(Medicalstudyzone - Com) Obs Image Bank

OBS/GYN
Image Bank
Index
Sl.No. Chapter Pg.No.
I Obstretics
Maternal Anatomy and physiology 09
Pelvis and Fetal Skull 21
Diagnosis of Pregnancy 32
Normal Labor 39
Induction of Labor 44
Haemorrhage in pregnancy 46
Antepartum Haemorrhage (APH) 58
Multifetal Pregnancy 64
Hypertensive Disorders in Pregnancy 73
Medical and Surgical Illness Complicating Pregnancy 78
Preterm Labor, PROM, Postmaturity, IUFD 81
Postpartum hemorrhage 94
Operative Obstetrics 96
Contraceptive Methods 100
II Obstetric Instruments 106
III Gynaecology
Anatomy and Histology 120
Puberty Normal and Abnormal 128
Menstrual cycle 131
Menopause 135
Sexual Development and Development Disorders 137
Infections 142
Disorders of Menstrual Cycles 154
Displacement of the Uterus 164
Infertility 169
Benign lesions and malignancy 176
IV Gynaecology Instruments 204
9
Obstetrics
Maternal Anatomy and physiology
ovary
Small intestine
Sacrum
fallopian tubes
uterus
Uterovesical pouch
Pouch of
Douglas
bladder
rectum
Symphysis Pubis
urethra
vagina
Labium majus
Sacrum
Peritoneum
ovary
fallopian tubes
uterus
Uterovesical pouch
Pouch of
Douglas bladder
rectum Symphysis Pubis
perineal body urethra
vagina
Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg4 )

10
THE UTERUS
l¥¥¥€*÷
Fundus
Corpus (5cms)
Body cavity Anatomical

Internal Os
(3.5cms)
Histological
Isthmus (0.5cms) Internal Os
Supravaginal portion
Cervix
(2.5cms) Portio vaginalis """" "
External os Q. Normal uterocervical

length in non pregnant
woman is ?
The ovary
Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 10)

11
GAMETOGENESIS
Primordial germ cell
Derived from epiblast
Endodermal wall of yolk sac (4th week)
Gonads (5th week)

12
Fertilization and implantation
Three portions of the

decidua—
Basalis,
Capsularis,
Parietalis
[NEET 2020]
Fertilization occurs
in ampulla of
Fallopian tube.

Reference: Williams Obstetrics 24th edition(pg 87)
13
Blastocysts. A. At 10 days. B. At 12 days after fertilization
The placenta
Albumin and Immunoglobulin M are high

molecular weight substance and cannot
' cross the placenta.
IN EET 18 ]

14
UMBILICAL CORD
Develops from extraembryonic mesoderm
Q. Deoxygenated blood is returned to the
MEET21
placenta from the fetus through ?
1. Two umbilical arteries

2. One umbilical vein (left)
3. Wharton’s jelly
4. Remains of allantoic diverticulum
5. Remains of vitellointestinal
duct (remnant of yolk sac)
Umbilical arteries carry deoxygenated blood
from fetus to the placenta
Umbilical vein carries oxygenated blood from
the placenta to the fetus.
CORD PROLAPSE COMPRESSION FETAL HYPOXIA
Fetal surface of placenta Maternal surface of placenta

Succenturiate lobe
Vessels extend from the
main placental disk to supply the small
round succenturiate lobe located beneath it.
Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 33 )

15
Sonographic imaging with color Doppler

shows the main placental disk implanted
posteriorly (asterisk). The Succenturiate
lobe is located on the anterior uterine wall
across the amnionic cavity. Vessels are
identified as the long red and blue crossing
tubular structures that travel within the
membranes to connect these two portions
of placenta.
Placental chorioangioma
These benign tumors have
components similar to blood vessels
and stroma of the chorionic villus.
Maternal serum alpha- fetoprotein
(MSAFP) levels may be elevated
Grossly, the chorioangioma is a round,

well-circumcised mass protruding
from the fetal surface.
Color Doppler imaging displays blood

flow through a large chorioangioma
with its border outlined by white
arrows.

16
Velamentous cord insertion.
A. The umbilical cord inserts into the B. When viewed sonographically and using
membranes. From here, the cord vessels color Doppler, the cord vessels appear to lie
branch and are supported only by against the myometrium as they travel to
membrane until they reach the placental insert marginally into the placental disk,
disk. which lies at the top of this image.
CORD ABNORMALITIES
SINGLE UMBILICAL ARTERY

Frequently associated with congenital malformation of the fetus (20–25%).
Renal and genital anomalies, Trisomy 18 are common.
Increased chance of abortion, fetal aneuploidy, prematurity, IUGR and increased
perinatal mortality

17
ovarian and endometrial cycles.
The ovarian-endometrial cycle has been structured as a 28-day cycle.
The follicular phase (days 1 to 14) is characterized by rising estrogen levels,

endometrial thickening, and selection of the dominant “ovulatory” follicle.
During the luteal phase (days 14 to 21), the corpus luteum (CL) produces estrogen and
progesterone, which prepare the endometrium for implantation. If implantation occurs,
the developing blastocyst begins to produce human chorionic gonadotropin (hCG) and
rescues the corpus luteum, thus maintaining progesterone production.

18
Human chorionic gonadotropin (hCG)

Glycoprotein containing two linked subunits alpha and beta.
Alpha unit contains 92 amino acids similar to LH, FSH and thyroid-stimulating
hormone. ( more similar to LH)
Beta unit contains 145 amino acids, and has specific biological activity in
pregnancy and ectopic pregnancy.
hCG starts rising soon after fertilization and is detected in the serum 1
week before the due menstrual period.
The level doubles every 2–3 days, peaks on the 100th day and then gradually
declines.
The hormone secreted by the syntiotrophoblast is luteotropic and secretes
progesterone by the corpus luteum until the tenth week when the placenta
takes over the hormonal functions.
With progesterone, it provides endometrial support to the embryo.
Role of hCG
Q. HCG is structurally and functionally similar to ?
It supports early pregnancy. INIKETZI
In ectopic pregnancy and missed abortion, the level is low and does not
double every 2–3 days.
In hyperemesis and in hydatidiform mole, the level is high, so also in
multiple and diabetic pregnancy.
While the level is high in trisomy 21 (Down syndrome), it is low in a fetus
with trisomy 18.
Ovarian stimulation in anovulatory infertility.
hCG is detected by n Urine pregnancy test.
Quantitative test in serum is useful in monitoring ectopic pregnancy and
follow-up of molar pregnancy.
In management decision-making in ectopic pregnancy.
Therapeutic Applications
In habitual abortion, it provides support to the embryo.

IVF programme: hCG given when the follicular size reaches 20 mm
causes follicular rupture 36–38 h following injection, and provides
support in implantation and endometrial vascularization.
In corpus luteal phase deficiency.
19
FETAL CIRCULATION
PLACENTA
LEFT UMBILICAL VEIN UMBILICAL ARTERIES
FETUS RIGHT AN LEFT

INTERNAL ILIAC ARTERIES
DUCTUS VENOSUS
RIGHT AND LEFT
COMMON ILIAC ARTERIES
INFERIOR VENACAVA
MIXES WITH VENOUS RETURN FROM AORTA
LOWER EXTREMITIES
RIGHT ATRIUM LEFT ATRIUM

FORAMEN OVALE
RIGHT VENTRICLE
PULMONARY ARTERY DUCTUS ARTERIOSIS

20
physiological change in pregnancy

Cardiovascular changes
Estrogen mediates rise in cardiac output by
increasing the pre-load and stroke volume,
'
[All Ms 19 ] Q. Respiratory changes

[NEET 19 ] in pregnancy? mainly via a higher overall blood volume
(which increases by 40–50%).
Respiratory changes
The heart rate increases,
FRC decreases by 10-25%,
Systolic and diastolic blood pressure drops
ERV 15-20%,
10–15 mm Hg in the first trimester and then
RV decreased by 20-25%, returns to the baseline in the second half of
TLC decrease. pregnancy.
Increase in the respiratory capacity by 5-10%,
RR by 1-2 breaths more than normal,
Changes in breast
Increase in the tidal volume 30-50%.
• Tenderness of the nipple or breast
¥;÷ ¥÷ :÷ii÷
• An increase in breast size over the
course of the pregnancy
• Changes in the color or size of the
nipples and areola
Hormonal changes
• More pronounced appearance of
÷Oestrogen
Progestrogen
Montgomery's tubercles
*Human placental lactogen

t FSH/LH GIT changes
Prolactin
÷ Oxytocin
Progesterone causes
smooth muscle relaxation
which slows down GI motility
and decreases lower
oesophagal sphincter (LES)
tone.
Renal changes Haematological changes

Increase in glomerular filtration
AFibrinogen and factor VIII
rate associated with an increase
in creatinine clearance, protein, Hyper-coagulable state
albumin excretion, and urinary Increased risk
glucose excretion. of DVT & PE
Increase in sodium retention
from the renal tube.
21
Pelvis and Fetal Skull
FETAL SKULL
[NEET 19 ]
Q. Vertex
presentation in
complete
Flexion
attitude?
[NEET 19 ]

22
Hk
.
23
PELVIS
INLET
Obstetric conjugate
Distance between the midpoint of the sacral promontory to prominent bony projection
in the midline on the inner surface of the symphysis pubis.
It is the shortest anteroposterior diameter in the anteroposterior plane of the inlet.
It measures 10 cm.
It cannot be clinically estimated but is to be inferred from the diagonal conjugate—
1.5–2 cm to be deducted or by lateral radiopelvimetry.
Diagonal conjugate
Distance between the lower border of symphysis pubis to the midpoint on the sacral
promontory.
It measures 12 cm.
It is measured clinically during pelvic assessment in late pregnancy or in labor.
Obstetric conjugate is computed by subtracting 1.5–2 cm from the diagonal
conjugate depending upon the height, thickness and inclination of the symphysis
pubis.

24
Measurement of Diagonal conjugate

OUTLET
Transverse
Intertuberous (11 cm or 4 ");
It measures between inner borders of ischial tuberosities.
Anteroposterior
It extends from the lower border of the symphysis pubis to the tip of the coccyx.
It measures 13 cm or 5 " with the coccyx pushed back by the head when passing
through the introitus in the second stage of labor; with the coccyx in normal
position, the measurement will be 2.5 cm less.
25
VARIATIONS OF FEMALE PELVIS
Inlet
Pelvis type Gynecoid Anthropoid
Shape Round Anteroposteriorly oval
Anterior and Both increased with slight

posterior segment Almost equal and spacious anterior narrowing
Sacral angle (SA) more than SA more than 90°. Inclined

Sacrum 90°. Inclined backwards. Well posteriorly. Long and
curved from above down and narrow. Usual curve
side to side
Pelvis type Android Platypelloid
Shape Triangular Transversely oval
Anterior and Posterior segment short and Both reduced-flat

posterior segment anterior segment narrow
Sacral angle less than SA more than 90°. Inclined

Sacrum 90°. Inclined forwards and posteriorly. Short and
straight straight

26
Cavity
Sacrosciatic Wide and shallow More wide and shallow

notch
Sidewalls Straight or slightly Straight or divergent

divergent
Sacrosciatic Narrow and deep Slightly narrow and small

notch
Sidewalls Convergent Divergent

27
Outlet
Ischial spines Not prominent Not prominent
Pubic arch Curved Long and curved
Subpubic angle Wide (85°) Slightly narrow

Bituberous
diameter Normal Normal or short
Ischial spines Prominent Not prominent
Pubic arch Long and straight Short and curved
Subpubic angle Narrow Very wide (more than 90°)
Bituberous
diameter Short Wide

28
Obstetric Outcome
Position Occipitolateral or oblique Direct occipitoanterior

occipitoanterior or posterior
Inlet
Diameter of
engagement Transverse or oblique Anteroposterior
Engagement No difficulty No difficulty except

Usual mechanism flexion is delayed
Cavity
Internal Easy anterior rotation

rotation Non-rotation common
Outlet
More incidence of face-

Delivery No difficulty
to-pubis delivery
Position Occipitolateral or oblique Occipitolateral

occipitoposterior
Inlet
Diameter of
Transverse or oblique Transverse
engagement
Difficult by exaggerated
Engagement Delayed and difficult
parietal presentation
Difficult anterior rotation. Not

Cavity
Internal Anterior rotation usually occurs

rotation occurs early above the ischial late in the perineum
spines, chance of arrest
Outlet
Difficult delivery with increased

Delivery No difficulty
chance of perineal injuries

29
FETAL lie
Relationship of the long axis of the fetus to the long axis of the
centralized uterus or maternal spine
NEETU
POSITION
Q. A 28 yr 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?
It is the relation of the denominator to

the different quadrants of the pelvis.
Most common:
left occipitoanterior (LOA)[1-111195^20]
Q. Identify right
occipitoanterior?

