Obstetrics & Gynecology I HANDBOOK11.pdf

Dr. Adenwali Hassan Ahmed
Lecturer of university and somaville university

1. HOPE UNIVERSITY
FACULTY OF MEDICINE

Hand book for Obstetrics & Gynecology I















Dr. Adenwali Hassan Ahmed:
(CMNs, Medical Doctor, Public Health Officer, Msc-Gyn/Obest.)

2. CONTENTS:

A. Obstetrics:
CHAPTER 1: Introduction
CHAPTER 2: Anatomy & Physiology in Relation to Pregnancy
CHAPTER 3: Normal Pregnancy
CHAPTER 4: Normal Labor
CHAPTER 5: Puerperium
CHAPTER 6: High-Risk Pregnancy & Complications
CHAPTER 7: Abnormal Pregnancy
CHAPTER 8: Operative Obstetrics
CHAPTER 9: Obstetric Emergencies
CHAPTER 10: Neonatology (Basics)

B. Gynecology:
CHAPTER 11: Introduction
CHAPTER 12: Developmental Abnormalities
CHAPTER 13: Menstrual Disorders
CHAPTER 14: Reproductive Endocrinology
CHAPTER 15: Benign Gynecological Conditions
CHAPTER 16: Malignant Conditions
CHAPTER 17: Urogynecology
CHAPTER 18: Infections
CHAPTER 19: Gynecological Procedures
CHAPTER 20: Recent Advances

3. Obstetrics:
Chapter 1: Introduction (Overview)
What is Obstetrics?
Obstetrics is the branch of medicine and surgery concerned with:
 Pregnancy
 Childbirth
 The postpartum period (puerperium)
It focuses on maternal and fetal health during these stages, ensuring the well-being of both
mother and baby.

Key Objectives of Obstetrics:
1. Ensure safe pregnancy and delivery
2. Monitor fetal development
3. Prevent and manage complications
4. Support maternal health before, during, and after birth
5. Educate about reproductive health and family planning

??? Scope of Obstetrics:
 Antenatal care (prenatal care): Monitoring pregnancy and preparing for delivery.
 Intrapartum care: Managing labor and childbirth.
 Postnatal care: Supporting recovery and infant health.
 Emergency care: Handling complications like preeclampsia, hemorrhage, etc.

??? History and Evolution:
 Obstetrics has evolved from a midwifery-based practice to a scientific and
specialized field.
 Advances in ultrasound, genetic testing, and surgical techniques (e.g., C-sections)
have improved outcomes.
 Collaboration with gynecology has formed the combined specialty: Obstetrics and
Gynecology (OB/GYN).

??? Roles of an Obstetrician:

4.  Diagnose and manage pregnancies
 Provide routine prenatal checkups
 Conduct deliveries (vaginal or cesarean)
 Identify and treat complications
 Offer postpartum support

??? Importance in Public Health:
 Maternal and infant mortality are key indicators of a nation's healthcare quality.
 Obstetric care helps reduce maternal deaths, neonatal deaths, and birth-related
complications.

6. Chapter 2: Anatomy & Physiology in Relation to Pregnancy

1. Female Reproductive Anatomy
A. External Genitalia (Vulva)
 Mons pubis – fatty tissue over the pubic bone
 Labia majora & minora – protective folds
 Clitoris – erectile tissue, highly sensitive
 Vestibule – area containing urethral and vaginal openings
B. Internal Genitalia
 Vagina – birth canal; receives sperm
 Uterus – where the fetus develops
o Fundus – top portion
o Body (corpus) – central portion
o Cervix – lower part; opens during labor
 Fallopian Tubes – transport egg from ovary to uterus; site of fertilization
 Ovaries – produce ova and hormones (estrogen & progesterone)

2. Physiological Changes During Pregnancy
Pregnancy triggers systemic changes across multiple body systems:
A. Reproductive System
 Uterus enlarges to accommodate the fetus (from ~70g to >1000g)
 Cervix softens (Goodell’s sign) and becomes more vascular (Chadwick’s sign)
 Vagina increases blood flow, secretions become more acidic (protective)
 Ovaries cease ovulation; corpus luteum supports early pregnancy
B. Cardiovascular System
 Blood volume increases by ~40–50%
 Cardiac output rises
 Heart rate increases (~10–15 bpm)
 Blood pressure may slightly decrease in 2nd trimester
C. Respiratory System
 Tidal volume increases
 Oxygen demand rises
 Slight hyperventilation occurs (helps remove fetal CO₂)
D. Gastrointestinal System

7.  Slowed motility → constipation
 Relaxation of esophageal sphincter → heartburn (GERD)
 Nausea and vomiting (esp. 1st trimester)
E. Renal System
 Glomerular filtration rate (GFR) increases
 Urinary frequency due to uterine pressure
F. Musculoskeletal System
 Lordosis (curved lower back) to support posture
 Ligament laxity (due to relaxin hormone) for pelvic flexibility
G. Skin Changes
 Linea nigra – dark line on abdomen
 Chloasma – ―mask of pregnancy‖ on the face
 Striae gravidarum – stretch marks
H. Endocrine System
 Placenta acts as an endocrine organ:
o hCG (human chorionic gonadotropin) – maintains corpus luteum
o Estrogen – promotes uterine growth, breast development
o Progesterone – maintains endometrium, inhibits contractions
o Relaxin – softens cervix, relaxes ligaments
o Prolactin – prepares breasts for lactation

3. Breast Changes
 Increase in size and vascularity
 Areola darkens; Montgomery glands enlarge
 Colostrum (early milk) may be secreted late in pregnancy

4. Placental Development
 Develops from trophoblast cells after implantation
 Functions:
o Nutrient/gas exchange
o Waste removal
o Hormone production
o Immune barrier

8. 5. Fetal Development Overview (Briefly Touched in Some Texts)
 Trimester division (First, Second, Third)
 Basic timeline of organ formation and fetal growth

10. Chapter 3: Normal Pregnancy

1. Definition of Pregnancy
 The physiological condition in which a fetus develops inside the uterus.
 Normal pregnancy refers to a pregnancy that progresses without major
complications and results in a healthy delivery.

2. Duration of Pregnancy
 40 weeks from the first day of the last menstrual period (LMP)
 Divided into three trimesters:
o 1st trimester: 0–13 weeks
o 2nd trimester: 14–26 weeks
o 3rd trimester: 27–40 weeks

3. Diagnosis of Pregnancy
A. Presumptive Signs (subjective)
 Amenorrhea (missed period)
 Nausea/vomiting (morning sickness)
 Breast tenderness
 Fatigue
 Urinary frequency
 Quickening (fetal movements felt ~18–20 weeks in primigravida, 16–18 in
multigravida)
B. Probable Signs (objective)
 Abdominal enlargement
 Goodell’s sign (softening of cervix)
 Chadwick’s sign (bluish discoloration of cervix/vagina)
 Hegar’s sign (softening of lower uterus)
 Positive pregnancy test (detects hCG)
C. Positive Signs
 Fetal heartbeat (detected by Doppler or stethoscope)
 Fetal movements felt by examiner
 Ultrasound showing fetus

11. 4. Physiological Changes in Pregnancy
Covered in more detail in Chapter 2, but here’s a quick reminder:
 Cardiovascular: ↑ blood volume, ↑ heart rate
 Respiratory: ↑ oxygen demand
 GI: nausea, constipation
 Musculoskeletal: postural changes
 Skin: pigmentation, stretch marks
 Endocrine: hormonal surge (hCG, estrogen, progesterone)

