irving’s operation
• Cook’s operation
• Uchida’s operation
• Pomeroy’s operation
• Fimbriectomy
3. Hysteroscopic method
4. Culdoscopic method
 5. Posterior colpotomy

12.Contraception for breast feeding mother

➢ Methods of first choice
• Natural family planning (LAM)
• IUDs
• Female sterilization
• Barrier methods
➢ Methods of second choice
• POPs
• Progesterone only injectables
• Sub dermal implants
• Hormone releasing IUD
➢ Methods of third choice
• COCs
• Combined monthly injectables

Dr.Kareem Eltriby

Normal pregnancy:
➢ Sperm count: 60- >180 million sperms
➢ Blastocyst (6-18 cell stage) is the implantation stage
➢ Implantation occurs at day 6-7 after ovulation (btw 7th and 10th day after LH
surge) and it occurs in the decidua basalis
➢ Challenges that meet the sperm: cervical mucus permeable at day of
ovulation, and tubal motility to assist the ovum
➢ Most common site of ectopic pregnancy: tubal ampulla
➢ Most common risk factor of placenta accreta→ scarred uterus (iatrogenic)
➢ Layers of decidua:
 1- Decidua basalis
2- Decidua capsularis
3- Decidua parietalis

➢ Chorionic villi:

➢ Layers of chorion:
➢ Placenta:

➢ Functions of the placenta:

1- Respiratory function: main function, considered fetal
respiratory organ (exchange of gases btw fetal and maternal
blood)
2- Hemopoietic function: producing fetal hb
3- Nutritive function: transfer of glucose, amino acids, vitamins
etc
4- Excretory function: acting as fetal kidneys
5- Secretory function: enzymes, proteins, hormones
6- Barrier function
7- Immunological function

➢ Abnormalities of the placenta

➢ Enumerate hormones of the placenta:
1- Estrogens (estriol)
2- Progesterone
3- Hcg
4- Hpl (human placental lactogen)
5- Others: relaxin (uterine relaxation) activin, inhibin, GnRH, CRH, TRH, CCT
(chorionic cortico tropin), MSH, thyrotropin, PRL
➢ Umbilical cord (single umbilical artery)

➢ Functions of amniotic fluid:

➢ Abnormalities of amniotic fluid:
1- Oligohydramnios
2- Polyhydramnios
3- Anhydraminos
➢ Nitabuch layer: zone of fibrinoid
degeneration between decidua basalis
 and trophoblastic layer (separates placenta from myometrium) so prevents
accrete, if not present in U/S →accreta
➢ 1-13 weeks (1st trimester), 13-26 weeks (2nd trimester, honeymoon of
pregnancy), 26-39 weeks (3rd trimester)

Abortion:
➢ Enumerate 8 causes of abortion

1- fetal causes:
➢ Usually produce early abortion
➢ Chromosomal abnormalities
a. Most common cause (50 %).
b. Rarely inherited (balanced chromosomal translocation).
c. Mainly in early abortions.
➢ Congenital Malformations
2- Local causes: uterine
a) Congenital uterine anomalies: as septate and bicornuate uterus.
b) Uterine fibroid: submucus myomas
c) Endometrial polypi
d) Intrauterine synaechae: (Ashermann syndrome)
e) Cervical insufficiency: (see later).
3- Systemic causes:
I. Endocrine:
• Diabetes mellitus (DM); uncontrolled DM
• Progesterone deficiency in early pregnancy: luteal phase defect
(LPD).
• Others: e.g. thyroid dysfunction, Cushing's syndrome, PCOS,
Hyperprolactinemia
II. Immunologic disorders & thrombophilia:
• Hypercoagulable state: inherited or acquired thrombophilia and
abnormalities of the immune system .
• SLE
• Antiphospholipid syndrome (APS)
III. Allogeneic factors.
IV. Infections: uncommon causes for 1st trimesteric abortion,
however chorioamnionitis, is an important cause for late 2nd
trimesteric pregnancy loss.
V. Acute maternal infection: (Listeria, Toxoplasma , parvovirus B19,
rubella, herpes simplex, cytomegalovirus).
VI. Acute febrile illness: persistent high grade fever.
VII. Ascending genital tract infections: (chlamydia, gonorrhea, and
GBS) leading to chorioamnionitis, and prostaglandin release .
VIII. Systemic illness
• Chronic hypertension, cardiac or respiratory diseases
• Chronic renal or liver diseases
• Anemia & severe malnutrition
II. Severe trauma:
• a) Invasive intrauterine procedures
• b) External trauma

