Part 2 book “Self assessment & review obstetrics” has contents: Hypertensive disorders in pregnancy, pregnancy in rh-negative women, liver, kidney and GI diseases in pregnancy, infections in pregnancy, gynaecological disorders in pregnancy, tuberculosis, epilepsy and asthma in pregnancy, drugs in pregnancy and high risk pregnancy,… and other contents.
e m om e c re m fre ks oo ks oo • Rise in B/P seen before 20 weeks + • No proteinuria m m eb eb eb m e e fre fre ks oo Gestational Hypertension • Like Preeclampsia but no proteinuria is associated e eb eb oo oo ks ks fre fre ks fre e co co e co • B/P does not come back to normal within 12 weeks of delivery oo eb m m m co m + e fre co m co m Literally means a hypertensive female has conceived e e fre Preeclampsia • Rise in B/P seen after 20 weeks of pregnancy + • Proteinuria (>300 mg in 24 hour urine collection or >30 mg/dl in a random urine sample or > + on.) + • B/P comes back to normal within 12 weeks of delivery oo ks Continued 24 hour urine protei measurement is gold standard in diagnosis of proteinuria Proteinuria of preeclampsia is non selective A diluted or concentrated urine or an aeraline specimen can give false should be dipstick Concept of Delta Hypertension: It is condition where B/P of a pregnant patient remains within normal range but a cutely increases from her own baseline levels Such females can develop eclamptic seizures or HELLP syndrome, inspite of being normotensive m fre ks m eb oo oo eb m m e e ks fre ks oo eb m co co fre fre Primigravida: Young or elderly (first time exposure to chorionic villi) Family history: Hypertension, or pre-eclampsia in previous pregnancy ok s eb o yy e Risk Factors for Pre-eclampsia yy co m m e co m m m eb m oo ks f eb eb m m co Chronic hypertension in pregnancy Note: In dipstick = trace = 0.15 to 0.3 g/L proteinuria + = 0.3 g/L 2 + = g/L + = g/L m e co m m co e re ks f oo oo eb m co m Pregnancyinduced hypertension ks oo eb m co m oo ks f eb eb m co m e ks fre re sf oo k eb m co m m 18 Hypertension in pregnancy is defined as systolic BP ≥ 140 mm of Hg or diastolic BP ≥ 90 mm of Hg on two occasions atleast hours but no more than days apart Diastolic BP is determined by the disappearance of sound (Korotkoff ph V) Korotkoff V is chosen as opposed to Korotkoff IV (muffing) as it is more reproducible and shows better correlation with the DBP in pregnancy For accuracy, mercury sphygmomanometer is preferred over automated ones (Means–a normotensive patient has conceived and due to some placental pathology, her B/P increases) co re fre ks oo oo eb m m e co co Definition m om e ks fre fre oo ks eb m e c co e co m m m m e e e m m co m Hypertensive Disorders in Pregnancy e m e co re oo ks f om m e c co e re oo ks f ks f oo ≥ 140/90 mm of Hg but less than 160/110 mm of Hg ≥ 160/110 mm of Hg eb eb eb ≥ 300 mg in 24 hour urine collection ≥ g in 24 hour urine collection or ≥ + or ≥ + on stick but < + persistently on dipstick m m m eb m Severe Preeclampsia oo oo k Mild preeclampsia Proteinuria m eb m sf Preeclampsia can Further be Divided into B/P eb oo oo eb m re yy co m yy e co yy ks fre m yy m yy e co yy Placental abnormalities: –– Hyperplacentosis: Excessive exposure to chorionic villi—(molar pregnancy twins, diabetes) –– Placental ischemia Obesity: BMI >35 kg/m2, Insulin resistance Pre-existing vascular disease New paternity Thrombophilias (antiphospholipid syndrome, protein C, S deficiency, Factor V Leiden Multifetal gestation Metabolic syndrome Homocysteinemia re eb m yy ks oo ks Self Assessment & Review: Obstetrics yy m om fre ks fre fre e e c co e co m m m m e e e m m co 250 Symptoms: co m e fre ks oo ks ks oo oo m eb eb m eb Present Elevated Elevated (N = 0.8 mg/dl, In these = 1.2 mg/dl) m oo eb m m eb oo ks ks oo eb m m fre ks fre e e e fre fre ok s A number of mechanisms have been proposed to explain its cause Those currently considered important include: yy Placental implantation with abnormal trophoblastic invation of uterine vessels eb o co co co m m e co m m m • HELLP syndrome is a variant of preeclampsia defined by following criteria: –– Hemolysis identified by Burr cells and schistocytes on an abnormal peripheral smear, an elevated serum bilirubin (>1.2 mg/dl) or LDH level (>600IU/L), or a low serum haptoglobin –– Thrombocytopenia with platelets 5.9 mg/dl at 24 weeks have a positive predictive value for preeclampsia Mean arterial Pressure in second trimester if mean arterial pressure is ≥ 90 mmHg in second trimester chances of developing preeclampsia increase Urinary Calcium Urinary calcium < 12 mg /dl in 24 hrs indicate impending preeclampsia (Preeclampsia is associated with hypocalciuria) Angiotensin sensitivity test It is based on the fact that women destined to develop preeclampsia lose their refractoriness to angiotensin between 28-32 weeks If a pressure response occurs with 12 mEq / L and arrest when > 15 mEq/L yy Cardiac arrest occurs when > 30 mEq/L yy Best marker of magnesium toxicity is pulse oximetry as oxygen saturation begins to drop before there is evidence of respiratory depression –– Magnesium sulfate acts synergistically with the muscle relaxants used for general anaesthesia.Q –– It decreases FHR variability in NST tracings –– The neuromuscular blocking action of MgSO4 may be potentiated by calcium channel blockers So, MgSO4 should be used cautiously with nifedipine –– It should be used with caution with general anaesthetics oo k eb m m om e ks fre fre oo ks eb m m co Repeat injection are given only if: • Knee jerks are present • Urine output > 30 ml/hour • Respiratory rate ≥ 14/min co m e c co e co m m m m e e e m m co Monitoring for magnesium