5. Routine Antenatal (Prenatal) Care
A. Schedule of Visits
 Monthly until 28 weeks
 Biweekly until 36 weeks
 Weekly until delivery
B. Initial Visit Includes:
 Full medical and obstetric history
 Physical exam
 Baseline labs (CBC, blood group, HIV, hepatitis B, syphilis, rubella, urine analysis)
 Dating ultrasound
C. Ongoing Care Includes:
 Monitoring weight, BP, fetal growth
 Fundal height measurement
 Fetal heart rate check
 Urine tests for protein and glucose
 Counseling on nutrition, rest, danger signs, and birth preparedness

6. Nutrition in Pregnancy
 Increased caloric intake (about 300–500 extra kcal/day)
 High in iron, calcium, folic acid, protein
 Supplements: Iron + folic acid to prevent anemia and neural tube defects

7. Minor Discomforts of Pregnancy
Common and usually not harmful:

12.  Nausea/vomiting
 Constipation
 Heartburn
 Backache
 Leg cramps
 Varicose veins
 Edema (swelling)
Management: Lifestyle changes, hydration, small frequent meals, light exercise

8. Fetal Development by Trimester
??? 1st Trimester
 Organogenesis occurs
 High risk of miscarriage
 Fetal heart visible on ultrasound by ~6 weeks
??? 2nd Trimester
 Fetal movements felt (quickening)
 Anatomy scan at 18–22 weeks
 Sex can usually be identified
??? 3rd Trimester
 Rapid growth and fat accumulation
 Lungs mature
 Fetus gets into position for birth

9. Psychological Aspects of Pregnancy
 Excitement, anxiety, mood swings
 Support and education are important
 Encourage partner/family involvement

10. Danger Signs in Pregnancy (even if it appears normal)
These require immediate medical attention:
 Bleeding
 Severe abdominal pain
 Severe headaches or blurred vision

13.  Swelling of hands/face
 Decreased fetal movements
 Fever
 Leaking of fluid from vagina

15. Chapter 4: Normal Labor

1. Definition of Labor
Labor is the process by which the fetus, placenta, and membranes are expelled from the
uterus through the birth canal.
Normal labor is:
 Spontaneous in onset
 At term (≥ 37 weeks)
 With vertex (head-first) presentation
 Without complications
 Completed within a reasonable time
 Results in vaginal delivery of a healthy baby

2. Signs of True Labor
 Regular, increasing contractions (intensity, frequency, and duration)
 Pain in lower back radiating to the abdomen
 Progressive cervical dilation and effacement
 Show – blood-tinged mucus discharge
 Rupture of membranes (spontaneous or artificial)
??? Distinguish from false labor (Braxton-Hicks contractions) which are irregular and don’t
cause cervical changes.

3. Stages of Labor
??? First Stage – Cervical Dilation
 From onset of true labor to full cervical dilation (10 cm)
 Divided into:
o Latent phase: 0–3/4 cm, slow progress
o Active phase: 4–10 cm, rapid cervical dilation
Normal rate:
 Nulliparous: ~1.2 cm/hr
 Multiparous: ~1.5 cm/hr
??? Second Stage – Expulsion of the Baby
 From full dilation to delivery of baby

16.  Strong, frequent contractions
 Maternal pushing efforts begin
 Duration:
o Nulliparous: up to 2 hours (3 with epidural)
o Multiparous: up to 1 hour (2 with epidural)
??? Third Stage – Expulsion of Placenta
 From birth of baby to delivery of placenta
 Normally within 5–30 minutes
 Managed actively with uterotonics (e.g., oxytocin) to reduce bleeding
??? Fourth Stage – Immediate Postpartum (Observation)
 First 1–2 hours after placenta delivery
 Monitor for:
o Hemorrhage
o Uterine tone
o Vital signs

4. Mechanism of Labor (Cardinal Movements)
The movements the fetus undergoes to navigate through the birth canal:
1. Engagement – fetal head enters the pelvic brim
2. Descent – downward movement through pelvis
3. Flexion – fetal chin tucks to present the smallest diameter
4. Internal rotation – head rotates to fit pelvis
5. Extension – head extends as it passes under pubic symphysis
6. External rotation (restitution) – head realigns with shoulders
7. Expulsion – rest of the body is delivered

5. Management of Normal Labor
A. First Stage
 Monitor:
o Maternal vitals
o Fetal heart rate (FHR)
o Uterine contractions
o Cervical dilation (via vaginal exam)
 Encourage mobility, hydration, and comfort
 Pain relief: non-pharmacological or epidural
B. Second Stage

17.  Support maternal pushing efforts
 Assist delivery if needed (e.g., episiotomy or vacuum in select cases)
 Continuous fetal monitoring
C. Third Stage
 Watch for signs of placental separation:
o Gush of blood
o Cord lengthening
o Uterine fundus rises
 Active Management:
o Oxytocin injection
o Controlled cord traction
o Uterine massage

6. Monitoring Tools
 Partograph: Graphical record of labor progress (dilation, descent, contractions,
vitals)
 Fetal monitoring:
o Intermittent auscultation
o Continuous CTG (Cardiotocography) in high-risk cases

7. Pain Management Options
 Breathing techniques and positioning
 Warm baths, massage
 Epidural analgesia
 Intravenous opioids (limited use)

8. Complications to Watch For
Even in expected normal labor, stay alert for:
 Prolonged labor
 Fetal distress
 Postpartum hemorrhage
 Retained placenta
 Perineal trauma
Immediate intervention may be required if complications arise — converting a "normal
labor" into a managed or assisted delivery.

18. Summary
Normal labor is a natural, physiological process. Its successful outcome relies on:
 Careful monitoring
 Supportive management
 Timely recognition of deviations
The goal is a safe vaginal delivery with a healthy mother and baby.
1. Diagram – Stages of Labor
+----------------------+----------------------------+
| Stage | Description |
+----------------------+----------------------------+
| 1st Stage | Cervical dilation (0–10 cm)|
| - Latent Phase | Slow progress (0–4 cm) |
| - Active Phase | Rapid progress (4–10 cm) |
+----------------------+----------------------------+
| 2nd Stage | Delivery of the baby |
+----------------------+----------------------------+
| 3rd Stage | Delivery of placenta |
+----------------------+----------------------------+
| 4th Stage | Observation (1–2 hrs) |
+----------------------+----------------------------+

2. Partograph Overview
A partograph is a tool used to monitor labor progress and spot abnormalities early.
Parameter What it Shows
Cervical dilation Labor progress (in cm)
Descent of head How far fetal head has moved down
Contractions Frequency and strength
Fetal heart rate Baby’s well-being
Maternal vitals BP, temperature, pulse
Urine output/tests Hydration, proteinuria, ketones
??? Used to detect prolonged labor or fetal distress

19. Chapter 5: Puerperium

1. Definition
Puerperium is the period following childbirth during which the maternal body undergoes
physiological changes to return to the non-pregnant state.
??? Duration: Usually 6 weeks (42 days) postpartum
??? Focuses on recovery of:
 Uterus
 Hormonal system
 Lactation
 Other organs and functions

2. Phases of Puerperium
Phase Time Period Key Focus
Immediate First 24 hours post-delivery Watch for hemorrhage and shock
Early Up to 7 days Physical recovery, bonding
Remote Up to 6 weeks Return of menstruation, uterus involution

3. Physiological Changes in the Puerperium
A. Uterine Involution
 Uterus returns to pre-pregnancy size (~6 weeks)
 Immediately after delivery, uterus is palpable at the umbilicus
 By day 10, no longer palpable abdominally

B. Lochia (Vaginal discharge)
Type Description Duration
Lochia rubra Red, blood-stained Days 1–3
Lochia serosa Pinkish-brown, watery Days 4–10

20. Type Description Duration
Lochia alba Whitish or yellowish-white Days 10–14+
??? Foul-smelling lochia = possible infection (puerperal sepsis)
C. Lactation (Breast Changes)
 Milk production stimulated by prolactin
 Milk ejection (let-down reflex) caused by oxytocin
 Colostrum: thick, yellow, antibody-rich milk for first few days
 Exclusive breastfeeding is encouraged for 6 months
D. Hormonal Adjustments
 Decline in hCG, estrogen, progesterone
 Return of ovulation in 6–8 weeks if not breastfeeding
 Breastfeeding delays ovulation (natural contraception for a few months)
E. Other Body Changes
 Urinary system: Bladder tone returns; risk of retention or infection early on
 GI system: Appetite returns; constipation common
 CV system: Blood volume and cardiac output normalize

4. Psychological Aspects
 Emotional changes common
o ―Baby blues‖: mild, self-limited mood swings (first week)
o Postpartum depression: lasts longer, needs treatment
o Postpartum psychosis: medical emergency
??? Support, rest, and family involvement are essential.

