Obstetrics Question Set-2

Recall :5×2=10
Q.1.
a) What is ANC? Tell the WHO schedule of ANC visits.
b) what are the aims and objectives of ANC

Problem:10×2=20

Q.2) A lady started profuse per vaginal bleeding following

delivery of fetus and placenta.
a) What is your diagnosis?
b) Outline the first line of management of such a case.

Q.3) A 28-year-old primigravid patient presented with sudden

gush of per vaginal watery discharge at her 35 weeks of
pregnancy.
a) What is your most probable diagnosis?
b) How will you manage this case?

Analytic:4×5=20

Q.4) A 25 years old lady delivered a healthy female baby 4days

back. She has no obvious complaints and all vital parameters are
normal involution and lochial discharge are normal.

a) What is your clinical diagnosis.

b) Mention 2 important investigation.
c) What is the rate of involution per day.
d) Name 5 causes of involution.
 Obs card question-2:

Recall:

Q.1:

a) Antenatal care (ANC):

Systematic supervision (careful history taking, examination and advice) of a pregnant woman is called
antenatal care.

WHO recommended antenatal visit:

In the developing countries, as per WHO recommendation, the visit may be curtailed to at least 4 in low risk
woman,

•First visit :around 16 weeks

•Second visit:Between 24-28 weeks

•Third visit : At 32 weeks

• Fourth visit :At 36 weeks

Traditional antenatal visit

•First visit: As early as pregnancy is detected

• At interval of 4 weeks up to 28 weeks

• At interval of 2 weeks up to 36 weeks

•Weekly interval till delivery.

b)Aims of antenatal care:

1. To screen the 'high risk' cases

2. To prevent or to detect and treat at the earliest any complication

3 . To ensure continued risk assessment and to provide ongoing primary preventive health care
4. To educate the mother about the physiology of pregnancy and labour by demonstrations, charts and
diagrams, so that fear is removed and psychology is improved

5. To discuss with the couple about the place, time and mode of delivery, provisionally and care of the newborn

6. To motivate the couple about the need of family planning and also appropriate advice to couple seeking
medical termination of pregnancy

Objective of antenatal care:

To ensure a normal pregnancy with delivery of a healthy baby from a healthy mother.

Problem:

Q-2:

a)My diagnosis is primary postpartum hemorrhage

b)Management of primary PPH:

Diagnosis

Symptoms:

Bleeding per vagina with or without visible blood clot within 24 hours following birth of the baby.

a. General examination:

1.Anemia

2.Features of shock

b. Abdominal examination:

1.Well contracted uterus

2.Uterus is found flabby and becomes hard on messasing

c.per vaginal examination :

1.Bleeding may be copius or slow trickle

2.Clotted blood may be seen

3.Placenta delivered/not delivered/partially delivered

Investigations :

1.Blood Blood grouping, Rh typing and cross matching, Hb%2.

2.Coagulation profils (BT, CT and Prothrombus time)

3.USG for any retained bits of placenta.

Treatment:

1.Call for help

2. To palpate the fundus and massage the uterus to make uterus hard

3.Look for the placenta is expelled out or not.

4. Intravenous access by two large bore intravenous caunula must be ensured.

5. Ergometrine 0.5 mg is given lotravenously.

6.Start a dextrose saline with oxytocin

7.misoprostol,prostaglandin E1 analogue can be given 400-1000gm rectally.

8.Blood sent urgently for grouping and cross matching and has to be given inmediately.

9.The bladder is to be emptied by catheter

10.If the features of placental separation is evident,The placenta has to be delivered by controlled cord traction.

11. If not separated, manual removal of placenta under G/A is to be done

12. Exploration of the genital tract to exclude trauma and placental tissue

13. If still bleeding continues certain mechanical methods have to be applied to stimulate the uterine

contraction and stoppage of bleeding.

Mechanical methods are

a. Bimanual uterine compression

b. Compression of the aorta Utering temponade

c.uterine temponade

d. Intrauterine packing
14. If bleeding continues one should think about defective coagulation.