30
OCCIPUT-POSTERIOR POSITION (OP)
In a vertex presentation where the occiput is placed posteriorly over the sacroiliac
joint or directly over the sacrum, it is called an occiput-posterior position.
right occipitoposterior (ROP)
When the occiput is placed over the right sacroiliac joint
Third position of the vertex
In more than 50%, the
left occipitoposterior (LOP) occipitoposterior position is
When placed over the left sacroiliac joint associated with either an
Fourth position of the vertex anthropoid or android pelvis.
direct occipitoposterior
When it points toward the sacrum.
Fetal factors
Marked deflection of the fetal head, too often favors posterior position of the vertex.
The causes of deflexion are:
(1) High pelvic inclination.
(2) Attachment of the placenta on the anterior wall of the uterus
(3) primary brachycephaly
ABDOMINAL EXAMINATION
Inspection: The abdomen looks flat, below the umbilicus.
Umbilical grip: The findings are:
(1) The fetal limbs are more easily felt near the midline on either side.
(2) The fetal back is felt far away from the midline on the flank and often
difficult to outline clearly.
(3) The anterior shoulder lies far away from the midline.
Pelvic grips: The findings are:
(1) The head is not engaged.
(2) The cephalic prominence (sinciput) is not felt so prominent as found in well-flexed
occipitoanterior. In direct occipitoposterior, the small sinciput is confused with breech.
Auscultation: The maximum intensity of the fetal heart sounds is heard on the flank and
often difficult to locate especially in LOP. However, in direct occipitoposterior, the FHS is
distinctly felt in the midline.
VAGINAL EXAMINATION
The findings in early labor are:
(1) Elongated bag of membranes which is likely to rupture during examination.
(2) The sagittal suture occupies any of the oblique diameters of the pelvis.
(3) Posterior fontanel is felt near the sacroiliac joint.
(4) The anterior fontanel is felt more easily
31
In late labor, the diagnosis is often difficult because of caput formation which
obliterates the sutures and fontanels.
Because of deflexion, engagement is delayed.
32
Diagnosis of Pregnancy
FIRST TRIMESTER (FIRST 12 WEEKS)
Amenorrhea
Morning sickness (Nausea and vomiting)
Breast discomfort /
Fatigue [MEET 19]
Pelvic changes Q. Changes in pregnancy?
4–8 weeks 10th week

Palmer’s sign
Hegar’s sign

Reference: Self Assessment & Review Obstetrics, Sakshi Arora (pg 61)
33
transvaginal ultrasonography
Gestational sac and yolk sac by 5 menstrual weeks

Fetal pole and cardiac activity — 6 weeks;
Embryonic movements by 7 weeks.
Fetal gestational age is best determined by measuring the CRL between 7 and 12
weeks (variation ± 5 days).
Doppler effect of ultrasound can pick up the fetal heart rate reliably by 10th
week.
SECOND TRIMESTER (13-28 WEEKS)

Quickening
Perception of active fetal movements by the women.
Usually felt about the 18th week, about 2 weeks earlier in multiparae.
Chloasma
Pigmentation over the forehead and cheek may appear at about 24th week.
Breast changes
(a) Breasts are more enlarged with prominent veins under the skin
(b) Secondary areola, usually appears at about 20th week
(c) Montgomery’s tubercles are prominent and extend to the secondary areola
(d) Colostrum becomes thick and yellowish by 16th week
(e) Variable degree of striae may be visible with advancing weeks.
34
Fundal height
Fundal height is increased with

progressive enlargement of the
uterus.
The height of the uterus is midway

between the symphysis pubis and
umbilicus at 16th week;
At the level of umbilicus at 24th week;
At the junction of the lower third and
upper two-thirds of the distance
between the umbilicus and ensiform
cartilage at 28th week
UTERINE CHANGES

35
THIRD TRIMESTER (29-40 WEEKS)
Lightening
At about 38th week, specially in primigravidae, a sense of relief of the pressure
symptoms is obtained due to engagement of the presenting part
Symphysis fundal height (SFH)

Upper border of fundus is located by ulnar border of left hand and this point is marked.
Distance between the upper border of symphysis pubis up to the marked point is
measured by a tape in centimetre.
After 24 weeks, SFH measured in cm corresponds to the number of weeks up to 36 weeks.
A variation of ± 2 cm is accepted as normal. Variation beyond the normal range needs
further evaluation
BEST PARAMETERS FOR ESTIMATION OF FETAL AGE
1ST TRIMESTER CROWN RUMP LENGTH NEETU
Q. A 28 yr woman has been

on OCPs for 5 months. She
2ND TRIMESTER BIPARIETAL DIAMETER
presents to the OPD with 6
weeks amenorrhea and her
3RD TRIMESTER FEMUR LENGTH UPT is positive. Which is the
most accurate method to
OVERALL CROWN RUMP LENGTH determine gestational age in
this woman?

36
Obstetric grips (Leopold maneuvers)
Fundal grip
The palpation is done facing the patient’s face.

The whole of the fundal area is palpated using
both hands laid flat on it to find out which pole
of the fetus is lying in the fundus:
(a) broad, soft and irregular mass
suggestive of breech, or
(b) smooth, hard and globular mass
suggestive of head.
In transverse lie, neither of the fetal poles are
palpated in the fundal area.
Lateral or umbilical grip
The palpation is done facing the patient’s face.

The hands are to be placed flat on either side of
the umbilicus to palpate one after the other, the
sides and front of the uterus to find out the
position of the back, limbs and the anterior
shoulder.
The back is suggested by smooth curved and
resistant feel.
The ‘limb side’ is comparatively empty and there
are small knob like irregular parts.
[1-111195^20] Q. Identify lateral grip.?
Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg89 )

37
Pawlik’s grip (Third Leopold)
The examination is done facing toward the

patient’s face.
The overstretched thumb and four fingers of the
right hand are placed over the lower pole of the
uterus keeping the ulnar border of the palm on
the upper border of the symphysis pubis.
When the fingers and the thumb are
approximated, the presenting part is grasped
distinctly (if not engaged) and also the mobility
from side to side is tested.
In transverse lie, Pawlik’s grip is empty.
Pelvic grip (Fourth Leopold)

The examination is done facing the
patient’s feet.
Four fingers of both the hands are placed on
either side of the midline in the lower pole
of the uterus and parallel to the inguinal
ligament.
The fingers are pressed downward and
backward in a manner of approximation of
finger tips to palpate the part occupying
the lower pole of the uterus (presentation).
If it is head, the characteristics to note are:
(1) precise presenting area (2) attitude and
(3) engagement.
To ascertain the presenting part, the greater mass of the head (cephalic prominence) is
carefully palpated and its relation to the limbs and back is noted.
The attitude of head is inferred by noting relative position of sincipital and occipital poles.
The engagement is ascertained noting the presence or absence of sincipital and occipital
poles or whether there is convergence or divergence of the finger tips during palpation.

38
parity index
Gravida denotes a pregnant state both present and past, irrespective of the period
of gestation.
Parity denotes a state of previous pregnancy beyond the period of viability.
Abortion o the total number of induced abortion or miscarriage or ectopic
pregnancy before 20 weeks
L represents number of living children
Q. A 25 yr woman presents to the antenatal OPD. This is her 2nd pregnancy and her 1 st
MEET 21 pregnancy was 4 years earlier where she delivered twins at term. Her parity index is?
39
Normal Labor
STAGES OF LABOR
: First stage
It starts from the onset of true labor pain and ends with full dilatation of the cervix.
“cervical stage” of labor.
Its average duration is 12 hours in primigravidae and 6 hours in multiparae.
:Second stage
It starts from the full dilatation of the cervix (not from the rupture of the
membranes) and ends with expulsion of the fetus from the birth canal.
It has got two phases—
(1) Propulsive phase—Starts from full dilatation up to the descent of the presenting
part to the pelvic floor.
(2) Epulsive phase - Distinguished by maternal bearing down efforts and ends with
delivery of the baby. Its average duration is 2 hours in
primigravidae and 30 minutes in multiparae.
:Third stage
It begins after expulsion of the fetus and ends with expulsion of the placenta and
membranes (after births).
Its average duration is about 15 minutes in both primigravidae and multiparae.
Duration is, however, reduced to 5 minutes in active management.
Fourthstage:
It is the stage of observation for at least 1 hour after expulsion of the after births.
During this period maternal vitals, uterine retraction and any vaginal bleeding are
monitored. Baby is examined.
separation of placenta
A) Central separation (Schultze):
Detachment of placenta from its uterine attachment
starts at the center resulting in opening up of few
uterine sinuses and accumulation of blood behind the
placenta (retroplacental hematoma). With increasing
contraction, more and more detachment occurs
facilitated by weight of the placenta and retroplacental
blood until whole of the placenta gets detached.
B) Marginal separation (Mathews-Duncan):
Separation starts at the margin as it is mostly
unsupported. With progressive uterine contraction,
more and more areas of the placenta get separated.
A. B. Marginal separation is found more frequently.

40
Cardinal movements of labor and delivery from a

left occiput anterior position.

41
Active Management of Third Stage of Labor (AMTSL)

42
Expectant management (traditional)
Controlled cord Fundal pressure

traction (modified
Brandt-Andrews method)
Management of third stage of labour
The placenta being inelastic shears off its attachment through the deep spongy
decidual layer.
There are two ways of separation—central (Schultze) and marginal (Mathews-
Duncan).
The bleeding is controlled by active myometrial contraction and retraction (living
ligature) and by thrombosis.
The expulsion may occur through “bearing-down” efforts or more commonly with
assistance.
Management is either by employing watchful expectancy or by active management
(WHO) in cases where oxytocin 10 units IV (slowly) or IM/methergine 0.2 mg IV is
administered within 1 minute following the delivery of the baby.
Placenta and the membranes should be examined following their expulsion.
The uterus is massaged to make it hard, which facilitates expulsion of
retained clots if any.

43
Partogram
Graphical recording of stages of labour including cervical dilatation,
descent and rotation of the head.
The latent phase of labour is up to 3 cm dilatation, and should not be more than 8
hours.
In the active phase which extends from 3 cm to complete cervical dilatation, labour is
expected to progress at the rate of at least 1 cm cervical dilatation per hour which
corresponds to the alert line.
The action line is drawn 4 hours to the right and parallel to the alert line in the WHO
partogram.
Labour is considered normal as long as the progress of cervical dilatation is to the
left of the alert line.
Prolonged labour is diagnosed, once the alert line is crossed, i.e., there is a shift to
the right. This is considered an indication for intervention.
[1-111195^20]
The graph
must be
plotted when
cervical
dilatation
reaches 4
cms.
44
Induction of labor
Initiation of uterine contractions (after the period of viability) by any method
(medical, surgical or combined) for the purpose of vaginal delivery.
Indications
Pre-eclampsia, eclampsia
Maternal medical complications
-
Diabetes mellitus
Chronic renal disease
= Cholestasis of pregnancy
Postmaturity
Abruptio placentae
Intrauterine Growth Restriction (IUGR)
Rh-isoimmunization
Premature rupture of membranes
Fetus with a major congenital anomaly
Intrauterine death of the fetus
[NEET 19 ]
Oligohydramnios, polyhydramnios
Q. Contraindication
Unstable lie-after correction into longitudinal lie for induction of
labor?
Contraindications
Contracted pelvis and cephalopelvic disproportion
Malpresentation (breech, transverse or oblique lie)
Previous classical cesarean section or hysterotomy
Uteroplacental factors: Unexplained vaginal bleeding, vasaprevia, placenta previa
Active genital herpes infection
High-risk pregnancy with fetal compromise
Heart disease
Pelvic tumor
Elderly primigravida with obstetric or medical complications
Umbilical cord prolapse
Cervical carcinoma

45
METHODS OF INDUCTION OF LABOR
Medical Methods MEDICAL INDUCTION
Intrauterine fetal death Prostaglandins PGE2, PGE1
Premature rupture of membranes Oxytocin
In combination with surgical induction (ARM) Mifepristone
Surgical Methods SURGICAL INDUCTION

Abruptio placentae Artificial rupture of the
Chronic hydramnios
membranes (ARM)
Severe pre-eclampsia/ eclampsia
In combination with medical induction Stripping the
To place scalp electrode for electronic fetal monitoring membranes
Combined Methods
To shorten the induction — delivery interval
(commonly done). Medical methods followed by surgical
or surgical methods followed by medical
Artificial rupture of the membranes
AMNIHOOK

46
Haemorrhage in Pregnancy
Abortion
Abortion is the expulsion or extraction from its mother of an embryo or fetus
weighing 500 g or less when it is not capable of independent survival
THREATENED MISCARRIAGE
Clinical entity where the process of miscarriage has started but has not
progressed to a state from which recovery is impossible
INEVITABLE MISCARRIAGE
Clinical type of abortion where the changes have progressed to a state
from where continuation of pregnancy is impossible.
COMPLETE MISCARRIAGE
When the products of conception are expelled en masse
THREATENED MISCARRIAGE INEVITABLE MISCARRIAGE COMPLETE MISCARRIAGE

47
MISSED MISCARRIAGE
When the fetus is dead and retained inside the uterus for a variable period, it is called
missed miscarriage or early fetal demise.
CARNEOUS MOLE:
Pathological variant of missed miscarriage affecting the fetus before 12 weeks.
Small repeated hemorrhages in the choriodecidual space disrupt the villi from its
attachments. The bleeding is slight, so it does not cause rupture of the decidua
capsularis.
The clotted blood with the contained ovum is known as a blood mole.
By this time, the ovum becomes dead and is either completely absorbed or remains
as a rudimentary structure.
Gradually, the fluid portion of the blood surrounding the ovum gets absorbed and the
wall becomes fleshy, hence the term fleshy or carneous mole

48
Human teratogenic drugs
Risk category of drugs during pregnancy*
Q. 25 yr primigravida is on indomethacin ( 25 mg TDS)

for polyhydramnios till 35 weeks. What abnormality
can the fetus have, if she goes into labor now?
MEET 121
49
Anticoagulants in pregnancy
Anticoagulants are indicated in cases with:

(a) Congenital heart disease,
(b) pulmonary hypertension,
(c) mechanical heart valve,
(d) atrial fibrillation.
The patient taking warfarin should discontinue it as soon as pregnancy is diagnosed and to
replace it by heparin 5,000 units twice daily subcutaneously up to 12th week.
Low molecular weight heparin (LMWH) can also be used.
This is then replaced by warfarin tablet 3 mg. daily to be taken at the same time each day
and continued up to 36 weeks.
Thereafter it is replaced by heparin up to 7 days postpartum. Warfarin is then to be
continued.
UFH, LMWH and Warfarin therapy do not contraindicate breast-feeding.
Q. A 28 yr primigravida who is a known case of Mitral valve replacement

presents at 36wks to the antenatal OPD. She is on warfarin 4mg. What is the
correct anticoagulant therapy?
NEETU
50
MEDICAL TERMINATION OF PREGNANCY (MTP)
The term induced abortion is defined as the medical or surgical termination of

pregnancy before the time of fetal viability.
Suction curette has been placed

through the cervix into the uterus.
The figure shows the rotary motion
used to aspirate the contents.