5. Postnatal (Postpartum) Care
??? Goals:
 Promote maternal recovery
 Encourage breastfeeding
 Prevent and detect complications
 Provide emotional support
 Counsel on family planning

21. ??? Monitoring:
 Vital signs, lochia, uterine tone
 Breast condition
 Bladder/bowel function
 Emotional state
??? Follow-up:
 Postnatal check-up at 6 weeks
 Pap smear, if due
 Discuss contraception options

6. Complications in Puerperium
Complication Description
Puerperal hemorrhage Heavy bleeding >500 ml after delivery
Puerperal sepsis Infection of genital tract
Mastitis Painful breast infection
Thrombophlebitis Clot in veins, especially legs
Postpartum depression Persistent sadness, anxiety
Urinary issues Incontinence or retention

7. Family Planning in Puerperium
 Important to counsel before discharge
 Methods include:
o Lactational amenorrhea method (LAM)
o Barrier methods (condoms)
o IUD (can be inserted postpartum)
o Pills or injectables (start after 6 weeks if breastfeeding)

Summary
The puerperium is a crucial phase where the mother physically and emotionally recovers
from childbirth. Proper postnatal care, education, and support help ensure:

22.  Safe recovery
 Successful breastfeeding
 Prevention of complications
 Family planning readiness

24. Chapter 6: High-Risk Pregnancy & Complications

1. Definition of High-Risk Pregnancy
A high-risk pregnancy is one in which the health or life of the mother, fetus, or both is at
greater risk than in a normal pregnancy due to pre-existing conditions, pregnancy-related
disorders, or complications that arise.

2. Categories of High-Risk Factors
A. Maternal Factors
 Age: <18 years or >35 years
 Pre-existing medical conditions:
o Hypertension
o Diabetes mellitus
o Cardiac disease
o Renal disorders
o Autoimmune diseases
 Previous obstetric history:
o History of miscarriage
o Preterm labor
o Cesarean section
o Stillbirth
B. Pregnancy-Related Conditions
 Multiple gestation (twins or more)
 Placental abnormalities (e.g., previa, abruption)
 Rh incompatibility
 Polyhydramnios or oligohydramnios
 Gestational diabetes
 Hypertensive disorders of pregnancy
C. Fetal Conditions
 Intrauterine growth restriction (IUGR)
 Congenital anomalies
 Non-reassuring fetal heart rate
 Preterm labor

3. Common High-Risk Conditions & Complications

25. 1. Hypertensive Disorders of Pregnancy
Types:
 Gestational hypertension: BP ≥140/90 mmHg after 20 weeks, no proteinuria
 Preeclampsia: Hypertension + proteinuria ± symptoms (headache, edema)
 Eclampsia: Preeclampsia + seizures
 HELLP syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets
??? Management:
 Close monitoring
 Antihypertensives (e.g., labetalol)
 Magnesium sulfate for seizure prevention (in eclampsia)
 Early delivery if severe

2. Gestational Diabetes Mellitus (GDM)
 Glucose intolerance first recognized in pregnancy
 Risks: Macrosomia, shoulder dystocia, stillbirth
??? Diagnosis: Oral glucose tolerance test (OGTT) at 24–28 weeks
??? Management:
 Diet and exercise
 Insulin if needed
 Monitor fetal growth



3. Antepartum Hemorrhage (APH)
A. Placenta Previa
 Placenta covers cervix (partially or fully)
 Painless bleeding in late pregnancy
 Requires C-section
B. Placental Abruption
 Premature separation of placenta
 Painful bleeding, uterine tenderness
 Can lead to fetal distress or death

26. 4. Rh Incompatibility
 Occurs when Rh-negative mother carries Rh-positive fetus
 Mother may develop antibodies that attack fetal RBCs
 Leads to hemolytic disease of the newborn
??? Prevention:
 Rhogam (anti-D immunoglobulin) at 28 weeks and after delivery

5. Preterm Labor
 Labor before 37 weeks gestation
??? Risk factors: Infection, short cervix, multiple gestation
??? Management:
 Tocolytics (to delay labor)
 Corticosteroids (for fetal lung maturity)
 Monitor and possibly admit for observation

6. Intrauterine Growth Restriction (IUGR)
 Fetus is smaller than expected for gestational age
??? Causes:
 Placental insufficiency
 Maternal hypertension, malnutrition
 Fetal anomalies or infections
??? Management:
 Frequent monitoring (USG, Doppler, NST)
 Early delivery if growth stops or fetal distress develops

7. Amniotic Fluid Disorders
Condition Description Risks

27. Condition Description Risks
Polyhydramnios Excess amniotic fluid Preterm labor, malpresentations
Oligohydramnios Too little amniotic fluid IUGR, fetal distress

8. Infections in Pregnancy
 TORCH infections (Toxoplasmosis, Others [syphilis, varicella], Rubella, CMV,
Herpes)
 Urinary tract infections (UTIs)
 HIV – risk of vertical transmission
??? Management:
 Early screening
 Appropriate antibiotic/antiviral therapy
 Monitoring fetal effects

4. Monitoring High-Risk Pregnancies
 More frequent antenatal visits
 Ultrasounds (growth, amniotic fluid, placental position)
 Doppler studies (blood flow to fetus)
 NST (Non-Stress Test) – fetal heart rate monitoring
 Biophysical profile (BPP)

5. Delivery Planning in High-Risk Cases
 Based on maternal and fetal condition
 Timing and mode of delivery may be altered
 NICU support may be needed
 Referral to tertiary center if complications expected

✅ Summary
A high-risk pregnancy requires:
 Early identification
 Close monitoring

28.  Multidisciplinary care
to ensure the best outcomes for both mother and baby.


29. Chapter 7: Abnormal Pregnancy

1. Definition
Abnormal pregnancy refers to any pregnancy that is complicated by abnormal
implantation, development, or function of the embryo/fetus, placenta, or maternal
physiology — leading to increased risk of complications.