toxicity yy Urine output should be at least 30 ml/hrQ yy Deep tendon reflexes (Patellar reflex) should be presentQ yy Respiration rate should be more than 14/min.Q yy Pulse oximetry should be ≥ 96% Remember m Hypertensive Disorders in Pregnancy e m e co e fre ks oo eb m m m co co e e fre fre ks ks oo oo eb eb m m oo eb m m eb oo ks fre ks fre e e co m co m m co e fre ks oo eb m co m co m e fre oo ks eb m m e co ks fre oo eb m e co m fre ok s re oo ks f eb m m m co e fre ks oo eb m co m e fre oo ks eb e c co e re ks f oo eb eb m co m e fre ks oo eb m om m co m e ks fre oo • Fibronectin – It is released from endothelial cells following endothelial injury Patients with preeclampsia have elevated levels of plasma fibronectin, a glycoprotein • Fetal DNA – Identification of fetal DNA in maternal serum also predicts preeclampsia m eb o m m m e co re sf oo k eb m First co m m oo ks f Doppler ultrasound Presence of diastolic notch between 22-24 weeks by Doppler velocimetry in the uterine artery predicts the development of preeclampsia It is probably the best available test m m co co m eb eb D Dietary manipulation–low-salt diet, calcium or fish oil supplementation Exercise–physical activity, stretching Antioxidants–ascorbic acid (vitamin C), a-tocopherol (vitamin E), vitamin D Antithrombotic drugs–low-dose aspirin co re fre ks oo oo eb eb Roll over test The test is done at 28-32 weeks It measures angiotensin sensitivity in susceptibles when they lie supine The woman is turned from the left lateral to the supine position If there is an increase in the diastolic blood pressure by 20 mm or more, the test is considered positive m R Prophylactic Measures for Prevention of Pre-eclampsia • • • • m om e ks fre fre oo ks Self Assessment & Review: Obstetrics Contd… m e c co e co m m m m e e e m m co 254 e m m e co oo ks f eb e c re oo ks f eb m eb d Nifedipine m om m co e re ks f c Labetalol oo b a-rhethyldopa 12 All of the following can be administrated in acute hypertension during labour except: [AIIMS May 14] b IV niroprusside Which is the drug of choice for severe preeclampsia? a Labetalol b Metaprolol [AI 08] c A-methyldopa d Nifidipine co m c IV dihydralazine 13 d IV diazoxide fre fre e e a IV labetalol co m oo ks oo ks 14 A 27 year primigravida presents with pregnancy induced hypertension with blood pressure of 150/100 mm of Hg at 32 weeks of gestation with no other complications Subsequently, her blood pressure is controlled on treatment If there are no complications, the pregnancy should be terminated at: [AIIMS May 06] a 40 completed weeks b 37 completed weeks c 35 completed weeks d 34 completed weeks eb m m m e ks ks fre fre co co 30 year old primi with 36 weeks of pregnancy with blood pressure 160/110 and urinary albumin is 3+ & platelet count 80000/mm3 What will be the management? a Betamethasone [PGI June 09] b MgSO4 c Labetalol d Urgent LSCS e Labour induction 16 A gravida patient with previous LSCS comes at 37 weeks, has BP = 150/100 mm of Hg And on pervaginal examination, cervix is 50% effaced station-3, os is closed and pelvis is adequate Protein uria is +1, Most appropriate step at the moment would be: a Antihypertensive regime and wait for spontaneous labor [AIIMS Nov 2010] b Wait and watch c Induce labour d Caesarean section e 15 oo eb m m co e fre ks eb oo oo eb m eb m m m a Enalapril m e fre oo ks Which of the following antihypertensives is not given in pregnancy? [AIIMS May 14] co m m co e co m fre 11 e d Fresh retinal hypertensive changes ok s re fre d Amlodipine ks fre c Increase in systolic BP by 30 mm Hg and diastolic by 15 mm Hg b ACE inhibitors/Enalapril oo m e co ks fre oo eb b Platelet count < 75,000 m eb o a Clonidine eb fre ks oo eb m co m e fre oo ks eb m a New onset proteinuria In PIH an impending sign of eclampsia is: a Visual symptoms [PGI Dec 98] b Weight gain of Ib per week c Severe proteinuria of 10 g d Pedal edema m eb m co e e fre Indicator of severe pre-eclampsia: [PGI Dec 09] a IUGR b Diastolic BP>110 mm of Hg c Pulmonary edema d Systolic BP> 160 e Oliguria All are prognostic indicators of pregnancy induced hypertension, except: [AIIMS May 01] a Low platelets b Serum Na c Elevated liver enzymes m d Serum uric acid All of the following indicate superimposed pre-eclampsia in a pregnant female of chronic hypertension except: [AIIMS May 14] ks eb co m eb co m m Risk factor for pre-eclampsia includes: a Age >35 years [PGI May 2010] b Obesity c Previous h/o preeclampsia d Multigravida e Antiphospholipid syndrome ks oo eb m co m 10 Which of the following antihypertensives is not safe in pregnancy? [AIIMS Nov 05; May 05] c α-Methyldopa oo ks fre e e co re sf [PGI 07] 255 All of the following may be used in pregnancy associated hypertension except: [AI 04] a Nifedipine b Captopril c Methyldopa d Hydralazine m Risk factor for preeclampsia: a Chronic hypertension b Smoking c Obesity d Multiparity e Placenta previa [PGI 06] m oo k eb oo oo eb m Risk factors for preeclampsia: a Chronic hypertenstion b Obesity c Placental ischaemia d Multigravida e Antiphospholipid syndrome m m om e ks fre fre oo ks eb m m QUESTIONS Which of the following seen in preeclampsia? [PGI 01] a Hypertension b Proteinuria c Convulsions d Pedal edema co e c co e co m m m m e e e m m co m co co m Hypertensive Disorders in Pregnancy e m e co re oo ks f ks oo eb m re e c om m co e re oo ks f eb m fre e co m co m e ks oo eb m m m fre e co co e fre ks oo eb co e fre ks eb oo oo eb m m co m e fre m eb oo ks A 32-year-old G3P2 woman at 35 weeks’ gestation has a past medical history significant for hypertension She was well-controlled on hydrochlorothiazide and lisinopril as an