Obstetrics & Gynecology: Original Review & Revision Hyderabad

OBSTETRICS &
GYNECOLOGY
Original Review &
Revision
Hyderabad
by Dr Raina Chawla
About me
Teacher
• @Cerebellum Academy
• @OBGclassesbyDrRaina/ OBG_classes_by_drraina
• @The White Army
• Adjunct Professor at ESIC Medical College, Faridabad
• Formerly at Lady Hardinge Medical College New Delhi and KMC, Mangalore
Senior Consultant and Unit Head @Sarvodaya Hospital
Poet @I_write_to_breathe
Mom to Eva and Neev

• Important High Yield Topics
• 19th: Gynecology
What we plan • 20th: Gyn MCQs and Obstetrics
to cover in the • How to solve MCQs
next 2 days! • Revise previous year questions!
• Lots and lots of Images and how to tackle
clinical scenarios in OBG
Mullerian Anomalies
ASRM MÜLLERIAN ANOMALIES CLASSIFICATION
2021: ASRM MAC 2021 TOOL
• Mullerian agenesis
• Cervical agenesis
• Unicornuate uterus
• Uterus didelphys
• Bicornuate uterus
• Septate uterus
• Longitudinal vaginal septum
• Transverse vaginal septum
• Complex anomalies
ASRM MAC 2021 TOOL
Mullerian Anomalies
1. Mullerian Agenesis (aka MRKH syndrome)
• Presentation
• Associated anomalies
• Investigations
• Treatment
2. Uni-cornuate uterus
3. Septate Uterus
4. Uterine Didelphys
5. Bicornuate uterus
Treatment: Surgical Reconstruction
Transverse Vaginal Septum
Imperforate Hymen
DES – Induced Reproductive Tract Abnormalities
• Synthetic non-steroidal estrogen

• 1940s-1960s: abortions, preterm
• DES exposure:
Q. In MRKH syndrome, all the following will be absent except?
A. Cervix
B. Fallopian Tubes
C. Ovaries
D. Uterus
Q. Complete failure of Mullerian duct (Paramesonephric duct) fusion will
result in:
A. Bicornuate uterus
B. Unicornuate uterus
C. Uterine didelphys
D. Septate uterus
Q. Identify this Mullerian anomaly on HSG
A. Bicornuate uterus
B. Septate uterus
C. Unicornuate uterus
D. Uterine didelphys
Q. A 34y woman presents with a history of 2 previous 1st trimester
losses. A hysteroscopy – laparoscopy reveals this. What is the best
management option?
A. Cervical cerclage
B. Hysteroscopic septal resection
C. Strassman metroplasty
D. Vaginoplasty
Q. Regarding MRKH syndrome, which is the incorrect
statement?
A. The karyotype is 46XX
B. Uterine transplantation is a possible treatment option for
conception
C. Secondary amenorrhea is a common presentation
D. McIndoe vaginoplasty involves creating a space between
the rectum and the bladder
Primary Amenorrhea
Important Points
DEFINITION
• In the absence of 20 sexual characters: 13 y
• In the presence of 20 sexual characters: 15 y
Absence of 20 sexual characters: NO Exposure to Estrogen

Normal functioning
Compartment 4
Hypothalamus
Normal Functioning Pituitary Compartment 3
Normal Functioning Ovaries Compartment 2
Normal Endometrial
Development
Compartment 1
Normal Outflow Tract

Compartment Defect Disorders/ syndromes
Compartment 1 Utero – vaginal agenesis (MRKH syndrome)
Imperforate hymen
Transverse vaginal septum
Androgen Insensitivity Syndrome (AIS)
Imperforate hymen
Compartment 2 Gonadal Dysgenesis
Turner Syndrome (45XO)
Pure gonadal dysgenesis (46XX)
Swyer Syndrome (46XY)
Resistant ovary syndrome (Savage syndrome) (46XX)
Imperforate hymen
Compartment 2 Gonadal Dysgenesis
Turner Syndrome (45XO)
Pure gonadal dysgenesis (46XX)
Swyer Syndrome (46XY)
Resistant ovary syndrome (Savage syndrome) (46XX)
Compartment 3 Neoplasia
Prolactinoma/ hyperprolactinemia
Empty Sella syndrome
Congenital pan hypopituitarism
Isolated FSH deficiency
Compartment 1
Compartment 2
Compartment 3
Compartment 4
Utero – Vaginal Agenesis/ MRKH syndrome
• 2nd most common cause of 10 amenorrhea
• 46XX
• External genitalia: female but small blind vagina
• Rudimentary/ absent uterus; Normal ovaries
• FSH/ LH:
• Estrogen:
• Associated renal anomalies
• Management:
• Sexual: Vaginoplasty (surgical/ non-surgical)
• Fertility: Surrogacy/ uterine transplant
Imperforate hymen
• Presents as cryptomenorrhea
• Normal 20 sexual characters
• h/o cyclical abdominal pain
• If hematocolpos/ hematometra is significant
• Abdominal mass
• Urinary retention
• Local exam: Bluish bulge with intact hymen
• Treatment: Cruciate incision
Androgen Insensitivity Syndrome
• X linked recessive
• Abnormality in the androgen receptor
• Karyotype:
• External genitalia:
• Secondary sexual characters:
• FSH: moderately ↑; serum testosterone - normal
• Management :
• Partial androgen insensitivity syndrome:
Gonadal Dysgenesis
• Abnormal development of the gonads (streak gonads)
• 20 sexual characters:
• Estrogen:
• FSH/ LH:
• Most common
• Management
Kallmann Syndrome
• Hypogonadotrophic hypogonadism with anosmia
• Associated cleft lip/ palate, cerebellar ataxia and nerve deafness
• Primary amenorrhea is the rule
• The ovaries are usually small
• FSH/ LH:
• Estrogen:
• Management:
Normal 20 sexual characters
Vaginal/ rectal examination or Ultrasound
Uterus absent Uterus present
Karyotyping
Outflow Obstruction? Normal Anatomy
46 XX 46 XY • Imperforate • Constitutional
hymen • Early PCOS
• Transverse vaginal • Prolactinoma
MRKH syndrome Androgen Insensitivity septum
Absent 20 sexual characters
Height
Normal Short
FSH FSH
Low High Low High
Isolated GnRH XX/XY gonadal Hypothalamic/ Turner

deficiency dysgenesis pituitary Syndrome
lesions
Q1. Match the correct condition with the karyotype
Disorder Karyotype
MRKH 46XX
Swyer Syndrome 46XY
Turner Syndrome 46XY
Androgen Insensitivity Syndrome 45XO

Q1. Match the correct condition with the karyotype
Disorder Karyotype
MRKH 46XX
Swyer Syndrome 46XY
Turner Syndrome 45XO
Androgen Insensitivity Syndrome 46XY

Q2. Which is an not a cause of secondary amenorrhoea
1. Kallman Syndrome
2. Turner mosaic
3. Fragile X pre-mutation
4. Sheehan syndrome
Q3. A 16 years old girl presented to the Gyne OPD with complaints of
primary amenorrhea. She has a female phenotype, and her height is
150 cm. She has poorly developed breasts. On further evaluation, a
vagina was present. Ultrasound reveals a normal uterus but gonads
were not detected. Investigations showed high FSH and karyotype is
XY. What is the probable diagnosis?
1. Gonadal dysgenesis
2. Androgen insensitivity
3. Kallmann syndrome
4. Adrenal hyperplasia
Q4. An 18 years old girl presents with primary amenorrhea. On
evaluation, she was having a karyotype of 45XO and an infantile
uterus. What should be done next?
1. HRT to induce puberty
2. Vaginoplasty
3. Clitoroplasty
4. Bilateral gonadectomy
Q5. A young female presents with primary amenorrhea. Examination
reveals normal breast development and absent axillary hairs. Pelvic
examination shows a normally developed vagina with clitoromegaly. On
ultrasound, gonads are visible in the inguinal region. What is the most
likely diagnosis?
1. Complete androgen insensitivity syndrome
2. Partial androgen insensitivity syndrome
3. Mayer Rokitansky Kuster Hauser syndrome
4. Gonadal dysgenesis
Q6. Investigation for primary amenorrhea in a girl with full development
of secondary sexual characteristics should be performed by what age?
A. 13
B. 14
C. 15
D. 16
Q7. What are the classic follicular - stimulating hormones (FSH) and
luteinizing hormone (LH) levels in Turner's syndrome?
A. High FSH, high LH

B. High FSH, low LH
C. Low FSH, high LH
D. Low FSH, low LH
Q8. Which of the following should be the next investigation in a
patient presenting with primary amenorrhea and normal secondary
sexual characteristics?
1. Ultrasound of Uterus
2. Serum FSH
3. Serum LH
4. Karyotyping
Q9. A 16 year old female presents with well develop secondary
sexual characters and ovary as the gonad. However, the uterus is
absent. She complains of primary amenorrhoea. What is the
diagnosis?
1. Turner syndrome
2. Mullerian agenesis
3. Sheehan's syndrome
4. Testicular feminizing syndrome
Q10. A 24 y woman is being evaluated for amenorrhea. You order
a hormonal profile. Which is the correct match?
Disorder Hormonal Profile

Premature ovarian failure FSH↑ LH↑ Estradiol↓
Asherman syndrome FSH↓ LH↓ Estradiol ↓
PCOS FSH (N) LH↑ Estradiol (N)
Sheehan syndrome FSH (N) LH (N) Estradiol (N)
Q10. A 24 y woman is being evaluated for amenorrhea. You
order a hormonal profile. Which is the correct match?
Disorder Hormonal Profile
Premature ovarian failure FSH↑ LH↑ Estradiol↓

Asherman syndrome FSH (N) LH (N) Estradiol (N)
PCOS FSH (N) LH↑ Estradiol (N)
Sheehan syndrome FSH↓ LH↓ Estradiol ↓
Q11. Which would be defined as primary amenorrhoea? A girl
presenting with not attaining menarche; with age and breast tanner
staging of?
A. Age 11, Tanner stage 1
B. Age 14 Tanner stage 1
C. Age 12, Tanner stage 4
D. Age 13, Tanner stage 5
Secondary Amenorrhea
• Absence of menstruation for > 6 months
Causes
• Uterine
• Ovarian
• Pituitary
• Hypothalamic
Evaluation of Secondary Amenorrhea
Contraception
Classification
Natural Methods:
Calendar method (rhythm method)
Cycle beads method
Basal body temperature method
Cervical mucus method
Symptothermal method
Lactational Amenorrhea Method
Barrier Method: Female
Spermicides
Intra – Uterine Devices
Timing of insertion
Absolute contra-indications (MEC 4)
• Pregnancy
• Infection
• Undiagnosed genital bleeding
• Cancer Malignancy
• Distorted cavity
“You can’t get Pregnant if you have an IUCD”

Missing thread?
Pregnancy with IUD
• Lowest rate: LNG IUS and Cu 380A
• Increased risk of ectopic
• What to do if pregnancy with IUD?
Hormonal contraception
Hormonal Contraception
• Pills • Pills
Progesterone Only
progesterone
Combined Estrogen and
• Injectable E & P • Injectable

• Transdermal patch • Implants
• Vaginal ring • Intra uterine device
Combined Oral Contraceptive Pills
Types
1. 1st generation pills: 50 μg EE
2. 2nd generation: 30-35 μg EE + LNG/ d-LNG
3. 3rd generation: 20-30 μg EE + norgestimate/ desogestrel/ gestodene
4. 4th generation: Progesterone: Drosperinone: Weak anti
mineralocorticoid activity
Combined Pills: Mechanism of Action
1. Ovulation suppression
2. Endometrial atrophy
3. Cervical mucous changes
4. Alteration of ovum transport
Combined Pills: Contra-indications: Absolute (4)
OCPs in Breast Feeding Women:
•MEC 4: < 6 weeks
•MEC 3: 6 weeks – 6 months
•MEC 2: > 6 months
Combined Oral Contraceptive Pills and
cancers
Missing a Pill
One Missed Pill
• The missed pill should be

taken as soon as possible
• The remaining pills taken as
usual
• No additional contraception
required
2 or more missed pills (> 48 h late)
• The last missed pill should be taken as soon as possible

• Leave the earlier missed pills
• Use additional contraception for 7 days
• Further to reduce risk of pregnancy
o If pills missed in 1st week: Consider Emergency

Contraception
o Pills missed in 2nd week: No need for Emergency

Contraception
o Pills missed in the 3rd week: Omit the pill free interval and
start the next pack after finishing the active pills in the
current pack
Vaginal Rings
Transdermal Contraceptive Patch
Progesterone Only Pills
• Contains only progesterone (LNG/ norgestrel/ desogestrel/
norethindrone)
Progestogen Only Injectable Contraception
Progestogen Only Injectable Contraception
Progesterone Implants
Progesterone containing Intra-uterine Devices
Progesterone containing Intra-uterine Devices
Contraindications to Mirena:
Long-Acting Reversible Contraception (LARC)
• Methods requiring administration less than 1 cycle/ month
• LARC Methods include
Emergency Contraception
Drug Dosage Time of use
Combined OCPs (Yuzpe
regime)
Combined OCPs (Yuzpe 100mcg of ethinyl estradiol Upto 72 h
regime) + 0.5 mg od Levonorgestrel
(LNG)
Progesterone only (LNG)
(LNG)
Progesterone only (LNG) 1 tablet containing 1.5 mg Upto 72 h
of LNG
Selective progesterone
receptor modulator
(Ulipristal acetate)
(LNG)
Progesterone only (LNG) 1 tablet containing 1.5 mg Upto 72 h
of LNG
Selective progesterone 1 tablet – 30mg of Upto 5 days
receptor modulator ulipristal acetate
(Ulipristal acetate)
Intra uterine copper device
GOI Contraceptives
Infertility: Important Points
Subfertility
Fecundability and Fecundity
Evaluation
• After 1 year of unprotected coitus