2. Types of Abnormal Pregnancy

1. Ectopic Pregnancy
Definition:
 Fertilized ovum implants outside the uterine cavity
 Most common site: Fallopian tube
??? Symptoms:
 Amenorrhea
 Unilateral lower abdominal pain
 Vaginal bleeding
 Signs of shock if ruptured
??? Diagnosis:
 Positive pregnancy test (hCG)
 No intrauterine gestational sac on ultrasound
 Transvaginal USG + serial β-hCG crucial
??? Management:
 Medical: Methotrexate (if early, unruptured)
 Surgical: Laparoscopy (salpingostomy or salpingectomy)

2. Molar Pregnancy (Hydatidiform Mole)
Definition:
 Abnormal fertilization leads to non-viable trophoblastic tissue
 A type of gestational trophoblastic disease (GTD)

30. Types:
Type Features
Complete mole No fetus, 46 XX (paternal only DNA)
Partial mole Abnormal fetus, 69 chromosomes (triploid)
??? Symptoms:
 Vaginal bleeding in early pregnancy
 Uterus larger than expected for gestational age
 High hCG levels
 Snowstorm appearance on ultrasound
 Hyperemesis gravidarum
??? Management:
 Suction evacuation
 Serial hCG monitoring until negative
 Contraception advised for 6–12 months to monitor recurrence

3. Missed Abortion
 Fetus dies but is retained in the uterus
 No fetal heart sounds
 Brownish discharge, no uterine growth
??? Management:
 Medical or surgical evacuation (D&C or misoprostol)

4. Threatened Abortion
 Vaginal bleeding without cervical dilation
 Viable pregnancy may continue normally
??? Management:
 Bed rest, monitoring, reassurance

5. Inevitable/Incomplete/Complete Abortion

31. Type Description
Inevitable Bleeding + cervical dilation, no expulsion yet
Incomplete Partial expulsion of products of conception
Complete All products expelled; uterus empty
??? Management:
 Depends on type and clinical condition
 May include uterine evacuation, monitoring, blood transfusion

6. Intrauterine Fetal Death (IUFD)
 Fetal death after 20 weeks but before delivery
??? Signs:
 No fetal movements
 Absent fetal heart sounds
 Ultrasound confirms no cardiac activity
??? Management:
 Induction of labor
 Psychological support
 Investigate cause

7. Blighted Ovum (Anembryonic Pregnancy)
 Gestational sac develops without an embryo
 Appears like early pregnancy but fails to develop
??? Management: Medical or surgical evacuation

8. Hyperemesis Gravidarum
 Severe, persistent vomiting during early pregnancy
 Leads to dehydration, weight loss, electrolyte imbalance
??? Management:

32.  IV fluids, antiemetics
 Correct electrolytes
 Rule out molar pregnancy

9. Cervical Incompetence
 Painless dilation of cervix in 2nd trimester
 Leads to recurrent mid-trimester losses
??? Management:
 Cervical cerclage (surgical stitch to keep cervix closed)

3. Diagnostic Tools for Abnormal Pregnancy
 Transvaginal ultrasound
 Serial β-hCG levels
 Pelvic examination
 Urine/blood tests
 Histopathology (after evacuation if needed)

4. Emotional and Psychological Support
 Abnormal pregnancies often lead to grief, anxiety, or depression
 Counseling and follow-up care are essential

✅ Summary
Abnormal pregnancies range from implantation issues (ectopic) to early developmental
failures (molar, missed abortion). Timely diagnosis, intervention, and emotional support are
essential to minimize risks and preserve future fertility and health.

33. Chapter 8: Operative Obstetrics

1. Definition
Operative obstetrics refers to the use of instruments or surgical techniques to assist in the
delivery of a baby when a normal vaginal delivery is not progressing or poses risk to the
mother or fetus.

2. Indications for Operative Delivery
Indications Explanation
Prolonged second stage of labor Failure of descent or arrest of labor
Fetal distress Non-reassuring fetal heart rate
Maternal exhaustion Inability to continue pushing
Certain maternal conditions Cardiac disease, severe hypertension
Malpresentation E.g., breech presentation
Failed instrumental delivery Need for cesarean section

3. Types of Operative Deliveries

A. Instrumental Vaginal Delivery
1. Forceps Delivery
o Metal instruments that grasp the fetal head.
o Types:
 Outlet forceps: when the head is visible at the perineum.
 Low forceps: head engaged but not visible.
 Mid-cavity forceps: head above ischial spines.
o Indications: Prolonged second stage, fetal distress, maternal conditions.
o Complications: Maternal soft tissue injury, fetal bruising, facial nerve palsy.
2. Vacuum Extraction
o Suction cup applied to fetal scalp.
o Less traumatic but limited use (head must be engaged).
o Indications: Similar to forceps.
o Complications: Scalp injuries, cephalohematoma.

34. B. Cesarean Section (C-Section)
 Surgical delivery of the fetus via abdominal and uterine incision.
Indications:
 Cephalopelvic disproportion (CPD)
 Placenta previa
 Fetal distress
 Failure to progress
 Breech or transverse lie
 Previous uterine surgery (scarred uterus)
Types of uterine incisions:
 Lower segment transverse incision (most common)
 Classical (vertical) incision (rare, more bleeding)
Complications:
 Infection
 Hemorrhage
 Injury to bladder or bowel
 Adhesions
 Risks in future pregnancies

4. Other Operative Procedures
 Episiotomy: surgical incision of the perineum to enlarge the vaginal opening.
 Symphysiotomy: rare procedure to widen pelvis by cutting the pubic symphysis.
 Internal podalic version: used to deliver second twin or malpresentation by hand.

5. Preparation for Operative Delivery
 Informed consent
 Assess fetal position and station
 Empty bladder
 Adequate analgesia or anesthesia
 Proper aseptic technique

6. Postoperative/Post-delivery Care

35.  Monitor for bleeding, infection
 Pain management
 Support for breastfeeding and bonding
 Assess for complications (e.g., urinary retention, wound healing)

7. Complications of Operative Obstetrics
Complication Possible Cause
Maternal hemorrhage Surgical injury or poor contraction
Infection (endometritis, wound) Poor asepsis, prolonged labor
Bladder or ureter injury During cesarean or forceps use
Neonatal trauma Instrumental delivery
Thromboembolism Prolonged bed rest, surgery

✅ Summary
Operative obstetrics involves skilled use of surgical and instrumental techniques to safely
deliver babies in complicated labors. Proper indication, technique, and aftercare are crucial to
minimize risks.

36. Chapter 9: Obstetric Emergencies

1. Common Obstetric Emergencies
Emergency Key Features Immediate Management
Postpartum
hemorrhage (PPH)
Blood loss >500 ml (vaginal),
>1000 ml (C-section)
ABCs, uterine massage, uterotonics, IV
fluids, blood transfusion, surgery if needed
Eclampsia Seizures in preeclampsia patient
Secure airway, magnesium sulfate, control
BP, delivery
Uterine rupture
Sudden abdominal pain, fetal
distress, vaginal bleeding
Emergency laparotomy, cesarean delivery
Cord prolapse
Umbilical cord presents before
fetus
Relieve pressure on cord, emergency C-
section
Amniotic fluid
embolism
Sudden respiratory distress,
hypotension
Supportive care, ICU admission
Shoulder dystocia
Failure of shoulders to deliver
after head
McRoberts maneuver, suprapubic pressure
Abruptio placentae
Painful vaginal bleeding, uterine
tenderness
Stabilize mother, urgent delivery if fetal
distress

2. Postpartum Hemorrhage (PPH)
 Primary PPH: within 24 hours postpartum
 Secondary PPH: after 24 hours, up to 6 weeks
Causes (4 Ts):
 Tone: uterine atony (most common)
 Tissue: retained placenta or clots
 Trauma: lacerations, uterine rupture
 Thrombin: coagulopathies
Management:
 Immediate fundal massage
 Uterotonics (oxytocin, misoprostol)
 IV fluids, blood transfusion
 Surgical intervention (e.g., uterine artery ligation, hysterectomy)

37. 3. Eclampsia
 Generalized tonic-clonic seizures in pregnant woman with hypertension and
proteinuria
Management:
 Magnesium sulfate (seizure prophylaxis and treatment)
 Control blood pressure (labetalol, hydralazine)
 Prompt delivery after stabilization
 Monitor mother and fetus closely