outpatient, but these drugs were discontinued when she found out that she was pregnant Her blood pressure has been relatively well controlled in the 120-130 mm Hg systolic range without medication, and urinalysis has consistently ks fre e co m 30 m oo eb m e co m fre ok s ks Best drug for management of eclampsia: a MgSO4 [AIIMS Nov 2010] b Lytic cocktail regime c Phenytoin d Diazepam oo 25 [Al 2011] Which of the following is the most likely diagnosis? a Chronic hypertension b Preeclampsia c Eclampsia d Gestational hypertension e Severe preeclampsia eb Earliest sign of Mg toxicity: a Depression of deep tendon reflexes b Respiratory depression c Cardiac arrest d Anuria eb o eb m ks fre 24 m m e co e fre Side effects of magnesium sulfate includes a Hypotension [PGI Dec 08] b Anuria c Coma d Pulmonary edema m oo eb co m m [AI 09] 23 oo ks eb m m fre fre ks ks All are true about pre eclampsia except: a Cerebral hemorrhage b Pulmonary edema c ARF d DVT fre m co e e fre 20 Which of the following is not a part of HELLP syndrome? a Hemolysis [AIIMS May 2014] b Elevated liver enzymes c Thrombocytopenia d Retroplacental hemorrhage oo ks Which is not a feature of HELLP syndrome: a Thrombocytopenia [AIIMS Feb 97] b Eosinophilia c Raised liver enzyme d Hemolytic anemia 22 Concentration of MgSO4 in the treatment of eclampsia in mEq/L: [PGI 99] a 7-10 b 10-15 c 2-4 d 4-7 m m eb 19 eb d Care of airway oo eb m co m 29 A 31-year-old G2P1 woman at 24 weeks’ gestation presents for a routine prenatal visit She reports an uneventful pregnancy other than early morning nausea and vomiting, which has subsided since her last visit She denies vaginal bleeding or contractions Blood pressure and routine laboratory values at previous visits had been normal Today her temperature is 37°C (98.6°F), pulse is 74/min, blood pressure is 162/114 mm Hg, and respiratory rate is 14/min Her uterine size is consistent with her dates, and her physical examination is unremarkable Laboratory tests show: [New Pattern Question] • WBC count: 9000/mm³ • Hemoglobin: 13 g/mL • Hematocrit: 39% • Platelet count: 240,000/mm³ • Blood urea nitrogen: 11 mg/dL • Creatinine: 1.0 mg/dL • Aspartate aminotransferase: 20 U/L Alanine aminotransferase: 12 U/L • Urinalysis reveals 3+ protein but no blood, bilirubin, bacteria, leukocyte esterase, or nitrites The patient is sent directly from the clinic for a nonstress test and an ultrasound Six hours later her blood pressure is rechecked, and it is 162/110 mm Hg m m c Immediate delivery 21 True about MgSO4: [PGI May 2010] a Tocolytic b Used in management of eclempsia c Cause neonatal respiratory depression MgSO4 is/are indicated in: [PGI Nov 2012] a Severe pre eclampsia b Eclampsia c Pre term labour d Prevention of cerebral palsy 28 All statements(s) is/are about use of magnesium sulphate except: [PGI May 2013] a Therapeutic level is 4-7 mEq/L b Used in spinal anesthesia c Used in seizure prophylaxis d Decrease neuromuscular blockage e Used in Pre-emptive analgesia ks f oo b Sedation of patient co m eb m co m eb oo k sf A 28 year old eclamptic woman develop convulsions The first measure to be done is: [AIIMS June 99] a Give MgSO4 26 27 oo co m ks fre re e e co co m m m eb oo 17 A female of 36 weeks gestation presents with hypertension, blurring of vision and headache Her blood pressure reading was 180/120 mm Hg and 174/110 mm Hg after 20 minutes How will you manage the patient? [AIIMS Nov 12] a Admit the patient and observe b Admit the patient, start antihypertensives and continue pregnancy till term c Admit the patient, start antihypertensives, MgSO4 and terminate the pregnancy d Admit oral antihypertensives and follow up in outpatient department m om e ks fre fre m eb oo ks Self Assessment & Review: Obstetrics 18 co e c co e co m m m m e e e m m co 256 e m m e co re fre oo ks f ks oo 257 eb eb om e c eb eb oo oo ks f ks f re re e co m m m m fre e co m co m e fre oo ks oo ks eb eb m m m fre e co co e fre ks ks oo eb m co e fre ks m eb oo oo eb m m co m e ks fre m co e fre m eb oo ks oo m e co ks fre oo eb m e co m fre m eb o ok s 34 Proved to be effective in the management of preeclampsia: [New Pattern Question] eb m co e fre ks oo eb m co m e fre oo ks eb m All of the following are predictive tests for PIH except a Rolling over test [New Pattern Question] b Serum uricacid c Gain in weight > kg in one month d Shake test m ks fre oo eb m co m e fre ks oo eb co m m Which of the following tests should be performed? a CVS [New Pattern Question] b Grp B streptococcal testing c Triple test d USG of fetal kidneys m co m e e co re sf oo k eb m m 32 A 25-Year-old female is months pregnant and presents to her obstetrician along with her first child She has not received any prenatal care She thinks she has gained adequate weight and her pregnancy has been uncomplicated till date Her past medical history is notable for hypertension for which she is currently taking enalapril • She is 168 cm (5’ 6”) tall, weight is 59 kg, B/P = 120/84 mm of hg and fundal ht is 17 cm Fetal movements are appreciated and FHR = 140/min • Results of dipstick are negative a Zinc b Calcium c Magnesium d None of the above 35 A 24-year-old woman with 36 weeks of pregnancy, suddenly complains of headache and blurring of vision Her B.P is 170/110 mm of Hg Urinary albumin is +++ and fundus examination shows areas of retinal hemorrhage The line of further management would be: [New Pattern Question] a Conservative treatment b Anticonvulsive therapy c Induction of labour d Cesarean delivery 36 Which type of eclampsia has the worst prognosis: [New Pattern Question] a Antepartum b Postpartum c Intrapartum d Imminent 37 Cause