OBG Marathon Revision

Prolapse

• Risk Factors: Precipitated Labor (<3 hours), Premature bearing down, Prolonged 2nd stage, Multiparity.
  Protective: Episiotomy (Reduces risk).
• Surgeries:
  • LeFort's Colpocleisis: Old, debilitated women (Sexual function lost).
  • Fothergill's (Manchester): Young women with elongation of cervix (Fertility preserved).
  • Sling Surgeries: Nulliparous prolapse (Shirodkar - Sacrum, Khanna - ASIS, Purandare - Rectus sheath).

Amenorrhea & Endocrinology

• Primary Amenorrhea: 13y (No secondary sexual characters) OR 15y (With secondary sexual characters).
  Management: 16y girl with breast/pubic hair -> Do Ultrasound first (Look for uterus).
• Secondary Amenorrhea: PCOD, Asherman's Syndrome, Sheehan's Syndrome.
• PCOS: Hirsutism (Ferriman-Gallwey score >8).
• Menopause: High FSH (>40), Low Estrogen.
• Ovulation Check: Serum Progesterone on Day 21 (>3 ng/ml).

Infections

Chlamydia: Indolent PID. Major cause of Infertility (Silent tubal damage).

Male Infertility (WHO 2021 Criteria)

• Volume: 1.4 ml
• Concentration: 16 million/ml
• Total Count: 39 million/ejaculate
• Motility: 42% (Total), 30% (Progressive)
• Morphology: 4% normal forms (Most important for IVF/ICSI).
• Klinefelter Syndrome (47XXY): Tall, Gynecomastia, Azoospermia. Most common cause of male infertility (genetic).

Ca Cervix

• Screening: Pap Smear (Fixative 95% Ethyl Alcohol - Do not dry).
• Staging (FIGO 2018): Clinical.
  • Stage 2A: Upper 2/3 Vagina.
  • Stage 2B: Parametrium involved (No free space between cervix and wall).
  • Stage 3A: Lower 1/3 Vagina.
  • Stage 3B: Pelvic Wall / Hydronephrosis (Most common presentation in India).
  • Stage 3C: Lymph Nodes (C1-Pelvic, C2-Paraaortic).
• Treatment:
  Upto 2A1: Radical Hysterectomy (Wertheim's).
  2A2 and beyond: Chemo-Radiation (Cisplatin + Brachytherapy).

Ca Endometrium

• Risk Factors: Obesity, Nulliparity, Late Menopause, Tamoxifen, PCOS (Unopposed Estrogen).
• Protective: Multiparity, COC pills, Smoking.
• Diagnosis: Endometrial Biopsy (Pipelle/Hysteroscopy). NOT Hysterectomy directly.
• Management: TAH + BSO.

OC Pills

• Start Post-Partum: 6 weeks (Non-breastfeeding), 6 months (Breastfeeding).
• Benefits: Reduces Ovarian, Endometrial, Colorectal CA.
• Risks: Small risk of Adenocarcinoma Cervix, Breast CA (Risk returns to normal after stopping).
• MEC 1 (No restriction): HIV/AIDS patients.

Emergency Contraception

• Drug of Choice: Levonorgestrel 1.5mg (within 72 hrs).
• Most Effective Method: Copper-T IUCD (Effective up to 5 days).

IUCD

• Contraindications: Pregnancy, Active PID, Undiagnosed bleeding, Distorted cavity.
• NOT Contraindicated in: Nulliparity, Previous Ectopic, Hypertension.
• Pregnancy with IUCD: Thread visible -> Remove immediately. Thread not visible -> Continue with 50% abortion risk.

Abortion

• Threatened Abortion: Bleeding PV + Os Closed + Live Fetus. Rx: Bed Rest + Progesterone.
• Cervical Incompetence: Painless 2nd trimester expulsion. Rx: Circlage (McDonald's / Modified Shirodkar).
  Shirodkar: For very short cervix/failed McDonald. Requires dissection of bladder.

Ectopic Pregnancy

• Most Common Site: Ampulla (Also MC site of rupture).
• Earliest Rupture: Isthmus.
• Diagnosis: TVS (Empty uterus + Adnexal mass) + hCG.
  Discriminatory Zone: hCG > 1500-2000 IU/L (Should see sac on TVS).

Molar Pregnancy

Follow up: Weekly hCG until negative -> Monthly for 6 months.

Dating & Screening

• Naegele's Rule: LMP + 9 months + 7 days.
• Down Syndrome Screening:
  • 11-13w: NT Scan + Double Marker (PAPP-A, hCG).
  • 16-18w: Quadruple Marker (AFP, uE3, hCG, Inhibin A).
  • High Risk: High hCG, High Inhibin A.
  • Confirmatory: CVS (10-13w), Amniocentesis (>15w).

Twins

• Chorionicity: Determined by splitting time.
  < 3 days: DCDA (Best prognosis).
  4-8 days: MCDA (Most common monozygotic).
  8-12 days: MCMA (Cord entanglement risk).
  >13 days: Conjoined Twins.
• Management:
  First baby Vertex -> Vaginal Delivery.
  First baby Non-Vertex -> LSCS.
  Monoamniotic -> LSCS at 32-34w.

Hypertensive Disorders

• Gestational HTN: HTN >20wks, No proteinuria. Normalizes postpartum.
• Pre-eclampsia: HTN >20wks + Proteinuria.
• Eclampsia: Seizures + HTN.
  Mgmt: Magnesium Sulfate (Pritchard Regimen).
  Toxicity: Loss of Knee Jerk (First sign) -> Resp Depression -> Cardiac Arrest.
  Antidote: Calcium Gluconate.

GDM (Gestational Diabetes)

• Screening (DIPSI/WHO): 75g Glucose (2 hr value). Single step.
  Criteria: Fasting >92, 1hr >180, 2hr >153. (Any one abnormal = GDM).

Active Management of 3rd Stage (AMTSL)

To prevent PPH (Atonic PPH is MC cause).

1. Oxytocin 10 IU IM (Within 1 min).
2. Controlled Cord Traction (CCT).
3. Uterine Massage.

Shoulder Dystocia

McRoberts Maneuver (Hyperflexion of hips) -> Suprapubic Pressure -> Woods Corkscrew -> Gaskin (All fours) -> Zavanelli (Push back & CS).

Occipito-Posterior (OP)

• Pelvis: Anthropoid Pelvis.
• Delivery: Face to Pubis (if persistent OP).
• It is NOT an indication for CS. Can deliver vaginally.

• Rupture Uterus: Scarred uterus. Loss of FHS, Fetal parts felt easily, Maternal Tachycardia. Rx: Laparotomy.
• Abruptio Placentae: Painful bleeding. Tender uterus (Couvelaire Uterus). DIC risk.
• Placenta Previa: Painless, Causeless, Recurrent bleeding. Warning hemorrhage. No PV exam.
• VVF (Vesicovaginal Fistula): Obstructed labor (Pressure necrosis). Repair after 3 months.