51
Ectopic pregnancy
Fertilized ovum is implanted and developed outside the normal endometrial cavity.
Secondary Abdominal Pregnancy

Continuation of fetal growth outside the tube
Fate of Secondary Abdominal Pregnancy
Death of the blastocyst
Massive intraperitoneal hemorrhage due to placental separation
Infection
Fetal death
Continue to term pregnancy (rare—1.0%) (risk of fetal malformation and deformation)
Unruptured tubal
ectopic pregnancy
MEET21
Q. A 24 yr Primi with a history of infertility for 3

years presents with 6 weeks amenorrhea. 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. B HCG : 2800 Ultrasound
reveals a left sided tubal gestational sac with no
cardiac activity. Which is the best management
option?

52
Ruptured ampullary early tubal pregnancy
This decidual cast was passed by a

patient with a tubal ectopic pregnancy.
The cast mirrors the shape of the
endometrial cavity, and each arrow
marks the portion of decidua that lined
the cornua.
Ruptured interstitial pregnancy.

Subtotal Hysterectomy done.

53
Ovarian pregnancy
A. Transvaginal sonogram B. Due to concern for extensive parasitic blood

shows a gestational sac supply to the pregnancy, exploratory laparotomy
containing fetal parts of a was performed. Here, the right ovary is lifted by the
16-week gestation. The surgeon, and the fallopian tube is the cordlike
placenta is marked by a red structure stretched across the top of the mass. Due
asterisk. to mass size and vascularity and scant normal
ovarian stroma, this patient was treated by right
salpingo-oophorectomy.
cesarean scar pregnancy.
☐Hysterectomy specimen
containing a cesarean
scar pregnancy.
This same hysterectomy specimen is transversely sectioned at
the level of the uterine isthmus and through the gestational
sac. The uterine body lies to the left, and the cervix is on the
right. A metal probe is placed through the endocervical canal to
show the eccentric development of this gestation. Only a thin
layer of myometrium overlies this pregnancy, which pushes
anteriorly through the uterine wall.

54

55
Gestational Trophoblastic Disease

Group of tumors typified by abnormal trophoblast proliferation.
Hydatidiform moles, which are characterized by the presence of villi,
Non- molar trophoblastic neoplasms, which lack villi.
Classification of GTD
[1-111195^20]
The definitive
management of molar
pregnancy - suction
and evacuation
Complete hydatidiform mole.
B. Low-magnification photomicrograph shows generalized

A. Gross specimen with
edema and cistern formation (black asterisks) within
characteristic vesicles of
avascular villi. Haphazard trophoblastic hyperplasia is
variable size
marked by a yellow asterisk on the right.

56
Characteristic feature of molar pregnancy is “snowstorm” appearance
partial hydatidiform mole
The affection of the chorionic villi is focal.

There is a fetus or at least an amniotic sac.
The fetus, if present, dies in early first
trimester. Rarely, the baby may be born
which is growth retarded with multisystem
abnormalities
[NEET 19 ]
Karyotype seen in partial

mole is 69XXY or 69XXX

57

58
Antepartum Haemorrhage (APH)

Antepartum Haemorrhage
Bleeding from or into the genital tract after the 28th week of pregnancy but before
the birth of the baby
PLACENTA PREVIA
When the placenta is implanted partially or completely over the lower uterine
segment (over and adjacent to the internal os) it is called placenta previa.
Four types of placenta previa depending upon the degree of extension of
placenta to the lower segment.
[NEET 19 ] Q. Identify type 3 placenta previa?

59
placenta accrete syndrome

Variants of placenta accrete syndrome are classified by the depth of
trophoblastic growth.
Placenta accreta indicates that villi are attached to the myometrium.
Placenta increta, villi actually invade the myometrium,
Placenta percreta- villi that penetrate through the myometrium and to or
through the serosa.
A. Cesarean hysterectomy specimen containing B. Hysterectomy specimen

a total placenta previa with percreta involving containing a partial placenta previa
the lower uterine segment and cervical canal. with placenta percreta that invaded
Black arrows show the invading line of the the lateral fundal region to cause
placenta through the myometrium. hemoperitoneum.

60

61
ABRUPTIO PLACENTAE
Bleeding occurs due to premature separation of normally situated placenta.
Bleeding is almost always maternal. But placental tear may cause fetal bleeding.
Following separation of the placenta, the blood

insinuates downwards between the membranes
Revealed
and the decidua. Ultimately, the blood comes
out of the cervical canal to be visible
externally. This is the most common type.
The blood collects behind the separated placenta or

collected in between the membranes and decidua.
Concealed
The collected blood is prevented from coming out
of the cervix by the presenting part which presses
on the lower segment. This type is rare.
In this type, some part of the blood collects inside

Mixed (concealed) and a part is expelled out (revealed).
Usually one variety predominates over the other.
This is quite common.
Concealed Revealed Marginal Preplacental

(subchorionic) (subamniotic)
Hypertensive pregnant woman with
abdominal pain, bleeding per vaginum, loss
[1-111195^20] of fetal movements- abruptio placenta

62
The features of retroplacental hematoma:

(a) Depression found on the maternal
surface of the placenta with a clot
which may be found firmly attached to
the area
(b) Areas of infarction with varying
degree of organization

63
COUVELAIRE UTERUS
Severe form of concealed abruptio

placentae. There is massive
intravasation of blood into the uterine
musculature upto the serous coat. The
condition can only be diagnosed on
laparotomy.

64
Multifetal Pregnancy
'
IN EET 18 ]
Best time to identify

type of twin
pregnancy-> 11-14
weeks

65
Dichorionic diamnionic twin placenta
The membrane partition that separated

twin fetuses is elevated and consists of
chorion (c) between two amnions (a).
Monochorionic monoamnionic cord entanglement
[AIIMS 2018]
Q. Identify
monochorionic
monoamniotic
Fetus papyraceous
Fetus papyraceous or compressus is a state
which occurs if one of the fetuses dies early.
The dead fetus is flattened, mummified and
compressed between the membranes of the
living fetus and the uterine wall. It may
occur in both varieties of twins, but is more
common in monozygotic twins and is
discovered at delivery or earlier by
sonography

66
Chorionicity of the placenta
twin peak sign

Best diagnosed by ultrasound at 10–13 weeks of gestation.
In dichorionic twins there is a thick septum between the two gestational sacs. It is
best identified at the base of the membrane, where a triangular projection is seen.
This is known as lambda or twin peak sign.
Presence of lambda or twin peak sign indicates dichorionic placenta
Presence of one gestational sac with a thin dividing membrane, and two
fetuses, (“T” sign) suggests monochorionic diamniotic pregnancy.
Marked growth discordance in acardiac twin

monochorionic twins.

67
Twin-Twin Transfusion Syndrome
Anastomoses between twins

may be artery-to- vein (AV),
artery-to-artery (AA), or
vein-to-vein (VV).
Blood is transfused from a donor twin to its
recipient sibling such that the donor may
eventually become anemic and its growth
may be restricted. In contrast, the
recipient becomes polycythemic and may
develop circulatory overload manifest as
hydrops
Twin reversed-arterial-perfusion sequence
In TRAP sequence, there is a normally formed donor twin that has features of heart
failure, and a recipient twin that lacks a heart.
TRAP sequence is caused by a large artery-to-artery placental shunt, often also
accompanied by a vein-to-vein shunt. Within the single, shared placenta, perfusion
pressure of the donor twin overpowers that in the recipient twin, who thus receives
reverse blood flow from its twin sibling.
The “used” arterial blood (colored blue) that reaches the recipient twin preferentially
goes to its iliac vessels and thus perfuses only the lower body. This disrupts growth and
development of the upper body.

68

69
Superfecundation
Fertilization of two different ova released in the same cycle, by separate acts
of coitus within a short period of time.
Homopaternal superfecundation refers to the

fertilization of two separate ova from the same
father, leading to fraternal twins;
Heteropaternal superfecundation is referred to
as a form of atypical twinning where, genetically,
the twins are half siblings – sharing the same
mother, but with different fathers.
Superfetation is the fertilization of two ova released in different menstrual cycles.

The nidation and development of one fetus over another fetus is theoretically possible
until the decidual space is obliterated by 12 weeks of pregnancy.
NEETU
Q. 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 case of?
70
AMNIOTIC FLUID DISORDERS
POLYHYDRAMNIOS
Liquor amnii exceeds 2,000 mL.
Amniotic fluid index (AFI) is more than 24 cm
and a deepest vertical pocket (DVP) is more than 8 cm.
FETAL ANOMALIES
Anencephaly
Open spina bifida
Esophagealorduodenalatresia
Facial clefts and neck masses
Hydrops fetalis
Aneuploidy
PLACENTA Chorioangioma of the placenta
MULTIPLE PREGNANCY
More common in monozygotic twins
MATERNAL [AIIMS 2018]
Diabetes
Cardiac or renal disease At term, the amniotic fluid will
be cloudy with white flakes.
IDIOPATHIC: 50–60%

71
ANENCEPHALY
Deficient development of the vault of the skull and brain tissue, but the facial
portion is normal.
The pituitary gland is often absent or hypoplastic.
Typically, there is marked diminution of the size of the adrenal glands probably
secondary to the absence of the pituitary gland.
Investigations
Diagnosis is made by elevated alpha-fetoprotein in amniotic fluid.
Diagnosis is confirmed by sonography
The findings around 10 weeks are:
(a) absence of cranial vault,
(b) angiomatous, brain tissue
Complications
(1) Hydramnios (70%),
(2) Malpresentation—face or breech,
(3) Premature labor, especially when associated with hydramnios,
(4) Tendency of postmaturity,
(5) Shoulder dystocia,
(6) Obstructed labor if the head and shoulders try to engage
together because of short neck.
Management
If confirmed before 20 weeks, termination of pregnancy is to be done.
The uterus is most often refractory to oxytocin because of low level of estriol Use of
prostaglandin vaginal gel (PGE2) has been proved to be effective in resistant cases.
During labor, there is tendency of delay. Shoulder dystocia should be managed by
cleidotomy.
Q. The following USG Abdomen of a

20 wk pregnant female.What is the
most probable anomaly ?
INKET'Ll
coronal section shows frog eye appearance

72
OLIGOHYDRAMNIOS
Liquor amnii is deficient in amount to the extent of less than 200 mL at term
Maximum vertical pocket of liquor is less than <2 cm or
when amniotic fluid index (AFI) is less than 5 cm
Fetal conditions
(i) Fetal chromosomal or structural anomalies
(ii) Renal agenesis
(iii) Obstructed uropathy
(iv) Spontaneous rupture of the membrane
(v) Intrauterine infection
(vi) Drugs: PG inhibitors, ACE inhibitors
(vii) Postmaturity
(viii) IUGR
(ix) Amnion nodosum
Maternal conditions
(i) Hypertensive disorders [NEET 20]
'
(ii) Uteroplacental insufficiency

Renal Agenesis -> Cause of
(iii) Dehydration oligohydraminos in early
(iv) Idiopathic. second trimester
COMPLICATIONS
Fetal
(1) Abortion
(2) Deformity due to intra-amniotic adhesions or due to compression-
alteration in shape of the skull, wry neck, club foot, or even amputation of the limb
(3) Fetal pulmonary hypoplasia
(4) Cord compression
(5) High fetal mortality.
Maternal
(1) Prolonged labor due to inertia
(2) Increased operative interference due to malpresentation.
TREATMENT
Oral administration of water increases amniotic fluid volume.
In labor, cord compression is common.
Amnioinfusion (prophylactic or therapeutic) for meconium liquor is found to
improve neonatal outcome.

73
Hypertensive Disorders in Pregnancy

PREECLAMPSIA
Development of hypertension to the extent of 140/90 mm Hg or more with proteinuria

after the 20th week in a previously normotensive and nonproteinuric woman.
Earliest evidence of preeclampsia-
Pitting edema over the ankles after 12 hours bed rest or rapid gain in weight

74

75
Hypertensive crisis
BP is >160/110 mm Hg or the mean arterial pressure (MAP) is >125 mm Hg
HELLP Syndrome
Hemolysis (H),
Elevated Liver enzymes (EL)
Low Platelet count (LP) (<100,000/mm3)
Rare complication of preeclampsia (10–15%)
ECLAMPSIA
Preeclampsia when complicated with grandmal seizures

(generalized tonic-clonic convulsions) and/or coma
Hematoma of tongue from laceration during an
eclamptic convulsion. Thrombocytopenia may
have contributed to the bleeding.
Q. A 35 yr old G2P1,L1 with previous normal delivery,

now in the third trimester presents to the antenatal
opd with BP 150/110 with proteinuria of 3+. Which
INIICEÑZI are the impending signs of eclampsia ?

76
Regimens of MgSO4 for the Management of Severe Preeclampsia and Eclampsia
Q.loading Dose of Mg So4?

[All Ms't 9 ]
Q.Management of severe preeclampsia?