of convulsion in eclampsia: [New Pattern Question] a Cerebral anoxia due to arterial spasm b Hypovolemia c Hypocalcemia d Shock 38 A pregnant woman in 3rd trimester has normal blood pressure when standing and sitting When supine, BP drops to 90/50 What is the diagnosis? [New Pattern Question] a Compression of uterine artery b Compression of aorta c Compression of IVC (inferior vena cava) d Compression of internal iliac vessels 39 The following are related to preeclampsia: [New Pattern Question] a It is a totally preventable disease b Systolic rise of blood pressure is more important than the diastolic c Eclampsia is invariably preceded by acute fulminating preeclampsia d Endothelial dysfunction is the basic pathology 40 In a pregnant female with BP 150/100 mm Hg, a protein/creatinine ratio of _ suggests development of preeclampsia: [New Pattern Question] a > 0.20 b > 0.30 c < 0.20 d < 0.30 41 High-risk factor for gestational hypertension include all except: [New Pattern Question] a BP ≥ 150/100 mm of Hg b Gestation age < 30 weeks c IUGR d Polyhydramnios 42 A chronic hypertensive pregnant female with BP controlled using antihypertensives should be delivered at: [New Pattern Question] a 38–39 weeks b 37–39 weeks c 36–37 weeks d 35–36 weeks m oo eb m m m co co m P/A Examination: ht of uterus ~ 28 weeks: � FHS regular � Fetal parts palpable She is admitted and monitored after hours her condition is unchanged which of the following is the next best step in management: [New Pattern Question] a Emergency cesarean section b Oral glucose tolerance test c I/V MgSO4 d Stabilisation of vital signs and bed rest e Follow up after weeks 33 om e ks fre fre m eb oo ks A 35 years old G1 P0 women at 28 weeks of pregnancy complaints of severe headache for days She doesn’t have any photophobia, vomiting and nausea but had dizzness Her BP is 155/85 mm of Hg, R/R-18/ min, P/R-120/min Urinalysis reveals +1 glycosuria, +2 proteinuria and 24 hours urine collection shows g protein e c co e co m m m m e e e m m co been negative for proteinuria at each of her prenatal visits She presents now to the obstetric clinic with a blood pressure of 142/84 mm Hg A 24-hour urine specimen yields 0.35 g of proteinuria Which of the following is the most appropriate next step? a Start iv furosemide [New Pattern Question] b Induce labor after doing Bischop score c Put her on hydralazine d Initial inpatient evaluation followed by restricted activity and outpatient management e Start her prepregnancy regime 31 co Hypertensive Disorders in Pregnancy e m e co re oo ks f ks Ans is a, c and e i.e Chronic hypertension; Placental ischemia; and Antiphospholipid syndrome e Ref Dutta Obs 7/e, p 220 re re ks fre re e Ans is a and c i.e Chronic hypertension and Obesity e c om m co e co co m m m eb eb oo E X P L A N AT I O N S & REFERENCES m m m m eb eb oo oo ks Self Assessment & Review: Obstetrics co m om fre ks fre fre e e c co e co m m m m e e e m m co 258 oo ks f ks f eb eb m e fre ks oo eb m co fre ks oo eb m ks co fre e e ks fre m eb oo oo eb m m co m m co e fre m eb oo ks ok s eb o m fre eb m m fre co ks oo oo eb “Although smoking during pregnancy causes a variety of adverse pregnancy outcomes, ironically, smoking has consistently been associated with a reduced risk of hypertension during pregnancy Placenta previa has also been reported to reduce the risk of hypertensive disorders in pregnancy.” —Williams 23/e, p 709 yy Smoking is also protective for fibroids and endometriosis Ans is a and b i.e Hypertension; and Proteinuria Ref Fernando Arias 3/e, p 415; COGDT 10/e, p 320 Hypertension: It is defined as systolic BP > 140 mm of Hg or diastolic BP > 90 mm of Hg on occasions atleast hours apart seen in previously normotensive female after 20 weeks of gestation or mean arterial pressure > 105 mm of Hg Note: A systolic rise of 30 mm Hg or a diastolic rise of 15 mm Hg is no longer a diagnostic criterion Proteinuria: Irreversible excretion of 300 mg of protein in 24 hours urine collection or atleast 30 mg/dl or 1+ dipstick in atleast random urine samples collected atleast hours apart but no more than days apart is significant proteinuria Edema: In pregnancy can be physiological or patholigical e co m m m eb oo ks ks fre fre • Though preeclampsia is considered as a disease of primigravida, if the first pregnancy was complicated by preeclampsia the risk in the next pregnancy is increased • Early onset preeclampsia should raised the suspicion of molar pregnancyQ As far as smoking is concerned m —COGDT 10/e, p 321 —COGDT 10/e, p 321 e m —COGDT 10/e, p 321 e co e co e Note: co m co m e m co m m m eb eb oo oo ks ks fre fre fre ks oo eb m } e e co m co m m m m eb – Obesity – African american ethinicity Obstetrical factors: – Previous history of preeclampsia – Multiple pregnancy – Hydrops fetalis with a large placenta – Molar pregnancy Medical factors: – Chronic hypertension – Antiphospholipid antibody syndrome – Inherited thrombophilias (Protein C, S, factor V leiden deficiency) – Diabetes mellitus/Gestational diabetes – Renal disease – Thyroid disease – Collagen vascular disease Placental factors: – Poor placentation and placental ischemia eb co m Ref Dutta Obs 6/e, p 222; Williams Obs 22/e, p 764, 765, 23/e, p 708, 709 ; COGDT 10/e, p 321 Preeclampsia is the development of ,(BP > 140/90 mm of Hg) with proteinuria after 20 weeks of gestation in a previously normotensive and non proteinuric patient Risk factors for Preeclampsia: Gentic factors: – Family history (of preeclampsia, eclampsia, hypertension) Maternal factors: – Nulliparous female – New paternity —Williams Obs 22/e, p 765, 23/e, p 709; COGDT 10/e, p 321 – Age < 20 