• After 6 months in women > 35 years/ menstrual irregularity
Causes of infertility
Male Factor Infertility
Pre-Testicular Causes Testicular Causes Post-Testicular
(Affecting
spermatogenesis and
testosterone production)
Female Factor Infertility
Ovarian Causes Tubal Causes Uterine Causes Others
Evaluation
Tests of Ovulation
Tests for Ovarian Reserve
Tests for Tubal motility
Laparoscopic Chromotubation
Other tests
1. Hysteroscopic cannulation and Falloposcopy
2. Hystero-salpingo-Contrast- Salpingography (HYCOSY)
• USG contrast media with galactose microparticles is infused in the uterine
cavity
• Flow of medium observed on USG
Tests for Uterine Factor
Semen Analysis
Semen analysis Reference Values
S. No Parameter Normal Value as per WHO
2010 criteria
1. Sperm concentration ≥ 15 million/ ml

2. Total sperm count > 39 million/ ml
3. Sperm motility ≥ 32% progressive
4. Morphology (strict criteria) ≥ 4%
5. Viability > 58%

Terminologies used for semen parameters
Normozoospermia:
Oligospermia:
Azoospermia:
Aspermia:
Asthenospermia:
Teratospermia:
Oligo-astheno-teratozoospermia (OATS):
MCQ 1
Q. A couple visits the OPD. They have been married for 6 months and
anxious to conceive. You reassure them and explain that normally, in
1year, the probability of them conceiving is?
A. 20%
B. 50%
C. 75%
D. 85%
MCQ 2
Q. The ability to conceive is known as
A. Fecundity
B. Fecundability
C. Fertility
D. Subfertility
MCQ 3
Q. A 35y woman, has been trying to conceive since 8 months. Her
cycles are regular and she has no significant complaints. She has
been having regular intercourse with her partner. What is the next
best step?
A. Advise her to wait for 4 more months
B. Start pre-conceptional folic acid
C. Order an ultrasound, a HSG and a semen analysis
D. Do a diagnostic laparoscopy
MCQ 4
Q. Male infertility is responsible for what % of infertility?
A. 10%
B. 20%
C. 30%
D. 40%
Treatment of Infertility
Causes of Infertility
Treatment of Anovulation
Ovulation Induction
Superovulation/ Ovulation enhancement
Controlled ovarian hyperstimulation

Drugs used in Ovulation Induction
1. Clomiphene Citrate
2. Aromatase Inhibitors: Letrozole
3. Gonadotropins
Role of Laparoscopic Ovarian Drilling:
A little bit about PCOS
Treatment of Uterine Factor Infertility
• Endometrial Polyps
• Leiomyomas
• Asherman Syndrome
• Septate uterus
Management of Tubal Factor Infertility
1. Proximal Tubal Occlusion:
2. Distal Tubal Obstruction
3. Hydrosalpinx
Treatment for male infertility
• Intrauterine Insemination
• Donor insemination
• IVF
• ICSI (very low sperm count < 1 million/ ml)

Surgical Retrieval of Sperms for ICSI and IVF
1. Microsurgical Epididymal
Sperm Aspiration (MESA)
2. Percutaneous Epididymal
Sperm Aspiration (PESA)
3. Testicular sperm Aspiration
(TESA)
4. Testicular sperm Extraction
(TESE)
5. Micro TESE
Assisted Reproductive Technology (ART)
• Clinical and laboratory techniques to
achieve pregnancy
ART Procedures
In Vitro Fertilization and Embryo Transfer (IVF-ET)
• Controlled ovarian hyperstimulation with FSH/ hMG
• Monitoring of ovarian follicles by TVS, estradiol levels
• Ovulation trigger
• Ovum pick up done 36h after trigger
• Sperm preparation
• Fertilization; checking after 20h (2 pro-nuclei)
• Embryo Transfer (48 – 72h or Day 5)
• Luteal phase support
Intracytoplasmic Sperm Injection
• A single mature sperm is injected into a
mature oocyte
• 40-60% success rates
• Useful in male infertility and IVF-ET
failures
Cryo preservation
• Cryopreservation of spermatozoa
• Cryopreservation of unfertilized oocytes:
• Ultrarapid cooling (vitrification)
• Cryopreservation of embryos
• Extra embryos
• Risk of OHSS
• Cryopreservation of ovarian tissue
Other terminologies
• In-vitro maturation of oocytes
• PGD
• Embryo biopsy from blastomere of embryo
• Polar body biopsy
• Tropho-ectoderm biopsy
• Gestational surrogacy
Complications of ART
OHSS:
• Seen in:
• Hallmark pathophysiological feature:
• Fluid shift
• VEGF (granulosa cells) is responsible; hCG stimulates its secretion
Risk Factors for OHSS
Young age
PCOS
Low BMI
H/o Previous OHSS
High AMH
> 14 follicles on trigger day
High estradiol levels > 4000 pg/ ml
Prevention
Trigger
GnRH antagonist cycles
Coasting (Delaying hCG admin)
Canceling the cycle (Definitive way)
Cryopreservation of the embryos
In-vitro maturation of oocytes
IV albumin
Avoid hCG for luteal support
OHSS: What you should know for NEET-PG
OHSS: Treatment
Mild OHSS No Treatment
Moderate OHSS Outpatient follow up, monitoring of symptoms
Severe OHSS
• Key: Correct the circulatory volume and
electrolyte imbalance
MCQ 1
Q. Intra cytoplasmic sperm injection is useful in?
A. Endometriosis
B. Mullerian agenesis
C. Oligospermia
D. PCOS
MCQ 2
Q. Which is incorrect regarding clomiphene citrate?
A. It causes mono follicular development
B. It has 2 components, out of which enclomiphene is more potent
C. There is an increased risk of multiple pregnancy
D. Ovulation induction will occur in 80% patients
MCQ 3
Q. A couple who is unable to conceive undergoes laparoscopy and
Chromotubation. This is the image. What is your diagnosis?
A. Adhesions
B. Chocolate cyst
C. Endometriosis
D. PID
MCQ 4
Q. All are complications of Artificial Reproductive Techniques
except?
A. Ovarian hyperstimulation syndrome
B. Heterotopic pregnancy
C. Multiple pregnancy
D. Fetal growth restriction
AUB
Abnormal Uterine Bleeding
Normal Menstrual Cycle: New FIGO
Endometrial Hyperplasia
Diagnosis
• Transvaginal ultrasound
Endometrial biopsy
Treatment of Endometrial Hyperplasia
Endometrial Hyperplasia
Simple Hyperplasia/ ATYPICAL ENDOMETRIAL

Complex Hyperplasia HYPERPLASIA
WITHOUT ATYPIA
Hysterectomy with B/l salpingo-

Cyclical oral progestogens
oophorectomy: Preferred modality of
LNG IUD
treatment
Office endometrial biopsy
If fertility preservation:
every 3 to 6 months till
High dose progestin therapy
complete resolution
3 monthly endometrial biopsies
Fertility complete: Hysterectomy
Adenomyosis
Diagnosis
Investigation of choice: Trans Vaginal
Sonography (TVS)
Leiomyoma: Classification
Red Degeneration
Images
Post menopausal Bleeding: Causes
Vulva
Vagina
Cervix
Uterus
Fallopian Tube
Ovary
Causes of PMB: Uterine causes
History and Examination
Examination
History • Vital signs
• Age of menopause • BMI
• Prior menstrual history • Abdominal examination
• Discharge • Local examination
• Abdominal pain • Speculum Examination
• Bimanual examination
Evaluation of PMB
“Main aim: Exclude Malignancy”
• Cervical biopsy from a suspicious mass
• Transvaginal ultrasound for
• Hysteroscopy
• Endometrial biopsy
• Others
Evaluation of
Post menopausal
PMB bleeding
History + Examination
Growth lesion on the Cervix looks normal

cervix
Pap smear and TVS (ET)

Cervical Biopsy
ET > 4mm ET ≤ 4mm
Endometrial Follow up
Biopsy EB if recurrent
episodes/ high risk
Obtaining an endometrial biopsy
• Dilatation and curettage

• Uterine cavity aspiration
• Hysteroscopic guided endometrial
aspiration
Ovarian Masses
Benign Ovarian Cysts
1. Functional ovarian cyst
2. Teratoma (dermoid)
3. Endometrioma
IOTA Scoring
Epithelial Ovarian Tumors
Risk Factors:
Genetic Associations
• BRCA 1 (17q21): 40%
• BRCA 2 (13q12): 15%
• HNPCC: 50% risk of endometrial; 12% risk of ovarian
Ovarian Tumor markers
• Ca125
• AFP
• LDH
• Beta HCG
• Inhibin A & B
Typical HPE
Meigs syndrome
• Solid ovarian mass (Fibroma)+ pleural effusion + ascites

Regarding Cisplatin resistance, read the statements below. Which is
correct?
1. Resistance is recurrence within 6 months
2. Partial sensitivity is recurrence within 6-12 months
3. Sensitive is recurrence > 12 months
A. 1
B. 2
C. 3
D. All of the above
Cervical cancer Screening and the HPV
vaccine
What do we test on cytology?
How do we Test?
HPV Testing
What Else?
Combined Tests
• Co-Testing
• Reflex Testing
Cervical Cytology: Bethesda System
• NIELM
• Epithelial Cell abnormalities: ASCUS, LSIL, HSIL, CIS, SCC
• Glandular cell abnormalities: AGCUS, endocervical carcinoma in situ,
Adenocarcinoma
Management of Abnormal HPV
• If HPV is Negative: Return to routine 5 yearly Screening
• If HPV positive Cytology: ≥ ASCUS COLPOSCOPY
HPV Genotype: High Risk AND BIOPSY
Management of Abnormal Cytology
• ASCUS
• HPV positive: Colposcopy and biopsy
• HPV negative: Return to normal testing
• LSIL
• HPV positive: Colposcopy and Biopsy
• HPV negative: Repeat cytology at 1y
• HSIL/ ASC-H: Colposcopy and Biopsy