[All Ms't 9 ]

77
Antihypertensive drugs
Antihypertensive drugs are essential when the BP is 160/110 mm Hg to protect the
mother from eclampsia, cerebral hemorrhage, cardiac failure and placental abruption.
Aim is to reduce BP to a mean less than 125 mm Hg.
Their benefit in mild or moderate hypertension is not yet known.
If there is any risk of target organ damage (kidney) antihypertensives are given to
maintain BPE140 mm Hg.
First line therapy is either methyldopa or labetalol.
Second line drug is nifedipine.
ACE inhibitors are avoided in pregnancy.
ACE inhibitors causes Renal hyperfusion —> Renal agenesis
Q. A 35 yr woman is a chronic hypertensive. She visits the clinic

for preconception counselling. Which of the following anti
hypertensives need to be stopped prior to conception?
NEET21
78
Medical and Surgical Illness Complicating Pregnancy

ANEMIA IN PREGNANCY
Anemia in pregnancy is present when the hemoglobin
concentration in the peripheral blood is 11 g/100 mL or less.
COMPLICATIONS OF ANEMIA IN
PREGNANCY
DURING PREGNANCY
Preeclampsia
Intercurrent infection
Heart failure
Preterm labor
DURING LABOR
Uterine inertia
Postpartum hemorrhage
Cardiac failure
Shock

79

80
DIABETES MELLITUS
GESTATIONAL DIABETES MELLITUS

Carbohydrate intolerance of variable severity with onset or first
recognition during the present pregnancy.
[NIEETÉO]
Pre gestational
diabetes-Caudal
regression/ sacral
agenesis
Fetal macrosomia (40–50%) with birth weight > 4 kg (>90th percentile)due to :

(a) Maternal hyperglycemia hypertrophy and hyperplasia of the fetal islets of
Langerhans
(b) Elevation of maternal free fatty acid (FFA) in diabetes leads to its increased
transfer to the fetus
[NEET la ]
acceleration of triglyceride synthesis
Q. Identify gestational DM from
adiposity the image of fetus?
Major Birth Defects in Infants of Diabetic Mothers (6–10%)
[All Ms't 9 ]
Q.Defects in GDM?

81
Preterm Labor, PROM, Postmaturity, IUFD
Preterm labor
labor starts before the 37th completed week (< 259 days), counting from the first day
of the last menstrual period
management of preterm labor

82
PRELABOR RUPTURE OF THE MEMBRANES

Spontaneous rupture of the membranes any time beyond 28th week of pregnancy
but before the onset of labor is called prelabor rupture of the membranes (PROM).
Rupture of membranes for > 24 hours before delivery is called prolonged rupture of
membranes.
Causes are
(1) Increased friability of the membranes;
(2) Decreased tensile strength of the membranes;
(3) Polyhydramnios;
(4) Cervical incompetence;
(5) Multiple pregnancy;
(6) Infection—Chorioamnionitis, urinary tract infection and lower genital tract infection;
(7) Cervical length < 2.5 cm;
(8) Prior preterm labor
(9) Low BMI (< 19 kg/m2).

83
POST TERM PREGNANCY

Pregnancy continuing beyond 2 weeks of the expected date of delivery (> 294 days)

84
INTRAUTERINE FETAL DEATH
Antepartum death occurring beyond the period of viability.

It usually results in the delivery of a macerated fetus.
Causes of Intrauterine Fetal Death
DIAGNOSIS
SYMPTOMS—Absence of fetal movements which were previously noted by the patient.
SIGNS
Gradual retrogression of fundal height and it becomes smaller than period of gestation.
Uterine tone is diminished and the uterus feels flaccid.
Braxton-Hicks contraction is not easily felt.
Egg-shell crackling feel of the fetal head is a late feature.
Fetal heart sound is absent
Fetal movements are not felt during palpation.

85
Sonography
(a)Lackof all fetal motions

(including cardiac) during a 10-
minute period of careful
observation with a real-time sonar
is a strong presumptive evidence
of fetal death and
(b) Oligohydramnios and collapsed
cranial bones are evident
Straight X-ray abdomen
Spalding sign—
Irregular overlapping of the cranial bones on
one another is due to liquefaction of the brain
matter and softening of the ligamentous
structures supporting the vault. It usually
appears 7 days after death.
Hyperflexion of the spine

Crowding of the ribs shadow
Appearance of gas shadow (Robert’s sign) in
the chambers of the heart and great vessels
may appear as early as 12 hours

86

87
Malpresentation and Cord Prolapse

breech presentation
In breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic
brim. It is the most common malpresentation.
varieties of breech presentation
Breech with extended Complete Footling

legs (Frank breech) (Flexed breech) presentation

88
Birth Injuries
following breech
delivery showing
dislocation of left
knee joint

89
Frank breech extraction (Pinard’s maneuver)
In Pinard’s maneuver, the middle and the index fingers are carried up to the popliteal
fossa. It is then pressed and abducted so that the fetal leg is flexed. The fetal foot is
then grasped at the ankle and breech extraction is accomplished.
LOVSET’S MANEUVER
It is widely practiced in preference to the classical method of bringing down an arm.
The baby is lifted slightly to cause lateral flexion. The trunk is rotated
through 180° keeping the back anterior and maintaining a downward traction.
This will bring the posterior arm to emerge under the pubic arch which is
then hooked out.
The trunk is then rotated in the reverse direction keeping the back
anterior to deliver the erstwhile anterior shoulder under the
symphysis pubis.

90
TRANSVERSE LIE
When the long axis of the fetus lies perpendicularly to the maternal spine or
centralized uterine axis, it is called transverse lie.

91
CORD PROLAPSE
Occult prolapse
Thecordisplaced by the side of the presenting part and is not felt by the fingers on
internal examination. It could be seen on ultrasonography or during cesarean section.
Cord presentation
The cord is slipped down below the presenting part and is felt lying in the intact bag of
membranes.

92
Cord prolapse
The cord is lying inside the

vagina or outside the vulva
following rupture of the
membranes

93
Fetal Anomalies
HYDROCEPHALUS
Excessive accumulation of cerebrospinal fluid (0.5–1.5 L) in the ventricles with

consequent thinning of the brain tissue and enlargement of the cranium occurs in 1
in 2,000 deliveries
ANENCEPHALY
The anomaly results from deficient

development of the vault of the skull
and brain tissue, but the facial portion
is normal. The pituitary gland is often
absent or hypoplastic. Typically, there
is marked diminution of the size of
the adrenal glands probably secondary
to the absence of the pituitary gland.

94
Any amount of bleeding from or into the genital tract following birth of the baby up to
the end of the puerperium, which adversely affects the general condition of the patient
evidenced by rise in pulse rate and falling blood pressure is called postpartum
hemorrhage

95
Any amount of bleeding from or into the genital tract following birth of the baby up to the end
of the puerperium, which adversely affects the general condition of the patient evidenced by rise
in pulse rate and falling blood pressure is called postpartum hemorrhage
Primary: Hemorrhage occurs within 24 hours following the birth of the baby.
These are of two types:
Bleeding occurs before expulsion of placenta.
Bleeding occurs subsequent to expulsion of placenta (majority).
Secondary: Hemorrhage occurs beyond 24 hours and within puerperium, also
called delayed or late puerperal hemorrhage.
Causes of PPH
Atonic PPH (Tone)
It is the most common cause of primary PPH accounting for 90% of cases.
The bleeding occurs as the blood vessels are not obliterated by contraction
and retraction of uterine muscle fibres
Traumatic PPH (Trauma)
Genital tract injuries like: Lacerations of the cervix, vagina and perineum;
NEETU
Colporrhexis and Rupture uterus
Q. Following delivery, a woman has a tonic
Coagulopathy (Thrombin)
PPH. Despite conservative measures, the
Disseminated intravascular coagulation (DIC) bleeding persists. She was taken to the OT
and hypofibrinogenemia are rare causes of PPH where the surgeon proceeds to do a
Other causes (Tissue) devascularization procedure. Which vessels
are ligated?
Retained products of conception
Surgical methods to control PPH

(a) B-Lynch compression suture (1997) and multiple square sutures: Both these
surgical methods work by tamponade (like bimanual compression) of the uterus
(b) Ligation of uterine arteries—the ascending branch of the uterine artery is ligated
at the lateral border between upper and lower uterine segment. In atonic
hemorrhage, bilateral ligation is effective in about 75% of cases.
(c) Ligation of the ovarian and uterine artery anastomosis, if bleeding continues, is done
just below the ovarian ligament.
(d) Ligation of anterior division of internal iliac artery (unilateral or bilateral)—reduces
the distal blood flow. It helps stable clot formation by reducing the pulse pressure up to
85%. Due to extensive collateral circulation, there is no pelvic tissue necrosis.
(e) Angiographic selective arterial embolization (bleeding vessel) under fluoroscopy
(interventional radiology) can be done using gel foam.
96
Operative Obstetrics
VERSION
Manipulative procedure designed to change the lie or to bring the comparatively

favorable pole to the lower pole of the uterus.
EXTERNAL CEPHALIC VERSION

Done to bring the favorable cephalic pole in the lower pole of the uterus
Step I : The breech is mobilized using both hands to one iliac fossa towards which the
back of the fetus lies. The podalic pole is grasped by the right hand in a manner like
that of Pawlik’s grip while the head is grasped by the left hand.
Step II : The pressure (firm but not forcible) is now exerted to the head and the breech in
the opposite directions to keep the trunk well flexed which facilitates version. The pressure
should be intermittent to push the head down towards the pelvis and the breech towards the
fundus until the lie becomes transverse. The FHR is once more to be checked.
Step III: The hand is now changed one after the other to hold the fetal poles to prevent
crossing of the hand. The intermittent pressure is exerted till the head is brought to the
lower pole of the uterus.

97
INTERNAL VERSION
Internal version is always a podalic version

and is almost always completed with the
extraction of the fetus.
INDICATIONS: Internal version is hardly
indicated in a singleton pregnancy in present
day obstetric practice. Its only indication
being the transverse lie in case of the second
baby of twins.
It must not be attempted in neglected obstructed

labor even if the baby is living.
PREREQUISITES FOR OPERATIVE VAGINAL FORCEPS OR VENTOUSE DELIVERY

98
EPISIOTOMY
Surgically planned incision on the perineum and the posterior vaginal wall during the
second stage of labor is called episiotomy (perineotomy).
Midline episiotomy
Two fingers are insinuated between the perineum and fetal head, and
the episiotomy is then cut vertically downward.
99
Perineal Tear
[AIIMS 120 ; NEETÉOT
Q.Degree of perineal tear?

100
Contraceptive Methods
[NEET 120]
Q.Identify Female
condom?
CONDOM
DIAPHRAGM

101
Fertility Awareness Methods (Rhythm Method)
COITUS INTERRUPTUS WITHDRAWAL
INTRAUTERINE CONTRACEPTIVE DEVICES IUCDs

102
STEROIDAL CONTRACEPTIONS
COMBINED ORAL CONTRACEPTIVES
Thromboembolism is an absolute
[NEET 19 ]
contraindication to OCP use.

103
IMPLANT
Implanon is a progestin only delivery system containing 3-ketodesogestrel (etonogestrel).

It is a long-term (up to 3 years) reversible contraception.
It consists of a single closed capsule (made of polydimethyl- siloxane 40 mm x 2 mm) and
contains 68 mg of etonogestrel (ENG).
It releases the hormone about 60 mcg, gradually reduced to 30 mcg per day over 3 years.
Implanon does not cause decrease in bone mineral density
Emergency Contraceptives

104
Female Sterilization

105
Q. Match the STD kits ?
INICET the
106
Obstetric Instruments
SIMPLE RUBBER CATHETER
Used to empty the bladder in cases with retention of urine during

(a) Pregnancy (Retroverted Gravid Uterus).
(b) Labor— (i) When the woman fails to pass urine by herself,
(ii) Before and after any operative interventions
(c) Postpartum—(i) During management of postpartum haemorrhage
(ii) Retained placenta
Other uses—(a) As a tourniquet,
(b) To administer O2 when nasal catheter is not available,
(c) As a mucus sucker—when it is attached to a mechanical or electric sucker.
FOLEY’s Catheter
The catheter is inserted within the
uterine cavity and the catheter
balloon is inflated with normal
saline. The balloon provides a
tamponade to the uterine surface.
The catheter drains the blood from
the uterine cavity if there is any.
Used for continuous drainage of bladder in cases with
(i) Eclampsia
(ii) Retroverted gravid uterus
(iii) To give rest to the bladder following any destructive operation and/ or
in a case with suspected bladder injury. It is usually kept for 7–10 days.
(iv) In the management of atonic PPH

107
LONG STRAIGHT SCISSORS
Used to cut umbilical cord

To make episiotomy
To cut suture materials as in
cesarean section.
EPISIOTOMY SCISSORS
It is bent on edge.
The blade with blunt tip
goes inside the vagina.
[AIIMS 2018]
Q. Identify the
instrument?
ALLIS TISSUE FORCEPS
To catch hold the anterior lip of the cervix in D + E operation.