III. Drugs and toxins:

• a) Chemotherapeutic agents (e.g. Methotrexate)
• b) Prostaglandins (e.g. Mesoprostol)
 • c) The use of NSAIDs: (but not acetaminophen) around the
time of conception
• d) Antiprogesterone (e.g. Mifeprostone)
• e) Large doses of: alcohol, caffeine, and some anaesthetic
and toxic gases are rare causes
IV. Unexplained

➢ Enumerate 5 complications of abortion:

• Bleeding
• Infection: Septic abortion
• Traumatic complications of surgical evacuation
• Hypofibrinogenaemia and DIC: longstanding missed abortion.
• Rh alloimmunization: if Rh – ve & did not receive the anti D.
• Psychological trauma
• Maternal mortality
ANTEPARTUM HEMORRHAGE:
➢ Mention 7 causes of placenta previa or accidental HMG
PP:
8. Advancing maternal age
9. High parity
10.Multiple gestation
11.Prior uterine scar (e.g. CS, myomectomy).
12.large sized placenta
13.Smokers
14.Rh incompatibility
15.Previous P.P
AP:
1. Pregnancy induced hypertension or chronic hypertension. “commonest”.
2. Chronic chorioamnionitis.
3. Direct external trauma to abdomen.
4. Short umbilical cord.
5. Sudden decompression of the uterus as in after ROM in polyhydramnios.
 6. Uterine anomaly or fibroid “weak implantation”.
7. Previous history of abruptio placenta, recurrence rate is 5-17% after one
episode, 25% after 2 episodes in 2 previous pregnancies.
8. Smoking -> placental ischemia -> liable for separation.
9. Folic acid deficiency.
10.Advanced maternal age.
11.Inc. with multiparity

➢ Mention complications of placenta previa or accidental HMG

Pp: During pregnancy :-
5. hemorrhage
6. Malpresentations and Non engagement of the head
7. CMF
8. IUGR
During Labour & Postpartum:
1. Obstructed, Prolonged Labour
2. Maternal & Fetal Distress (Ashyxia)
3. PPHge(causes),
4. Placenta accreta,
5. P.sepsis,
6. Increased c.s rates.
7. PROM
Ah:
1- Maternal :-
A. Shock ( Hgic, Neurogenic )
B. Consumptive coagulopathy : Hypofibrinogenaemia & DIC
C. Ischemic necrosis of distant organs ( Renal F., Ant. Pit. Necrosis Sheehan S)
D. Uteroplacental apoplexy (Couvelaire uterus)
E. Amniotic fluid embolism.
F. Atonic postpartum hge
G. Maternal mortality
H. Puerperal sepsis
 2- Fetal :-

a) Increased Perinatal mortality,

b) IUGR,
c) Prematurity,
d) NN Anemia.,
e) CMF
f) Asphyxia

➢ Enumerate 6 causes of DIC in obstetric ( Exam question )

7- Concealed accidental hge
8- Severe PET
9- Missed and septic abortion
10- IUFD
11- Excess stored blood transfusion
12- Amniotic fluid embolism
Mcq
1. Complications of accidental hge DO NOT include:
a) Hemorrhagic shock.
b) Consumptive coagulopathy.
c) Asherman's syndrome. 
d) Sheehan’s syndrome.
e) Intrauterine fetal loss.

2. A 35-year-old woman (gravida 1, para 0) presents at 35 weeks’ gestation,

complaining of the abrupt onset of frequent, painful abdominal
contractions, back pain, and moderate vaginal bleeding. On examination,
 the uterus is firm and moderately tender. The physician should take
which of the following actions?
a) Administration of ritodrine
b) Rule out placental abruption and advise immediate delivery 
c) Assure the patient that this often happens towards end of pregnancy
d) Immediately send the patient for an ultrasound and a chest x-ray
e) Advise the patient to rest in the examination room until the pain subsides
while performing hematologic and coagulation studies

3. A 37-year-old gravid 4 para 3 presented as an emergency at the 37 weeks’ gestation

with painless mild unexplained vaginal bleeding.
There was no sign of onset of labor and previous antenatal care was uneventful.
Which of the following measures is immediately indicated?
a) Cesarean section
b) Induction of labor
c) Coagulation profile
d) Rupture of membranes
e) Urgent ultrasound 

4. Which abnormality in this patient is associated with the elevated blood

pressure?
a) Obstructed labor.
b) Placental abruption. 
c) Prolonged labor.
d) Cervical dystocia.
e) None of the above.