Management of Abnormal Biopsy
• CIN 1: Co-test after 1 year/ Ablative procedures
• CIN 2/3:
• LEEP/ LLETZ Preferred
• Ablative procedures if TZ is entirely seen, no endocervical extension, not
pregnant, no suspicion of cancer
Ablative Procedures
• Thermo-ablation
• Cryotherapy: N2O
• -890
• 2 sequential freeze thaw cycles (3
min/ 5 min)
• 5 mm depth of destruction
• Laser Ablation: CO2 laser
Excisional Procedures
Excision of TZ including a portion
of the endocervical canal
• Loop Electro Excisional Procedures:
LLETZ: Treatment of Choice
• Cold knife conization
• Lesion extending into the endocervix
• Cytology – histology discordance
• Suspected micro-invasive cancer
• Recurrent high-grade lesion
• Laser conization
Other Important Points
• LLETZ with margins negative: HPV Co-testing at 12, 24 months
• LLETZ with margins positive: Repeat excision/ Hysterectomy
• Indications for hysterectomy in CIN
• AIS
• CIN 3 with margins involved in older women/ unsure of follow up
• Recurrent high-grade lesion
HPV Vaccine
• Prevention of primarily CIN & Ca cervix
• Also, against: Ca vulva, vagina, anal canal, penis and oropharynx &
genital warts
• Contains recombinant VLP (L1 synthetic capsid protein)
• Types
1. Cervarix: Bivalent (16,18)
2. Gardasil: Quadrivalent (6,11,16,18)
3. Gardasil 9: Nonavalent (6,11,16,18,31,33,45,52,58)
• IAP: Girls 9 to 14 years: 2 doses; > 15 years (3 doses)
New!
Gestational Trophoblastic
Neoplasia
GTN: Important Points
Management
• Staging
• Prognostic Score
Important Vaginal Infections
Distinguishing features of vaginitis
Feature
Discharge
Other Symptoms
Signs
pH
Diagnosis
Feature Bacterial Vaginosis
Discharge White, thin, homogenous
Foul odor
Other Symptoms -
Signs No erythema
pH > 4.5
Diagnosis Amsel Criteria (at least 3 of)
Feature Bacterial Vaginosis Trichomoniasis
Discharge White, thin, homogenous Yellow, Frothy
Foul odor Foul odor
Other Symptoms - Pruritis, Dysuria
Signs No erythema Strawberry Vagina
pH > 4.5 > 4.5
Diagnosis Amsel Criteria (at least 3 of) Wet mount
• Clue cells on wet mount Motile organisms
• Whiff test: Amine odor
with KOH
• pH > 4.5
• Homogenous, non viscous
milky white discharge
Feature Bacterial Vaginosis Trichomoniasis Candidiasis
Discharge White, thin, homogenous Yellow, Frothy Thick, curdy
Foul odor Foul odor No odor
Other Symptoms - Pruritis, Dysuria Pruritis, dysuria
Signs No erythema Strawberry Vagina Erythema ++
pH > 4.5 > 4.5 < 4.5
Diagnosis Amsel Criteria (at least 3 of) Wet mount KOH
• Clue cells on wet mount Motile organisms Pseudohyphae or spores
• Whiff test: Amine odor
with KOH
• pH > 4.5
• Homogenous, non viscous
milky white discharge
Some Images in Gynecology
Q1. All the following are advantages of this
instrument except?
A. It allows visualization of all vaginal walls
B. The groove allows for drainage of secretions
C. It is self retaining
D. Several cervical and uterine procedures can be
carried out
Q2. This instrument can be used in all of the following procedures
except?
A. Culdocentesis
B. Cu-T removal
C. To take a pap smear
D. Visualization of the cervix
Q3. In which of the following surgeries, will
this instrument most commonly be used?
A.Abdominal hysterectomy
B. Vaginal hysterectomy
C. Ovarian cystectomy
D.Tubal ligation
Q4. A 42-year woman is undergoing an endometrial
biopsy for abnormal uterine bleeding. You are
assisting the resident for the procedure, and you
are asked to hold the anterior lip of the cervix with
the instrument shown below. What is the name of
this instrument?
A. Allis forceps
B. Long artery forceps
C. Rong forceps
D. Vulsellum
Q5. Identify this procedure
A.Trans-vaginal tape
B. Burch colposuspension
C. Anterior colporrhaphy
D.Trans-obturator tape
Q6. Identify this instrument and the procedure
it is used in?
A.Ovum forceps; Dilatation and evacuation
B. Sponge holding forceps; Dilatation and
evacuation
C. Ovum forceps, Dilatation and curettage
D.Sponge holding forceps, Dilatation and
curettage
Q7. Identify the procedure being done
A.Cervical biopsy
B. Cervical conization
C. Cervical cerclage
D.Large loop excision of the transformation
zone
Q8. The instrument shown below is useful in which surgery?
A.Ovarian cystectomy
B. Myomectomy
C. Tubal recanalization
D.Vaginal hysterectomy
Q9. Identify this instrument
A.Bonney’s myomectomy clamp
B. Green Armitage
C. Shirodkar’s clamp
D.Uterine manipulator
Q10. This instrument is used in the following
A.To hold the cervix in a vaginal hysterectomy
B. To hold the angles of the uterine incision in a
cesarean section
C. To hold the angles of the vault in an
abdominal hysterectomy
D.To hold the angles of the vault in a vaginal
hysterectomy
Q12. Identify the instrument shown
A. Hysteroscope
B. Intra-uterine insemination cannula
C. Leech Wilkinson cannula
D. Uterine manipulator
Q13. A 44-year-old woman undergoes a dilation and curettage for
abnormal uterine bleeding. Identify this instrument used in the
procedure.
A. Ovum forceps
B. Punch biopsy forceps
C. Tenaculum
D. Uterine curette
Q14. A 56y lady presents with postmenopausal bleeding. On
speculum examination, a growth is seen on the cervix as
shown. Which instrument should be used to take a biopsy of
the growth?
A. Allis forceps
B. Bard Parker handle with scalpel
C. FNAC needle
D. Punch biopsy forceps
Q15. The following instruments are used in which
procedure?
A. Cervical biopsy
B. Colposcopy
C. Dilatation and curettage
D. Pap smear
Q16. Identify this instrument
A.Leech Wilkinson cannula
B. Hegar Dilator
C. Hawkin Amber Dilator
D.Uterine curette
Q17. Identify this instrument:
A.Laparoscopic grasper
B. Laparoscopic ring applicator
C. Laparoscopic scissors
D.Laparoscopic bipolar coagulator
Q18. The following instrument was used in a 24y woman
who wanted an MTP at 8 weeks of gestation. All are signs of
completeness of procedure except?
A. Grating sensation on all 4 walls
B. Absence of air bubbles
C. Bleeding stops
D. Gripping sensation of the internal os
Q19. A 34y infertile woman is diagnosed to have a
large 7 cm intramural fibroid distorting the uterine
cavity as shown on USG. The best management is?
A. IVF
B. Laparoscopic myomectomy
C. GnRH analogues
D. Uterine artery embolization
Q21. A 19 y girl presents with abdominal
pain. A diagnosis of ovarian dermoid is
made. The image shows the surgical
procedure being done, which is?
A. Laparotomy and ovarian cystectomy
B. Laparoscopic ovarian cystectomy
C. Laparoscopic ovariectomy
D. Laparoscopic hysterectomy
Q22. A 21 y girl presents with acute abdominal
pain and vomiting. On laparoscopy, this is the
image seen. What is the diagnosis?
A. Ovarian cyst rupture
B. Haemorrhage into ovarian cyst
C. Ectopic pregnancy
D. Torsion of ovarian cyst
Q23. A 45 y lady presents with
menorrhagia. A saline infusion
sonography reveals the following
image. The best management would
be:
A. Laparoscopic myomectomy
B. Hysteroscopic polypectomy
C. Laparoscopic hysterectomy
D. Vaginal hysterectomy
Q24. A 29y infertile woman, on
laparoscopy was found to have an ovarian
cyst, which ruptured intra-op and
chocolate like material drained. The
diagnosis is?
A. Dermoid
B. Endometriosis
C. Mucinous adenocarcinoma of the
ovary
D. Genital TB
Q25. A 24y infertile patient shows the
following HSG report. The most likely
organism is:
A. Gonorrhea
B. Mycobacterium tuberculosis
C. Chlamydia
D. Trichomonas vaginalis
Q26. A 26y with tubal block on HSG undergoes a diagnostic laparoscopy. The
following finding is seen. What is the diagnosis?
A. Endometriosis
B. Genital TB
C. PID
D. PCOS
Q27. An 18y unmarried girl presents with delayed
menstrual cycles and acne. An ultrasound shows
the following image. The best management option
is:
A. Clomiphene citrate
B. Combined Oral Contraceptive Pills
C. Laparoscopic ovarian drilling
D. Reassurance
Q28. A 45 y underwent hysterectomy for
AUB. The cut section of the uterus is as
seen. The diagnosis is?
A. Cervical fibroid
B. Intramural fibroid
C. Submucous fibroid
D. Subserous Fibroid
Q29. Identify the instrument used to insufflate the peritoneal cavity.
1. Lind’s needle
2. Verres needle
3. Mathew needle
4. Jack needle
Q30. A 28y married woman presents
with a painful swelling in the vulvar
region as shown. The diagnosis is?
A. Bartholin’s cyst
B. Rectocele
C. Uterine prolapse
D. Vulval hematoma
Q31. A 62 y woman presents with a vaginal mass as
shown. All are supports of the uterus except?
A. Cardinal ligaments
B. Pubo-urethral ligaments
C. Recto-vaginal fascia
D. Round ligament
Q32. A 30y presents with woman with
recurrent mid trimester abortions. An HSG
is done. What is the diagnosis is?
A. Arcuate uterus
B. Bicornuate uterus
D. Septate uterus
Q33. Under the national family planning program, the
following contraception contains?
A. Levonorgestrel
B. Etonorgestrel
C. Medroxy Progesterone Acetate
D. Desogestrel
Q34. The LNG-IUS system as shown below can be used
for all the following except?
A. Adenomyosis
B. Contraception
C. Endometrial hyperplasia
D. Asymptomatic fibroid uterus
Q35. Identify the progesterone component
in this contraceptive.
A. Levonorgestrel
B. Norelgestromin
C. Etonogestrel
D. Norethisterone acetate
Q36. All are true regarding this contraceptive
method except?
A. It is inserted using withdrawal technique
B. Mechanism of action is primarily by preventing
fertilization
C. It should be removed after 5 years
D. Is absolutely contra-indicated in women with
pelvic tuberculosis
Q37. All are advantages of this contraceptive method
except?
A. Can be inserted up to 8 hours before intercourse
B. Can be used multiple times
C. Prevents sexually transmitted diseases
D. 95% effective with perfect use
Q38. The contraceptive shown below
contains which class of drug?
A. Combined Estrogen + Progesterone
B. Progesterone
C. Selective Estrogen Receptor Modulator
D. Selective Progesterone Receptor
Modulator
Q39. A 42y woman with a h/o breast cancer is
on tamoxifen. She presents with AUB, and an
USG shows this. Next best management is?
A. Cervical biopsy
B. Dilatation and curettage
C. Fractional curettage
D. Hysteroscopic guided biopsy
Q40. A 16y girl presents with cyclical abdominal pain and primary
amenorrhea. On examination, the following is seen. The best
management is?
A. Excision and drainage
B. Cruciate incision and drainage
C. Laparoscopy and repair
D. Hysteroscopy
Operative Gynecology
Operative Gynecology
• HYSTERECTOMY
Q. A 44-year-old woman undergoes a total hysterectomy for painful
fibroids. The ovaries will not be removed during the procedure.
Which of the following ligaments must be preserved?
A. Infundibulum-pelvic Ligament
B. Ovarian Ligament
C. Transverse Cervical Ligament
D. Uterosacral ligament
Q. All are true of internal iliac artery (hypogastric artery) ligation except?
A. It is used in the control of refractory pelvic haemorrhage

B. Reduces bleeding by decreasing the pulse pressure
C. Ligation is done proximal to the posterior division
D. Ureter is liable to get injured during the procedure
Common iliac
artery
Internal iliac
artery
Internal iliac
vein
External iliac Posterior
artery branch of
internal iliac
artery
Obturator
Anterior branch
nerve
of internal iliac
artery
• Branches of the anterior internal iliac A: supply the pelvic organs
and perineum
“MR SVIGIP Owns Unusual Views”
• Branches of the posterior iliac A: supplies the buttocks and thigh
“Sit In Line”
Q. All are true about uterine vessels except:
A. The uterine artery arises from the anterior division of internal iliac
artery.
B. The uterine artery crosses below the ureter about 2 cm lateral to
the cervix
C. The uterine artery gives rise to the arcuate arteries, which
penetrate the uterus
D. The uterine vein drains into the internal iliac vein
• The ureter enters the pelvis by crossing over the bifurcation of the
common iliac artery
• Passes medial to the ovarian vessels
• As it descends, it lies medial to the internal iliac branches
• Traverses through the cardinal ligament 1 – 2cm lateral to the
cervix
• Courses below the uterine artery antero-medially towards the
bladder base
• LAPAROSCOPY
Diagnostic and Therapeutic
Hysteroscope
Important Points
MCQs Previous 2 Year Questions - Gynecology
Q1. A 16-year-old girl with a partial transverse vaginal septum presents
with dysmenorrhea and chronic pelvic pain.
Which of the following is she likely to have?
A. Theca lutein cyst
B. Endometriosis
C. Tubo-ovarian abscess
D. Dermoid cyst
Transverse Vaginal Septum
• Primary Amenorrhea
• Cyclical abdominal pain due to
hematocolpos
• If untreated – hematometra and
endometriosis
Q2. A 28 y P0A3 with recurrent 2nd trimester abortions was found to
have a uterine septa on sono-salpingography. What is the BEST
management option?
A. Dilatation and curettage
B. Laparoscopic metroplasty
C. Hysteroscopic septal resection
D. Laparotomy and metroplasty
Q3. A 28year woman being evaluated for infertility was found to have
a uterine didelphys on 3D ultrasound. All are possible complications
except?
A. Preterm labor
B. Endometriosis
C. Transverse lie
D. Abortions
Q4. A 28-year-old woman is undergoing evaluation for successive
recurrent pregnancy losses. On ultrasound, a Mullerian anomaly is
suspected. What is the BEST way to confirm this?
A. Trans vaginal ultrasound
B. Hysterosalpingography
C. CECT
D. Hysteroscopy and laparoscopy
• Transvaginal ultrasound
• HSG
• Sono-salpingography
• 3D USG
• MRI
• Hysteroscopy + Laparoscopy
Q5. A 25y woman had evacuation of molar pregnancy done 6 months
earlier. She now presents with general ill-health, breathlessness, cough
and irregular vaginal bleeding. On chest X-Ray, there are canon ball
metastases. Her beta hCG levels are high. Which is the BEST
management option?
A. Multi dose Inj Methotrexate and Inj Folinic acid
B. Hysterectomy
C. Single dose Inj methotrexate
D. Multiple drug regime EMA-CO
Q6. Reema Devi, A 28y newly married woman presents to your sub center
for contraceptive advice. She is started on Oral Contraceptive Pills. She
presents after 2 weeks with a history of missing 4 tablets on different days
in the first 2 weeks of the cycle. What will you advise her?
A. Discontinue the packet and start an alternate method of contraception
B. Take 4 tablets the next day, continue the remaining packet, use
additional contraception (condom) and give Emergency Pill if h/o
intercourse in the last 72 h
C. Take the next pill as soon as possible, continue the remaining packet,
use additional contraception (condom) and give Emergency Pill if h/o
intercourse in the last 72 h
D. Take the next pill as soon as possible and continue the remaining
tablets
2 or more missed pills
One Missed Pill (> 48 h late)
• The missed pill should • The last missed pill should be taken as soon
be taken as soon as as possible
possible • Leave the earlier missed pills
• The remaining pills • Use additional contraception for 7 days
taken as usual • Further to reduce risk of pregnancy
• No additional o If pills missed in 1st week: Consider
contraception Emergency Contraception
required o Pills missed in 2nd week: No need for
o Pills missed in the 3rd week: Omit the
pill free interval and start the next pack
after finishing the active pills in the
current pack
Q7. A 30year woman has been diagnosed to have pulmonary
tuberculosis. She is started on first line anti-tubercular treatment
as per guidelines. She is also taking oral contraceptive (OC) pills for
contraception. Her doctor advises her to use another
contraceptive method. What is the reason for this advice?
A. OC pills can cause failure of anti-tubercular treatment
B. Rifampicin is teratogenic
C. Rifampicin induces metabolism of OC pills
D. Indomethacin is teratogenic
Oral Contraceptive Pills and Drug Interactions
1. Enzyme Inducing Drugs (Rifampin, rifabutin) significantly reduce OCP efficacy
2. Other medications that reduce OCP efficacy: Amoxicillin, Ampicillin,
Erythromycin, Fluconazole, Griseofulvin, Itraconazole, Ketoconazole, Metronidazole
and Ritonavir
3. Anti-Epileptic Drugs which reduce OCP efficacy (induce CYP P450):
Carbamazepine, Ethosuximide, Phenobarbital, Phenytoin, Primidone,
Oxcarbazepine, Topiramate
4. Avoid OCPs with Lamotrigine. Lamotrigine clearance is increased in the presence
of Estrogen containing oral contraceptives.
Q8. A 55-year-old lady with 5 children presents with leakage of urine on
coughing. On examination, there is a 2nd degree uterine prolapse and
cystocele. What is the most likely urinary abnormality?
A. Overflow incontinence
B. Urge incontinence
C. Stress incontinence
D. Neurogenic bladder
Q9. A 28-year woman with infertility presents to you. On ultrasound
there is an intramural fibroid measuring 7 x 5 cm near the right cornua
and another intramural fibroid measuring 5 x 5 cm near the left cornua.
HSG reveals bilateral tubal block at the region of the tubal ostia. Semen
parameters are normal and there is no ovulatory disturbance. What is
the BEST management for this woman?
A. GnRH analogues
B. Laparoscopic myomectomy
C. ART
D. Uterine artery embolization
Indication for myomectomy in Infertility
• All submucosal fibroids
• Intramural fibroids distorting the cavity; > 5 cm
• Subserous fibroid: only for improving symptoms/ pregnancy
outcome
Q10. A 25-year woman who is anxious to conceive comes to the OPD
with complaints of profuse white vaginal discharge for 2 days. There is
no itching, and her menstrual cycles are regular. The most likely
diagnosis is:
A. Trichomoniasis
B. Physiological
C. Bacterial vaginosis
D. Candidiasis
Q11. A 39-year woman presents to the medicine OPD with complaints
of fatigue and lethargy. She gives a history of delivering a 3.5 Kg baby
5 years earlier following which she received multiple blood
transfusions. She never resumed menstruation following delivery and
also had failure of lactation. Which is the most likely diagnosis?
A. Euthyroid sick syndrome
B. Hypothyroid
C. Sheehan Syndrome
D. Late onset blood transfusion reaction
Q12. A 12y girl is brought to the OPD by her mother. She is concerned
that she is shorter than her peers. On examination there is ptosis on
the right side, shield like chest and a webbed neck. On evaluation,
which of the following would you expect to find?
A. Ultrasound showing streak ovaries and a small uterus
B. ECHO showing tricuspid stenosis
C. Ultrasound showing hepatomegaly with altered echotexture
D. Ultrasound showing single kidney
Q13. Identify the type of hymen
A. Septate
B. Semi-lunar
C. Annular
D. Cribiform
Types of Hymen
Q14. Which is a contra-indication to this?
A. Menstruation
B. Trophoblastic disease
C. Condom rupture during intercourse
D. Following Delivery
Absolute c/I to Cu containing IUD
• Pregnancy
• Unexplained vaginal bleeding
• Gestational trophoblastic disease
• Cervical cancer
• Endometrial cancer
• Ovarian cancer
• STI/ PID
Q15. A 59y old woman presents with anogenital warts. Genotyping of the
virus is done, and it shows her to be at risk for atypia/ squamous cell
carcinoma. The likely genotype is?
A. HPV 18
B. HPV 2
C. HPV 7
D. HPV 11
• Infection with low-risk HPV : Benign/ low-grade cervical-cell abnormalities,
laryngeal papilloma's, and cutaneous or genital warts
• 90% of all anogenital warts: HPV 6 and 11.
• Infection with high-risk types can cause both low-grade and high-grade
cervical-cell abnormalities
• High-risk HPV is detected in approximately 99% of all cervical cancers,
anal cancers, 75% of vaginal cancers, 70% of oropharyngeal cancers,
of penile cancers
Q16. A 35y man who is undergoing evaluation for infertility; semen analysis shows
azoospermia. A testicular biopsy done shows the following image. The diagnosis is?
A. Germ cell tumor
B. Sertoli cell only syndrome
C. Testicular atrophy
D. Orchitis
Sertoli cell only syndrome
• Only Sertoli cells line the seminiferous
tubules of the testis (wind swept
appearance)
• Absent germ cells
• Very low or absent spermatogenesis
• These patients are typically normal on
physical examination
• Diagnosis is usually made based on
testicular biopsy findings.
Q17. A 28y woman who delivered 18 months back and is breastfeeding seeks
contraceptive advice. Her periods are irregular and heavy. The best
contraceptive for her would be?
A. Progestasert
B. NET-EN
C. Mala – N
D. CuT 380 A
Q18. Identify the anomaly
A. Septate uterus
B. Bicornuate uterus
D. Unicornuate uterus
Bicornuate uterus Septate
• HSG demonstrates separate • HSG of a septate uterus represents
fusiform uterine horns varying degrees of the midline septum
• Inter-cornual angle of >105º • A V-shaped configuration often with
an angle <75º between the two
uterine horns
Q19. You are asked to prepare the discharge summary of a patient who has had a
repair for VVF. For how long will you ask her to abstain from sexual intercourse and
delay conception by?
A. 6 weeks abstinence and delay conception by 6 months
B. 6 months abstinence and delay conception by 6 years
C. 3 weeks abstinence and delay conception by 2 years
D. 3 months abstinence and delay conception by 1 year
OBSTETRICS &
GYNECOLOGY
Original Review &