To hold the apex of episiotomy wound during repair.
To catch hold of margins of peritoneum, rectus sheath, vaginal mucosa during repair.
To catch hold of the torn ends of the sphincter ani externus prior to suture in repair of
complete perineal tear.
To catch hold the margins and angles of the uterine flaps in LSCS after the delivery of
the baby as an alternative to Green-Armytage hemostatic clamp.
108
LONG STRAIGHT HEMOSTATIC FORCEPS

Not commonly used in
obstetrics.
Used to clamp pedicle while
removing uterus as in
rupture uterus.
Umbilical cord may be
clamped as an alternative to
Kocher’s.
KOCHER’S HEMOSTATIC FORCEPS
To clamp the umbilical cord for

better grip and effective
crushing effect to occlude the
vessels.
In low rupture of the membranes
as surgical induction of labor or
augmentation of labor
GREEN–ARMYTAGE HEMOSTATIC FORCEPS
Cannot be used in classical

cesarean section.
Alternative to this Allis tissue
forceps may be used.
Forceps is used in lower segment cesarean section

(Total four forceps are ordinarily required—one for each angle and one for each flap.)
Functions
Hemostasis
To catch hold of the margins so that they are not missed during suture.
109
SPONGE HOLDING FORCEPS
Toileting the vulva, vagina and perineum prior to and following delivery.
Antiseptic painting of the abdominal wall prior to cesarean section.
To catch hold the membranes if it threatens to tear during delivery of the placenta.
To catch hold the cervix for inspection in suspected cervical tear.
To catch hold the cervix during encirclage operation.
OVUM FORCEPS
It has got no catch and the blades are slightly bent and fenestrated.
Absence of catch minimizes uterine injury, if accidentally caught.
It prevents crushing of the conceptus.
It is to be introduced with the blades closed, to open up inside the uterine cavity, to
grasp the products and to take out the instrument with a slight rotatory movement.
The rotatory movements not only facilitate detachment of the products from the
uterine wall but also minimize the injury of the uterine wall, if accidentally grasped.
110
UTERINE DRESSING FORCEPS
To swab the uterine cavity following D + E with small gauze pieces

To dilate the cervix in lochiometra or pyometra.
MULTIPLE TOOTHED VULSELLUM
Used to catch hold the anterior lip of the cervix in

(a) D + E operation
(b) Suction evacuation
As it produces trauma to the soft and vascular cervix, Allis tissue forceps is used instead.
GIANT VULSELLUM
Used in destructive
operation specially in
evisceration to have a
good grip of the fetal
parts for giving traction.
111
UTERINE SOUND
To know the position of the uterus and the length of the uterine cavity prior to
dilatation of the cervix in D + E operation.
To sound the uterine cavity to detect any foreign body (IUCD).
It acts as a first dilator of the cervical canal.
CERVICAL DILATORS
HAWKIN-AMBLER
DAS OR HEGAR’S DILATORS
Hawkin-Ambler
It has got 16 sizes, the smallest one being 3/6 and the largest one being 18/21.
The number is arbitrary in the scale of Hawkin- Ambler.
The smaller one denotes measurement at the tip and the larger one measures the
maximum diameter at the base in mm.
Das or Hegar’s dilators
Double ended.
The minimum size is 1/2 and the maximum size is 11/12.
The number represents the diameter in mm.
Both the sides are used with the lower number first.
Used in dilatation of the cervical canal prior to evacuation operation.
112
FLUSHING CURETTE
It is a blunt curette used in the operation of D + E.

Previously, it was used to flush the uterine cavity with lukewarm antiseptic solution—
passing through the communicating channel.
UTERINE CURETTE
It may be sharp at both ends or sharp at one end and blunt at the other.
Used in the operation of D + C for incomplete abortion.
In D + E operation,curettage is done by blunt curette as uterine wall is very soft.
Also used in D + C operation one week following evacuation of hydatidiform mole.
SHORT CURVED OBSTETRIC FORCEPS (WRIGLEY’S FORCEPS)
It can only be used as outlet forceps for extraction of the head

113
LONG CURVED OBSTETRIC FORCEPS
It is commonly used in low forceps operation
KIELLAND’S FORCEPS
It is usually used as rotation forceps in deep transverse arrest of occipito-posterior

position of the head or in unrotated vertex or face presentation.
CUSCO’S BIVALVE SELF RETAINING VAGINAL SPECULUM
To visualize the cervix and

vaginal fornices for any local
cause (polyp, ectopy) of APH.
To inspect the cervix and to
prepare cervical smear for
cytology screening.
To detect leakage of liqor
from the cervical os in a case
of suspected PROM.
114
SIMS’DOUBLE BLADED POSTERIOR VAGINAL SPECULUM
The blades are of unequal breadth to facilitate introduction into vagina depending upon
the space available (narrow blade in nulliparous and wider blade in parous women).
To inspect the cervix and vagina and to detect any injury following delivery.
To clean the vagina following delivery.
To inspect the cervix and vagina to exclude any local cause for bleeding in APH
(Cusco’s speculum preferred).
During D & E operation.
DOYEN’S RETRACTOR
It is used to retract the abdominal wall as well as the bladder for proper exposure of
lower uterine segment during LSCS.
It is to be introduced after opening the abdomen; to be temporarily taken off while the
baby is delivered, to be reintroduced after delivery of the baby and finally to be
removed after toileting the peritoneal cavity.
Q. Identify the instrument?
[All Ms't 9 ]
115
FORCEPS’ AXIS TRACTION DEVICES
It includes axis traction rods (right and left) and handle.

The rods are assembled in the blades of long-curved obstetric forceps prior to
introduction and lastly the handle is attached to the rods.
The devices are required where much forces are necessary for traction as in mid
forceps operation.
These are less commonly used now.
MUCUS SUCKER
Disposable
Metal
It is used to suck out the mucus from the naso-oropharynx following delivery of the
head of the baby.
The mucus should be sucked prior to the attempt of respiration, otherwise the
tracheobronchial tree may be occluded leading to inadequate pulmonary aeration and
development of asphyxia neonatorum.
The metal sucker requires a sterile simple rubber catheter to be fitted at one end and a
sterile piece of gauze to the other end.
Currently electric or the disposable sucker is being used.
116
CORD-CLAMP (DISPOSABLE)
It is made of plastic and is supplied in a sterile pack.

The serrated surface and the lock make its grip firm.
It occludes the umbilical vessels effectively.
The cord clamp is to be kept in place until it falls off together with the detached
stump of umbilical cord.
VENTOUSE CUP WITH TRACTION DEVICE
It is used in the operation of vacuum extraction of the head.

The cup is to be fitted to the scalp of the forecoming head by producing “chignon”
with the help of vacuum.
The cup has got various sizes
Fallopian RING APPLICATOR

Used for tubal ligation
[NIEEÑZO]
Q. Identify the
instrument?
117
PINARD’S STETHOSCOPE
It should be held firmly at right angle to the point on the abdominal wall.
The ear must be firmly closed to the aural end.
It should not be touched by hand while listening.
PERFORATOR (OLDHAM’S)
The instrument is required in craniotomy to perforate the skull bone for

decompression of the fetal head.
118
MANUAL VACUUM ASPIRATION (MVA) SYRINGE
Used for evacuation of the uterus by creating a vacuum.

It is used upto 12 weeks of pregnancy.
Advantages: (iv) with local anesthesia,
(i) It is simple, (v) effective (98%),
(ii) safe, (vi) less traumatic and
(iii) can be done as an outpatient basis, (vii) it takes less time (10–15 min).
PLASTIC SUCTION CANNULA (KARMAN’S TYPE)
It is used for S + E and MVA .

Cannulas are used for S+ E when
attached with MVA syringe.
The plastic cannula has got
advantages over the metallic
one as it causes less damage to
the uterine wall and the product
sucked out is visible.
The vacuum must be broken
before it is withdrawal.
Appropriate size of the cannula (diameter in mm) needed for a particular case,
is same to the duration of pregnancy in weeks.
4–6 weeks size with 4–7mmcannula
7–9 weeks size with 5–10 mm cannula
9–12 weeks with 8–12 mm size cannula
119
TROLLY WITH INSTRUMENTS PREPARED FOR CESAREAN SECTION OPERATION
(1) Mops (large swabs), (12) Kocher’s clamps,

(2) Electrodiathermy set, (13) Long artery forceps,
(3a) Suction tube with cannula, (14) Allis tissue forceps (long variety),
(3b) Baby suction catheter, (15) Green Armytage forceps,
(4) Towel clips, (16) Little wood's forceps,
(5) Kidney dish, (17) Allis tissue forceps (short variety),
(6) Gauze pieces, (18) Artery forceps (short variety),
(7) Lanes tissue forceps, (19) Dissecting forceps toothed and non toothed,
(8) Needle holders, (20) Scissors (straight and curved variety),
(9) Empty bowl, (21) Knives (two),
(10) Obstetric Forceps (Wrigley’s), (22) Bowl with povidone iodine lotion,
(11) Doyen’s retractor, (23) Sponge holding forceps (two),
(24) Suture packets.
1h11CETZI Q. Instuments used for LSCS ?

120
Gynaecology
Anatomy and Histology
Levator ani muscles
Reference:DC DUTTA’s TEXTBOOK OF GYNECOLOGY (pg 1)

Reference: Shaw’s Textbook of Gynaecology (pg 1)
121
Anatomy of the vulva
Variations of the hymen
Contents of broad ligament
[MEET 2020J
Q.Remnant of Wolffian
duct is located in ?

122
Hd
development
development of female reproductive systems from the primitive
genital ducts
development of genitourinary system
A)formation of müllerian tubercle (C & D) further development of the paramesonephric

(B) earliest development of vaginal ducts and urorectal septum, permanent
plate and mesonephric duct (metanephric) kidney and urogenital sinus
123
Normal Histology
Graafian follicle.
Discus proligerus showing

granulosa cells, the ovum and the
membrana limitans externa.
Theca interna cells are few.
Endometrium—secretory hypertrophy (early stage). The

Normal endometrium in the
gland is crenated, the lumen contains mucous secretion
proliferative phase
and the inner border of the cells is irregular. Subnuclear
vacuolation is well seen. The surrounding stroma is
oedematous and the hypertrophied stroma cells are
widely separated from each other

124
Microscopic appearance of
dried cervical mucus showing
the ‘fern appearance’
Congenital Malformation of
Female Genital Organs
imperforate hymen
Due to failure of disintegration of the central cells of the Müllerian eminence that
projects into the urogenital sinus
The existence is almost always unnoticed until the girl attains the age of 14–16 years.
As the uterus is functioning normally, the menstrual blood is pent up inside the vagina
behind the hymen (cryptomenorrhea).
Depending upon the amount of blood so accumulated, it first distends the vagina
(hematocolpos).
The uterus is next involved and the cavity is dilated (hematometra).
In the late and neglected cases, the tubes may also be distended after the fimbrial
ends are closed by adhesions (Hematosalpinx)
treatment
Cruciate incision is made in the hymen.
The quadrants of the hymen are partially excised not too close to the vaginal mucosa.
Spontaneous escape of dark tarry colored blood is allowed
NEETU
[NEET 120 ]
Q. 16 yr old girl with a partial transverse vaginal
History of cyclical abdominal pain, primary
septum presents with dysmenorrhea and chronic
amenorrhea and bulging vaginal membrane->
pelvic pain. What is the most common complication? Imperforate Hymen

125
Hematocolpos and hematometra

due to imperforate hymen
Ultrasonographic view of hematometra and
hematocolpos in a girl with imperforate
hymen
Tense bulging of the hymen Spontaneous escape of dark tarry

in hematocolpos blood following incision

126
Malformations of the Müllerian ducts [NEET'2O]
Common lateral fusion defects affecting Transcervical hysteroscopic

resection of septum has the
the development of the uterus. best obstetric outcome
Uterus didelphys Uterus bicornis Uterus bicornis

with septate vagina unicollis.
Uterus septus Uterus subseptus Uterus unicornis

with a rudimentary horn
[ÑEET2☐ /
[NEET 18 ]
Q. A 28 yr woman being evaluated for infertility was found to have a Fate of Müllerian duct is determined by the
uterine didelphys on 3D ultrasound.what are possible complications? presence or absence of Y chromosome.
Uterus didelphys
established using two Rubin’s
cannula inserted in either half
prior to injecting radio-opaque
dye during
hysterosalpingography

127
Unicornuate uterus Bicornuate uterus

confirmed by laparoscopy
Hysteroscopic view
of a septate uterus
MEET 21
Q. A 28 yr 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?
Ultrasonographic
view of a septate
uterus

128
Puberty Normal and Abnormal

TaNNER sTaGEs OF PUBERTaL DEVELOPmENT IN GIRLs
PRECOCIOUs PUBERTY
Girls who exhibit any secondary sex characteristics before the age of 8 or
menstruate before the age of 10.
CaUsEs OF PRECOCIOUs PUBERTY B
Precocious puberty—a girl aged 11

129
Premature thelarche
Isolated development of breast tissue before the age of 8 and commonly
between 2 and 4 years of age. Either one or both the breasts may be enlarged
Premature pubarche
Isolated development of axillary and or pubic hair prior to the age of 8
without other signs of precocious puberty.
Premature menarche
Isolated event of cyclic vaginal bleeding without any other signs of
secondary sexual development.
DELaYED PUBERTY
Breast tissue and/or pubic hair have not appeared by 13–14 years or menarche appears
as late as 16 years. The normal upper age limit of menarche is 15 years.
CaUsEs OF DELaYED PUBERTY
[NEET 120 ]
Pubarche-
Development of axillary
and pubic hair.
Not mediated by estrogen,
Occurs due to
testosterone in both sexes

130
PUBERTY mENORRhaGIa
Menstrual abnormality in adolescents are common.

The periods may be heavy, irregular or scanty initially.