4. Uterine Rupture
 Rare but life-threatening
 Risk factors: scarred uterus (previous C-section), obstructed labor
Signs:
 Sudden, severe abdominal pain
 Loss of fetal station
 Vaginal bleeding
 Maternal shock
Management:
 Emergency laparotomy and cesarean section
 Blood transfusion and resuscitation

5. Cord Prolapse
 Umbilical cord slips ahead of presenting part, risking cord compression and fetal
hypoxia
Management:
 Position mother to relieve pressure (knee-chest, Trendelenburg)
 Manually elevate presenting part if possible
 Immediate cesarean section

6. Shoulder Dystocia

38.  Fetal shoulders stuck after delivery of the head
Signs:
 Turtle sign (head retracts)
 Failure to deliver shoulders
Maneuvers:
 McRoberts maneuver (hyperflex maternal hips)
 Suprapubic pressure
 Delivery of posterior arm

7. Amniotic Fluid Embolism (AFE)
 Sudden cardiovascular collapse due to amniotic fluid entering maternal circulation
Signs:
 Dyspnea, hypotension, coagulopathy
Management:
 Intensive supportive care (O2, fluids, vasopressors)
 ICU monitoring

8. Abruptio Placentae
 Premature separation of normally implanted placenta
Symptoms:
 Painful vaginal bleeding
 Uterine tenderness and rigidity
Management:
 Stabilize mother (IV fluids, blood)
 Monitor fetus
 Expedite delivery if indicated

39. Summary
Obstetric emergencies require rapid recognition, effective resuscitation, and timely
intervention to prevent maternal and fetal morbidity and mortality.

40. Chapter 10: Neonatology (Basics)

1. Definition of Neonatology
Neonatology is the branch of pediatrics that deals with the medical care of newborn infants,
especially the ill or premature newborn.

??? 2. The Neonatal Period
 The first 28 days (4 weeks) after birth.
 Divided into:
o Early neonatal period: first 7 days
o Late neonatal period: day 8 to 28

??? 3. Physiological Adaptations at Birth
System Changes at Birth
Respiratory Initiation of breathing; clearance of lung fluid
Cardiovascular Closure of foramen ovale, ductus arteriosus
Thermoregulation Shift to maintaining body temperature independently
Metabolic Activation of gluconeogenesis and thermogenesis

4. Immediate Care of the Newborn
 Apgar Score (at 1 and 5 minutes)
o Appearance, Pulse, Grimace, Activity, Respiration
o Scores 0–10; <7 may need intervention
 Airway clearance
 Thermal protection
 Early skin-to-skin contact
 Initiate breastfeeding within 1 hour

5. Common Neonatal Assessments
 Physical exam: weight, length, head circumference
 Vital signs: temperature, heart rate, respiratory rate

41.  Screening tests: hearing, metabolic diseases (e.g., PKU)

6. Common Neonatal Problems
Problem Features Management
Hypothermia Low body temp, lethargy Warm environment, monitor
Hypoglycemia Jitteriness, poor feeding
Early feeding, glucose
monitoring
Jaundice
(Physiological)
Yellow skin/eyes after 24 hours, resolves by
day 7
Phototherapy if severe
Respiratory distress Tachypnea, grunting, nasal flaring
Oxygen therapy, NICU if
needed

7. Neonatal Resuscitation
 Follow the ABC approach:
o Airway: clear if obstructed
o Breathing: stimulate or ventilate if no breathing
o Circulation: chest compressions if heart rate <60 bpm
 Use of oxygen, intubation if needed

8. Breastfeeding Benefits
 Provides optimal nutrition
 Transfers maternal antibodies
 Enhances bonding
 Reduces infections

✅ Summary
Basic neonatal care focuses on supporting the newborn’s transition, ensuring stable vital
functions, and early detection of problems to improve outcomes.

42. Gynecology - Chapter 11: Introduction

1. Definition of Gynecology
Gynecology is the branch of medicine that deals with the health of the female reproductive
system, including the uterus, ovaries, fallopian tubes, vagina, and external genitalia, as well
as the breasts.

2. Scope of Gynecology
 Diagnosis and treatment of disorders related to:
o Menstrual cycle abnormalities
o Infections of the reproductive tract
o Hormonal disorders
o Benign and malignant tumors
o Infertility
o Contraception
o Pelvic floor disorders
o Menopause and associated conditions

3. Anatomy and Physiology Overview
 Female reproductive organs:
o Internal: ovaries, fallopian tubes, uterus, cervix, vagina
o External: vulva, labia, clitoris, Bartholin’s glands
 Menstrual cycle:
o Phases: menstrual, proliferative, secretory
o Controlled by hormones: FSH, LH, estrogen, progesterone

4. Common Gynecological Complaints
 Abnormal uterine bleeding
 Pelvic pain
 Vaginal discharge
 Infertility
 Menstrual irregularities
 Sexual dysfunction

??? 5. Diagnostic Tools in Gynecology

43.  Pelvic examination
 Pap smear (cervical cytology)
 Ultrasound (transvaginal and abdominal)
 Hysteroscopy and laparoscopy
 Hormonal assays
 Biopsy of lesions

6. Importance of Gynecological Health
 Preventive care: regular screening for cervical and breast cancer
 Early detection and treatment of infections and malignancies
 Counseling on reproductive health and contraception

Summary
Gynecology covers a wide range of women’s reproductive health issues. A good
understanding of anatomy, physiology, and common complaints is essential for effective
diagnosis and management.

44. Chapter 12: Developmental Abnormalities

1. Overview
Developmental abnormalities refer to congenital malformations of the female genital tract
caused by errors in embryological development of the Müllerian ducts (paramesonephric
ducts) and related structures.

2. Embryology Recap
 The Müllerian ducts develop into the fallopian tubes, uterus, cervix, and upper two-
thirds of the vagina.
 The sinovaginal bulbs form the lower one-third of the vagina.
 Abnormalities arise due to:
o Failure of formation
o Failure of fusion
o Failure of resorption

3. Types of Developmental Abnormalities

A. Hypoplasia or Agenesis
 Complete or partial absence of uterus, cervix, and/or vagina.
 Examples:
o Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome,
MRKH): absent uterus and upper vagina, normal ovaries.
 Clinical presentation:
o Primary amenorrhea with normal secondary sexual characteristics.

B. Unicornuate Uterus
 Only one Müllerian duct develops fully.
 Small or absent contralateral horn.
 May have rudimentary horn, sometimes non-communicating.
 Associated with infertility, miscarriage, or preterm labor.

45. C. Didelphys Uterus
 Complete failure of fusion of Müllerian ducts.
 Two separate uteri and two cervices.
 May have double vagina or longitudinal vaginal septum.
 Often asymptomatic but may cause reproductive issues.

D. Bicornuate Uterus
 Partial fusion failure.
 Two uterine horns sharing a single cervix.
 Can lead to miscarriage, preterm birth.

E. Septate Uterus
 Failure of resorption of the midline septum after fusion.
 Single external uterine contour with internal division by a fibrous or muscular septum.
 Most common uterine anomaly associated with recurrent pregnancy loss.
 Surgical correction (metroplasty) can improve pregnancy outcomes.

F. Arcuate Uterus
 Mild concavity of the uterine fundus.
 Usually no significant clinical effect.

4. Vaginal Anomalies
 Imperforate hymen: vaginal outflow obstruction; presents with primary amenorrhea
and cyclic pain.
 Transverse vaginal septum: partial or complete obstruction.
 Vaginal agenesis: part of MRKH syndrome.