Revision
Hyderabad
by Dr Raina Chawla
Attempting Clinical Scenarios
in Obstetrics
Clinical Scenarios in Obstetrics
2 most important Questions!
1. When to Deliver?
2. How to Deliver?
Remember 2 other things!
• If the delivery is before 34 weeks – Give corticosteroids! (But only if
you have time!!!)
• If the delivery is before 32 weeks – Give MgSO4 for neuroprotection

of the fetus.
Timeline
28 34 37 38 39 40 41 42
Hypertensive Disorders in Pregnancy
Disorder About
CHRONIC HYPERTENSION
GESTATIONAL HYPERTENSION
PREECLAMPSIA
ECLAMPSIA
PREECLAMPSIA SUPER-IMPOSED ON CHRONIC

HYPERTENSION
Hypertension in Pregnancy
28 34 37 38 39 40 41 42
Hypertensive Disorders of Pregnancy

1. Mild Preeclampsia and gestational HTN: 37 weeks
2. Severe preeclampsia: 34 weeks
3. Severe Preeclampsia with
• HELLP
• Pulmonary edema
• Eclampsia
• Abruption
• Non reassuring fetal status
Also Remember
MgSO4 is very essential in prevention of eclampsia and should be given
asap in severe preeclampsia
MCQ 1
Q. A 33 weeks multigravida woman presented with a BP of 160/100 mmHg
associated with epigastric pain, headache, visual symptoms, proteinuria 3+ . What
is the next best step in the management?
A. Immediate cesarean
B. Dexamethasone for fetal lung maturity
C. Induction of labor
D. MgSO4
MCQ 2
Q. A multipara women is presenting at 36th week of pregnancy with low platelet
count, raised serum transaminases and mild hemolysis. What should be the next
line of management?
A. Intravenous corticosteroids
B. Wait & watch
C. Delivery of the baby
D. Intra-amniotic corticosteroid
MCQ 3
Q. A 29y primigravida presents at 37 weeks. Her BP is 130/90 mmHg and

urine protein is 2 +. What is the next best management?
A. Induction of labor
B. Emergency LSCS
C. Induction of labor at 40 weeks
D. Elective LSCS at 40 weeks
MCQ 3
Q. A 28-year-old primigravida woman presents at 28 weeks gestation with
headache and a blood pressure of 160/110 mm Hg. Investigations reveal 2+
proteinuria on dipstick, deranged liver function tests and a platelet count of
60,000/ml? What is the best management?
A. Oral antihypertensive therapy
B. Platelet transfusion
C. Magnesium sulphate therapy and induction of labour
D. Intravenous immunoglobulin therapy
Diabetes in Pregnancy: Gestational Diabetes
28 34 37 38 39 40 41 42
GDM with well controlled blood sugar: Induction of labour should be

scheduled at or after 39 weeks pregnancy
GDM (poorly controlled): 37-39 weeks OR Earlier
Diabetes in Pregnancy: Pre – gestational
Diabetes
28 34 37 38 39 40 41 42
No complications: 37-39 weeks

Complications (Metabolic/ maternal/ fetal): 37 weeks
GDM Pre-gestational Diabetes
Diagnosed during pregnancy Present before pregnancy
Requires OGTT at 24-28 weeks for diagnosis Can be diagnosed based on a raised HbA1C or
a raised FBG in the 1st trimester
Maternal and perinatal mortality more in the Congenital anomalies and spontaneous
latter half of pregnancy abortions if uncontrolled in the 1st trimester
Ketosis is uncommon Ketosis is more common
No end organ complications Diabetic nephropathy/ retinopathy can be
present’ Preeclampsia and IUGR more
common in such scenarios
Diet and exercise sufficient in majority If on metformin, it is continued, Insulin may
be additionally required
OHAs are useful Insulin Is usually required
MCQ 1
Q. A 34 y lady G2P1L1 is at 34 weeks gestation. She is an overt diabetic
on insulin. Her blood sugar levels are under control. She is concerned at
what gestational age should her delivery be planned?
A. 34 weeks
B. 37 weeks
C. 38 weeks
D.40 weeks
Fetal Growth Restriction
28 34 37 38 39 40 41 42
• Decided by umbilical artery flow on Doppler

History (Risk Factors)/ Examination (uterine height/ SFH)
Fetal Biometry < 10th percentile/

serial measurements indicative of FGR
Umbilical Artery Doppler
Normal PI/ RI á (Reduced EDV) A/REDV
Repeat USG Twice Weekly

& Doppler 2 Umbilical Artery
weekly Doppler • Plan Delivery if >
Weekly Biometry 34 weeks
• If < 34 weeks:
Plan Delivery Corticosteroids
• Plan Delivery at 37 and then plan
at 37 weeks
weeks delivery
• Plan Delivery > 34
weeks if static
growth > 3 weeks
Middle Cerebral Artery Doppler
• A compromised fetus will redistribute blood to essential organs (The
brain)
Doppler Changes in FGR
• Cerebro-Placental Ratio
• CP Ratio = PI of MCA
PI of umbilical artery
• CP Ratio > 1: Normal
• CP Ratio < 1: Brain sparing effect
Video (Desktop)
MCQ 1
A 30y G2 with a previous LSCS presents at 35 weeks pregnancy with fetal growth
restriction. An umbilical artery doppler reveals the following.
A. Biophysical profile
B. Emergency LSCS
C. Induction of labor
D. Repeat Doppler after 1 week
MCQ 2
A 30-year-old primigravida , diagnosed with gestational
hypertension and fetal growth restriction , presents at 33
weeks of pregnancy for ultrasound. Ultrasound reveals an
estimated fetal weight less than 10th percentile for normal and
amniotic fluid index of 7 cm. The Umbilical artery doppler
shows the following picture
A. Immediate LSCS
B. Repeat USG with assessment of BPP & umbilical artery
doppler after 2 weeks
C. Repeat USG with assessment of BPP & umb artery artery
doppler twice weekly
D. Gv steroid cover and deliver
Obstetric Cholestasis
• 2nd most common cause of jaundice in pregnancy
• 3rd trimester, itching, mild jaundice
• Recurrent, OCP use
• Serum bile acid: most specific investigation
• Risk of meconium-stained amniotic fluid, fetal distress and still birth
• Treatment: Urso-deoxycholic acid
• IOL: 37 weeks
Acute Fatty Liver of Pregnancy
• MC cause of liver failure in pregnancy
• 1 in 10000
• Association with Pre-eclampsia, Primigravid, Twin pregnancy, Male fetus
• 3rd trimester
• C/f: Persistent nausea and vomiting, Malaise, anorexia, epigastric pain,
progressive jaundice
• Fetal distress and fetal death
• Management: Immediate delivery, intensive support and management of
coagulopathy
Liver Disorders
28 34 37 38 39 40 41 42
Multiple Pregnancy
1. Dizygotic
2. Monozygotic
Monozygotic Twins
Management of Twin Pregnancy
• DCDA: Delivery at 38 weeks

• Uncomplicated MCDA: 34 – 37 weeks
• MCMA twins: 32 – 34 weeks
Confirm presentation
§ Cephalic – Cephalic (most common)
§ Cephalic – Non cephalic
§ Non cephalic – cephalic/ non cephalic
Close monitoring in Labor
• Clamp cord
Conduct Delivery of 1st twin • Withhold
methergine
• Note the time
Reassess lie and presentation of 2nd twin
Longitudinal Lie Transverse Lie
ARM/ Oxytocin ECV/ EPV
IPV + Breech Extraction

Indications for Elective LSCS in Multiple Pregnancy
1. First fetus non-cephalic

2. Triplets and above
3. Conjoined Twins
4. Monoamniotic twins
5. Discordant twins (severe)
MCQ 1
Q. A 32y primigravida who conceived after IVF came for an antenatal
checkup at 38 weeks of gestation. Her obstetric history revealed that she has
DCDA twins. On examination, the first twin was in breech position and the
maternal BP - 140/90 mm Hg on 2 occasions with grade 1+ proteinuria. What
should be done next?
A. Monitor BP and terminate pregnancy if BP rises

B. Immediate C-section
C. Terminate pregnancy at 40 weeks of gestation
D. Induce labour with PGE2 gel
Antepartum Haemorrhage
• Placenta Previa
• Abruptio Placentae
• Local causes/ Unexplained/ Vasa previa
Clinical Features
• PAINLESS
• RECURRENT
• APPARENTLY CAUSELESS
Investigations
Ultrasound
• Modality of choice
• Preliminary investigation of choice: Transabdominal
ultrasound (TAS)
• Transvaginal ultrasound: More accurate; Done if any
doubt on TAS; Safe
MRI
• Useful in some situations
• More useful in morbidly adherent placenta
Diagnosed Placenta Previa
< 37 weeks > 37 weeks
• No/ minimal active bleeding

• Maternal condition good Immediate Delivery
• Fetal condition good
• No gross fetal abnormality
(usually cesarean)
Yes to all No to any 1
McAfee Delivery
Johnson (usually
(Expectant) cesarean)
37 weeks or no to any
1 during expectant
management
MCQ 1
Q. A 36-year lady with twin pregnancy conceived through IVF
presents at 32 weeks with painless vaginal bleeding. This is
the 2nd such episode and ultrasound reveals placenta previa.
Her PR is 80/min and BP is 110/70 mmHg. FHR 1 is 140 bpm
and FHR 2 is 156 bpm. How will you manage this patient?
1.Immediate cesarean delivery
2.Expectant management
3.Arrange blood and plan cesarean at 34 weeks
4.Induction of labor
Placental Abruption
Clinical Classification
Grade 0: Asymptomatic
Grade 1: Vaginal bleeding mild; uterine tenderness minimal or absent, FHR – good
Grade 2: Vaginal bleeding: mild – moderate, Uterine tenderness +; No maternal

shock; Fetal distress/ death
Grade 3: Bleeding: moderate/ severe; Marked uterine tenderness; fetal death +;

maternal shock/ DIC/ ARF +
Diagnosis
Clinical
Management
• Emergency measures
• Immediate Delivery is the rule
How to Deliver?
• If fetal distress/ maternal shock – expedite (Cesarean delivery unless patient in
advanced labor)
• If no fetal distress or fetal demise has already occurred OR no maternal distress:
Induce/ Augment (ARM ± Oxytocin)
MCQ 1
Q. A 34y primi at 32 weeks presents to the emergency with vaginal
bleeding. On examination, her BP is 140/ 90 mmHg. Abdominal
examination reveals the uterus to be 32 weeks. Fetal heart rate is 100 bpm.
A vaginal exam reveals the cervix to be 4cm dilated. What is the next best
step in management?
A. Emergency LSCS
B. ARM and oxytocin
C. Corticosteroids and tocolysis
D. Urgent ultrasound
Timeline: APH
28 34 37 38 39 40 41 42
Rh Isoimmunization: Understanding the concept
1st Pregnancy In between 2nd Pregnancy