131
Menstrual cycle
The ovarian-endometrial cycle has been structured as a 28-day cycle.

The follicular phase (days 1 to 14) is characterized by rising estrogen levels,
endometrial thickening, and selection of the dominant “ovulatory” follicle.
During the luteal phase (days 14 to 21), the corpus luteum (CL) produces estrogen and
progesterone, which prepare the endometrium for implantation. If implantation occurs,
the developing blastocyst begins to produce human chorionic gonadotropin (hCG) and
rescues the corpus luteum, thus maintaining progesterone production.
Hormone acting on post ovulation

endometrium - Progesterone
[NEET 19 ]
132
Endometrium in proliferative and early secretory phase.
Tendency of tortuosity of the glands and the characteristic subnuclear vacuolation
in early secretory phase
Vaginal cytology
In the late proliferative phase, there are preponderance of superficial large

cornified cells with pyknotic nuclei. The background is clear. In the premenstrual
phase, there is preponderance of navicular cells. The background is dirty
133
Endometrium in secretory and menstrual phase.

Marked tortuosity of the glands with secretion in the lumen in the midsecretory
phase. The nucleus is pushed to the base
AppRoXimAte time inteRVAl of eVents in menstRUAl cYcle

pRioR to oVUlAtion

134
ceRVicAl cYcle, VAGinAl cYcle AnD GeneRAl cHAnGes

in follicUlAR AnD lUteAl pHAse
Transvaginal scan demonstrating

thickened, triple line endometrium
(preovulatory phase)

135
Menopause
Permanent cessation of menstruation at the end of reproductive life due to loss of
ovarian follicular activity. It is the point of time when last and final menstruation occurs.
Hormone levels in a menopausal woman
Early features of menopause

• Hot flushes
• Sweating
• Insomnia
• Headache
• Psychological
• Cancer phobia
• Dyspareunia, decreased libido
• Pseudocyesis
• Irritability
• Depression, insomnia, tiredness
• Lack of concentration, loss of memory
• Urinary stress incontinence, dyspareunia
Cytology of senile vaginitis

136
horMone rePlACeMent therAPy (hrt)
Indicated in menopausal women to overcome the short-term and long-

term consequences of estrogen deficiency.
Commonly used estrogens are conjugated estrogen (0.625–1.25 mg/day) or
micronized estradiol (1–2 mg/day).
Progestins used are medroxyprogesterone acetate (2.5–5 mg/ day), micronized
progesterone (100–300 mg/day) or dydrogesterone (5–10 mg/day).
ContrAinDiCAtions to hrt
[All Ms't 9 ]
Q. Contraindications of HRT?
risK fACtors for osteoPorosis in A WoMAn

137
Sexual Development and Development Disorders

Development of male and female reproductive organs

138
Development of gonads and genital organs

139
Ambiguous genitalia in a child with an Female hermaphrodite showing hypertrophy

XY karyotype and partial androgen of the phallus, masculine appearance of the
insensitivity. glans and rudimentary scrotal sac.
Turner’s syndrome
Marked cubitus valgus

NEETU
Q. A 12 yr 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?
Webbing of the neck and aplasia of breasts.

140
Q. Karyotype image
given below is? IMI CET '2l
The karyotype shown is 47 XXY

suggestive of Klinefelter syndrome.
141
Hirsutism
Distribution of coarse hair in a female normally present in a male, i.e. upper lip, chin, chest,
lower abdomen and thighs.
Virilization refers to a condition of hirsutism associated with other male characteristics
such as temporal baldness, hoarse voice, clitoromegaly and muscle enlargement as well as
defeminization such as amenorrhoea and breast atrophy.

142
Infections
Mode of spread in gonococcal infection
Condyloma acuminatum of the vulva.
Venereal warts caused by the HPV,

which is a small DNA double-ended virus.
These warts spread diffusely over the
whole of the vulval area. The verrucous
growths may appear discrete or
coalesce to form large cauliflower-like
growths.
[NEET 120]
Q. Cause of Multiple
warty growth on the
Vulcan and around
anal canal?
[NEET 120]
Q. Causative organism of
vulval warts ?

143
Recurrent herpes genitalis
Recurrent STD infection caused

by the double- stranded DNA of
herpes simplex virus (almost
80% are type-II infections).
The incubation period is 3–7 days.
Herpes simplex virus type I affects
only 30% vulval lesions.
It mostly affects women between 20
and 30 years.
Granuloma Inguinale (Donovanosis)

The causative organism of
granuloma inguinale is
Calymmatobacterium granulomatis.
It is a Gram-negative bacillus causing
chronic ulcerative infection of the
vulva.
It begins as a painless nodule which later
ulcerates to form multiple beefy red
painless ulcers that tend to coalesce, the
vulva is progressively destroyed and
minimal adenopathy may occur.
Q. Causative agent of Granuloma
[NIEETKO] inguinal?
Syphilis
Caused by the motile spirochete Treponema

pallidum.
Primary Syphilis.
The macular lesion becomes papular and then
ulcerates. The ulcer(s) is painless and firm, with a
punched out base and rolled edges.

144
Early condylomas of secondary syphilis
secondary syphilis
Condylomata lata are the classic
findings; these are highly contagious
exophytic broad excrescences that
ulcerate. These are commonly seen on
the vulva, perianal area and upper
thighs. After 2–6 weeks, it passes into
the phase of latent syphilis. There are
no clinical manifestations present;
however, the serologic test for syphilis
is positive. This stage lasts for 2–10
weeks
Laparoscopic view of gonococcal and chlamydial

infection showing Fitz-Hugh Curtis syndrome.
Laparoscopy reveals, apart from

tubal disease, a band of fibrous
tissue on right side stretching
from fallopian tube to the under
surface of the liver

145
Miliary tuberculosis.
Tubercles are seen over the

uterus and the tube. The
peritoneum and intestines
which are all studded with
miliary tubercules.
tubercular endometritis
Hysterosalpingogram showing
marked extravasation of dye in
venous and lymphatic channels.
History of amenorrhea along

Pelvic tuberculosis with presence of palpable
abdominal pelvic mass in
Hysterosalpingogram showing beaded appearance addition to fever , weight
of the tube with variable filling density. loss, abdominal pain,
ascittes-> suggestive of
'
Genital tuberculosis
[NEET 20]

146
Bilateral tuboovarian mass (calcification Tubercular cervix proved by biopsy. The

on the right) due to genital clinical diagnosis was confused with
tuberculosis. TAH with BSO done malignancy.
following antitubercular drug therapy Appears as an ulcerated or hypertrophic
growth which bleeds on touch.
seXuallY transmitted inFeCtions

147
Pelvic Inflammatory Disease
Spectrum of infection and inflammation of the upper genital tract organs typically
involving the uterus (endometrium), fallopian tubes, ovaries, pelvic peritoneum and
surrounding structures
Organisms responsible for pelvic inflammatory disease
Stages of PID
cLinicaL featUres Of acUte pid
/
[NEET 18 ]
Long standing pelvic

inflammation->
Pyometra

148
Bilateral tubo-ovarian abscess
An acute pyosalpinx is surrounded by adhesions which fix it to the back of the broad
ligament, the ovary, the sigmoid colon, adjacent coils of intestine and posterior
surface of the uterus. The wall of the tube is thickened and the tube is tense with
pent up fluid

149
ambULatOrY management Of acUte pid
indicatiOns fOr hOspitaLiZatiOn
inpatient antibiOtic therapY

150
A retort-shaped pyosalpinx
BArTHOLIN’S CyST
Bartholin’s glands are the two pea sized

(2 cm) glands, located in the groove
between the hymen and the labia minora
at 5 O’Clock and 7 O’Clock position
Bartholin’s abscess is the end result of
acute bartholinitis. The duct gets blocked
by fibrosis and the exudates pent up inside
to produce abscess. If left uncared for,
the abscess may burst through the lower
vaginal wall. A sinus tract may remain
with periodic discharge through it.
BArTHOLIN’S CyST
There is closure of the duct or the opening
Treatment of an acinus.The cause may be infection or
Marsupialization is the trauma followed by fibrosis and occlusion of
gratifying surgery for the lumen.
Bartholin’s cyst.

151
DIFFErENTIAL DIAgNOSIS OF VAgINAL DISCHArgE
Vaginal itching, Foul smelling frothy vaginal discharge and

"
[NEET 20] strawberry cervix- Trichomonas vaginalis
gONOCOCCAL AND pyOgENIC SALpINgITIS

gonococcal pyogenic

152
intrauterine infections
T Toxoplasmosis
MEET21
syphilis, varicella-zoster, Q. A 21 yr old primigravida presents to the
O parvovirus B19, Zika virus
antenatal OPD. Her school going nephew who
R Rubella lives in the same house has contracted
varicella. A blood sample is taken for
C Cytomegalovirus
antibodies against varicella. The report is
Herpes negative. What does this signify?
H
VARICELLA
Congenital- Intrauterine transmission
Pregnant female gets chicken pox in Ist trimester- TERATOGENICITY
Most severe form , limb atrophy/ hypoplasia, cortical atrophy, cicatrise (scars )
Neonatal - Perinatal transmission
Most common
Risk period- 5 days before and 2 days after delivery
Clinical features: Necrotising pneumonia
Vesicular skin rash
Prevention : VZIG varicella zoster immunoglobin
Treatment : acyclovir to both mother and baby
Varicella in pregnancy
Varicella zoster virus (DNA) does cross the placenta and may cause congenital or
neonatal chickenpox.
Maternal mortality is high due to varicella pneumonia.
Other maternal complications are: encephalitis and bacterial superinfection.
Congenital varicella syndrome (CVS) is characterized by: hypoplasia of limb, psychomotor
retardation, IUGR, chorioretinal scarring, cataracts, microcephaly and cutaneous scarring.
The risk of congenital malformation is nearly absent when maternal infection occurs after 20
weeks. Varicella (live attenuated virus) vaccine is not recommended in pregnancy.
Varicella PCR can identify VZV specific DNA from vesicular fluid.
ELISA can detect VZV specific IgG and IgM.
Varicella zoster immunoglobulin (VZIG) should be given to exposed non-immune patients
as it reduces the morbidity.
VZIG should also be given to newborn exposed within 5 days of delivery.
Oral acyclovir, valacyclovir is safe in pregnancy and reduce the duration of illness when
given within 24 hours of the rash. However, it cannot prevent congenital infection.
153
herpes simplex virus

Usually transmitted sexually by an infected partner but may possibly be transmitted by
orogenital contact.
The incubation period is 2–14 days.
CliniCal Features
Symptoms of the first attack usually appear less than 7 days after sexual contact. Initially,
red painful inflammatory area appears commonly on the clitoris, labia, vestibule, vagina,
perineum ,and cervix.
Multiple vesicles appear which progress into multiple shallow ulcers and ultimately heal up
spontaneously by crusting.
It takes about 3 weeks to complete the process. Inguinal lymphadenopathy occurs.
Constitutional symptoms include fever, malaise, and headache.
There may be vulvar burning, pruritus, dysuria, or retention of urine.
diagnosis
Virus tissue culture and isolation — confirmatory.
Detection of virus antigen by ELISA or immuno- fluorescent method.
PCR test to identify the HSV DNA is the rapid, specific, and most accurate test.
Treatment
Acyclovir which inhibits the intracellular synthesis of DNA by the virus, reduces the
symptoms, duration of viral shedding, and helps in rapid healing.
Its prophylactic use can reduce the episodes of recurrence.
Saline bath may relieve local pain.
Recurrent STD infection caused by the

double- stranded DNA of herpes simplex
virus (almost 80% are type-II infections).
The incubation period is 3–7 days. Herpes
simplex virus type I affects only 30% vulval
lesions.
It mostly affects women between 20 and 30
years.
MEET 21
Q. A 28 yr primigravida presents at 36 wks with labor pain and 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?
154
Disorders of Menstrual Cycles

DYSMENORRHEA
Painful menstruation of sufficient magnitude so as to incapacitate day-to-
day activities.

155
Types of abnormal uterine bleeding
MENORRHAGIA
Menorrhagia is defined as cyclic bleeding at normal intervals; the bleeding is either

excessive in amount (> 80 mL) or duration (>7 days) or both.
The term menotaxis is often used to denote prolonged bleeding.
PElvIC PATHOlOGy
CAuSES Of MENORRHAGIA

156
Aetiology of menorrhagia
Management of menorrhagia
Reference:DC DUTTA’s TEXTBOOK OF GYNECOLOGY (pg185)

157
METRORRHAGIA
Irregular, acyclic bleeding from the uterus.
Menometrorrhagia is the term applied when

the bleeding is so irregular and excessive
that the menses (periods) cannot be
Metrorrhagia due to identified at all.
cervical polyp

158
OlIGOMENORRHEA
Menstrual bleeding occurring more than 35 days apart and which remains
constant at that frequency is called oligomenorrhea.
COMMON CAuSES Of OlIGOMENORRHEA
Amenorrhea
Absence of menstruation
Sheehan’s syndrome
1h11 CETZI
Postpartum Haemorrhage causes vascular thrombosis of
Q. Cause of 2˚ Amenorrhoea? pituitary vessels-> Panhypothyroidism-> amenorrhea
[NEET '20]
159
Q. A 39 yr 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? NEETU
Primary amenorrhoea refers to the failure of onset of menstruation beyond the

age of 16 years regardless of development of secondary sexual characters.
Secondary amenorrhoea refers to the failure of occurrence of menstruation for
6 months or longer in women who have previously menstruated.
Physiological amenorrhoea naturally prevails prior to the onset of puberty, during
pregnancy and lactation and after menopause.
Pathological amenorrhoea is the result of genetic factors, systemic diseases,
endocrinopathies, disturbance of the hypothalamic–pituitary–ovarian–uterine axis,
gynatresia, nutritional factors, drug usage, psychological factors and other rarer causes.