years or > 35 years co m oo oo oo k sf Ans is a,b, c,d and e i.e Age > 35 years, Obesity, Previous h/o preeclampsia, Multigravida and Antiphospholipid antibody syndrome co e e co co e co co e e oo ks fre re C eb o ok sf Figs 4A to C: (A) 2D fetal profile, (B) 3D fetal profile; and (C) 3D image of a fetus m fre ks oo eb m e m m e co co e fre fre ks oo eb $ PLGVDJLWWDO YLHZ RI WKH IDFH VKRXOG EH REWDLQHG 7KLV LV GH¿QHG by the presence of the echogenic tip of the nose and rectangular shape of the palate anteriorly, the translucent diencephalon in the center and the nuchal membrane posteriorly (Fig 2) eb y m 7KH PDJQL¿FDWLRQ RI WKH LPDJH VKRXOG EH VXFK WKDW WKH IHWDO KHDG and thorax occupy the whole screen B m The fetal crown-rump length should be between 45 and 84 mm y eb o y m The gestational period must be 11–13 weeks and six days At and after 14 weeks of gestation with fetus is often in a vertical position, ZKLFK PDNHV LW GLI¿FXOW WR REWDLQ WKH DSSURSULDWH LPDJH m y ks co co ok s oo ks fre eb The ‘Fetal Medicine Foundation’ (London) has laid down the following guidelines for correct measurement of ‘Nuchal Translucency: m fre e e c e re ks f A MEASUREMENT OF NUCHAL TRANSLUCENCY oo fre eb m m om 3D-USG IN OBSTETRICS The detection rate of about 75–80% can be obtained by screening of fetuses by NT alone with maternal age for trisomy 21 and other major aneuploidies with a false positive rate of 5% The detection rate can be improved to 90% by a combination of NT with maternal serum free ȕK&* DQG SUHJQDQF\DVVRFLDWHG SODVPD SURWHLQ $ 3$33$ oo ks f oo ks oo ks eb Fig 3: Correct placement of calipers for measurement of nuchal translucency m m co m • Nonaneuploidy structural defects and syndromes—congenital diaphragmatic hernia, congenital heart disease, omphalocele, skeletal dysplasia, fetal infections, etc eb oo eb m co m e fre fre • Aneuploidy—trisomies (including Down’s syndrome) and Turner’s syndrome eb re fre e ks oo eb m m e co Fig 2: Nuchal translucency measurement by ultrasound The fetus should be in a neutral position, with the head in line with the spine The widest part of translucency must always be measured • Measurements should be taken with the inner border of the horizontal OLQH RI WKH FDOLSHUV SODFHG RQ WKH OLQH WKDW GH¿QHV WKH QXFKDO WUDQVOXFHQF\ thickness (Fig 3) ks oo eb Increased nuchal translucency (≥3 mm) can be associated with a number of anomalies, including: m oo eb m co m e co m fre oo ks eb m m e co fre eb oo ks NUCHAL TRANSLUCENCY AND CHROMOSOMAL DEFECTS ks ks oo eb m m m e co ks fre oo eb m Fig 1: Increased nuchal translucency (NT) m fre fre fre e c ok s eb o eb m USG SHOWING INCREASED NUCHAL TRANSLUCENCY m e co m om m e co re ks f oo IMPORTANT ULTRASOUNDS AND DOPPLER IMAGES co e oo e co re ks f oo eb m fre e co co m fre oo ks oo ks eb m fre e co co ks m m m eb eb o oo B eb m eb o ok sf oo ks fre re e Figs 9A and B: Cervix bisected to achieve access to the vesicouterine peritoneum Slight traction on the bladder with Babcock’s forceps brings connecting tissue strands into view for excision and the plane for access Soure: Shet SS Access to vesicounterine and rectouterine pouches In: Sheth SS (Ed) Vaginal hysterectomy, (2nd edn.) New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd; 2014.pp.31-50 co co A e y 'LIIXVH RU IRFDO ODFXQDU ÀRZ SDWWHUQ 6RQROXFHQW YDVFXODU ODNHV ZLWK WXUEXOHQW ÀRZ W\SL¿HG E\ KLJK YHORFLW\ (peak systolic velocity >15 cm/s) and low resistance waveform Hypervascularity of the uterine–bladder interface with abnormal blood vessels linking the placenta to the bladder, and Markedly dilated vessels over the peripheral subplacental region fre e y ok s y m CHARACTERISTICS OF PLACENTA ACCRETA ON COLORED DOPPLER m m e co fre ks oo eb m eb oo eb m eb m om e c oo ks fre eb m m co e fre ks oo e e co fre ks oo eb m co m e re ks f oo eb On gray-scale ultrasound imaging, the presence of at least one of the following characteristics is required to indicate placenta accreta: as shown in Figures 8A and B y Complete loss of the retroplacental sonolucent zone y Irregular retroplacental sonolucent zone y Thinning or disruption of the hyperechoic uterine serosa-bladder interface y The presence of focal exophytic masses invading the urinary bladder and y The presence of abnormal placental lacunae Likewise, the diagnosis of placenta accreta was regarded as positive when any one of these color Doppler criteria was present y Fig 7: Monochorionic monoamniotic twin gestation at 10 weeks’ gestation Note: The lack of a dividing membrane and the close proximity of the fetuses A single yolk sac was also noted eb m co m ks m m e co fre eb oo ks m fre e fre m eb IMAGING FOR ADHERENT PLACENTA CHARACTERISTICS OF PLACENTA ACCRETA ON GREYSCALE USG: Fig 6: Dichorionic diamniotic twin gestation at week’ gestation Note the thick dividing membrane and wedge-shaped “lambda sign,” the area at the top of the image, which represents the junction of the placenta Note: The thick dividing membrane and wedge-shaped ‘lambda’ sign, the area at the top of the image, which represents the function of the placentas m B Figs 8A and B: Umbilical artery Doppler: (A) absent end-diastolic flow; (B) Reversed end diastolic flow USG OF DICHORIONIC DIAMNIOTIC TWIN m ks ks oo eb m e co m m oo ks A Fig 5: Conjoined twin pregnancy at weeks’ gestation Note the fetal heads and apparent fusion at the thorax and abdomen In this image, there is also a single amnion and chorion identified Note: The two fetal heads and aparent fusion at thorax and abdomen USG OF CONJOINED TWINS fre fre fre e c ok s eb o m UMBILICAL ARTERY DOPPLER e co ks fre oo eb m e co m om m e co re ks f oo DOPPLER ARTERY