Understanding the Concept
Fetal Hemolysis
Fetal Anemia
Changes in fetal circulation Progressive worsening in each

pregnancy with hemolysis
Increased blood flow to occurring earlier
the brain
Increased PSV in the MCA
Hydrops Fetalis
Fetal Death
Feto-maternal haemorrhage (FMH)
How does sensitization occur?
• 0.1ml can incite an Ab response;
• 16 % likelihood to develop allo – immunization if no prophylaxis is given
• 90% of allo immunization happens at delivery
• 10% occurs because of other inciting events
Other Inciting Events
Pregnancy Loss
Spontaneous abortion
Induced abortion
Molar pregnancy
Ectopic pregnancy
Suction evacuation of products of
conception
Other inciting events
Pregnancy Loss Procedures

Spontaneous abortion Chorionic villous sampling
Induced abortion
Amniocentesis
Molar pregnancy Cordocentesis

External cephalic version
Ectopic pregnancy
conception
Other Inciting Events
Pregnancy Loss Procedures Others

Spontaneous abortion Chorionic villous sampling Delivery (90%)
Induced abortion Amniocentesis Abdominal trauma
Molar pregnancy Cordocentesis Antepartum haemorrhage
Unexplained vaginal bleeding in

Ectopic pregnancy External cephalic version
pregnancy
conception Manual removal of placenta
2 Scenarios
Rh neg pregnancy (not iso-immunized)
Rh iso-immunized pregnancy
Determine Blood group and Rh type
of woman at 1st prenatal visit
If Rh negative, determine the Rh

status of the partner/ husband
If Rh negative, no risk If Rh Positive: 50 – 100%

of immunization chance that the baby is
Rh positive depending on
whether the partner is
Provide Routine
heterozygous or
antenatal care
homozygous for the D
Antigen
Do an ICT
Negative: Positive:
Not Sensitized Sensitized
Rh negative unsensitized (ICT negative): Prevention
• ICT of the mother is done to determine level of unbound Ab if

any
• If ICT is negative – repeat monthly
• Anti D prophylaxis (300 mcg or 1500 IU) IM at 28 weeks
(reduces risk of 3rd trimester FMH from 2 to 0.1%)
• Repeat Anti D prophylaxis (300 mcg) within 72 h of delivery if
the neonate is Rh positive. This reduces the risk of allo
immunization at delivery by 90 %
Prevention
Prophylaxis to also be given in the following events:
Pregnancy Loss Procedures Other

Ectopic Pregnancy Chorionic Villous Sampling Delivery
Spontaneous abortion Amniocentesis Abdominal Trauma
Elective abortion Fetal Blood Sampling Placental abruption
Fetal death Evacuation of molar Unexplained vaginal bleeding
pregnancy during pregnancy
Manual Removal of Placenta
External cephalic Version
Prevention
• Less than 12 weeks: 50 mcg, After 12 weeks: 300 mcg

• 300 mcg neutralizes 30 ml of fetal blood (or 15 ml of fetal RBC)
• Whenever in doubt: give
• Anti-D Ig is derived from human plasma donated by individuals with high titre
Anti-D immunoglobulin D Antibodies
• T1/2 -16 – 24 days
Precautions to prevent/ minimize FMH
• Avoid post dates
• Prevent blood spillage in the peritoneal cavity at the time of
cesarean
• Avoid prophylactic methyl-ergometrine
• Gentle MRP
Rh iso-immunized pregnancy (ICT positive)
Fetal red cells are
destroyed
Fetal anemia
Redistribution of
fetal blood flow: ↑
PSV of MCA
Hb < 4g: Fetal

hydrops
Fetal death
ICT Titers
Less than Critical

> Critical titer titer
Repeat titers
Check Severity of monthly till 24
fetal anemia weeks, weekly
thereafter
• Check ICT monthly till 24 weeks and

weekly thereafter till critical titers are
reached
• 1:16: Critical titer
• Once critical titer is reached: Check PSV
of MCA (on USG Doppler)
• Repeat MCA-PSV weekly
• If MCA – PSV > 1.5 MoM: Indicative of
fetal anemia; indication for cordocentesis
for fetal Hb and Hematocrit
• If HCt < 30%, intra-uterine transfusion
done
• Earlier: Amniotic fluid

spectrophotometry was done to
determine the level of bilirubin in
the amniotic fluid
• Bilirubin peaks at 450 nm on
spectrophotometry.
• This value is then plotted
Rh iso-immunized pregnancy (ICT
positive)
Planning delivery of an Rh iso-immunized pregnancy
• Delivery at 34 weeks or earlier if indicated
ü There is progressive worsening and earlier onset in subsequent

pregnancies.
ü If h/o sensitization in earlier pregnancy: Monitoring should start
earlier and critical titers aren’t required to start MCA PSV
monitoring
•
Rh negative mother; Rh
positive father
Booking ICT
ICT Positive
ICT Negative (< 1:16)
Repeat 4 weekly
OR at 28 weeks Repeat ICT 4
and 34 weeks weekly till 24
weeks then
Ant-D at 28 Deliver by 40 weekly
weeks weeks
Deliver after 37 ICT remains
weeks < 1: 16
Anti – D within 72 h if
baby is Rh +ve
ICT > 1:16
MCA PSV every week

from 24 weeks
PSV > 1.5 PSV < 1.5

MoM MoM
Repeat PSV Terminate at

> 34 < 34 MCA weekly 37 weeks
weeks weeks
Hct < 30%: IUT every

Deliver Cordocentesis 2 weeks
MCQ 1
Q. A 26-year-old G3A2, Rh negative pregnant lady presents at 28 weeks of
pregnancy with an Indirect Coomb’s Test (ICT) report of 1:32. What is the
next best step in her management?
A. Repeat ICT after 2 weeks
B. Give steroid cover and deliver
C. Perform ultrasound assessment including MCA-PSV
D. Perform intrauterine transfusion
MCQ 2
Q. A 32-year-old G3A2, Rh Negative, pregnant lady presents at 31 weeks
pregnancy with Indirect Coomb’s Test (ICT) titre of 1:64. Ultrasound
assessment shows MCA PSV corresponding to 1.5 MOM. What is the next
step in management?
A. Cordocentesis & Intrauterine transfusion (if necessary)
B. Repeat ICT after 2 weeks
C. Give maternal steroid and deliver
D. Repeat MCA-PSV after 2 weeks
Rh iso-immunization
28 34 37 38 39 40 41 42
Imaging in Obstetrics
Early Pregnancy
Snowstorm Complete Hydatiform Mole
Bagel sign and Blob Sign Tubal Ectopic
Buddha Sign Hydrops Fetalis – Scalp

edema
Spalding Sign Intra Uterine Fetal Demise –
Overlapping of fetal skull bones
Banana Sign Spina bifida - cerebellar

curvature increased
Lemon sign Spina bifida - pinching of

calvarium
Double Bubble Duodenal Atresia
sign
Keyhole Sign Posterior Urethral Valve
Frog eye/ frog Anencephaly

face sign
Lambda sign Dichorionic Diamniotic twin
Reverse T Sign Monochorionic Diamniotic Twin

ECTOPIC PREGNANCY
Ectopic Pregnancy
Ectopic Pregnancy
• Most common site
• Most common site in the tube

Heterotopic Pregnancy
Risk factors for Ectopic Pregnancy
Evolution of Tubal Ectopic
Clinical Features
Vaginal Abdominal
bleeding Pain
Delayed
menstruation
Clinical Features
Ruptured Ectopic: More severe symptoms and signs
Diagnosis
• Clinical
• Investigations
• Imaging studies
• Procedures:
Ruptured Ectopic
• Clinical Diagnosis
Unruptured Ectopic
Investigations play an
important Role
Sonographic Findings
INTRAUTERINE PREGNANCY
Gestational Sac
Sonographic Findings: Unruptured
Ectopic
Role of Beta hCG in ectopic pregnancy
2 concepts
1. Doubling Time
2. Discriminatory Zone
Positive UPT + pain +
bleeding
Stable Unstable Surgical

Management
Trans –
Vaginal
Ultrasound
Intra – Ectopic
Uterine Non – diagnostic
Pregnancy
Pregnancy
Serum β-hCG
at 0h and 48h
Serum β-hCG at
0h and 48h
Doubling (> 60% Falling (> 15% Sub-Optimal

increase) decrease) (increase or
decrease)
Failing PUL ? Ectopic

Intra-uterine Ectopic
Pregnancy
Pregnancy
(Repeat Scan
once beta hCG
crosses the Weekly Beta Weekly Beta hCG
discriminatory hCG till Persisting
zone) disappears PUL
Discriminatory Zone Suboptimal rise/ fall/

reached: TVS: IU plateauing x 3 times:
confirmed Repeat TVS
Culdocentesis
Laparoscopy
• Confirmatory/ if diagnosis in in doubt
• Diagnostic and Therapeutic
History, Examination and Investigations
Unruptured Ruptured
Expectant Surgical
Medical
Laparoscopy Laparotomy
Conservative (Salpingostomy) OR Salpingectomy

Managing a
Ruptured Tubal
Ectopic
Managing an
Unruptured Tubal
Ectopic
Expectant Management
Medical Management
Methotrexate
Dosing One dose, repeat if necessary
Methotrexate
Medication dose
1. Methotrexate 50 mg/m2 BSA
2. Leucovorin NA
Methotrexate
Medication dose
2. Leucovorin NA
Serum βhCG level Day 1 (baseline), Day 4, Day 7
Methotrexate
Medication dose
2. Leucovorin NA
Indication for additional dose If serum βhCG does not decline by 15% from day 4 to
day 7
OR less than 15% decline during weekly surveillance
Methotrexate
Medication dose
2. Leucovorin NA
Indication for additional dose If serum βhCG does not decline by 15% from day
4 to day 7
OR less than 15% decline during weekly
surveillance
Surveillance Once 15% decline is achieved, then weekly βhCG
until undetectable
Surgical Management in Unruptured Ectopic
Surgical Management
Unruptured Ectopic: Laparoscopy
• Salpingostomy
• Salpingectomy
Ovarian Ectopic
Spiegelberg Criteria
Abdominal Ectopic
Studdiford Criteria
Cervical Ectopic
• Rubin’s criteria
Cesarean Scar Ectopic
Cornual Pregnancy
Heterotopic Pregnancy
Important Points to solve Questions!
• Ruptured Ectopic pregnancy: Clinical Diagnosis; Surgical management is the rule!
• No role of beta hCG in a ruptured ectopic pregnancy
• Beta hCG is important in determining
• Management in a Pregnancy of Unknown Location
• Determining the mode of management in an unruptured ectopic
• What is Doubling time?
• What is Discriminatory Zone?
• Remember Criteria for Expectant/ medical and surgical management
MCQs
Q1. A 23-year woman comes to the OPD with amenorrhea of 5 weeks. Her urine
pregnancy test is positive. A transvaginal ultrasound is done which shows normal uterus
and adnexa. What is the next appropriate step in the management?
A. Do a serum βhCG and repeat after 48 hours

B. Do a laparoscopy
C. Inj Methotrexate
D. Repeat TVS after 1 week
Q2. A 34y old lady with a history of a tubal sterilization operation is diagnosed to have
an unruptured ectopic pregnancy of size 4 cm. Serum βhCG is 6000 IU/L. The preferred
management option is:
A. Laparoscopic salpingectomy
B. Laparoscopic salpingostomy
C. Inj Methotrexate single dose
D. Inj Methotrexate multiple doses
Q3. A 28-y woman with a history of infertility for 3 years presents with 6 weeks
amenorrhoea. She has mild abdominal pain and spotting PV. Her UPT is weakly positive.
On examination, she is hemodynamically stable. There is a 3 x 2.5 cm left sided adnexal
lesion. Beta HCG is 2500 IU. Ultrasound reveals a left sided tubal gestational sac with no
cardiac activity. Which is the BEST management option?
A. Expectant management
B. Salpingectomy
C. Milking the tube
D. Inj Methotrexate
A 31 yr woman presented to the emergency with generalized abdominal
pain and vaginal spotting. Her last menstrual period was about 2 months
earlier. On examination she is pale, her PR is 120/ min, BP is 90/60 mmHg.
Abdominal examination reveals guarding and rigidity. A UPT done is faintly
positive. What is the next best step in management?
A. Urgent ultrasound
B. Shift to the O.T. for an emergency laparotomy
C. Send an urgent serum βhCG
D. Do a dilatation and evacuation
Which is not a risk factor for ectopic pregnancy?
A. Condom
B. Progesterone only pills
C. IUD
D. Tubal Ligation
The classic triad of clinical features in an ectopic pregnancy is:
A. Bleeding, pain, delayed menstruation

B. Pain, bleeding, syncope
C. Pain, delayed menstruation, pallor
D. D. Pallor, pain, delayed menstruation
A 27 yr G1 presents with delayed periods. She complains of mild
abdominal pain. On examination the abdomen is soft and a bimanual exam
reveals cervical motion tenderness. This is the ultrasound Doppler image.
What is your diagnosis?
A. Corpus luteal ovarian cyst

B. Intra-uterine pregnancy
C. Ruptured ectopic
D. Unruptured ectopic
The most common site for an ectopic pregnancy is?
A. A B A
C
B. B
C. C
D. D D
All are indications for expectant management of an unruptured ectopic
pregnancy except?
A. Mild abdominal pain