Coagulation defect has to be corrected by

a. Fresh blood transfusion

b. Fresh frozen plasma

c. Platelet transfusion

15. When the mechanical and medical measures fail to control bleeding, surgical intervention is required.

Surgical interventions are

a. Bilateral internal iliac artery ligation

b. Stepwise devascularization of the uterus

c. Compression sutures to maintain uterine contraction

d.arteial embolisation

e.subtotal or total abdominal hysterectomy

Q-3:

a)A primi with 35 weeks of pregnancy with premature rupture of membra b)Management of PROM

b)• Diagnosis

sudden gush of watery discharge

• Clinical features

Symptoms:

Sudden gush of fluid per vagina or watery vaginal discharge or continuous leaking through vagina

Sign:
1. Maternal temperature (↑ in chorioamnionitis) and pulse

2. Fetal heart rate

3. P/ A examination:

• Reduced size of uterus than the period of gestation

• Reduced liquor volume

4. Sterile speculum examination

Helps to confirm diagnosis by:

1. Demonstration of fluid, vernix or flecks

2. Odour of vaginal discharge

3. To exclude cord prolapse

4. To see dilatation & effacement of cervix

5. To take endocervical swab

6. To perform Nitrazine test and Fern test.

Vaginal examination is generally avoided in PROM

Investigation :

1. Complete blood count

2. Urine R/M/E and C/S

3. Endocervical swab: Gram stain & culture

4. Ultrasonography (gestational age and fetal biophysical profile)

5. CTG

6. Nitrazine test

7. Fern test (to note the characteristic ferning pattern when a smeared slide is examined under microscope)

8. Nile blue sulphate test

Treatment
General treatment

1. Hospitalization

2. Bed rest with bathroom privilege

3. Wearing of clean vulval pad

4. Broad spectrum antibiotics

5. Counselling of mother

6. Maternal and fetal monitoring

a. Maternal monitoring (Temp, Pulse, BP, SFH, liquor volume, odour of liquor,uterine tenderness)

b. Fetal monitoring (FHR 4 hourly, CTG daily and biophysical profile weekly)

Obstetrical management

1. Management of PROM with Chorioamnionitis

Termination of pregnancy irrespective of gestational age.

• mode of termination

Induction of labour: with oxytocin for short period (if vaginal delivery is notcontraindicated)

b. Caesarean section:*If vaginal delivery is contraindicated

*If not delivered by 12 hours of diagnosis of chorioamnionitis

2. Management of term PROM without chorioamnionitis (> 37 weeks of gestation)

Active management (Best option)

i. Induction of labour with oxytocin (if cervix is ripe)

ii. LUCS (for obstetric indication)

b. Expectant management (if cervix is not ripe)

Non intervention (wait for 6-12 hours to allow ripening of cervix and spontaneous onset of labour)

3. Management of pre-term PROM without chorioamnionitis

If gestational age more than 34 weeks but less than 37 weeks

1.Expectant management :As long as no sign of chorioamnionitis.

ii. Active management:

Induction of labour with oxytocin

LUCS (for obstetric indication)

b.

Gestational age between 24 and 34 weeks

• Expectant management

1.Corticosteroids (Inj. Dexamethasone (6mg) IM 12 hourly for total 4 doses for lung maturation)

2.Tocolytics (for 48 hours to allow lung maturity)

In utero transfer of fetus to a center with neonatal support.

c. Gestational age < 24 weeks

Active termination of pregnancy due to poor prognosis (best option)

Analytic:4x5=20

Answer

a. 5th day of normal puerperium following vaginal delivery.

b. Hb%, urine for R/M/E

c. 1" 24 hours the level remains constant. Thereafter there is a steady decrease in height by 1.25cm per 24
hours

d. puerperal sepsis, retained bits of placenta, multiple pregnancy, maternal ill health, caesarean
section, uterine fibroid
Recall: 5x2=10

1. Define PID?
2. Normal semen value suggested by WHO.

Problem: 10x2=20

Q1. A 25 years old lady attended at GOPD with amenorrhea for 1 year. She had undergone D&C 1
year back due to septic abortion.
a. What is your probable diagnosis?
b. How will you manage her?

Q2. A 15 years old girl presented top you with cyclic lower abdominal pain. Her menarche yet
not started. P/V showing bluish membrane at the introitus.
a. What is your probable diagnosis?
b. How will you treat her?

Analytic: 4x5=20

1. A 25 year old lady presented with a history of three successive abortion at mid trimaster.

a) What is your diagnosis?

b) What are the causes of this abortion?
c) What is management of habitual abortion due to cervical incompetence.
what are the complication arise in circlage operation?