IMAGES USG OF CONJOINED TWIN m eb USGs IN TWIN PREGNANCY co e fre e co eb m m co co fre e fre e oo ks ok s eb eb o m m m m sf oo ks fre re e e co co e co fre eb m m eb o ok ks oo eb co e fre oo ks oo ks eb m om e c oo ks fre eb m m m re e fre fre ks oo eb m co m co e fre ks oo ks f co m m e co e co e re ks f oo eb oo m m m m Fig 12: Spalding sign Note: The overlapping of bones: Spalding; sign characteristic of IUD fre eb oo ks m m eb Note: The snowstorm appearance of H mole Fig 11: USG showing snow storm appearance of hydatidiform mole eb eb m co m ks oo eb eb USG OF H MOLE m eb oo oo ks Figs 10A and B: MRI images: (A) placenta percreta (B) placenta previa without invasion m ks oo fre e B USG OF IUD m e co m A fre ks fre e co m m y Uterine bulging Heterogenous signal intensity within the placenta Dark intraplacental bands on T2-weighted imaging eb y eb o y oo ks ok s fre fre e c e co m om m e co re ks f m eb oo CHARACTERISTICS OF PLACENTA ACCRETA ON MRI co e oo ks fre eb m co co e Specimen Hydrocephalus fre ks oo eb m co fre e ok s eb o m m om e c ks oo eb m fre co e co m m e co e fre oo ks eb m fre ks oo eb m m e co fre eb oo ks m Specimen Conjoined twins m e re sf ok eb o oo ks fre eb m co m e re ks f oo eb m Specimen Anencephaly m m e co fre ks oo eb m m co e fre ks oo eb m e co re ks f oo eb m co m fre e ks oo eb m m e co e co m fre oo ks eb m ks fre oo eb m fre ks oo eb m co e e co m om fre e c fre ks oo eb m ok s eb o m m e co re ks f oo eb m SPECIMENS IN OBSTETRICS Specimen Spina Bifida co e fre ks ks ok s fre fre e c e co m om m e co re ks f eb m e co co m ks f re fre e ks oo oo eb eb m m m m oo oo eb A eb eb oo oo ks fre ks fre e co e co m m m m m eb eb o oo IMPORTANT FIGURES IN OBSTETRICS co e fre ks oo m m e oo ks fre sf m eb ok eb o m co co e re fre ks oo eb m e fre ks oo eb eb eb o m m e co e fre ks oo eb m m co fre e ok s oo ks fre eb m m co Fig 5: Relation of the amniotic cavity: End of the 8th week Note: The types of decidua Fig 3: Fundal height at various gestations (weeks) m co co m e fre om e c e re ks f oo eb eb eb co m m m Figs 4A and B: (A) Fetal surface of the placenta showing attachment of the umbilical cord with ramification of the umbilical vessels (B) Maternal surface of the placenta showing shaggy look with cotyledons limited by fissures m oo B Fig 2: Structure of a mature spermatozoon: PM = Plasma membrane; A = Acrosome; OAM = Outer acrosomal membrane; IAM = Inner acrosomal membrane; AC = Acrosomal cap; ES = Equatorial segment; PA = Postacrosomal region m oo ks ks eb oo ks fre fre e co e co m m Fig 1: Coronal section showing different parts of uterus co e fre ks ks eb m co e fre ks oo eb m co m e co B oo ks fre re e A eb m eb o ok sf Figs 6A and B: Delivery of the aftercoming head by malar flexion and shoulder traction—(A) Original Mauriceau-Smellie-Veit; (B) Modification (preferred) m oo eb co e fre ks oo eb m m co fre e ok s eb o m m e co fre ks ks m ks f oo m co m e fre oo ks eb m om e c eb m m co eb eb m e co fre ks oo ks fre Fig 5: Continuation of the Burn-Marshall method Figs 3A to C: Pinard’s manuever—(A) Flexion and abduction of popliteal fossa; (B) To catch hold the ankle; (C) To pull down by movement of abduction oo re fre e ks oo m Fig 4: Delivery of after-coming head by Burns-Marshall method oo eb m co m e e C fre B e co co m e co m fre oo ks eb m m e co fre re ks f oo eb oo oo eb m m m e co ks fre oo eb eb oo ks m m A eb fre fre e c ok s eb o eb m m Ritgen’s maneuver: For normal delivery Fig 1: Assisted delivery of the head by extension, exerting and upward pressure to the chin by the right hand placed over the anococcygeal raphe (Ritgen’s maneuver) Fig 2: Both groin traction for assisted breech delivery m e co m om m e co re ks f oo MANEUVERS IN OBSTETRICS co e oo ks fre eb m co co e fre ks oo eb m co fre e ok s eb o m m om e c oo ks fre eb m co m e re ks f oo eb m ks oo eb m fre co e co m m e co e fre oo ks eb m fre ks oo eb m m e co fre eb oo ks m co m e co re ks f oo eb m e co m fre e ks oo eb m m e co Figs 7A and B: Cephalohematoma versus subgaleal hematoma (A) Cephalohematomas are limited to suture lines (B) In subgaleal hematomas, the bleeding crosses suture lines, causing diffuse welling that can indent on plapation fre oo ks eb m ks fre oo eb m B m e re sf ok eb o m m e co fre ks oo eb m m co e fre ks oo eb m A fre ks oo eb m co e e co m om fre e c fre ks oo eb m ok s eb o m m e co re ks f oo eb m co e e co re ks f co e fre ks oo eb m m eb Cesarean section Cesarean hysterectomy Exploratory laparotomy for ruptured tubal ectopic pregnancy e fre ks ok s fre e co co m om oo eb m eb o Fig 4: m m eb ok eb o m co e oo ks fre re e co m Routine per speculum examination in gynecology Colposcopy Endometrial biopsy Cervical punch biopsy Pap smear Insertion and removal of intrauterine contraceptive device (IUCD) Intrauterine insemination (IUI) sf m e co fre y y y y y y y ks oo eb m oo eb m co m e fre oo ks – – – e c oo ks fre eb m m co e fre ks oo fre ks oo eb m co m m m e co fre m co m e re ks f oo eb m Gynecologic – Abdominal hysterectomy – Wertheim’s hysterectomy – Tuboplasty – Sling operation – Purandare’s cervicopexy – Exploratory laparotomy for ovarian tumors – Myomectomy Obstetric Uses Along with Sim’s speculum, to visualize cervix by retracting anterior vaginal wall eb y eb oo ks eb oo ks m y Cusco’s self-retaining vaginal speculum Material: Stainless steel Sterilization: Autoclaving and boiling Fig 2: Sims anterior vaginal wall retractor Material: Stainless steel Sterilization: Autoclaving and boiling m fre e ks oo eb eb m m e co fre Gynecologic – Routine gynecological examination to visualize vagina and cervix – To collect discharge from posterior fornix – Hysterosalpingography (HSG) – Gynecological operations Obstetric – Routine per speculum examination – 0DQXDO YDFXXP DVSLUDWLRQ 09$ ¿UVW WULPHVWHU PHGLFDO termination of pregnancy (MTP) – Cervical cerclage – Diagnose and repair cervical tear Uses ks oo eb m e co m fre oo ks oo eb m Sterilization: Autoclaving and boiling y fre fre e c ok s eb o m m ks fre e co Uses Sims posterior vaginal speculum Material: Stainless steel y Fig 3: Doyen’s retractor Material: Stainless steel Sterilization: Autoclaving Fig 1: Uses e co m om m e co re ks f oo eb m INSTRUMENTS co e fre oo e co re ks f oo co e fre ks m m co co oo ks fre e fre e ok s eb m m eb eb o Fig 9: Allis tissue-holding forceps Material: Stainless steel Sterilization: Autoclaving and boiling m oo eb eb m om e c oo ks fre ks f oo eb e fre oo ks ks oo co m e re To retract the bladder away from cervix and uterus during vaginal hysterectomy It is introduced into anterior pouch after the uterovesical fold of peritoneum has been opened To retract lateral and anterior vaginal walls during any vaginal operation eb m co m m e co fre Flushing curette Material: Stainless steel Sterilization: Autoclaving and boiling eb m m eb eb m m m e co fre eb oo ks Fig 8: Dilatation and evacuation operation Landon bladder retractor Material: Stainless steel Sterilization: Autoclaving and boiling m m co m oo ks oo ks fre fre e e co m To retract abdominal wall during tubal ligation To retract bladder and posterior vaginal wall during hysterectomy To retract bladder during abdominal hysterectomy Use Fig 6: y y y y eb Vaginal hysterectomy Anterior colporrhaphy Kelly’s repair )RWKHUJLOO¶VPRGL¿HG )RWKHUJLOO¶V UHSDLU 9HVLFRYDJLQDO ¿VWXOD UHSDLU Schauta’s hysterectomy Uses ks ks oo eb m m m e co ks fre m eb oo Uses y fre fre e c ok s eb o eb m Uses Fig 5: Auvard’s speculum Material: Stainless steel Sterilization: Autoclaving y y y y y y e co m om m e co re ks f oo Right angle retractor Material: Stainless steel Sterilization: Autoclaving and boiling m e oo ks fre Contd m eb ok eb o m co co re e y General: To hold the rectus sheath while opening and closing abdominal wall Gynecologic: To hold the edges of vagina – In anterior colporrhaphy, enterocele repair, colpoperineorrhaphy ks m eb oo oo eb m y sf fre Fig 7: ks fre e e co co m m Uses co e fre e co re m co co m e e m m eb eb oo ks oo ks fre fre fre co e ks ok s fre Uses fre e co m Kocher’s clamp Material: Stainless steel Sterilization: Autoclaving and boiling 7KH EODGHV PD\ EH FXUYHG RU ÀDW RU VWUDLJKW 2QH EODGH KDV D ORQJLWXGLQDO ULGJH ZKLFK ¿WV LQ D ORQJLWXGLQDO JURRYH RQ WKH RWKHU blade It has transverse serrations on its blade oo eb eb o m m m m sf oo ks fre re e e co co e co fre eb m m eb o ok ks oo eb m ks f oo eb eb m m e co Fig 12: To clamp the uterosacral ligaments, uterine blood vessels and the cornual structures or the infundibulopelvic ligaments in vaginal hysterectomy y Ophorectomy for ovarian cysts or tumors y Removal of pedunculated leiomyomatous polyps y Salpingectomy for tubal ectopic gestation y Cesarean hysterectomy y Clamping the umbilical cord of the newborn y $UWL¿FLDO ORZ UXSWXUH RI PHPEUDQHV To hold the uterus during abdominal hysterectomy eb e fre ks eb m co m fre e oo y oo oo eb m y General – Painting and preparing parts preoperatively – Swab out cavities like vagina and pelvic cavity Gynecologic – For applying pressure over deep bleeding points during pelvic surgery – To check hemostasis of stumps during vaginal hysterectomy – For packing away omentum and intestines out of pelvis in gynecological operations Obstetric – To hold lips of pregnant cervix during tightening of os – For diagnosis and repair of cervical tear – Swab out blood in uterine cavity Hysterectomy m co m Fig 11: oo eb y ks oo ks fre ks f oo eb m m Uses oo eb m re e y om y e c y For hemostasis Holding structures like peritonium, rectus sheath, vessels, muscles, etc during any operative procedure For suture removal Can be used for clamping placenta after delivery of baby co m y ks ks fre oo ks eb m m e co fre eb oo ks m Uses Sponge-holding forceps Material: Stainless steel Sterilization: Autoclaving and boiling ks e co m e co oo eb m Fig 10: Curved artery forceps Material: Stainless steel Sterilization: Autoclaving fre fre e c ok s eb o m m In vaginal hysterectomy, abdominal hysterectomy Fothergill’s repair 5HSDLU RI YHVLFRYDJLQDOUHFWRYDJLQDO ¿VWXOD To hold the cervix Abdominal hysterectomy To hold the lips of pediatric cervix To hold the uterus Vaginal and abdominal hysterectomy, myomec tomy, utriculoplasty – Marchetti test for detection of stress urinary incontinence Obstetric – In lower segment cesarean section (LSCS) to hold angles of uterine incision – For correction of acute inversion of uterus ks fre y – – – – – – – – e co m om m e co re ks f m eb oo Contd co e fre oo e co re ks f oo eb m e fre ks oo eb co e oo ks ok s fre fre e co m m m Fenton Dilator eb o eb It is similar to Hegar dilator except for two important differences—it is more tapering and hollow inside m oo ks fre eb m co co m e fre eb For the rapid dilatation in: y Prior to endometrial curettage y 3ULRU WR VXFWLRQ DVSLUDWLRQ IRU ¿UVW WULPHVWHU 073 y Prior to suction evacuation of mole y Removal of endometrial polyp, placental polyp, leiomyomatous polyp y Hysteroscopy y Amputation of cervix, Fothergill’s operation, following cervical conization y Cervical stenosis y Application of intrauterine radiotherapy y Primary dysmenorrhea y Diagnosis of incompetent os m om e c e re ks f To hold tubular structures like: y Fallopian tubes in tubal sterilization, ruptured tubal ectopic pregnancy y