160

161

162
DySfuNCTIONAl uTERINE blEEDING (Dub)

State of abnormal uterine bleeding without any clinically detectable organic,
systemic, and iatrogenic cause (Pelvic pathology, e.g. tumor, inflammation or
pregnancy is excluded).
Cystic glandular hyperplasia
Metropathia hemorrhagica, Schroeder’s disease
This type of abnormal bleeding is usually met in premenopausal women.
Due to disturbance of the rhythmic secretion of the gonadotropins.
Microscopically
There is marked hyperplasia of all the
endometrial components. There is
however, intense cystic glandular
hypertrophy rather than hyperplasia
with marked disparity in sizes. Some of
the glands are small, others are large
giving the appearance of “Swiss cheese”
pattern
MEDICAl MANAGEMENT Of Dub
SuRGICAl
MANAGEMENT Of Dub
Uterine curettage
Endometrial ablation/resection
Hysterectomy

163

164
Displacement of the Uterus
Round ligament maintains the anteversion

/
[NEET 18 ]
of uterus during pregnancy.
Hodge pessary
The pessary acts by stretching the
uterosacral ligaments so as to pull the
cervix backwards

165
genital prolapse
ETIOlOgy Of PElVIC ORgaN PROlaPSE (POP)

166
Quantitative gradings of Pelvic Organ Prolapse
Second degree
uterine prolapse.
Marked cystocele and there
is decubitus ulcer
Inflect 21
Q. Identify the image ?

167
Vault prolapse following vaginal

hysterectomy. Scar is seen in the centre
MaNagEMENT Of PROlaPSE

168
Complete chronic
inversion of uterus with
a fundal fibroid
The protruding mass has got the
following features :
(i) Globular, (ii) No opening in the
leading part, (iii) Shaggy look, (iv)
Tumor may be present at the bottom.
Cervical fibroid polyp

confusing diagnosis with chronic
inversion. Note the uterine sound
into the cervical canal
[NEET 19 ]
Q.Management of third degree

uterine prolapse> 40yrs of age?

169
Infertility
Failure to conceive within one or more years of regular unprotected coitus.
Primary infertility denotes those patients who have never conceived.
Secondary infertility indicates previous pregnancy but failure to conceive subsequently.
male infertility
common caUses of male infertility
1NlCET2l
Q.To call the Semen Analysis as

normal, What should be the
least percentage of
morphological normal sperm ?
[AIIMS 2018]
The most important

marker of male fertility-
morphology of sperms.

170
[AIIMS 2018]
Q. Diagnose oligospremia?

171
Female Infertility
Possible mechanism of infertility in women

with Pelvic enDometriosis
hysterosalPingograPhy (hsg)
Cervical canal is in continuity with the peritoneal cavity through the tubes.
As such, entry of dye into the peritoneal cavity when instilled transcervically under
pressure, gives evidence of tubal patency.

172
Normal hysterosalpingogram. Note HSG showing a filling defect in the

both the fallopian tubes are patent with uterine cavity which represent a polyp
spill into the peritoneal cavity or fibroid
HSG showing bilateral dilated Hysterosalpingogramshowingunicornuat

fallopian tubes with no free euterus. The fallopian tube is patent and
spill suggestive of bilateral dye is seen in the peritoneal cavity.
hydrosalpinx
'
Q. Identify bilateral hydrosalpinx?
[NEET 20 ]

173
Hysterosalpingogram
demonstrating a bicornuate
uterus. The dye which is present
in the peritoneal cavity
demonstrates patency of the
left fallopian tube.
Diagnostic laparoscopy and

chromopertubation with
methylene blue dye showing
free spill of the dye at the
fimbrial end, indicative of a
patent tube.
Hysteroscopic cannulation of the

fallopian tube.

174
DrUgs UseD in inDUction of ovUlation

inDications of ivf

175
assisteD reProDUctive techniqUes (art)
technique of intracytoplasmic sperm injection (ICSI)

176
Benign lesions and malignancy

Vulva and Vagina
classiFication oF VulVal DErmatosEs
Lichen sclerosis
The entire vulva is involved. Lesion

encircles the vestibule. It involves
clitoris,labia minora, inner aspects of
labia major and the skin around the
anus. It is usually bilateral and
symmetrical in a figure of eight
distribution. It does not involve the
vestibule or extend into the vagina or
anal canal. It may even extend to the
perineum and beyond the labiocrural
folds to the thighs.

177
Lichen sclerosis.
Histology shows hyperkeratosis,
but the epidermis is thinner than
normal. The most striking
feature of lichen sclerosis is the
presence of a hyaline zone in the
superficial dermis. This is the
result of oedema and
degeneration of the collagen and
elastic fibres of the dermis.
Vulval dystrophy associated with malignancy
The malignant potential of

vulval intraepithelial
neoplastic (VIN) disorders is
about 2–4 percent
About 50 percent of all invasive
carcinomas of the vulva arise in an
area of chronic vulval epithelial
disorder.
Vulval fibroma
Fibroma is the most common benign solid tumor of

the vulva. It arises from deeper connective tissues
of the labia majora (dermatofibroma). Vulval
fibroma grow slowly. It may be small but malignant
change is very low. Surgical removal is necessary
as they produce discomfort

178
Vulval lipoma
Benign tumors of
vulva
gartnEr’s cyst
Usually situated in the anterolateral wall

of the vagina. The epithelium is low
columnar and secretes mucinous material
which is pentup to form the cyst. The
treatment is by surgical excision
Vaginal wall inclusion cyst Same cyst is being excised

179
Vulval Hematoma
Accident, as falling astride on any sharp or pointed object, is not uncommon
specially in young girls.
It may produce bruising of the vulva or at times give rise to vulval hematoma .
Major accident may involve fracture of pelvic of bones causing injuries to
pelvic viscera like bladder or rectum apart from vagina.
There may be supralevator hematoma.
Even, fall on a sharp object may produce the above picture or perforate the
vaginal wall with injury of the surrounding viscera.
Management
Assessment of the general condition and the nature and extent of the
injuries inflicted should be done first.
Small vulval hematoma, if not spreading may be left alone but if it is a big
one or spreading, along with resuscitative measures, the hematoma is to be
tackled under general anesthesia.
This includes scooping of the blood clots after giving an incision, secure
hemostasis and obliteration of the dead space by interrupted mattress
sutures.
In supralevator hematoma or in cases of suspected gut injuries,
laparotomy is indicated and appropriate measures taken.
INICEÉZI
Q. Identify the image ?
A 17-year-old-girl suffered extensive vulval

hematoma following a fall on a chair
180
Cervix
Nabothian cyst of cervix

These are usually multiple.
They are formed due to blocking of the cervical
gland mouths usually as a result of healing of
ectopy (epidermidization).
The pent up secretion produces cysts of varying
sizes from microscopic to pea.
The presence of the cysts furthest from the
external os indicates the extent of
transformation zone.
The lining epithelium is columnar.
The treatment is directed towards chronic
cervicitis.
ELONgATION Of ThE CERVIX
Congenital elongation of Supravaginal elongation of

cervix with prolapse cervix in prolapse

181
Uterus
Fibromyomas (leiomyomas, fibroids or simply myomas)
Various types of uterine fibroids

182
Multiple fibroids causing marked Cut section of a uterus showing a

distortion of the uterus. The uterine submucous fibroid
corpus is almost completely replaced by /
[NEET 18 ]
multiple myomas in subserous,
Q. Identify the image?
intramural and submucous positions.
Ultrasonographic view of a
Submucous fibroid polyps,
uterine fibroid
sessile and pedunculated

183
submucous myoma. Interstitial fibroid uterus.
Subserous fibroid seen on laparoscopy

Multiple uterine fibroids
(A) Subserous fibroid associated (B) Uterus studded with multiple

with uterine pregnancy. fibroids and pregnancy.

184
symptoms of Fibroid uterus
NEETU
Q. A 28 yr 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?
cOmplIcatIOns OF FIBROIDs
secOnDaRy cHanges In FIBROIDs
[NEET 19 ]
Red degeneration of fibroid presents with Torsion of subserous pedunculated

acute abdominal pain, vomiting, fibroid presents with severe abdominal
leukocytosis and raised ESR. pain . Fever and leukocytosis

185
InDIcatIOns OF myOmectOmy

186
pOlyps
[MEET120]
Visualisation of feeding
vessel on USG ->
Endometrial polyp
Cervical mucous polyp

The commonest type of benign
uterine polyp is mucous one. It may
arise from the body of the uterus or
from the cervix
The polyp mainly arises from the
endocervix and rarely from the
ectocervix.
The stimulus of epithelial
overgrowth is probably due to
hyper estrinism, chronic irritation
by infection or localized vascular
congestion.
Naked eye appearance shows the polyp of usually small size rarely
exceeding 1–2 cm, single and red in color.
The pedicle may be long enough to reach the vaginal introitus
Cervical fibroid polyp may be Fibroid polyp. Note the wide pedicle
confused with inversion. and thinning out of the cervix

187
Ovary
Bilateral lutein cysts in association with
hydatidiform mole
Usually bilateral and caused by excessive chorionic gonadotropin secreted in cases of

gestational trophoblastic tumors.
Formed with administration of gonadotropins or even clomiphene to induce ovulation.
Usually lined either by theca lutein cells, called theca lutein cyst or by granulosa
lutein cells, called granulosa lutein cyst.
Spontaneous regression is expected within few weeks following effective therapy of
the tumors with the gonadotropin level returning back to normal.
laparoscopic view of the

polycystic ovarian disease
Multiple cysts (12 or more) of 2–9 mm
size are located peripherally along the
surface of the ovary giving it a ‘neck-
lace’ appearance on ultrasound. These
are persistent atretic follicles. Theca
cell hyperplasia and stromal
hyperplasia account for the increase in
the size of the ovary which amounts to
more than 10 cm3 in volume.

188
cLAssIFIcATION OF OVARIAN TuMOR
mucinous cyst adenoma
largest benign ovarian tumor.

The wall is smooth, lobulated with whitish or bluish white hue.
At places, it is thin so as to be translucent.
The content inside is thick, viscid, mucin — a glycoprotein with high content of
neutral polysaccharides.
It is colorless unless complicated by hemorrhage.
The cyst is frequently multiloculated, sometimes with papillary growth arising
from the septum

189
papillary serous cyst adenoma

Microphotograph showing the lining
epithelium of papillary serous cyst adenoma.
The cells form long papilliform processes
The papillary structures consist of broad
dense fibrous stroma covered by single or
multiple layers of columnar epithelium.
There may be presence of ciliated,
secretory and peg cells resembling tubal
epithelium
Serous cyst arises from the totipotent
surface epithelium of the ovary.
dERMOId cysT
Arises from the germ cells arrested
after the first meiotic division.
Content is a predominantly sebaceous
material with hair.
There may be clear fluid (cerebrospinal
fluid) derived from the neural tissues
(choroid plexus).
There is one area of solid projection
called Rokitansky’s protuberance which
is covered by skin with sweat and
sebaceous glands. It is here that teeth
and bones are found.
A rare one consists predominantly of thyroid tissue — called struma ovarii, which
may be associated with hyperthyroidism.

190
Bilateral ovarian tumor in a perimenopausal woman treated by total

hysterectomy with bilateral salpingo-oophorectomy
Torsion of the pedicle

of an ovarian tumor.
Parovarian cyst
The ovary is seen separated and
the uterine tube is stretched
over the cyst

191
Q. A 26 year old female with dull aching pain in lower abdomen had undergone two normal vaginal
delivery, no gynaecological complaints. Her last periods was 3 weeks. On per vaginal examination a
cystic mass was identified in left fornix. Ultrasonography shows Left ovarian clear cyst of 5cm. What is
IN ICETZI the next best investigation to be done for diagnosis ?
Complications of Ovarian Cyst

Torsion (M/c tumor to undergo torsion – Dermoid cyst
Management = immediate surgery Detorsion and cystectomy, preserving ovary)
Rupture of cyst (M/c with corpus luteum cyst)
Haemorrhage in cyst (M/c with serous cystadenoma)
Infection pseudomyxoma peritonei (M/c in mucinous cystadenoma)
Malignancy (risk of malignancy is maximum in Serous cystadenoma (40%)
Least (1–2%) in Dermoid cyst)
192
EndomEtriosis
Presence of functioning endometrium (glands and stroma) in sites other than uterine
mucosa is called endometriosis.
Common sites of endometriosis
Laparoscopy is the gold standard in the diagnosis of endometriosis.
Appearance of old endometriosis with ‘tattooing’ (blue-grey lesions), and red, brown,
and black raised lesions of active endometriosis at the time of laparoscopy.

193
Pelvic endometriosis showing Complete obliteration of the pouch of Douglas

red lesions on laparoscopy.
Laparoscopic view of bilateral

endometriosis.
Endometriotic cyst (chocolate cyst) cyst has burst

194
Adenomyosis
These ectopic endometrial tissues may be found in the myometrium when it is called
endometriosis interna or adenomyosis.
Laparoscopic view of adenomyosis of

the uterus.
There is diffuse symmetrical enlargement of the uterus; the posterior wall is often
more thickened than the anterior one.
On cut section, there is thickening of the uterine wall. The cut surface presents
characteristic trabeculated appearances. Multiparous women>40 yrs,
There may be visible blood spots at places presenting with abdominal
mass with free adnexa and
myometrial cysts on MRI->
[NEET 19 ] Adenomyosis

195
Genital Malignancy
Vulval carcinoma
Vulval carcinoma on
labium majus
(commonest site)
Procidentia associated with

carcinoma clitoris
(second common site of vulval
malignancy)

196
Vaginal carcinoma
carciNoMa cErviX
Exophytic type of cervical

squamous cell carcinoma—
radical hysterectomy done
Ulcerative type of cervical malignancy

with a friable growth on the posterior lip.
Radical hysterectomy done. Uterine
arteries are ligated at origin
[1-111195^20]
Females 21 to 65 years of
age should be screened for
carcinoma cervix.