5. Clinical Presentation
 Primary amenorrhea
 Recurrent pregnancy loss
 Infertility
 Dysmenorrhea
 Obstetric complications (preterm labor, malpresentation)

46. 6. Diagnosis
 History and physical examination
 Pelvic ultrasound
 MRI pelvis (best for detailed anatomy)
 Hysterosalpingography (HSG)
 Diagnostic laparoscopy and hysteroscopy

7. Management
Abnormality Management
MRKH syndrome Vaginal reconstruction if needed
Septate uterus Surgical metroplasty (resection of septum)
Unicornuate uterus Monitor pregnancy closely
Didelphys uterus Usually conservative, surgery rarely required
Vaginal obstruction Surgical correction (e.g., hymenotomy)

Summary
Developmental abnormalities of the female reproductive tract can significantly impact
fertility and pregnancy outcomes. Accurate diagnosis and appropriate management are key to
improving reproductive health.

47. Chapter 13: Menstrual Disorders

1. Introduction
Menstrual disorders encompass any deviations from the normal menstrual cycle in terms of
frequency, regularity, duration, or amount of bleeding.

2. Normal Menstrual Cycle Recap
 Duration: 21–35 days (average 28 days)
 Flow: 3–7 days
 Volume: 30–80 ml blood loss
 Controlled by interplay of hypothalamus, pituitary, ovaries, and endometrium

3. Classification of Menstrual Disorders

Disorder Definition Key Features
Amenorrhea Absence of menstruation Primary or secondary
Dysmenorrhea Painful menstruation Primary or secondary
Menorrhagia
(Hypermenorrhea)
Excessive menstrual bleeding (>80 ml
or >7 days)
Prolonged, heavy bleeding
Metrorrhagia Irregular bleeding between periods
Spotting or breakthrough
bleeding
Polymenorrhea
Frequent menstruation (<21-day
intervals)
Short cycles
Oligomenorrhea
Infrequent menstruation (>35-day
intervals)
Sparse or delayed cycles
Hypomenorrhea Scanty menstrual flow Very light bleeding

48. 4. Amenorrhea
 Primary Amenorrhea: No menstruation by age 15 (with secondary sexual
characteristics) or 13 (without them)
 Secondary Amenorrhea: Absence of menstruation for 3+ months after previously
normal cycles
Causes:
Primary Amenorrhea Causes Secondary Amenorrhea Causes
Hypogonadism (e.g., Turner syndrome) Pregnancy (most common)
Müllerian agenesis Hypothyroidism
Androgen insensitivity syndrome Pituitary tumors
Outflow tract abnormalities (imperforate hymen) PCOS

5. Dysmenorrhea
 Primary: Painful menstruation without pelvic pathology; usually begins within 6–12
months of menarche
 Secondary: Due to pelvic pathology (endometriosis, fibroids, PID)
Management:
 NSAIDs
 Hormonal contraceptives
 Treat underlying cause if secondary

6. Menorrhagia
 Causes:
o Fibroids
o Adenomyosis
o Coagulopathies
o Endometrial hyperplasia or carcinoma
 Investigations:
o CBC, coagulation profile
o Pelvic ultrasound
o Endometrial biopsy (if >35 years or abnormal bleeding)
 Management:
o Medical: Tranexamic acid, NSAIDs, hormonal therapy
o Surgical: Endometrial ablation, hysterectomy (last resort)

49. 7. Metrorrhagia and Irregular Bleeding
 Commonly caused by anovulatory cycles, infections, polyps, or malignancy
 Requires thorough evaluation with history, examination, and investigations

8. Polymenorrhea and Oligomenorrhea
 Usually due to hormonal imbalances like PCOS, thyroid disorders, or stress
 Managed by treating underlying causes and regulating cycles hormonally if needed

9. Investigations for Menstrual Disorders
 Pregnancy test
 Hormonal assays (FSH, LH, prolactin, TSH)
 Pelvic ultrasound
 Endometrial biopsy
 Hysteroscopy/laparoscopy for structural causes

10. General Management Principles
 Identify and treat underlying cause
 Symptomatic relief (pain, bleeding)
 Hormonal regulation when appropriate
 Counseling and follow-up

Summary
Menstrual disorders are common and can significantly affect quality of life and fertility. A
systematic approach to diagnosis and tailored treatment is essential.

50. Chapter 14: Reproductive Endocrinology

1. Introduction
Reproductive endocrinology studies the hormonal control of reproduction in both females
and males, including the hypothalamic-pituitary-gonadal axis and its influence on fertility,
puberty, and menstrual cycles.

2. Hypothalamic-Pituitary-Gonadal (HPG) Axis
 Hypothalamus secretes GnRH (gonadotropin-releasing hormone) in a pulsatile
manner.
 GnRH stimulates the anterior pituitary to release:
o FSH (follicle-stimulating hormone)
o LH (luteinizing hormone)
 FSH and LH act on the ovaries to regulate:
o Follicle development
o Ovulation
o Steroid hormone production (estrogen and progesterone)

3. Ovarian Hormones
 Estrogen:
o Produced mainly by developing follicles
o Promotes endometrial proliferation, secondary sexual characteristics
 Progesterone:
o Produced by corpus luteum after ovulation
o Prepares endometrium for implantation, maintains pregnancy
 Inhibin:
o Secreted by granulosa cells; inhibits FSH secretion

4. Menstrual Cycle Hormonal Changes
 Follicular phase: rising FSH → follicle maturation → estrogen secretion
 Ovulation: LH surge triggers release of the oocyte
 Luteal phase: corpus luteum produces progesterone and estrogen
 If no pregnancy: corpus luteum degenerates, progesterone drops, menstruation occurs

51. 5. Common Disorders in Reproductive Endocrinology

A. Polycystic Ovary Syndrome (PCOS)
 Characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries
 Hormonal findings: ↑ LH/FSH ratio (>2:1), ↑ androgens
 Clinical features: irregular menses, hirsutism, infertility, obesity
 Management: lifestyle changes, hormonal contraceptives, insulin sensitizers

B. Hypogonadism
 Primary hypogonadism: ovarian failure (e.g., Turner syndrome) → ↑ FSH and LH
 Secondary hypogonadism: hypothalamic or pituitary dysfunction → ↓ FSH and LH

C. Hyperprolactinemia
 Causes: pituitary adenoma, hypothyroidism, medications
 Effects: galactorrhea, amenorrhea, infertility
 Treatment: dopamine agonists (e.g., bromocriptine)

D. Thyroid Disorders
 Both hypothyroidism and hyperthyroidism affect menstrual function and fertility
 Must be evaluated in reproductive endocrine disorders

6. Other Hormones Affecting Reproduction
 GnRH analogs: used therapeutically to suppress or stimulate gonadal function
 Human chorionic gonadotropin (hCG): mimics LH, supports corpus luteum
 Relaxin, oxytocin, prolactin: roles in pregnancy and lactation

7. Diagnostic Evaluation
 Hormonal assays: FSH, LH, prolactin, estradiol, testosterone, TSH
 Imaging: pelvic ultrasound for ovarian morphology
 Dynamic tests: GnRH stimulation test

52. 8. Therapeutic Applications
 Hormonal contraception
 Ovulation induction (clomiphene citrate, gonadotropins)
 Treatment of endocrine disorders causing infertility

Summary
Reproductive endocrinology is vital to understanding female fertility and menstrual
regulation. Disorders of this system can lead to significant reproductive health issues but are
often manageable with appropriate hormonal therapies.

53. Chapter 15: Benign Gynecological Conditions

1. Introduction
Benign gynecological conditions are non-malignant disorders affecting the uterus, ovaries,
cervix, and vagina, often causing symptoms like pain, abnormal bleeding, or infertility.