Round ligaments y Ureters in Wertheim’s hysterectomy y Vas in vasectomy y Appendix and cecum in appendicectomy oo eb m Hegar dilator Material: Stainless steel Sterilization: Autoclaving and boiling It is a solid rod-curved near the tip and tapering towards the tip The curve is shallow and the dilating portion is within terminal 1.5 cm of the dilator oo ks oo eb co m m m Uses Fig 16: Uses Fig 14: Straight Babcock forceps Material: Stainless steel Sterilization: Autoclaving and boiling eb ks oo eb m m e co ks eb oo ks fre fre y Hysterosalpingography Chromopertubation test Rubin’s test e co y m Special Use y m co m y fre e e co m fre To hold tough structures like: – Tendon – Fascia – Skin – Rectus sheath – Uterine wall, etc Can be used for hemostasis oo ks eb To hold the lips of nulliparous cervix To hold cervical stump in subtotal hysterectomy m y ks ks oo eb m m m e co ks fre oo eb m y fre fre e c ok s eb o eb m Uses y Fig 13: Tenaculum Material: Stainless steel Sterilization: Autoclaving and boiling Uses e co m om m e co re ks f oo Tooth forcep Material: Stainless steel Sterilization: Autoclaving and boiling Use m co co e e sf oo ks fre re fre eb m m eb o ok ks oo eb Fig 15: m m eb oo ks fre e e co co m m Same as that of Hegar dilator co e e co co e m m co co ks fre e fre e ok s oo m eb eb o m m e oo ks fre sf m eb ok eb o m co co re fre e m e co It is used to elevate and manipulate position of uterus for following: – Laparoscopic sterilization – Sterilization by mini laparotomy – Visualization of pelvic structures by laparoscopy ks oo re fre ks oo eb eb m om e c eb eb ks f fre oo ks ks oo oo ks fre Fig 20: Hulka uterine manipulator Material: Stainless steel Sterilization: Autoclaving and boiling m m co e fre oo eb m co m To hold anterior lip of cervix in: – Endometrial biopsy – IUCD insertion – Intrauterine insemination – Vaginal hysterectomy – Cauterization of cervix and cervical biopsy To hold posterior lip of cervix in: – Colpopuncture for suspected ruptured ectopic pregnancy – Culdoscopy – Posterior colpotomy e e co fre y y ks m fre oo eb m fre e ks oo eb m y Uses Removal of an embedded IUD from the uterine cavity Removal of tubal prosthesis from the uterine cavity oo eb Uses eb m co m e re ks f oo eb Uses y Vulsellum Material: Stainless steel Sterilization: Autoclaving and boiling m m m e co fre m m Fig 18: IUCD removing hook Material: Stainless steel Sterilization: Autoclaving and boiling y co m e co m fre eb Gynecological uses – Diagnostic Primary or secondary infertility for ovulation detection Tuberculous endometritis Abnormal uterine bleeding Endometrial hyperplasia/endometrial carcinoma Carcinoma cervix Secondary amenorrhea Postmenopausal bleeding – Therapeutic Dysfunctional uterine bleeding (DUB) Asherman’s syndrome To remove embedded intrauterine device (IUD) Obstetrical uses: – MTP, check curettage – Blunt curettage in abortions – Secondary persistent pulmonary hypertension (PPH), subinvolution eb oo ks y m Fig 19: oo ks oo eb m y ks ks oo eb m m m e co ks fre Uses y fre fre e c ok s eb o oo eb m Sharp and blunt curette y e co m om m e co re ks f Fig 17: co e e co co co e fre oo ks ok s eb eb o m m m m e e co co e co Fig 25: sf oo ks fre re fre m eb ok eb o m oo eb m e fre eb fre e co m m m Karman cannula A long tubular structure made of plastic or metal y Types: 5LJLG RU ÀH[LEOH y Sizes: 4–12 mm y Parts – Distal end: Double whistle at the terminal end – Proximal end: Fixes into syringe – Superior overhanging edge acts as a curette The number of cannula corresponds to diameter of cannula in millimeters A plastic cannula is preferred because it is less traumatic, transparent and disposable ks ks oo ks oo ks Fig 24: eb om e c eb m m co fre Fig 23: oo re oo e fre fre ks oo ks fre ks f oo e eb m co m m e co y Evacuation of products of conception in abortion and vesicular mole Evacuation of products of conception in secondary PPH oo eb m co m e re High amniotomy 7R GUDLQ D K\GURFHSKDOLF KHDG WKURXJK D VSLQD EL¿GD LQ FDVH RI a breech delivered up to the head eb eb oo ks oo eb m m m e co fre eb oo ks m Fig 22: m m eb It is absent $Q\WKLQJ KHOG LQ EODGHV LV ¿UPO\ FDXJKW EXW QRW QLSSHG DQG VR no crushing Ovum forceps is differentiated from sponge holding forceps by following points: – It has no lock – It has no serrations Catch lock is absent so less chances of injury to intra-abdominal structures y Uses Drew-Smythe catheter Material: Stainless steel Sterilization: Autoclaving and boiling It is S-shaped and has a side opening to drain liquor amnii It has a spring loaded stylet with a blunt tip y co m y ks f fre oo ks eb oo eb m Lock y y Blades are spoon-shaped, fenestrated and have blunt ends Longitudinal fenestrations can hold good amount of tissue fre e e co m m e co ks fre Fig 21: Same as that of Hulka uterine manipulator Uses m Blades y Uses ks ks oo eb m m Parts y Vitoon uterine manipulator Material: Stainless steel Sterilization: Autoclaving and boiling fre fre fre e c ok s eb o eb m e co m om m e co re ks f oo Haywood Smiths ovum forceps Designed by Haywood Smiths ... up in outpatient department m om e ks fre fre m eb oo ks Self Assessment & Review: Obstetrics 18 co e c co e co m m m m e e e m m co 25 6 e m m e co re fre oo ks f ks oo 25 7 eb eb om e c eb... Ref Dutta Obs 6/e, p 22 2; Williams Obs 22 /e, p 764, 765, 23 /e, p 708, 709 ; COGDT 10/e, p 321 Preeclampsia is the development of ,(BP > 140/90 mm of Hg) with proteinuria after 20 weeks of gestation... Ref Dutta Obs 7/e, p 22 4 Ans is b i.e Serum sodium e m e co re oo ks f ks Self Assessment & Review: Obstetrics oo ks m om fre ks fre fre e e c co e co m m m m e e e m m co 26 0 oo re re ks fre