197
ENDoMEtrial carciNoMa
Diffuse type of
endometrial carcinoma
The spread is through the endometrium.
The myometrium is commonly invaded;
may invade to reach the serosal coat
Localized: The usual site is on the fundus.
It is either sessile or pedunculated.
Myometrial involvement is late

198
Adenocarcinoma of the
endometrium, the commonest
histologic type. There is
significant cellular mitotic
activity. The glands are
arranged back-to-back
5-yEar survival ratE

199
gEstatioNaltroPhoblastic DisEasE (gtD)
[All Ms't 9 ]
Q. Stage of GTD that has

metastasis to lung?
[NEET la ]
Q. Malignant forms of
gestational trophoblastic
neoplasm?
Transvaginal color Doppler scan of chorio-

Choriocarcinoma of diffuse type
carcinoma showing randomly dispersed vessels

200
choriocarciNoMa
Highly malignant tumor arising from the
chorionic epithelium.
The primary site is usually anywhere in the uterus.
The common sites of metastases are lungs
(80%), anterior vaginal wall (30%), brain (10%),
liver (10%) and others.
Trophoblastic disease following a
normal pregnancy is either choriocarcinoma or
PSTT and not a benign or invasive mole.
Choriocarcinoma of diffuse type
Clinical Features
Persistent ill health.
Irregular vaginal bleeding, at times brisk.
Continued amenorrhea.
Other symptoms due to metastatic lesions are:
Lung:Cough, breathlessness, hemoptysis.
Vaginal: Irregular and at times brisk hemorrhage.
Cerebral: Headache, convulsion, paralysis or coma.
Liver: Epigastric pain, jaundice.
Patient looks ill. Cannon ball shadow in the left apical and mid region
Pallor of varying degrees. of the lung with pleural effusion in choriocarcinoma
Physical signs are evident according to the organ involved.
Bimanual examination reveals subinvolution of the uterus. There may be a purplish red nodule in
the lower-third of the anterior vaginal wall. Unilateral or bilateral enlarged ovaries may be
palpable through lateral fornices.
Treatment
Chemotherapy is now the mainstay in the treatment.
Whether a single agent or multidrug regimen is to be
used, depends on the risk factors present.
In general, patients with non-metastatic (low risk)
and good prognosis disease are treated effectively
with single agent therapy (Methotrexate or
Q. A 25 yr woman had evacuation of molar pregnancy
Actinomycin). done 6 months earlier. She now presents with
The patients with poor prognosis metastatic disease General ill health, breathlessness, cough and
should be treated with combination drug regimen irregular vaginal bleeding. On chest X-ray, there are
canon ball metastasis. Her beta hCG levels are high.
(EMACO regimen).
Which is the best management option?
MEET 21
201
MaligNaNt ovariaN tuMors
Solid ovarian tumor
Bilateral malignant epithelial tumors of the ovary

202
sEX corD stroMal tuMors
granulosa cell tumor
Call-Exner bodies and are

pathognomonic of granulosa cell tumor. Presence of Call-Exner bodies
(microfollicular pattern) are diagnostic
theca cell tumour of the ovary

203
MEtastatic tuMors of thE ovary
The common primary sites from where metastases to the ovaries occur are
gastrointestinal tract (pylorus, colon and rarely small intestine), gallbladder,
pancreas, breast and endometrial carcinoma.
The mode of spread from the primary growth is through retrograde lymphatics
or by implantation from metastases within the peritoneal cavity.
Hematogenous spread is also there.
These are usually

bilateral, solid with
irregular surfaces
Krukenberg tumor
The stroma is highly cellular. The mucin

within epithelial cells compresses the
nuclei to one pole, producing ‘signet ring’
appearance. The scattered ‘signet ring’
looking cells are characteristic of
Krukenberg tumor

204
Gynaecology Instruments
SPatula and cytobruSh
Ayre’s spatula (wooden or plastic) and the endocervical brush are used [All Ms't 9 ]
for collection of cells for cytology screening. Q.Identify the instrument?
SimS’double bladed PoSterior vaginal SPeculum

Used in vaginal operations such as D + C, D
+ E, anterior colporrhaphy, vaginal
hysterectomy, etc. to retract the
posterior vaginal wall.
To visualize the cervix and inspect the
abnormalities in the anterior vaginal wall
like cystocele, VVF or Gartner’s cyst after
placing the patient in Sims’ position.
To collect the materials from the vaginal
pool for cytology or Gram stain and
culture.
cuSco’S bivalve SelF-retaining vaginal SPeculum

To visualize the cervix and vaginal fornices.
To collect cervical smear for cytologic screening
and vaginal pool materials
To have cervicovaginal swabs for Gram stain and
culture.
To insert or to remove IUCD or to check the
threads.
To perform minor operations like punch
biopsy, surface cauterization or snipping a small
polyp.
Reference:DC DUTTA’s TEXTBOOK OF GYNECOLOGY (pg 627 )

205
auvard’S SelF-retaining PoSterior vaginal SPeculum
It is used as posterior vaginal wall retractor in

operations like anterior colporrhaphy, vaginal
hysterectomy, etc.
It should be used only when the operation is done
under general or regional anesthesia as the
instrument is heavy. It requires no assistant.
(Prolonged use may cause perineal pain in the
postoperative period).
Female metal catheter
To empty the bladder prior to major vaginal operations.

It facilitates the operation and minimizes the injury to the bladder.
To confirm the diagnosis of Gartner’s cyst from cystocele.
It is not used in obstetrics to avoid trauma.
Single toothed vulSellum
To hold the cervix after opening the vault of vagina and to give traction while the
remaining vault is being cut in total abdominal hysterectomy.
To hold the new cervical stump after amputation of the cervix and in Fothergill’s operation
To hold the cervical stump left after subtotal hysterectomy.
Sometimes to hold the anterior lip of nulliparous cervix in operation of D + C (Allis’ tissue
forceps preferred).
206
multiPle toothed vulSellum
To hold the parous cervical lip in operations like D + C, anterior colporrhaphy or

vaginal hysterectomy. Its function is to make the cervix steady by traction.
To remove a polyp by twisting as an alternative to Lane’s tissue forceps

To hold the fundus of the uterus and to give traction while the clamps are placed in
operation of total abdominal hysterectomy for benign lesion.
anterior vaginal wall retractor
To retract the sagging anterior vaginal wall to have a good look on the cervix while
retracting the posterior vaginal wall by the Sims’ speculum.
laneS tiSSue ForcePS
To hold parietal wall (bulk of tough tissues) for retraction during abdominal operations
with transverse incision (hysterectomy).
To hold the polyp or fibroid in polypectomy or myomectomy operation.
To hold the towel during draping.
207
uteruS holding ForcePS
To fix and steady the uterus when conservative surgery is done on the adnexae
The blades are protected with rubber tubes to minimize trauma to the uterus.
cervical occluSion clamP
The blades are guarded with rubber tubes to avoid trauma to tissues.
Evaluation of tubal patency during laparotomy (following tuboplasty).
myoma Screw
To fix the myoma after the capsule is cut open and to give traction while the myoma is
enucleated out of its bed (myomectomy).
To give traction in a big uterus (multiple fibroid) requiring hysterectomy while the
clamps are placed.
208
bonney’S myomectomy clamP
Used in myomectomy operation.

It curtails the blood supply to the uterus temporarily, thereby minimizing the
blood loss during operation.
hySteroSalPingograPhy cannula (leech wilkinSon variety)
In HSG, a syringe is required to push the dye. Iodine containing radio-opaque dye
(urograffin) is used. It is done in the radiology department without anesthesia.
Also used for hydrotubation.
landon’S bladder retractor
In vaginal hysterectomy.
To keep the bladder up, to facilitate opening of the uterovesical peritoneum.
To introduce it through the opening of the uterovesical pouch and to retract the bladder
while the clamps are placed. This prevents injury to the bladder.
To inspect the suture lines after completion of vaginal plastic operations by retracting
the anterior or posterior vaginal wall.
Intravaginal plugging can be done under its guidance.
To use as lateral vaginal wall retractor while theclamps are placed.
209
Balfour self-retaining retractor
To retract the abdominal wall all around.

To expose the field of operation widely (no
assistant is needed for manual retraction).
Deaver’s retractor
Used in abdominal operation to retract the viscera as and when required in order to
facilitate the operative procedures like abdominal hysterectomy. For that purpose, it
may also be used as a lateral retractor.
To retract the parietal wall during abdomino-pelvic surgery (hysterectomy).
To retract the bladder and intestines during the surgery.
long Straight hemoStatic ForcePS (SPencer well’S)
It is used as a clamp in
(a) hysterectomy
(b) salpingectomy
(c) salpingo-oophorectomy
operation.
To catch a bleeding vessel for
hemostasis deep into the pelvis.
210
babcock’S ForcePS
To hold the Fallopian tube in

tuboplasty operation
To hold lymph nodes during
dissection in radical hysterectomy
To hold the appendix during
appendicectomy.
BArkelAy Bonney vAginAl ClAmp
To occlude the vaginal canal prior to cutting the vagina in Wertheim’s hysterectomy.
Punch bioPSy ForcePS
To take biopsy from the cervix.

The biopsy is taken as an outdoor procedure without anesthesia.
The site of biopsy is either from the suspected area or Schiller’s iodine or
colposcopically directed.
looP hook
To remove IUCD from the uterine cavity when the threads are missing
211
Papanicolaou Test
Screening for cancer.
INICETZI
First described by Papanicolaou and Traut in 1943, Q. Instruments used in PAP smear?
‘Pap test’ or a surface biopsy or exfoliative cytology
Time for initiating pap smear: 21 years of age regardless of the age of first sexual
intercourse.
Instrument used: Ayres spatula and endocervical brush
Method: Ayres spatula is rotated through 360 over portio vaginalis of cervix
and 1st slide is prepared
With cytobrush, 2nd slide is prepared from endocervix
Control slide prepared from posterior wall/posterior fornix of vagina
Fixative used : 95 % ethyl alcohol and ether.
Papanicolaou sampling devices. Left to right:

CervixBrush,Cytobrush,woodenspatula,plastics
patula,tonguebladeandcotton swab applicator.
PAPANICOLAOu’S GRADING
212
Retract Vagina
Ayres spatula is rotated through 360

over portio vaginalis of cervix
1st slide is prepared with cytobrush,

2nd slide is prepared from endocervix
Control slide prepared from posterior wall/posterior fornix of vagina
Fixation using 95 % ethyl alcohol and ether.
Management Strategies
Pap smear report Next step
Normal/reactive/infective Resume pap smear as per ACOG guidelines
• Repeat pap smear after 6 months

ASCUS • If female is > 30 years, do HPV-DNA testing
Atypical squamous cells of
• If pap smear report this time is >ASCUS or if
undetermined significance
HPV-DNA testing is positive- colposcopy is done
• Best method of following ASCUS is immediate
colposcopy (biopsy)
LSIL
• Colposcopy (Gold standard) + endocervical
Low grade squamous
curettage
intraepithelial lesion
• If lesion is visible—punch biopsy
HSIL • Colposcopy (Gold standard) + endocervical
High grade squamous curettage
intraepithelial lesion • If lesion is visible—punch biopsy
Q. Correct order of steps in taking PAP smear ?

IIVICETZI
213
214
215

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OBS/GYN

II Obstetric Instruments 106

Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg4 )

Body cavity Anatomical

External os Q. Normal uterocervical

Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 10)

Derived from epiblast

Endodermal wall of yolk sac (4th week)

Gonads (5th week)

Fertilization and implantation

Three portions of the

Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 27)

Blastocysts. A. At 10 days. B. At 12 days after fertilization

Albumin and Immunoglobulin M are high

Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 34)

1. Two umbilical arteries

Fetal surface of placenta Maternal surface of placenta

Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 33 )

Sonographic imaging with color Doppler

Grossly, the chorioangioma is a round,

Color Doppler imaging displays blood

Reference: Williams Obstetrics 24th edition(pg 120)

Velamentous cord insertion.

SINGLE UMBILICAL ARTERY

Reference: Williams Obstetrics 24th edition(pg 123)

ovarian and endometrial cycles.

The ovarian-endometrial cycle has been structured as a 28-day cycle.

The follicular phase (days 1 to 14) is characterized by rising estrogen levels,

Reference: Williams Obstetrics 24th edition(pg 81)

Human chorionic gonadotropin (hCG)

In habitual abortion, it provides support to the embryo.

FETUS RIGHT AN LEFT

RIGHT ATRIUM LEFT ATRIUM

PULMONARY ARTERY DUCTUS ARTERIOSIS

physiological change in pregnancy

[All Ms 19 ] Q. Respiratory changes

*Human placental lactogen

Renal changes Haematological changes

Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 96)

Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 101)

Measurement of Diagonal conjugate

VARIATIONS OF FEMALE PELVIS

Shape Round Anteroposteriorly oval

Anterior and Both increased with slight

Sacral angle (SA) more than SA more than 90°. Inclined

Pelvis type Android Platypelloid

Shape Triangular Transversely oval

Anterior and Posterior segment short and Both reduced-flat

Sacral angle less than SA more than 90°. Inclined

Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 402)

Sacrosciatic Wide and shallow More wide and shallow

Sidewalls Straight or slightly Straight or divergent

Pelvis type Android Platypelloid

Sacrosciatic Narrow and deep Slightly narrow and small

Sidewalls Convergent Divergent

Reference:DC DUTTA’s TEXTBOOK OF OBSTETRICS (pg 402)

Pelvis type Gynecoid Anthropoid

Ischial spines Not prominent Not prominent

Pubic arch Curved Long and curved