5. The CORRECT statement for placenta previa:

1. Is more common in multiparous patients. 
2. Classical caesarean section is best performed for most cases.
3. Immediate hospital admission is indicated only in severe bleeding.
4. Clinical presentation with bleeding is usually before 28 weeks
gestational age.
5. Preterm labor is a rare associated problem.

6. A 32-year- old P2, both deliveries were by CS. Now ultrasound done
at 22 weeks shows that the placenta is grade 0 and located
anteriorly down to the level of internal os. She is at increased risk of
which of the following complications
1. Placenta accreta. 
2. Abruption placenta.
3. Cerebrovascular accident.
4. Amniotic fluid embolus.
5. Pulmonary edema.

7. A 20-year-old primigravida, 32 weeks gestation, presents with

profuse vaginal bleeding with pain and tenderness per abdomen.
The most probable diagnosis is
1. Abruptio placentae. 
2. Placenta praevia.
3. Marginal sinus bleed.
4. Vaginitis.
5. Uterus rupture.
 8. All are correct regarding placenta previa EXCEPT:
1. Is more common in patients who have had previous uterine surgery.
2. Increases the risk of PPH
3. Is associated with an increase of prematurity.
4. Mostly needs C.S. if presents at term.
5. Primarily it associate PIH 

9. As regards vasa previa, the CORRECT statement is:

1. It is usually manifested by recurrent vaginal bleeding.
2. It is the commonest cause of antepartum hemorrhage.
3. Vaginal delivery is safe.
4. You can examine the patient vaginally at reception room
5. It may be diagnosed by ultrasound. 

10.A Para 5 woman presented at 36 weeks gestation with vaginal

bleeding, tonic contracted uterus and fetal heart sounds were not
audible, the complications of her condition DO NOT include:
1. Hemorrhagic shock.
2. Consumptive coagulopathy.
3. Cervical dystocia. 
4. Acute renal failure.
5. Intrauterine fetal loss.

11.As regards placenta previa, the followings are true EXCEPT:

1. It is manifested by painless recurrent vag. bleeding.
2. The initial hemorrhage is usually fatal. 
3. It may predispose to postpartum hemorrhage.
4. Its incidence is affected by parity.
5. The placental site can be located by ultrasound.

12.A para 5 woman presented at 36wks pregnancy with vaginal

bleeding, tonic contracted uterus and fetal heart sounds were not
audible, the complications of her condition DO NOT include:
1. Hemorrhagic shock.
2. Consumptive coagulopathy.
3. Retraction ring of the uterus. 
4. Sheehan syndrome.
5. Intrauterine fetal loss.

13.The followings are risk factors for development of placental

abruption EXCEPT:
1. Short umbilical cord
2. Folic acid deficiency
3. Pre-eclampsia
4. History of threatened abortion 
5. Previous placental abruption

14.The INCORRECT statement, regarding abruptio placentae, is:

1. May cause consumptive coagulopathy.
2. May lead to acute renal failure.
 3. Maternal mortality rate is 10%. 
4. IUFD may occur if the placenta is separated.
5. May cause hemorrhagic shock.

Infections
➢ Mention causative organisms for PID
• POLYMICROBIAL
• Chlamydia trachomatis
• Neisseria gonorrhea
• Anaerobes
– Bacteroides, Peptostreptococcus, Peptococcus
• Facultative organisms
– Gardnerella, Streptococcus, E. Coli

➢ Mention the risk factors of PID

• Infection with Neisseria or Chlamydia
• Previous episodes of PID
 • Sexual behavior (multiple partners)
• Age
• Menstrual cycle influences
• Contraceptive choices
• Douching

➢ Mention the complications of PID ( Exam question very important )

1. Infertility
o 1st episode→ 20%
o >3 episodes→ 50-80%
2. Ectopic pregnancy
3. Chronic abd pain
4. TOA
5. Pyosalpinx
6. Pelvic adhesions
7. Dsypareunia
8. Fitz-Hugh Curtis