2. Common Benign Conditions

A. Uterine Fibroids (Leiomyomas)
 Definition: Benign smooth muscle tumors of the uterus.
 Epidemiology: Most common pelvic tumor in women of reproductive age.
 Symptoms: Menorrhagia, pelvic pressure, pain, infertility.
 Diagnosis: Ultrasound (heterogeneous, hypoechoic masses).
 Management:
o Medical: NSAIDs, hormonal therapy (GnRH analogs).
o Surgical: Myomectomy, hysterectomy if severe.

B. Endometriosis
 Definition: Presence of endometrial tissue outside the uterus.
 Symptoms: Dysmenorrhea, chronic pelvic pain, dyspareunia, infertility.
 Sites: Ovaries, fallopian tubes, peritoneum.
 Diagnosis: Laparoscopy (gold standard).
 Management:
o Medical: NSAIDs, hormonal contraceptives, GnRH analogs.
o Surgical: Excision or ablation of lesions.

C. Adenomyosis
 Definition: Endometrial tissue within the myometrium.
 Symptoms: Heavy menstrual bleeding, dysmenorrhea, enlarged uterus.
 Diagnosis: Ultrasound or MRI.
 Management:
o Medical: Hormonal therapy.
o Surgical: Hysterectomy in severe cases.

54. D. Ovarian Cysts
 Types:
o Functional cysts (follicular, corpus luteum)
o Pathological cysts (dermoid, endometrioma)
 Symptoms: Often asymptomatic; pain if rupture or torsion.
 Diagnosis: Ultrasound.
 Management:
o Observation for functional cysts.
o Surgery if symptomatic or suspicious.

E. Pelvic Inflammatory Disease (PID)
 Definition: Infection of upper genital tract.
 Symptoms: Lower abdominal pain, fever, vaginal discharge.
 Complications: Infertility, ectopic pregnancy.
 Management: Broad-spectrum antibiotics.

F. Benign Cervical Conditions
 Cervical Polyps: Small, benign growths causing spotting.
 Nabothian cysts: Mucous-filled cysts on cervix, usually asymptomatic.


3. Diagnosis
 Clinical history and pelvic examination
 Ultrasound imaging
 Laparoscopy/hysteroscopy if needed
 Laboratory tests (e.g., CA-125 for ovarian masses, though mostly for malignancy)

4. General Management Principles
 Symptomatic relief
 Preservation of fertility when possible
 Regular follow-up and monitoring

55. Summary
Benign gynecological conditions are common and often manageable. Understanding their
presentation and treatment options helps improve patient quality of life and reproductive
outcomes.

56. Chapter 16: Malignant Conditions

1. Introduction
Malignant gynecological conditions refer to cancers of the female reproductive organs
including the cervix, uterus, ovaries, vagina, vulva, and fallopian tubes. Early detection and
management are crucial for improving survival.

2. Common Gynecological Malignancies

A. Cervical Cancer
 Etiology: Strongly associated with persistent infection with high-risk HPV types (16,
18).
 Screening: Pap smear, HPV testing.
 Symptoms: Abnormal vaginal bleeding, post-coital bleeding, discharge.
 Diagnosis: Colposcopy and biopsy.
 Staging: FIGO staging system.
 Treatment:
o Early: Surgery (conization, hysterectomy)
o Advanced: Radiotherapy and chemotherapy

B. Endometrial (Uterine) Cancer
 Risk factors: Unopposed estrogen exposure, obesity, diabetes.
 Symptoms: Postmenopausal bleeding (most common).
 Diagnosis: Endometrial biopsy.
 Staging: FIGO system.
 Treatment: Hysterectomy with bilateral salpingo-oophorectomy, radiation,
chemotherapy as needed.

C. Ovarian Cancer
 Types: Epithelial (most common), germ cell, stromal tumors.
 Symptoms: Vague symptoms like abdominal bloating, pain, early satiety.
 Diagnosis: Ultrasound, CA-125 marker, surgical staging.
 Treatment: Surgery (debulking) + chemotherapy.
 Prognosis: Often diagnosed late; poor prognosis.

57. D. Vaginal and Vulvar Cancer
 Rare malignancies.
 Symptoms: Vulvar itching, masses, bleeding.
 Diagnosis: Biopsy.
 Treatment: Surgery, radiotherapy.

3. Risk Factors
 HPV infection (cervical, vulvar)
 Age
 Family history
 Hormonal factors (e.g., unopposed estrogen)
 Lifestyle (smoking, obesity)

4. Diagnostic Modalities
 Pap smear and HPV testing
 Pelvic examination and biopsy
 Imaging: Ultrasound, MRI, CT scan
 Tumor markers (e.g., CA-125 for ovarian cancer)

5. Staging
 Based on FIGO (International Federation of Gynecology and Obstetrics) criteria.
 Determines extent of disease and guides treatment.

6. Treatment Principles
 Surgery: Removal of tumor and staging.
 Radiotherapy: For local control.
 Chemotherapy: Systemic treatment for advanced disease.
 Targeted therapy and immunotherapy emerging.

7. Prevention and Screening
 HPV vaccination for cervical cancer prevention.

58.  Regular Pap smears and HPV screening.
 Awareness of symptoms for early detection.

Summary
Malignant gynecological conditions require early diagnosis and a multidisciplinary approach
for effective management. Screening and prevention play a vital role in reducing incidence
and mortality.

59. Chapter 17: Urogynecology

1. Introduction
Urogynecology is a subspecialty that deals with female pelvic floor disorders, including
urinary incontinence, pelvic organ prolapse, and other functional abnormalities of the
bladder, urethra, and vagina.

2. Anatomy and Physiology
 Pelvic floor muscles support the bladder, uterus, rectum.
 The urethral sphincter controls urine flow.
 Coordination between muscles and nerves maintains continence.

3. Common Urogynecological Disorders

A. Urinary Incontinence
 Types:
o Stress incontinence: leakage with increased intra-abdominal pressure
(coughing, sneezing).
o Urge incontinence: sudden, intense urge to urinate followed by involuntary
leakage.
o Mixed incontinence: combination of stress and urge.
o Overflow incontinence: due to bladder outlet obstruction or underactive
bladder.
 Causes:
o Weak pelvic floor muscles
o Neurological disorders
o Bladder abnormalities
 Diagnosis:
o History and physical exam
o Urinalysis
o Urodynamic studies
 Management:
o Lifestyle changes (weight loss, fluid management)
o Pelvic floor muscle training (Kegel exercises)
o Medications (anticholinergics for urge incontinence)
o Surgical options (e.g., sling procedures)

60. B. Pelvic Organ Prolapse (POP)
 Descent of pelvic organs (bladder, uterus, rectum) into the vaginal canal due to
weakening of pelvic floor support.
 Types:
o Cystocele (bladder prolapse)
o Rectocele (rectal prolapse)
o Uterine prolapse
 Symptoms: pelvic pressure, urinary problems, bowel dysfunction.
 Diagnosis: Pelvic examination, POP-Q (Pelvic Organ Prolapse Quantification)
system.
 Treatment:
o Conservative: pessaries, pelvic floor exercises
o Surgical: repair or hysterectomy

C. Other Disorders
 Fistulas: abnormal connections (e.g., vesicovaginal fistula) causing continuous
leakage.
 Overactive bladder syndrome
 Chronic pelvic pain related to pelvic floor dysfunction

4. Diagnostic Tools
 Pelvic examination
 Urodynamic testing
 Ultrasound or MRI for pelvic floor imaging
 Cystoscopy (if indicated)

5. Management Principles
 Individualized based on severity and patient preference
 Conservative management first-line
 Multidisciplinary approach involving physical therapy, surgery, and behavioral
therapy

Summary
Urogynecology addresses disorders impacting a woman’s quality of life due to urinary and
pelvic floor dysfunction. Early diagnosis and comprehensive management can significantly
improve symptoms.