B. Gestational sac size < 3.5 cm with no cardiac activity
C. Clinically stable
D. βhCG < 1000 IU/L
Prenatal Screening
Outline
• Screening for pre-existing conditions
• Screening for pregnancy related conditions
• Pre-eclampsia
• Diabetes in pregnancy
• Screening for fetal conditions
Screening for Pre –
Screening for Pregnancy Screening for Fetal
existing maternal
associated conditions Conditions
conditions
• Anemia • Pre-eclampsia • Down Syndrome
• Diabetes • Gestational Diabetes • NTDs and other
(Pregestational) Mellitus anomalies
• Thyroid disorders • In certain populations:
• Asymptomatic scrrening for Cystic
bacteriuria fibrosis, Thalassemias
• Viral infections etc.
Screening for Pre-existing
Maternal Conditions
Screening for Anemia
• Hb checked pre-conceptionally
• Checked at booking visit and every trimester
• As per “Anemia Mukt Bharat”: Hb checked at every contact
Screening for overt diabetes
• HBA1C
• FBS
• RBS
Screening for Thyroid disorders
• Why screen?
• How to screen?
• TSH levels during pregnancy are lower in the 1st trimester
• Pregnancy-specific levels for TSH

Screening for infections
• Potential for vertical transmission
Screening for UTI
o UTI is common in Pregnancy
o Screening every trimester

Screening for Pregnancy
Associated Conditions
Screening for Pre-eclampsia
• History and MAP
• Ultrasound (PI of uterine artery)
• Biochemical Factors
Medical history Ultrasound markers Biochemical markers
(Uterine A Pl)
PE risk calculation
Low risk High risk
Routine antenatal care Intensive antenatal care
Low dose aspirin prophylaxis

before 16 weeks
Screening for Diabetes in Pregnancy
• India: DIPSI test
Screening for Fetal Conditions
Down Syndrome
Down Syndrome Screening
• Every woman has a background risk
• This risk is based on age
At 25y: 1 in 5000
At 30y: 1 in 1000
At 33y: 1 in 500
At 35y: 1 in 250
At 40y: 1 in 70
At 45y: 1 in 20
• When?
• How?
• Serum Analytes or Ultrasound assessment
• The screening results are based on a Likelihood ratio
• The maternal age risk is multiplied by this ratio
• Predetermined value, above which, the test is “positive”
• If screen positive: Offer genetic counselling with confirmatory
tests
1st Trimester Screening (11 – 14 weeks)
1. Ultrasound 2. Biochemical serum analytes
1st Trimester Screening (11 – 14 weeks)
3. Combined
1st Trimester Screening (Ultrasound)
1st Trimester Screening (Serum Analytes)
Β hCG PAPP-A
TRISOMY 21
Β hCG PAPP-A
TRISOMY 21
TRISOMY 18
Β hCG PAPP-A
TRISOMY 21
TRISOMY 18
TRISOMY 13
1st Trimester Screening (Ultrasound)
Detection Rate
NT
Dual marker
Combined Test
2 nd Trimester Screening
1. Biochemical Markers (Serum analytes):
2 nd Trimester Screening
2. Ultrasound (TIFFA):
2nd Trimester Screening (Biochemical Markers)
Beta hCG AFP uE3 Inhibin A
Trisomy 21
Trisomy 21 ↑ ↓ ↓ ↑
Trisomy 18 ↓ ↓ ↓
Trisomy 21 ↑ ↓ ↓ ↑
Trisomy 18 ↓ ↓ ↓
Trisomy 13 --- ↑ ---

2nd Trimester Screening (Ultrasound)
Non-Invasive Prenatal Testing (NIPT)/ Cell
Free DNA
Prenatal Diagnostic Tests
• Chorionic Villous Sampling
• Amniocentesis
• Cordocentesis
Q. In a woman with a Down Syndrome fetus, triple test was done. What would the
expected result be?
A. High βhCG, low ue3, low AFP
B. Low βhCG, high ue3, high AFP
C. High βhCG, high ue3, low AFP
D. Low βhCG, low ue3, high AFP

Q. Which of the following is not included in quadruple test for
antenatal detection of Down syndrome?
A. AFP
B. ß- hCG
C. Unconjugated Estriol
D. Inhibin-B
Q. Non-Invasive Prenatal Testing (NIPT) is?
A. Amniocentesis for evaluation of fetal chromosomal anomalies
B. Pre-conceptional gene testing of an ova
C. Maternal serum for evaluation of Down syndrome
D. Testing of maternal tissue
Q. A 34y primi presents at 12 weeks for a routine check up. The following
measurement was taken on the ultrasound (marked by yellow cursors) What is this
measurement?
A. Crown rump length
B. Nasal bone
C. Nuchal fold thickness
D. Nuchal translucency
Q. As per DIPSI, a value of more than how much is diagnostic of
gestational diabetes
A. 120 mg/dl
B. 130 mg/dl
C. 140 mg/dl
D. 200 mg/dl
Q. A 35y primi at 12 weeks presents to the OPD. Her mother is hypertensive. On
ultrasound, the uterine artery PI > 1. What is the best intervention to reduce her
risk of developing preeclampsia after 20 weeks?
A. Starting her on low molecular weight heparin
B. Starting her on high dose calcium
C. Starting her on aspirin
D. Starting her on labetalol
Q. The risk of asymptomatic bacteruria developing into pyelonephritis if
not treated is?
A. 10%
B. 15%
C. 25%
D. 50%
Abortions and Recurrent
Pregnancy Loss
MOST COMMONS
• Most Common Cause of Spontaneous 1st/ 2nd Trimester abortion:
• Most Common Chromosomal abnormality causing spontaneous abortion
• Most common aneuploidy seen in abortions:
• Most common Trisomy seen in spontaneous abortions:
• Single most frequent specific chromosomal abnormality seen:

Recurrent Pregnancy Loss
§ Classical Definition: ≥ 3 abortions

§ ASRM: ≥ 2 losses
§ Primary and Secondary
§ Chance of successful pregnancy:

§ Reduces with increasing no of losses
§ Reduces with increasing age
If asked
1st trimester RPL:
2nd trimester RPL:

Cervical Insufficiency
• Typical Presentation:
• Etiology
• Congenital
• Acquired
Diagnosis
• History
• During Pregnancy
• In between pregnancies
Cervical Cerclage: Management
• When?
• In whom?
Old Terminology New Terminology
Prophylactic/ Elective History Indicated
Therapeutic/Salvage Ultrasound indicated
Therapeutic/Salvage Ultrasound indicated
Rescue, emergency, urgent Examination indicated
• How?
1. Trans-vaginal
2. Trans-abdominal
Transvaginal Procedures
Lash and Lash
Transabdominal cerclage (By Benson and Durfee)
Contraindications to cerclage: 5 A’s
• Any Bleeding
• Any Leaking
• Any Infection
• 4cm/ uterine Activity
• Fetal death/ Anomaly
APLA
• Diagnosed based on
• Sapporo’s Criteria
• Lab and Clinical criteria
• At least 1 clinical and 1 lab criteria
Clinical Criteria Lab Criteria (Present ≥ 2 occasions at
• Obstetric least 12 weeks apart)
• Vascular
• Reason for pregnancy loss in APLA:
ØInhibition of trophoblast function and differentiation leading to
placental dysfunction
• Management of APLA
Cause Diagnosis Treatment
Genetic (Balanced
translocation)
Genetic (Balanced
translocation)
Endocrine
1.Thyroid dysfunction
2. Diabetes
3. Luteal phase defect
4. PCOS
Genetic (Balanced
translocation)
Endocrine
2. Diabetes
4 PCOS
Anatomical
1.Fibroids (submucosal)
2. Uterine anomalies
3 Asherman Syndrome
4 Cervical insufficiency
Genetic (Balanced
translocation)
Endocrine
2. Diabetes
4. PCOS
Anatomical
1.Fibroids (submucosal)
2. Uterine anomalies
3 Asherman Syndrome
4 Cervical insufficiency
Immunological
APLA
MCQs
Q. A 25-y woman presents to the emergency with a history of
amenorrhea for 2. & a half months. She complains of abdominal pain
and vaginal bleeding since a day. On examination her PR and BP are
normal. Abdominal examination reveals mild tenderness. On speculum
examination, there is bleeding from the cervical os. Bimanual
examination reveals a 10 weeks uterus, and the cervix admits 1 finger.
The most likely diagnosis is?
A. Missed abortion
B. Incomplete abortion
C. Inevitable abortion
D.Fibroid polyp
Q. A woman comes to the Gynae OPD for pre-conceptional counseling,
with history of two second trimester abortions. What is the next
investigation you will advise?
A.TVS
B.Hysteroscopy
C.Endometrial biopsy
D.Chromosomal abnormalities
Q. A 28 years old patient with recurrent abortion is diagnosed to have
antiphospholipid syndrome. What will be the treatment?
A. Only aspirin
B. Only low molecular weight heparin
C. Aspirin and low molecular weight heparin
D.D. Aspirin plus LMWH and prednisolone
Q. The cerclage procedure NOT done during pregnancy is?
A. Lash
B. Laparoscopic
C. Wurm
D. Bensen
Q. A 39y G2P1 presents at 18 weeks 5 days for her routine targeted
fetal anomaly ultrasound. The fetal anatomy appears normal, but the
cervical length is 15mm. Despite being counselled that there is no clear
proven benefit for the same; the patient insisted on a cervical cerclage.
Which of the following is a complete contra-indication to cerclage?
A. Positive fetal fibronectin test
B. Membranes bulging into the vagina
C. Ruptured membranes
D. Advanced maternal age
Q. A 28 y P0A3 with recurrent 2nd trimester abortions was found to
have a uterine septa on sono-salpingography. What is the BEST
management option?
A. Dilatation and curettage
B. Laparoscopic metroplasty
C. Hysteroscopic septal resection
D. Laparotomy and metroplasty
Q. A 28-year-old woman is undergoing evaluation for successive
recurrent pregnancy losses. On ultrasound, a Mullerian anomaly is
suspected. What is the BEST way to confirm this?
A. Trans vaginal ultrasound
B. Hysterosalpingography
C. CECT
D. Hysteroscopy and laparoscopy
Q. A P0A3 presents with a history of 3 abortions. The first at 8 weeks,
the 2nd at 11 weeks and the 3rd at 24 weeks with a history of early
onset pre-eclampsia. Which of the following is the most likely cause of
her abortions?
A. Syphilis
B. APLA
C. TORCH
D. GDM
Image Based Discussion
Obstetrics Part
Images of the Placenta
Q1. Identify this placental abnormality
A. Battledore insertion
B. Circumvallate placenta
C. Velamentous insertion
D. Succenturiate lobe
VELAMENTOUS INSERTION
BATTLEDORE INSERTION
SUCCENTURIATE LOBE
CIRCUMVALLATE PLACENTA
Q2. A 24 y Primigravida delivers a 3kg baby vaginally. Following delivery of the
placenta, you notice excessive vaginal bleeding. Your assistant examines the
placenta and shows it to you. What is the possible diagnosis?
A. Abruptio placentae
B. Bilobed placenta
C. Missing Cotyledon
D. Uterine Inversion
Q3. The image shows a placenta. This represents:
A. Trichorionic Triamniotic
B. Trichorionic Monoamniotic
C. Monochorionic Triamniotic
D. Monochorionic Diamniotic
Q4. A 24 y primigravida presents at 5 weeks gestation. A transvaginal
ultrasound reveals the following image. Identify the structure shown by the
arrow.
A. Gestational sac
B. Fetal pole
C. Ectopic pregnancy
D. Yolk sac
o Intra uterine gestational sac: visible by 5 weeks (TVS)
o Embryo with cardiac activity: by 6 weeks (TVS)
o Embryo should be visible once MSD is 25 mm; otherwise, it is
anembryonic
o Cardiac activity should be seen once the embryo length is 7 mm
Q5. A 32y woman presented to the OPD with history of irregular spotting for 2
months and abdominal pain. Her urine pregnancy test was positive. A transvaginal
ultrasound revealed the image shown. The most probable diagnosis is:
A. Incomplete abortion
B. Intra-uterine pregnancy
C. Ruptured ectopic pregnancy
D. Unruptured ectopic pregnancy
Q6. A 36-year-old woman presents to the OPD with complaints of 3 months
pregnancy with vaginal bleeding. On examination the uterus is midway between
the pubic symphysis and the umbilicus. An ultrasound shows the following picture.
What is the best management option?
A. Mifepristone + Misoprostol
B. Conservative management
C. Suction & Evacuation
D. Inj. Methotrexate
Molar Pregnancy
Q7. A 31 y G2 presented for an ultrasound at 13 weeks. On ultrasound a large septate
neck swelling was seen. What is the possible karyotypic abnormality?
A. 47 XXY
B. 45 XO
C. 46 XX
D. Trisomy 21
Q8. The measurement in the ultrasound shown is taken between
A. 10 – 13 weeks
B. 11- 13 weeks
C. 10 – 14 weeks
D. 11 – 14 weeks
Q9. A 27y lady presented to the OPD. She shows you the ultrasound images of her 1st
pregnancy and says there was a fetal anomaly for which she underwent medical
termination of pregnancy. She is now anxious to plan her next pregnancy. What should
be advised?
A. Amniocentesis after she conceives
B. Parental karyotype
C. Pre-conceptional folic acid
D. Non-invasive prenatal testing
Q10. This image shows overlapping of skull bones seen in intrauterine
fetal demise. This sign is known as:
A. Halo sign
B. Ball sign
C. Spalding sign
D. Buddha sign
Ultrasound:
• Absent cardiac activity
• Scalp edema
• Collapsed cranial bones
• Overlapping of cranial bones
• Oligohydramnios
X – Ray Findings
• Robert sign (earliest sign)
• Ball’s Sign
• Halo sign
• Spalding’s sign
• Crowding of ribs
Q11. A 28 y G2P1 with a previous LSCS presents to the emergency with painless
bleeding PV. Her PR is 84/ min and BP is 120/ 80 mmHg. On examination the uterus is
relaxed, non tender and corresponds to 28 weeks gestation. The Fetal heart rate is 156
bpm. An ultrasound done showed the following image. What is the next best step in
management?
A. Emergency cesarean section
B. Steroids followed by emergency cesarean section
C. Steroids and conservative treatment
D. Induction of labor after steroids
Q12. A 26 y primigravida complained of decreased fetal movements for 2 days. A
modified Biophysical profile was done. The image shows which component of
this test?
A. Amniotic Fluid Index
B. NST
C. Fetal tone
D. Fetal breathing movement
Q13. A 23 y old presents to the OPD at 14 weeks. She has been diagnosed with twin
pregnancy and shows you this image of her ultrasound. What is the type of twins?
A. Monochorionic monoamniotic
B. Monochorionic diamniotic
C. Dichorionic monoamniotic
D. Dichorionic diamniotic
Q1. Identify the grip shown in the image?
A. Fundal grip
B. Lateral grip
C. Pawlik grip
D.Pelvic grip
Q2. Identify the position of the fetus
A. ROP
B. LOP
C. ROA
D.LOA
R
Q3. Identify this device.
A. Cardiotocograph
B. Doppler Ultrasound
C. Non-invasive prenatal testing
D. Vibroacoustic stimulator
Q4. A 25 y primigravida is in labor. At 5 cm dilatation, an ARM is done which shows
meconium-stained liquor. The CTG trace is as shown. The decelerations seen are:
A. Early
B. Late
C. Prolonged
D. Variable
Q5. What is the presenting diameter of the fetal head in the attitude
shown in the image?
A. Suboccipito-bregmatic
B. Submento-bregmatic
C. Occipito-frontal
D.Vertico-mental
Q6. A 30 y G2 presents to the labor room at 39 weeks in labor. On examination,
her vitals are stable. Abdominal examination reveals a term uterus with 3
contractions lasting for 35 seconds in 10 mins. On vaginal examination, the
cervix is 5 cm dilated, well effaced and the vertex is at 0 station. You are asked
to plot a partograph. Where will you put the initial marking of cervical
dilatation?
A. On the Alert line
B. On the Action line
C. To the left of the Action line
D. To the right of the Alert line
Q7. The following incision was given during delivery of a patient. What is the
order of layers in which this incision will be sutured?
A. Muscle, Skin, Mucosa
B. Skin, Muscle, Mucosa
C. Mucosa, Muscle, Skin
D. Mucosa, Skin, Muscle
Muscles cut in an episiotomy:
• Superficial and deep transverse
perineal muscles
• Bulbospongiosus
• Part of Levator Ani
Q8. Identify the presentation.
A. Complete breech
B. Frank breech
C. Footling breech
D. Kneeling breech
Q9. Identify this maneuver
A. Mauriceau Smellie Viet
B. Burns Marshall
C. Wigand Martin
D. Lovset
Q10. Identify the image:
A. Vulval carcinoma
B. Sarcoma Botryoides
C. Vulval hematoma
D. Bartholin cyst
Important Obstetric
Maneuvers
Leopold Maneuvers
Modified Ritgen
Maneuver
Pinnard Maneuver
Lovset Maneuver
Burn Marshall
Mauriceau Smellie Viet
Prague Maneuver
McRoberts Maneuver
Woods Corkscrew
Maneuver
Gaskin Maneuver
Zavanelli Maneuver
Brandt Andrews Technique
Shiny Shultz
Dirty Duncan
Q11. A 24 y primigravida is in labor at 39 weeks. During 2nd stage of labor, fetal distress
is observed. All the following are pre-requisites for applying the forceps shown below
except?
A. The fetal scalp is seen at the perineum without separating the labia
B. The rotation exceeds 450
C. The fetal skull has reached the pelvic floor
D. The fetal head is on the perineum
Q12. The instrument shown below is placed at what point on the fetal scalp?
A. Extension point
B. Flexion point
C. Anterior fontanelle
D. Posterior fontanelle
Q. The fetus seen in this image would have been born to a mother having which
condition?
A. CMV
B. Diabetes
C. Epilepsy
D. Varicella
Q. Which teratogenic drug can cause this anomaly?
A. Losartan
B. Methotrexate
C. Phenytoin
D. Thalidomide
Teratogen Defect
Antiepileptic Drugs Facial features, Distal digital hypoplasia (Fetal
hydantoin syndrome)
ACE-I and ARBs Fetal renal hypoperfusion
Alcohol Fetal Alcohol Syndrome
Lithium Ebstein’s anomaly
Indomethacin Premature closure of the ductus arteriosus
Methimazole Cutis aplasia
Warfarin Warfarin embryopathy
Thalidomide Phocomelia
Methotrexate Clover leaf skull
DES(Diethyl Stilbestrol) Clear cell adenocarcinoma, T-shaped uterus,
hypospadias
SSRIs
Q. This graph shows the levels of beta-hCG in pregnancy. At what
gestational age, is the beta-hCG level the highest?
A. 6 weeks
B. 10 weeks
C. 20 weeks
D. 32 weeks
Q4. A 34 y P2L2 who had earlier undergone tubectomy, presented to the emergency
with abdominal pain and amenorrhoea of 2 months. This was the intra-operative
finding on laparoscopy. What is the best management option?
A. Hysterectomy
B. Salpingectomy
C. Salpingostomy
D. Salpingotomy
Varicella in Pregnancy
• Congenital Varicella Syndrome