Student notes

Physiology of pregnancy changes

- During 1st 12 weeks, corpus luteum secrets progesterone, placenta (decidua
or trophoblast) secrets b-hcg which is responsible for changes during
pregnancy
- Uterine anatomical changes:
- Uterus increases in size, before 12 weeks its not palpable, at 12 weeks it
changes from a pelvic organ into an abdominal organ and is palpable by
fundal level exam
- If palpable at umbilicus, its at 22 weeks, xiphisternum at 36 weeks then
afterwards it descends for engagement
- Shape changes from pear shaped (pyriform) to globular (12weeks at
placental take over) to ovoid (28 weeks at age of viability and on) to
spherical at 36 weeks
- Right dextrorotation due to rectosigmoid motility, so it may compress right
ureter so later→ physiological mild dilatation of the right ureter and pelvic
calyceal system (hydronephrosis) and mild compression on IVC and aorta
(when bradycardia is found→sleep on left side)
- Capacity increases 500-1000x
- Weight increases 20x
- Histological changes:
- Endometrium becomes decidua, myometrium →hypertrophy and
hyperplasia, peritoneum and uterine ligaments hypertrophy bc of Inc.
vascularity
- Uterine physiological changes:
- Palmer’s sign- contractions in 1st trimester
- In 2nd trimester either physiological (Braxton-hick’s) or abnormal (preterm
labour pains)
- They are irregular, painless, sporadic, unpredictable, non-rhythmic, doesn’t
increase in frequency and intensity and no cervical dilatation or effacement
(cervical length and thinning)
- Preterm labour pain is the opposite
- Blue or violet discoloration in cervix and vagina (Chadwick’s sign) and
pulsation in the vaginal fornices (posterior more felt) called osiander’s sign
- Breast Inc. in size and vascularity, nipples prominent and erectile, 1ry
areola at 2 months, 2ndry areola at 20 weeks (5 months)
- Montgomery’s tubercles: hypertrophied sebaceous glands (5-15 mm)
- Milk secretion from day 1 of pregnancy could happen
- Systemic changes:
- Heart: apex rises upwards till 4th intercostal space
- Heart rate increases 10-15 bpm
- cardiac output begins from week 10 till week 20 (maximum) and remains
maximum till end of pregnancy (not cardiac load) bc fetal circulation opens
- cardiac load begins from week 28 till 32 (maximum) and remains till end of
pregnancy) bc cardiac load is cardiac output and blood volume (Inc. to
maximum during 28 to 32, plasma Inc. 30% and red cell mass Inc. 15% so
viscosity Inc.) so load increases on heart from 28 till 32 therefore heart
patients are dyspnoeic at 28-32 and if there’s a pathology it could manifest
during that interval
- Cardiac load also increases postpartum bc fetal circulation closed so body
could accumulate the increased blood volume into the normal circulation
(heart patients at risk again)
- Blood pressure decreases gradually and reaches lowest at the end of late
2nd trimester then rises after, due to peripheral vascular resistance
- Supine hypotension syndrome: in supine position, the gravid uterus
compresses IVC (mainly) and aorta so decreases venous return and cardiac
output and blood pressure decreases immediately (patient stands up or left
tilt)
- Varicose veins due to compression of gravid uterus on vessels and lower
limb, also due to muscle relaxing effect of progesterone (given during
preterm labour contractions)
- Hypercoagulable state (WHY PREGNANT WOMEN ARE MORE LIABLE TO
DVT): due to 1- smooth muscle relaxing effect of progesterone on blood
vessels (stasis), 2- increased production of coagulation factors
(2,5,7,8,9,10,12), 3- decrease in fibrinolytic activity 4- compression of gravid
uterus on vessels
- In respiratory system: residual volume decreases due to compression of
lungs
- Urinary system: mild hydronephrosis on RT side due to right dextrorotation
of uterus, dilatation/stones/infection liability
- Filtration rate increases bc blood volume increases, more blood flow so
creatinine clearance increases and serum creatinine decreases
- Incidence of UTI increases mainly due to: relaxant effect of progesterone,
hypertrophy of lower ureter, right dextrorotation of uterus and dilatation
of right ovarian veins causes pressure on right ureter
- Compression on urinary bladder and urinary symptoms mostly at 1st
trimester then 3rd trimester but not second
- Vomiting in pregnancy 1- effect of hcg on gastric mucosa (gastric oedema)
2- vitamin b deficiency (aggravate vomiting) 3- Gerd bc of relaxing effect of
progesterone
- Vomiting accepted once/twice and at morning time
- Hyperemesis: bc of Inc. in hcg for example during mole, multiple gestations
(check u/s for differentiating)
- Skin changes: linea rubra then albicans then nigra, itching, spider nevi,
palmer erythema, chloasma gravidarum (facial butterfly pigmentation)
- Endocrinal changes: prolactin inc 10x reaches 200 so milk secretion from 1st
day and thyroid gland more active due to Inc. in hcg and thyrotropins, and
total t3, t4 Inc. bc of an Inc. in TBG (thyroglobin binding globulin), free t3
and t4 doesn’t increase
- Glucose Inc. due to hpl and cortisol