61. Chapter 18: Infections

1. Introduction
Infections in the female reproductive tract are common and can involve the vagina, cervix,
uterus, fallopian tubes, ovaries, and pelvic peritoneum. Prompt diagnosis and treatment
are vital to prevent complications like infertility and sepsis.

2. Common Gynecological Infections

A. Vaginitis
 Inflammation of the vagina causing discharge, itching, and irritation.
 Common causes:
o Bacterial vaginosis (BV): overgrowth of anaerobic bacteria, characterized by
thin, gray discharge with fishy odor.
o Candida vulvovaginitis: yeast infection causing thick, white, curdy
discharge.
o Trichomoniasis: sexually transmitted protozoal infection with frothy, yellow-
green discharge.
 Diagnosis: Microscopy, culture, pH testing.
 Treatment:
o BV: Metronidazole or clindamycin
o Candida: Antifungals (e.g., fluconazole)
o Trichomoniasis: Metronidazole

B. Cervicitis
 Inflammation of the cervix, often due to STIs.
 Common pathogens: Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes
simplex virus (HSV).
 Symptoms: vaginal discharge, bleeding, dyspareunia.
 Diagnosis: Cervical swabs, PCR testing.
 Treatment: Antibiotics or antivirals as per organism.

C. Pelvic Inflammatory Disease (PID)
 Infection of upper genital tract (endometrium, fallopian tubes, ovaries).
 Usually polymicrobial, often due to ascending STIs.

62.  Symptoms: lower abdominal pain, fever, vaginal discharge, cervical motion
tenderness.
 Diagnosis: Clinical criteria, ultrasound.
 Treatment: Broad-spectrum IV or oral antibiotics.

3. Obstetric Infections
 Chorioamnionitis: infection of fetal membranes during labor.
 Endometritis: infection of uterine lining postpartum or post abortion.
 Management: Antibiotics, supportive care.

4. Sexually Transmitted Infections (STIs)
 Overview of common STIs affecting the female genital tract:
o HPV: linked to cervical cancer
o Herpes simplex virus: recurrent painful ulcers
o Syphilis, HIV, Hepatitis B: systemic implications
 Prevention: safe sex, screening, vaccination (HPV, Hep B)

5. Diagnostic Tools
 Microscopy and culture
 PCR and antigen detection tests
 Serology for systemic infections
 Pelvic ultrasound for abscesses or tubo-ovarian involvement

6. Prevention
 Safe sexual practices
 Routine screening in high-risk populations
 Vaccination (HPV, Hepatitis B)
 Prompt treatment of partners to avoid reinfection

Summary
Gynecological and obstetric infections are diverse and can range from mild to life-
threatening. Early diagnosis, appropriate antimicrobial therapy, and preventive strategies are
essential for optimal outcomes.

63. Chapter 19: Gynecological Procedures

1. Introduction
Gynecological procedures include a wide range of diagnostic and therapeutic interventions
performed to evaluate and treat disorders of the female reproductive system.

2. Diagnostic Procedures

A. Pelvic Examination
 Visual and manual inspection of external and internal genitalia.
 Includes speculum examination and bimanual palpation.

B. Pap Smear (Papanicolaou Test)
 Screening test for cervical dysplasia and cancer.
 Cells collected from the cervix and examined cytologically.
 Followed by colposcopy if abnormal.

C. Colposcopy
 Magnified visual examination of the cervix.
 Allows targeted biopsy of suspicious lesions.

D. Endometrial Biopsy
 Sampling of the endometrial lining.
 Indicated for abnormal uterine bleeding or suspected hyperplasia/cancer.

E. Hysteroscopy
 Endoscopic visualization of the uterine cavity.
 Used to diagnose and treat intrauterine pathology (polyps, fibroids, adhesions).

64. F. Laparoscopy
 Minimally invasive surgery using a camera inserted into the peritoneal cavity.
 Used for diagnosis and treatment of pelvic pathology (endometriosis, ovarian cysts).

3. Therapeutic Procedures

A. Dilation and Curettage (D&C)
 Dilatation of the cervix and scraping of the endometrium.
 Indications: abnormal bleeding, retained products of conception.

B. Tubal Ligation
 Surgical sterilization by occluding or removing fallopian tubes.
 Methods: clips, rings, cauterization.

C. Myomectomy
 Surgical removal of uterine fibroids.
 Can be done via laparotomy, laparoscopy, or hysteroscopy.

D. Hysterectomy
 Removal of the uterus.
 Types: total, subtotal, radical.
 Indications: fibroids, malignancy, severe bleeding.

E. Insertion of Intrauterine Device (IUD)
 Contraceptive device placed in the uterine cavity.
 Requires proper technique to avoid complications.

65. 4. Minimally Invasive Techniques
 Use of laparoscopy and hysteroscopy reduces morbidity and recovery time.
 Increasingly preferred for diagnostic and operative interventions.

5. Preoperative and Postoperative Care
 Informed consent and counseling.
 Preoperative investigations.
 Monitoring for complications.
 Postoperative follow-up.

Summary
Gynecological procedures range from simple office-based tests to complex surgeries.
Mastery of indications, techniques, and complications is essential for effective management.

66. Chapter 20: Recent Advances

1. Introduction
Recent advances in obstetrics and gynecology have improved diagnosis, treatment, and
outcomes, leveraging technology and research to enhance women's health care.

2. Advances in Obstetrics
A. Fetal Medicine
 Non-invasive prenatal testing (NIPT):
o Cell-free fetal DNA testing from maternal blood for chromosomal
abnormalities.
 Fetal surgery:
o In-utero interventions for conditions like spina bifida and congenital
diaphragmatic hernia.
 Advanced ultrasound and MRI:
o Improved imaging for detailed fetal anatomy and growth assessment.

B. Monitoring and Management of High-Risk Pregnancies
 Use of doppler ultrasound to assess fetal well-being.
 Biophysical profile scoring combining ultrasound and NST (non-stress test).
 Telemedicine for remote monitoring.

3. Advances in Gynecology
A. Minimally Invasive Surgery
 Robotic-assisted laparoscopy:
o Enhanced precision and visualization in procedures like hysterectomy and
myomectomy.
 Single-port laparoscopy:
o Reduced scarring and quicker recovery.

B. Endometrial Ablation Techniques
 New devices allow safer and more effective treatment of abnormal uterine bleeding.

67. C. Improved Contraceptive Methods
 Long-acting reversible contraceptives (LARCs) like hormonal IUDs and implants.
 Development of male contraceptives (under research).

D. Assisted Reproductive Technologies (ART)
 Advances in IVF protocols, embryo freezing (vitrification).
 Preimplantation genetic diagnosis (PGD) to prevent genetic diseases.
 Ovarian tissue freezing for fertility preservation.

4. Molecular and Genetic Advances
 Understanding of genetic markers for cancer risk (BRCA mutations).
 Targeted therapies based on molecular profiling.
 Role of epigenetics in reproductive disorders.

5. Telemedicine and Digital Health
 Remote consultations and monitoring improving access to care.
 Use of mobile apps for menstrual tracking and fertility awareness.

6. Immunotherapy and Vaccines
 Development of vaccines beyond HPV (e.g., therapeutic vaccines for cervical cancer).
 Immunomodulatory treatments for recurrent pregnancy loss.

Summary
The field of obstetrics and gynecology is rapidly evolving with technological innovations and
personalized medicine approaches enhancing patient care, outcomes, and quality of life.