• If exposure happens during delivery; newborn faces serious threat
(30% mortaility)
• 2 scenarios
• Maternal Exposure
• Maternal Infection
OBG Classes by Dr Raina

Rubella in Pregnancy
• Classic Triad of Gregg

• Extremely teratogenic in 1st trimester
• Immunization: Pre conceptional!

CMV
• Most common perinatal infection in developed world

• High rate of fetal infection (40-50%)
• Congenital CMV: Peri ventricular calcifications
• Late sequelae in neonate
• Termination can be offered if detected early

Herpes in Pregnancy
• Primary genital HSV: High risk of prenatal infection
• Painful genital vesicular lesions
• Transmission common during delivery
• Elective LSCS in active herpes at term

Group B Streptococcus
• Risks
• Imp: Early onset neonatal sepsis: (< 7 days)
• Screening and Prophylaxis for perinatal infections: (ACOG)
• Women are screened for GBS colonization at 35 – 37 weeks (Rectovaginal swab)
• Intrapartum Prophylaxis indicated if:
• Prophylaxis is: Penicillin G (alternative: Ampicillin)

Syphilis in Pregnancy
• VDRL may be false positive; Always confirm with specific test like FTA-ABS/
MHA-TP/ TPPA
• Gradually improving obstetric history (Abortion → Stillbirth→ Neonatal
death → Congenital Syphilis)
• USG: FGR, Fetal hydrops, placentomegaly
• Congenital syphilis: hepatosplenomegaly, hydropic features, purpura/
petechiae, lymphadenopathy
• Treatment: Inj Benzathine penicillin
• Screening in 1st trimester for all pregnant women in the
1st trimester
New Topics in Obstetrics!
• LAQSHYA
• Cesarean Scar Pregnancy
• Placenta Accrete Syndromes
• Labor Care Guide
• MTP Amendment Act 2021
Cesarean Scar Pregnancy
Placenta Accrete
Syndromes (PAS)
• Failure of separation (partial or
complete) of the placenta from the
underlying uterine wall.
Types
3 subtypes:
1. Placenta accreta (also called placenta creta, vera, or adherenta): where the
villi attach directly to the surface of the myometrium without invading it
2. Placenta increta: where the villi penetrate deeply into the myometrium up to
the external layer
3. Placenta percreta: where the invasive villous tissue reaches and penetrates
through the uterine serosa
Risk Factor
Previous cesarean with placenta previa: most common risk

factor
Diagnosis
Normal
1. 2D (conventional) Ultrasound
• Loss of the “clear zone”
• Abnormal placental lacunae
• Bladder wall interruption
• Myometrial thinning
• Placental bulge
• Focal exophytic mass usually in the
bladder PAS
Diagnosis…
2. Color Doppler imaging

• Uterovesical hypervascularity
• Sub-placental hypervascularity
• Bridging vessels
• Placental lacunae feeder vessels
• Intra-placental hypervascularity
Investigation of Choice
DIAGNOSIS…
3. MRI:
• Especially useful when ultrasound is
inconclusive and in posteriorly placed
placentas
• Also useful in percreta in determining the
depth of invasion
Pre-natal Screening
• Clinical Risk Factors
• Ultrasound in the 1st trimester: Cesarean scar
pregnancy
• Mid-trimester USG
Management
• Surgical non-conservative
• Surgical conservative
Management: Surgical non-conservative
Cesarean Hysterectomy:
• Safest
• Most Practical
Management: Surgical non-conservative: Important
Points
• Timing: Planned between 34 to 37 weeks
• Pre op Hb build up
• Intra op:
• Uterine incision: Classical
• Leave placenta behind
• Hysterectomy (risk of urological injuries increased)
• Preventing blood loss
Surgical: Conservative
Defines all procedures that aim to Avoid hysterectomy and its related morbidity
and consequences.
1. Leaving the placenta in situ (the expectant approach)
2. One-step conservative surgery (removal of the accreta area)/ The Triple-P
procedure (Peri-op placental localization + Pelvic devascularization +
Placental non-separation and myometrial resection)
• Use of interventional radiology (embolization, placement of balloon catheters
etc.)
Questions
Q1. Risk factors for Placenta Accreta include all the following except
A. Previous LSCS scar

B. Previous curettage
C. Previous myomectomy
D. Previous placenta previa
Q2. All are features of placenta accreta on Ultrasound & Doppler except:
A. Hypervascularity of the uterine serosa-bladder wall interface
B. Presence of hypoechoic retroplacental zone between the placenta and the
uterus
C. Placental vascular lacunae
D. Placental bulging into the posterior bladder wall
Q3. In which of the following conditions will the below incision not be
given during cesarean section?
A. Abruptio Placentae
B. Densely adherent bladder
C. Large low-lying leiomyoma
D. Placenta accreta
Q4. A 24y G2 with a previous cesarean presents at 30 weeks with c/o painless
vaginal bleeding. The ultrasound shows a low-lying placenta. The resident thinks it
could be placenta accreta and orders which investigation?
A. Color Doppler
B. CT scan
C. CT angiography
D. MRI
WHO Labour Care Guide: the next generation partograph
• Primarily designed to be used for the care of

apparently healthy pregnant women and their
babies (i.e., women with low-risk pregnancies)
• Should be initiated when the woman enters the

active phase of the first stage of labour (5 cm or
more cervical dilatation), regardless of her parity
and membranes status.
Structure of the WHO Labour Care Guide
• Section 1: Identifying information and labour characteristics at admission

• Section 2: Supportive care
• Section 3: Care of the baby
• Section 4: Care of the woman
• Section 5: Labour progress
• Section 6: Medication
• Section 7: Shared decision-making
MTP Amendment 2021
Features Previous Law Latest amendments
Indications: Applicable to married Unmarried women also
Contraceptive failure women covered
Gestational Age Limit 20 weeks 20-24 weeks in select
conditions
Beyond 24 weeks for

substantial fetal congenital
anomalies
Medical practitioner 1 RMP till 12 weeks 1 RMP till 20 weeks
opinion needed 2 RMPs till 20 weeks 2 RMPs for 20-24 weeks
> 24 weeks: Medical board
Q1. A 25 y primigravida is on indomethacin (25mg TDS) for
polyhydramnios till 35 weeks. What abnormality can the fetus have, if
she goes into labor now?
A. Flap closure of foramen ovale
B. Patent ductus arteriosus
C. Premature closure of the ductus arteriosus
D. Premature closure of the ductus venosus
Indomethacin in Pregnancy
Uses in Obstetrics
• Tocolytic
• Polyhydramnios
If given after 32 weeks, known to cause premature closure of the

Ductus Arteriosus leading to Pulmonary hypertension and fetal death
Q2. Deoxygenated blood is returned to the placenta from the fetus
through?
A. Umbilical artery
B. Umbilical vein
C. Ductus arteriosus
D. Ductus venosus
Q3. A married woman gives birth to twins. The husband doubts he is
the father and gets a paternity test done. The test shows that he is the
father of one infant but not the other. This is:
A. A case of superfetation
B. One infant is atavistic
C. A case of superfecundation
D. One infant is suppositious
Superfecundation
• Fertilization of 2 ova in the same menstrual
cycle
Superfetation
• Fertilization of 2 ova released in 2 different
menstrual cycles
• Not proven in humans; known to occur in
animals
Q4. A 28 y primigravida who is a known case of mitral valve
replacement presents at 36 weeks to the antenatal OPD. She is on
warfarin 4mg. Which is correct regarding anticoagulant therapy?
A. Discontinue warfarin and start heparin
B. Discontinue warfarin and start heparin and aspirin
C. Discontinue warfarin and start aspirin
D. Continue warfarin and start heparin
• Women on Oral Anticoagulant therapy (Warfarin) should be started
on LMWH/ UFH
• Risk of Warfarin embryopathy at a dose > 5 mg
• If planned vaginal delivery, shift to Heparin at 34 – 36 weeks
Q5. A 25y woman presents to the antenatal OPD. This is her 2nd
pregnancy, and her 1st pregnancy was 4 years earlier where she
delivered twins at term. Her parity index is
A. G2P1
B. G2P2
C. G3P1
D. G3P2
Q6. A 28 y primigravida is in labor. She has a repeated urge to pass
urine and has premature bearing down. On examination there is infra-
umbilical flattening, and the fetal heart is heard on the lateral side.
What is the most likely presentation/ position?
A. Knee
B. Occipito-posterior
C. Brow
D. Right dorso-anterior
Occipito-Posterior Position – Diagnosis
History
• Early rupture of membranes
• Frequent filling of bladder
• Premature bearing down
Abdominal Exam
• Inspection: infra-umbilical flattening
• Grips: Head un-engaged
• Auscultation: FHS - flanks
Q7. Following delivery, a woman has atonic PPH. Despite conservative
measures, the bleeding persists. She ahs taken to the OT where the
surgeon proceeds to do a devascularization procedure. Which vessels
are ligated?
A. Uterine, ovarian, internal iliac
B. Uterine, ovarian, external iliac
C. Uterine, vaginal, pudendal
D. Uterine, internal iliac, obturator
PPH Management
• Mechanical and Medical methods
• Surgical methods
• Stepwise Devascularization
• Compression sutures
• Hysterectomy
• Uterine Artery Embolization
Q8. A 21-year-old primigravida presents to the antenatal OPD. Her
school going nephew who lives in the same house has contracted
varicella. A blood sample is taken for Antibodies against varicella. The
report is negative. What does this signify?
A. Susceptible to chicken pox
B. Immune to chickenpox
C. Susceptible to zoster
D. Immune to zoster
Chickenpox in Pregnancy
• Pregnant women with uncertain/ no previous history of
chickenpox, with exposure to infection should have a blood test
to determine VZV immunity or non-immunity.
• If not immune to VZV and she has had a significant exposure:
varicella-zoster immunoglobulin (VZIG)
• VZIG is effective up to 10 days after contact
Symptomatic treatment
• Oral Acyclovir: if within 24 hours of the onset of the rash and if > 20 weeks
• Intravenous Acyclovir should be given to all pregnant women with severe
chickenpox.
• VZIG has no therapeutic benefit once chickenpox has started
• Women who develop chickenpox in pregnancy should be referred to a fetal
medicine specialist, at 16–20 weeks or 5 weeks after infection
• If infection occurs in the last 4 weeks of a woman’s pregnancy, risk of
varicella infection of the newborn. A planned delivery should normally be
avoided for at least 7 days after the onset of the maternal rash to allow for
the passive transfer of antibodies from mother to child.
Congenital Varicella Syndrome is characterized by
• Chorioretinitis
• Microphthalmia
• Cerebral cortical atrophy
• Fetal growth restriction
• Hydronephrosis
• Limb hypoplasia
• Cicatricial skin lesions
The highest risk of fetal infection is between 13-20 weeks

Q9. A 28 y primigravida presents at 36 weeks with painful vulval ulcers.
She does not give history of similar lesions ever in the past. On
examination, there are multiple painful vesicular lesions. Which is the
best treatment option?
A. Analgesics and antibiotics
B. Acyclovir and elective LSCS
C. Antivirals and spontaneous vaginal delivery
D. Acyclovir and induction of labor
• Diagnosis: Herpes Simplex
• Painful vesicular lesions
• Primary HSV: very high risk of neonatal infection
• Treatment:
• Acyclovir
• Elective cesarean for active primary genital HSV infection
Q10. A 35-year woman is a chronic hypertensive. She visits the clinic for
preconception counseling. Which of the following anti-hypertensives
need to be stopped prior to conception?
A. Calcium channel blockers
B. Alpha methyl dopa
C. ACE inhibitors
D. Labetalol
Q11. A 28-y woman with a history of infertility for 3 years presents with
6 weeks amenorrhoea. She has mild abdominal pain and spotting PV.
Her UPT is weakly positive. On examination, she is hemodynamically
stable. There is a 3 x 2.5 cm left sided adnexal lesion. Ultrasound
reveals a left sided tubal gestational sac with no cardiac activity. Which
is the BEST management option?
A. Expectant management
B. Salpingectomy
C. Milking the tube
D. Inj Methotrexate
Management Options in Unruptured Ectopic
Expectant Management Medical Management (Methotrexate) Surgical Management in

Only for clinically stable Indications: An unruptured ectopic Unruptured Ectopic Offer surgical
asymptomatic women with an pregnancy with: management to:
ultrasound diagnosis of ectopic i. Patient hemodynamically stable i. Significant pain OR
pregnancy with the following AND ii. Adnexal mass ≥ 35 mm OR
features ii. No significant symptoms AND iii. Fetal heartbeat visible on an
i. Clinically stable with No pain AND iii.Gestational sac size < 3.5 cm AND ultrasound OR
ii. Serum βhCG < 1000 IU/L AND iv.No visible cardiac activity AND iv. Serum hCG level of 5,000 IU/L or
iii.Tubal ectopic < 35mm with no v. Serum βhCG < 5000 IU/L AND more
visible heartbeat AND vi.No contraindication to
iv.Able to return for follow up Methotrexate
History, Examination and Investigations
Unruptured Ruptured
Expectant Surgical
Medical
Laparoscopy Laparotomy
Conservative (Salpingostomy) OR Salpingectomy

Q12. A 28y woman has been on OCPs for 5 months. She presents to the
OPD with 6 weeks amenorrhoea and her UPT is positive. Which is the
most accurate method to determine gestational age in this woman?
A. Counting 280 days from LMP
B. Counting 256 days from UPT positive
C. CRL on ultrasound
D. Examination of uterine size
Q9. A patient at 22 weeks presents with profuse vaginal
bleeding. Her Blood pressure and sugars are normal. The likely
site of implantation is?
A. Ovarian
B. Tubal
C. Internal os
D. Abdominal
Q10. A 39y G2P1 presents at 18 weeks 5 days for her routine
targeted fetal anomaly ultrasound. The fetal anatomy appears
normal, but the cervical length is 15mm. Despite being
counselled that there is no clear proven benefit for the same; the
patient insisted on a cervical cerclage. Which of the following is a
complete contra-indication to cerclage?
A. Positive fetal fibronectin test

B. Membranes bulging into the vagina
C. Ruptured membranes
D. Advanced maternal age
Absolute contra-indications to
cervical cerclage
• Chorioamnionitis
• Ruptured membranes
• Current vaginal bleeding
• Uterine contractions
• Cervix > 4cm dilated
• Fetal death
Q11. A G3P2L2 presents at 7 weeks for termination of pregnancy by
medical methods. As per CAC guidelines, the following drugs are used:
A. Mifepristone + Methergine
B. Mifepristone + Methotrexate
C. Mifepristone + Misoprostol
D. Mifepristone + Medroxyprogesterone acetate
Q12. A 34 weeks primigravida presents with jaundice and a BP of 140/
96 mmHg. Her investigations reveal a serum bil of 1.5 mg/dl, SGOT –
150, SGPT – 200. Her LDH is 700 and platelet count is 75000. Her KFT
and coagulation profile were normal. What is her diagnosis?
A. Acute fatty liver of pregnancy
B. Viral hepatitis
C. Intrahepatic cholestasis of pregnancy
D. HELLP syndrome
Q13. a 34y G2P1 presents at 35 weeks. She has no complaints and is
appreciating fetal movements well. She had a previous classical
cesarean at 25 weeks for eclampsia and severe FGR. She is currently on
low dose aspirin and prenatal vitamins. On examination, the uterus is
SFH is 38 cm and FHR is 140 bpm. An ultrasound reveals a single live
fetus in breech presentation, placenta posterior and amniotic fluid
normal. The patient desires a vaginal delivery. What is the best
management?
A. Review USG after 2 weeks

B. Schedule elective LSCS at 37 weeks
C. ECV at 36 weeks
D. Await spontaneous labor and then do an internal podalic version
Q14. A primigravida presents to the labor room at 40 weeks. She
has been in labor for 3 hours. Which of the following which
determine she is in active labor?
A. 2 contractions, each lasting 30 seconds in 10 mins

B. Cervical dilatation > 5 cm
C. Head 5/5 palpable on abdominal examination
D. Rupture of membranes
Q15. A multigravida is in 2nd stage of labor since 2h with good
uterine contractions. On examination, the head is 1/5th palpable.
FHR is 140 bpm. On vaginal examination, the cervix is fully dilated;
the head is at the ischial spines in ROT position. Caput is ++ and
moulding is ++. How will you deliver her?
A. Emergency LSCS
B. Mid-cavity forceps
C. Await 1 more hour
D. Vacuum delivery
Deep Transverse Arrest
• Good uterine contractions

• Head at 0 station (Ischial spines)
• Sagittal suture in the transverse diameter
• 1 hour
• No progress
• Treatment:
• Primi/ features of obstruction: Cesarean
• Multigravida: Vacuum/ rotational forceps
Q16. Collapse in a patient during labor/ delivery followed
by bleeding and DIC in the absence of coexisting conditions
is most likely due to:
A. Amniotic fluid embolism
B. Postpartum haemorrhage
C. Eclampsia
D. Peripartum cardiomyopathy
Amniotic Fluid Embolism
• Serious intrapartum complication
• Caused by amniotic fluid entering the maternal circulation
leading to features of hypotension, shock and collapse
• 80% mortality
• Risk factors:
• Suspected diagnosis; confirmed on autopsy (presence of fetal
squamous cells in maternal pulmonary circulation)
• Management: Resuscitation, oxygenation and correction of
coagulopathy
Q17. A 22y type 1 DM is in the post operative ward following a cesarean
done for failed induction (for preeclampsia with severe features). She
complains of drowsiness and altered sensorium. She is on maintenance
MgSO4 infusion and on IV infusion of insulin. On examination, her PR is
70/ min. BP is 140/ 98 mmHg. RR is 10/min. Auscultation of lungs reveals
bilateral normal air entry. Abdominal examination reveals a firm uterus
with normal tenderness. Pfannensteil scar is intact and there is no
significant vaginal bleeding. B/l patellar reflexes are absent. A urine
dipstick for protein and sugar is negative and a capillary glucose sample is
270 mg%. The suspected diagnosis is?
A. Magnesium toxicity
B. Diabetic ketoacidosis
C. Postpartum eclampsia
D. Peripartum cardiomyopathy
Q18. Which of the following will you see long bone fractures in the fetus on
antenatal ultrasound?
A. Marfan syndrome
B. Osteogenesis imperfecta
C. Achondroplasia
D. Cretinism
• Spectrum of the defects characterized by fragile bones
• There are at least 8 recognized forms of osteogenesis
imperfecta, designated type I through type VIII
• Type I is the mildest form and type II is the most
severe
• Most cases that present prenatally are types II and III:
Q19. A G2P1 presents at 28 weeks. On examination, the uterus
is 24 weeks. On ultrasound there is absent liquor. Which could
be the most likely cause?
A. Fetal renal anomalies
B. Congenital heart disease
C. Tracheo-esophageal fistula
D. Hydrocephalus
Q21. A 34y woman is advised an ultrasound doppler and a
double marker between 11-14 weeks. Doppler of the umbilical
artery helps predict?
A. Late onset preeclampsia
B. Early onset preeclampsia
C. Fetal growth restriction
D. Placenta accreta
Q22. A 34y woman develops pre-eclampsia at 28 weeks. She is very
anxious and asks why this has developed. You explain to her that
there was a problem in development of maternal fetal circulation in
early pregnancy. What is the cause for this?
A. Poor invasion by villous trophoblast of the spiral arterioles
B. Poor invasion by villous trophoblasts of the radial arterioles
C. Poor invasion by extra villous trophoblasts of the arcuate
arteries
D. Poor invasion by the extravillous trophoblast of the spiral
arterioles
Q23. A primigravida at 12 weeks visits the antenatal OPD. She
wants to know the additional daily calorie requirement she
would need to take?
A. 300Kcal throughout pregnancy
B. 400Kcal in the 2nd trimester
C. 400Kcal in the 3rd trimester
D. 200Kcal in the 2nd trimester
• Institute of Medicine (2006) recommends adding
• 0 Kcal in 1st trimester
• 340 Kcal in 2nd trimester
• 452 Kcal in 3rd trimester
• ICMR (2010): + 350Kcal in pregnancy

Q24. On the 2nd post natal day, where will the fundus of the
uterus be?
A. 1F below the umbilicus
B. 2F below the umbilicus
C. 3F below the umbilicus
D. 4F below the umbilicus
Q25. A 28y woman is on her 3rd post natal day. A psychiatric
consultation is sought in view of occasional crying episodes,
fatigue and lack of sleep. What is the likely diagnosis?
A. Puerperal blues
B. Puerperal depression
C. Puerperal insomnia
D. Puerperal anxiety
Q27. Which hormone stimulates the male fetus to produce
testosterone?
A. Inhibin from corpus luteum
B. hCG from placenta
C. Maternal LH
D. Fetal GnRH
• Leydig cell differentiation and proliferation depends on
placental hCG in the first and second trimesters of fetal life
• And on fetal pituitary LH thereafter
Don’t Stop Dreaming!
Go that Extra Mile…
This life’s all we’ve got!
Let’s do this in Style!!!
- Raina

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OBSTETRICS &

Senior Consultant and Unit Head @Sarvodaya Hospital

Mom to Eva and Neev

• Synthetic non-steroidal estrogen

Absence of 20 sexual characters: NO Exposure to Estrogen

Normal Functioning Pituitary Compartment 3

Normal Functioning Ovaries Compartment 2

Normal Outflow Tract

Vaginal/ rectal examination or Ultrasound

Uterus absent Uterus present

Low High Low High

Isolated GnRH XX/XY gonadal Hypothalamic/ Turner

Swyer Syndrome 46XY

Turner Syndrome 46XY

Androgen Insensitivity Syndrome 45XO

Swyer Syndrome 46XY

Turner Syndrome 45XO

Androgen Insensitivity Syndrome 46XY

A. High FSH, high LH

Disorder Hormonal Profile

Disorder Hormonal Profile

Premature ovarian failure FSH↑ LH↑ Estradiol↓

“You can’t get Pregnant if you have an IUCD”

• Injectable E & P • Injectable

• The missed pill should be

• The last missed pill should be taken as soon as possible

o If pills missed in 1st week: Consider Emergency

o Pills missed in 2nd week: No need for Emergency

• After 1 year of unprotected coitus

1. Sperm concentration ≥ 15 million/ ml

5. Viability > 58%

Superovulation/ Ovulation enhancement

Controlled ovarian hyperstimulation

• ICSI (very low sperm count < 1 million/ ml)

Moderate OHSS Outpatient follow up, monitoring of symptoms

Simple Hyperplasia/ ATYPICAL ENDOMETRIAL

Hysterectomy with B/l salpingo-

Growth lesion on the Cervix looks normal

Pap smear and TVS (ET)

ET > 4mm ET ≤ 4mm

• Dilatation and curettage

• Solid ovarian mass (Fibroma)+ pleural effusion + ascites

• HSIL/ ASC-H: Colposcopy and Biopsy

A. It is used in the control of refractory pelvic haemorrhage

“MR SVIGIP Owns Unusual Views”

• Branches of the posterior iliac A: supplies the buttocks and thigh

Original Review &

2 most important Questions!

• If the delivery is before 32 weeks – Give MgSO4 for neuroprotection

PREECLAMPSIA SUPER-IMPOSED ON CHRONIC

Hypertensive Disorders of Pregnancy

Q. A 29y primigravida presents at 37 weeks. Her BP is 130/90 mmHg and

GDM with well controlled blood sugar: Induction of labour should be

No complications: 37-39 weeks

• Decided by umbilical artery flow on Doppler

Fetal Biometry < 10th percentile/

Umbilical Artery Doppler

Normal PI/ RI á (Reduced EDV) A/REDV

Repeat USG Twice Weekly